CMS Issues Memo Outlining Concern with SNF Practices Related to Disenrollment from Medicare Advantage and Dual Demonstration Plans

In a memo dated May 26th, the Centers for Medicare and Medicaid Services (CMS) asserts that they continue “to see an unacceptable practice of LTC facilities disenrolling beneficiaries from Medicare advantage prescription drug plans (MAPDs) and enrolling them into stand-alone drug plans (PDPs) without the beneficiary’s or the representative’s knowledge and/or complete understanding.” They go on the state that “Similarly unacceptable practices have been seen among LTC facilities serving Medicare-Medicaid (dually eligible) enrollees eligible to join a Medicare-Medicaid plan (MMP) as part of a demonstration under the Financial Alignment Initiative”, which would include the Commonwealth Coordinated Care (CCC) program in Virginia.  

Specifically related to the Dual programs, CMS states that “CMS and the states have received mass requests, all initiated and completed by LTC facility staff, to opt out or disenroll LTC facility residents from MMP coverage…”  CMS reasserts that “Only a beneficiary or his/her representative can execute a valid request to opt out or disenroll from an MMP or enroll in a PDP or MAPD” and that “State Survey Agencies will continue to monitor LTC facilities for compliance with regulations.”  

You may recall that there was concern early in CCC implementation that facility staff was being asked by residents or their families what they should do in regards to CCC and the Department of Medical Assistance Services (DMAS) articulated a concern that “providers” were opting people out of the program.  DMAS provided a couple of examples of alleged influence in nursing facilities, some of which were determined to be legitimate opt-outs, despite the accusation.  VHCA sought specific guidance from DMAS to direct the extent of information facility staff should provide, and DMAS issued a memo outlining the relevant federal and state regulations protecting beneficiary choice.  Subsequent to that memo, VHCA communicated to the membership reiterating beneficiary rights in regards to enrollment decisions and recommending staff stick to the “facts” regarding the CCC program as opposed to any judgements relative to a resident’s decision to participate. Since that original discussion nearly a year ago, we have not been informed of any specific concerns regarding nursing facility involvement in opt-out decisions.

In fact, nursing facility resident enrollment in CCC only trails the “community well” enrollment by 4.5 percentage points (47.6% nursing facility enrollment v. 52.1% community well).  Since the “community well” by definition are not high utilizers of covered services, it is not clear to VHCA what “provider” would be opting-out that population, yet their opt-out rate is similar to that of nursing facility residents.  What our members have seen are opt-outs based on assigned physician (primarily) non-participation in CCC and reaction to the more complicated and often denied authorization of needed services.  Keep in mind that Medicare Advantage penetration in Virginia was only 18.1% in May 2015 (according to CMS data); it is not entirely clear why the low enrollment in CCC remains a surprise to anyone, particularly given the numerous implementation issues still unresolved.