Medicare Savings Program Medicare Savings Program Advocacy:Advocacy:

Garcia v. SebeliusGarcia v. Sebelius

Pam WalzPam Walz

Amy HirschAmy Hirsch

Wey-Wey KwokWey-Wey Kwok

The problems we kept seeing The problems we kept seeing (over and over again)(over and over again)

Delays in enrollmentDelays in enrollment Data matches between DPW and SSA just once per Data matches between DPW and SSA just once per

monthmonth At least 2-3 months if everything went perfectlyAt least 2-3 months if everything went perfectly Several months to more than a year if the data did not Several months to more than a year if the data did not

matchmatch No system to timely address these errorsNo system to timely address these errors No notice to applicants No notice to applicants Need to wait for Part A enrollment until after Part B Need to wait for Part A enrollment until after Part B

enrollment completedenrollment completed

Problems, cont.Problems, cont.

QMBs enrolled in Part B, but not Part AQMBs enrolled in Part B, but not Part A Individuals who became eligible for Medicare Individuals who became eligible for Medicare

after age 65after age 65 Individuals who initially rejected Medicare due Individuals who initially rejected Medicare due

to misinformationto misinformation SSI recipients who were missed by auto-SSI recipients who were missed by auto-

accretionaccretion

Problems, cont.Problems, cont.

Frequent failure to review for 3 months’ Frequent failure to review for 3 months’ retroactive coverageretroactive coverage Short form MSP application did not have a Short form MSP application did not have a

place to request and did not ask for place to request and did not ask for verification of retroactive eligibilityverification of retroactive eligibility

Problems, cont.Problems, cont.

Misinformation provided to applicantsMisinformation provided to applicants Lack of knowledge by DPW caseworkersLack of knowledge by DPW caseworkers Applicants bounced back and forth between Applicants bounced back and forth between

the welfare and Social Security offices when the welfare and Social Security offices when trying to enroll in Part A and the MSPtrying to enroll in Part A and the MSP

Social Security staff telling MSP eligible Social Security staff telling MSP eligible individuals that they would have to pay for individuals that they would have to pay for Medicare and not telling them about MSPMedicare and not telling them about MSP

Garcia v. SebeliusGarcia v. Sebelius

State told us problems all Feds’ fault— so State told us problems all Feds’ fault— so we sued feds as well as statewe sued feds as well as state

SSA & DHHS (for CMS) officials as fed SSA & DHHS (for CMS) officials as fed defendantsdefendants

State & local welfare officials as state defsState & local welfare officials as state defs

Litigation StrategyLitigation Strategy

State approves individuals for MA, and State approves individuals for MA, and Buy-InBuy-In

Feds also must approve indiv (data match)Feds also must approve indiv (data match)

& deduct premiums from Social Security& deduct premiums from Social Security

Need all three agencies (state, CMS, SSA) Need all three agencies (state, CMS, SSA) to resolve data exchange issuesto resolve data exchange issues

Litigation TheoriesLitigation Theories

Claims under Medicaid statute & regsClaims under Medicaid statute & regs

Claims under Medicare statuteClaims under Medicare statute

Due Process ClaimsDue Process Claims

Litigation StrategyLitigation Strategy

Complex facts, dense statutes -- need to Complex facts, dense statutes -- need to make it very simple & clear for court:make it very simple & clear for court:

Low income elderly & disabled individuals Low income elderly & disabled individuals being denied access to medical care being denied access to medical care because of out-dated bureaucratic because of out-dated bureaucratic computer problemscomputer problems

Litigation StrategyLitigation Strategy

Convince state of savings through getting Convince state of savings through getting folks onto Medicare as primary payorfolks onto Medicare as primary payor

Seek early negotiations, ask for tech & Seek early negotiations, ask for tech & program staff involvementprogram staff involvement

Issues are extremely fact intensive, not Issues are extremely fact intensive, not well suited to judicial resolutionwell suited to judicial resolution

NegotiationsNegotiations

Surprise! Feds were already:Surprise! Feds were already: Accepting data daily from other states (but Accepting data daily from other states (but

would not disclose which states!)would not disclose which states!) Responding to data dailyResponding to data daily Allowing advance submissionsAllowing advance submissions Allowing simultaneous Part A & Part B Allowing simultaneous Part A & Part B

submissions submissions

NegotiationsNegotiations

State had out-dated info on fed State had out-dated info on fed proceduresprocedures

State needed lots of tech assistance from State needed lots of tech assistance from feds feds

SettlementSettlement

DPW agreed to begin submitting MSP DPW agreed to begin submitting MSP enrollment requests on a daily basis.enrollment requests on a daily basis.

DPW also agreed to begin accepting DPW also agreed to begin accepting responses to its MSP enrollment requests responses to its MSP enrollment requests on a daily basis.on a daily basis.

Notice to applicants whose MSP Notice to applicants whose MSP enrollment is not effectuated by the first enrollment is not effectuated by the first month after submissionmonth after submission

Settlement, cont.Settlement, cont.

Computer runs every 2 months to identify Computer runs every 2 months to identify (and enroll) individuals 65 or older who are (and enroll) individuals 65 or older who are not enrolled in MSP for both Parts A and not enrolled in MSP for both Parts A and B.B.

Simultaneous enrollment in MSP for Parts Simultaneous enrollment in MSP for Parts A and B.A and B.

Protocols and timeframes for case workers Protocols and timeframes for case workers to resolve data errors in enrollment to resolve data errors in enrollment submissionssubmissions

Settlement, cont.Settlement, cont.

Protocols to facilitate case worker Protocols to facilitate case worker communication with central DPW staff and communication with central DPW staff and with local SSA offices to resolve with local SSA offices to resolve enrollment problems.enrollment problems.

Training for County Assistance Office staff!Training for County Assistance Office staff! Instructions for case workers on Instructions for case workers on

retroactive eligibility, and notice to retroactive eligibility, and notice to applicants not found eligible for retroactive applicants not found eligible for retroactive coveragecoverage

Settlement, cont.Settlement, cont.

Revision of MSP application to solicit Revision of MSP application to solicit information to determine retro coverage.information to determine retro coverage.

Notice of availability of retroactive Notice of availability of retroactive coverage on MSP eligibility notices.coverage on MSP eligibility notices.

Revision of Medical Assistance Eligibility Revision of Medical Assistance Eligibility Handbook sections on MSP.Handbook sections on MSP.

Reports to plaintiffs’ counsel.Reports to plaintiffs’ counsel.