Web Site: http://www.protectionandadvocacy.com
A National Medicare Ombudsman Project-An Opportunity
Missed
From 1999 to 2000, a demonstration project ($850,000)
to develop a national ombudsman program for low-income Medicare beneficiaries
was assigned by the Health Care Financing Administration (now the Centers
for Medicare and Medicaid) to the National Association of Protection and
Advocacy Systems, Inc. (NAPAS) in Washington, D.C. NAPAS is the membership
association for the nationwide network of federally mandated disability
rights agencies-the
Protection and Advocacy (P&A) System and Client
Assistance Program (CAP) (with an annual budget of ~$100 million).
The purpose of the demonstration project was to enroll
low-income Medicare beneficiaries, both senior citizens and beneficiaries
with disabilities under 65 years, into their state Medicaid programs (also
called the "dual eligibles). In 2000, only 5.2 million people from a total
of ~16 million had enrolled in their state Medicaid program. These beneficiaries
are particularly hard to reach for reasons, such as, cultural barriers,
severe disabilities, administrative barriers to enrollment, cognitive impairments,
and lack of knowledge about the availability of the benefit. The intent
of the demonstration project was to design a national ombudsman program
for Medicare beneficiaries as well as provide one-on-one counseling to
low-income Medicare beneficiaries. The demonstration project was targeted
both to senior
citizens and to beneficiaries with disabilities under
65 years who comprise the ~39 million Medicare (1999) beneficiary population.
Why is the dual eligible program important to Medicare
beneficiaries? The Medicare beneficiary gets his/her Part B premiums ($54.00
in 2002) paid by their Medicaid programs as well as premiums and deductibles,
depending on his/her annual income. State Medicaid programs pay for prescription
drugs and Medicare does not. This is extremely important to beneficiaries
with disabilities under 65 years who rely on their medication to prevent
acute
care episodes with their chronic diseases. Many states
have developed prescription drug assistance programs for their senior citizens
but have, in many cases, excluded beneficiaries with disabilities under
65. Finally, access to durable medical equipment and other technologies
are more readily available, and reimbursement is more flexible through
the Medicaid program than that through Medicare.
The P&A system was unique because it had the capability
of providing both consumer counseling and legal services under the same
umbrella organization. The federal government provides information to beneficiaries
in booklet form and on the Internet, but there is no organization currently
who can interpret the information for beneficiaries, conform it to state
law, regulations, and alternate state benefit programs, tailor it to each
individual's income and social service benefit situation, inform Medicare
beneficiaries of program and coverage changes, and assist beneficiaries
who may be dropped by their Medicare+Choice plan of alternative health
plans options. If the beneficiary encountered problems with Medicaid enrollment,
then the P&A could have conducted administrative hearings to petition
the state. In this manner, Medicare beneficiaries could make informed decisions
about their health care
with use of information from an objective source and
would have their legal rights protected as well.
What were some of the problems uncovered? In one state, the Medicaid program determined that it was paying Part B premiums for deceased beneficiaries and cleaned its computer data files thereby throwing many people off the program with no warning and no explanation to beneficiaries. One beneficiary was enrolled in the program but did not receive benefits for nearly two years. Medicaid applications were being lost because no one assigned a number to the application form for internal tracking. Information from the Medicaid program was not in an alternative format nor multiple languages. Beneficiaries did not want to go to their local Medicaid offices to complete applications due to the stigma involved.
Unfortunately, during the initial implementation phase
of the demonstration project, I and other members of the disability community
suspected that NAPAS may have been misusing public funds to the detriment
of the demonstration project. Suspicions later led to the HHS OIG conducting
a federal audit. The HHS OIG audited 25%, or $200,000, of the total $850,000.
Of the 25%, the OIG recommended reimbursement for $135,371, or 67.6% of
the 25% total project expenditures. The Administration on Developmental
Disabilities within the
Administration on Children and Families will be taking
final action on the findings by January 31, 2002. The web site for the
audit report is http://oig.hhs.gov/oas/reports/region3/30100219.htm.
The financial issues of this demonstration project may jeopardize the policy
findings and the opportunity of the disability organization to participate
in the implementation of programs to increase health care for these vulnerable
Medicare beneficiaries.
For the disability community, this demonstration project
exposed certain managerial and fiscal irregularities with the national
network federally charged with protecting the civil rights of people with
disabilities. Medicare beneficiaries are still being prevented from receiving
health care benefits for which they are legally entitled under the dual
eligible program.
Shelley McLane
Senior Health Policy Analyst
Location: Arlington, VA
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