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
"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