Dual Eligibles Gain Time To Choose Different HMO

Settlement of a suit filed by the Pennsylvania Health Law Project (PHLP) on behalf of “dual eligibles” in that state means that those individuals will have an extended grace period to disenroll from the Medicare HMO in which they were automatically placed to obtain prescription drug coverage under the new Medicare Part D drug program.

That's critical because often those HMOs have a restricted provider network that does not include the psychiatrists they were seeing previous to the start of the prescription drug program on January 1.

Now, the PHLP and the federal Centers for Medicare and Medicaid Services (CMS) have reached a settlement in which the grace period during which individuals can disenroll from one plan and switch to another plan—which had been until March 31—has been extended to June 30.

Moreover, psychiatrists who have been treating patients in this category may continue to do so and to submit claims to the Medicare HMO even though they may not be a participant in the network.

The HMO is required to pay the Medicare fee-for-service rate or billed charge, whichever is lower, for any Medicare-covered service provided during the period beginning January 1 and ending June 30, according to a notice that CMS sent out to Medicare-participating providers in Pennsylvania.

The suit was filed by the PHLP on behalf of dual eligibles in the state who—because of peculiarities in the design of Pennsylvania's public health insurance programs—were subject to one of the more glaring foul-ups accompanying the new Part D program when CMS“ auto-enrolled” those individuals into Medicare HMOs.

The result, in short, was that individuals landed in plans in which their treating psychiatrist was often not a participating provider.

A September 2005 letter from the Pennsylvania Psychiatric Society (PPS) to CMS, which was also accompanied by a letter from APA, outlined the problem.

“Most dual eligibles in Pennsylvania are required by the state to receive health care services through managed care plans contracting with the state to provide Medicare services,” the PPS letter stated.“ However, the design, structure, payment rules, and contracting details are such that most dual eligibles do not receive health care services from providers who are in the parent company's Medicare HMO.

“This is especially true in psychiatry, where behavioral health services have been deliberately carved out and separately contracted to the county government to ensure a seamless mental health system for patients funded with public dollars,” the letter continued. “If CMS auto-enrolls patients into the Medicare HMO of the company responsible for the patient's Medicaid HMO, those patients will for the most part be restricted to a network of providers that does not include the providers they normally see.” ▪