Managed Care:
IS MANAGED CARE TAKING A BITE OUT OF YOUR BOTTOM LINE?
Published on Thu Jan 12, 2006
You could find out too late the prescription drug benefit is hitting you in the wallet.
Home health agencies that thought they were an arm's length away from the new Part D prescription drug benefit under Medicare had better think again.
Just because agencies don't furnish the drugs doesn't mean they aren't affected by the changes surrounding the new benefit, experts warn. The more beneficiaries an HHA serves who are dually eligible for Medicare and Medicaid, the more likely the HHA could see a big financial impact in the beginning of 2006.
That's because nearly six million dual eligibles nationwide have been transferred from Medicaid plans that formerly paid for their drugs to new Special Needs Plans (SNPs) under Medicare that are administered by managed care organizations, the Government Accountability Office notes in a recent report.
In some states, when the beneficiaries were passively enrolled without their consent into the SNPs, they were also switched over from regular fee-for-service Medicare into a full Medicare Advantage plan.
In other states, beneficiaries weren't automatically enrolled in full MA plans, but were convinced by MA marketers to elect such plans along with their drug benefit. Beneficiaries often don't understand that the switch will affect their home health or other Medicare-covered services in any way, advocates charge.
Medicare managed care has been on the rise in recent months anyway, thanks to more generous reimbursement, notes consultant Alison Cherney with Brentwood, TN-based Cherney & Associates. That means agencies should expect to see more patients in general, not just dual eligibles, signing onto MA plans.
HHAs can expect to see more states hop on the passive enrollment bandwagon as the savings from switching benes from Medicaid to Medicare becomes clear, predicts consultant Steve Braff with The Braff Group in Palm Springs, CA. "States strapped for cash will support this covert shift from Medicaid to Medicare Advantage. Last I checked that was about all of them," Braff quips.
Beneficiary representatives are suing in one state that allowed the passive enrollment into full MA plans. The Pennsylvania Health Law Project has filed a class action lawsuit on behalf of beneficiaries against the Centers for Medicare & Medicaid Services to stop the passive enrollment.
CMS didn't have the legal authority to allow passive enrollment and didn't notify beneficiaries properly of the change, the suit charges. "Passive enrollment will cause poor Medicare beneficiaries in Pennsylvania to lose the freedom of choice of health care providers which is guaranteed by the Medicare statute," PHLP says in a release. Benes will be limited to network providers and subject to utilization controls under the plans that they didn't choose. Opt Out Not Always A Viable Option Even though they were sent notices about the change, many dually eligible home health patients [...]
