Medicare Hoping to Nudge Seniors Out
of Drug, Health Plans with Low Ratings
time Medicare officials have tried to steer beneficiaries away from some
private drug and medical plans, while still allowing them to operate
By Susan Jaffe, Kaiser Health News
Medicare 2013 Open Enrollment
Oct. 15 thru Dec. 7
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2012 - Medicare officials are trying a novel
approach during this open enrollment season to
gently nudge a half million beneficiaries out of
26 private drug and medical plans that have
performed poorly over the past three years.
It begins with letters informing
seniors they are enrolled in a plan that received low ratings.
"We encourage you to compare this
plan to other options in your area and decide if it is still the right
choice for you,"
the letter from Medicare urges.
About 375,000 members of Medicare Advantage plans received the letters,
along with 150,000 drug plan members in 48 states, the District of
Columba and Puerto Rico, including California, Florida, Illinois, New
Jersey, Ohio and Texas.
story was produced in collaboration with
The effort marks the first time
that Medicare officials have tried to steer beneficiaries away from some
private drug and medical plans, while still allowing them to operate.Officials havealso warned the plans that they may be
cancelled in the future.
Instead of a typical government
form letter, each one was addressed to the individual member by name and
tells the beneficiary that her plan "has been rated 'poor' or 'below
average'" because it earned less than three stars under Medicare's
five-star rating system for three consecutive years.
Yet that may not be enough to catch
"Some people don’t change no matter
how many letters you send them," says Leta Blank, program director for
the Montgomery County, Md., Senior Health Insurance Assistance Program,
which helps seniors evaluate their coverage options. There are dozens of
plans on sale in most counties. Even if a different plan is cheaper,
studies have shown few seniors change plans. "They are paralyzed. It’s a
very difficult issue," Blank says.
For many beneficiaries, plan
ratings are not as important as price, any restrictions on drugs, such
as special authorizations needed or requirements to try a substitute
drug first,and in the case of a medical plan, whether their
doctors participate, she said.
In addition to the letters,
Medicare is making it harder for people to sign up for one of the 26
plans. If they search for plans on Medicare’s plan finder website, they
can access and join other, better performing plans electronically but to
join one of the 26, they must contact that insurance company directly.
Those plans also have a special warning symbol next to their names to
highlight their low ratings.
And the government will continue to
prod even after the usual enrollment period ends Dec. 7.
Seniors who do pick plans with poor
track records will have one chance to switch next year into a better
plan (earning three or more stars). And Medicare officials are
considering sending a reminder in the mail in February. Most of the
roughly 13.3 million Medicare Advantage members and about 19 million
drug plan enrollees are locked in to their plans for a year.
"We want to make it easy for
beneficiaries to find and select the highest quality plans, and
discourage people from staying in chronically low-performing plans,"
said Isabella Leung, a Medicare spokeswoman.
But if beneficiaries insist on
staying in a low-rated plan, they eventually could be forced out. The
notices do not explain that the plans may be in serious trouble. In
April, the Centers for Medicare and Medicaid Services, which oversees
Medicare, warned insurers that plans rating less than three stars over
three years "have ignored their obligation to meet program requirements
and [are] substantially out of compliance with their Medicare contracts
over a period of time."
Such plans can expect greater
scrutiny, the letter continues, beginning with notices to beneficiaries
alerting them to their plans' low ratings. "They should also expect CMS
to initiate action to terminate their contract" after CMS confirms that
the consistently low scores reflect violations of Medicare rules. In
October, CMS prohibited one of the 26 plans from enrolling new members.
Robert Zirkelbach, a spokesman for
America’s Health Insurance Plans, an industry trade group, said the
letter to beneficiaries is "premature" because the ratings system is
flawed. It is based on measures that do not sufficiently take into
account, for example, plans serving a disproportionate number of
beneficiaries with multiple chronic conditions or special needs, or who
live in medically underserved areas. "These are unique challenges to
providing care to those populations," he said.
"It’s important to make sure we get
the measures right before we move on to these other steps," he said.
Leslie Fried, director for policy
and programs at the National Council on Aging, a Washington, D.C.,
advocacy group, said the letter didn’t have to mention potential plan
terminations. "The letter tells people what they need to know about the
quality of their plan and that they should consider changing to a higher
performing plan," she said. "It’s an important first step."
And if seniors ignore the warning,
that’s their choice, she said. "If people are satisfied with their plan
and it is currently contracted with CMS, isn’t that a decision they
should be allowed to make?"
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