Comments on CMS’ Beneficiary Protections Chapter in Medicare Managed Care Manual

Comments on CMS’ Beneficiary Protections Chapter in Medicare Managed Care Manual

Comments submitted by CHA, drafted jointly with various advocacy organizations. Recommends new and strengthened beneficiary protections for Medicare Managed Care plans. See also CMS’ Chapter 4 in the Medicare Managed Care Manual (PDF).

Draft Revision of Chapter 4: Comment/Response Form

Name of Commenting Organization: Center for Medicare Advocacy, California Health Advocates, National Senior Citizens Law Center, Health Assistance Partnership

Vicki Gottlich (
David Lipschutz
Georgia Burke (
Kelly Brantley (

Phone: 202-293-5760 (Vicki Gottlich)

General comment; p. All: Restructuring

Add to the beginning of the chapter a statement that requirements specific to PFFS and MSA plans have been moved, and that current rules apply until the new chapter is issued.

Section 10.3; p. 6: Dropping optional supplemental benefits

Mandate that plans refund premiums and cancel additional premiums for enrollees who drop or discontinue optional supplemental benefits.

Section 10.5; p. 10: Non-exclusive SNP plans

Eliminate reference to non-exclusive SNPs. All SNPs must serve only the designated populations in 2010. SNP shouldn’t count as only plan offering drug coverage.

Section 10.6; p. 11: Discriminatory plan names

Prohibit plan names that discourage enrollment by certain beneficiaries, ex. “senior.” We suggest that CMS rescind the grandfathering of current plan names that are discriminatory.

Section 10.9; p. 13: Clarification to 3d bullet in this section

Add “type” after the word provider in the second line.

Section 10.9; Table II; p. 14: Clarification

Change “Must” to “Must offer” in all columns.

Section 10.10, 10.21; p. 14, 19: Role of plan regarding balance billing

Add: Plans must protect enrollees against providers that balance bill or seek to collect payments for which the enrollee is not responsible.

Section 10.10 sub 2); p. 15: Examples not exhaustive

Indicate the situations are illustrative and not exhaustive.

Section 10.10; p. 16: Missed appointment charges

Eliminate. Providers serving Medicare beneficiaries should not be permitted to charge for missed appointments. If, however, such charges are permitted, these charges should not exceed the enrollee’s cost-sharing for the appointment.

Section 10.22; p. 20: Lifetime reserve days vs. supplemental benefit days

Clarify that plans must charge days available under a supplemental benefit before charging lifetime reserve days, and supplemental days don’t count against lifetime reserve.

Section 30.1; p. 25-28: Definition of supplemental benefits

The standards for determining what is an acceptable supplemental benefit still are not clear. Change “maid service” to “homemaker service.” See comments re: example chart, Section 30.3.

Section 30.2; p. 28: Anti-discrimination

Add that the anti-discrimination and anti-steerage requirements apply to mandatory and optional supplemental benefit packages.

Section 30.3; p. 29-32: Examples of supplemental benefits

Include a statement in Table III that some of these services may be covered by Medicaid. Require plans to inform beneficiaries of that in their marketing of their supplemental benefit packages and when authorizing coverage of services for enrollees.

Section 30.3; p. 29-32: Examples of supplemental benefits

We question the distinctions in some of the examples. For example, why are dance classes covered at a gym but not in other settings where they also are designed as preventive exercise? Why Tai chi and not yoga classes at a yoga studio?

Section 30.3, p. 32: Notes to Table III

Note 2 to Table III needs to be clearer about the services paid for under the home health benefit that could also be considered homemaker or “maid” services. See 42 CFR 409.45.

Section 40.4, 40.8, 40.9, Table IV; p. 41-49: Dual purpose OTC items

The standards for determining what is an acceptable supplemental benefit still are not clear. Change “maid service” to “homemaker service.” See comments re: example chart, Section 30.3.

Section 50.1; p. 51:Bullet on original Medicare cost-sharing caps

We do not understand what is meant by this limitation. We think you are saying that plans cannot impose cost-sharing in excess of 50%, but it is not clear. Regardless, we believe that 50% is too high. Plans should not be allowed to impose cost sharing that exceeds that of original Medicare.

Section 50.2; p. 52: Cost sharing for preventive services in RPPOs

Clarify that RPPOs with a single deductible cannot apply the deductible to preventive benefits for which the deductible does not apply in original Medicare.

Section 100.2; p. 65-66: PPO point of service

We fail to understand how a PPO can offer a POS option, when a PPO by definition allows its enrollees to go to non-network providers and pay higher cost sharing. This section should be eliminated.

Section 110.1; p. 69: Access and availability rules, 4th bullet re: cultural competence

We recommend that CMS expand reference to accessibility to include persons with impaired vision and other disabilities. In addition, the examples of how to meet the accessibility requirements should be expanded to include hiring and training of bilingual providers and staff, and provision of translated, Braille and large print written materials. Further, we ask CMS to require that the MAOs ensure that there is adequate training of all staff and that there are protocols in place with respect to cultural competency, how to work with interpreters, and how to use available resources needed to insure accessibility.

Section 120.1; p. 72-73: Information to be posted on web site

Add that an MAO offering a drug plan must post the formulary, including all prior authorization and utilization management requirements, and pharmacy lists.

Section 120.2. p. 73-75: Information to be provided – statement of benefits

Add at the end of this section that plans must send enrollees a statement of the benefits they have received.

Karen Fletcher
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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