January 27, 2006 FAMILIES USA 2006 HEALTH ACTION CONFERENCE Daniel J. Schreiner Medicare Beneficiary Ombudsman CMS Office of the Medicare Ombudsman Meet

January 27, 2006

FAMILIES USA 2006 HEALTH ACTION CONFERENCE

Daniel J. SchreinerMedicare Beneficiary Ombudsman

CMSOffice of the Medicare Ombudsman

Meet the Medicare Beneficiary Ombudsman

The Medicare Ombudsman: A Voice for Beneficiaries

Agenda

• Medicare Beneficiary Ombudsman• Ombudsman’s Responsibilities• Ombudsman’s Goals• Performance-Based Approach• Benchmarks for Success• The Plan for 2006• Beneficiary Outreach• Working with the Ombudsman• Ombudsman Resources


Medicare Beneficiary Ombudsman

• Created by Section 923 of the Medicare Modernization Act (MMA)

• “Voice for Medicare Beneficiaries”

• Work closely with the Centers for Beneficiary Choices

• Direct access to CMS Administrator


Ombudsman’s Responsibilities

• Receive and provide assistance to beneficiaries– Complaints– Grievances– Inquiries

• Assist in collecting information to file an appeal

• Help with Medicare Advantage Disenrollment


Ombudsman’s Responsibilities

• Assist with information related to the new income-related premium adjustment

• Work with State Health Insurance Programs (SHIPs)

• Submit an annual report to Congress– Ombudsman activities– Recommendations on improvements to

Medicare


Ombudsman’s Goals

Holding the System Accountable

• Create a process to capture and incorporate the “voice of the beneficiary” as a critical component to the development and improvement of all assistance programs

• Implement a performance measurement system to identify and help resolve systemic issues in the beneficiary service experience

• Make recommendations for overall program improvement based on analysis of trends and information from Medicare beneficiaries and advocates


Performance-Based Approach

• Achieve continuous improvement of – Medicare’s existing contractors– Federally staffed complaint, grievance, and

inquiry operations

• Provide better coordination among existing entities

• Provide opportunity for sustained improved performance


Performance-Based Approach

• Desired results are articulated

• Performance standards defined

• Performance will be measured

• Patterns of problems identified

• “Best Practices” shared

• Data fed back into the system


Benchmarks for Success

• Proven institutionalized process for hearing beneficiary needs

• Business processes aligned with customer needs

• Reported service experience improvements


The Plan for 2006

• Develop mechanisms for hearing the “Voice of the Beneficiary” (e.g., Open Door forums, regional/local partner meetings, beneficiary meetings)

• Develop a Web Site as a communication vehicle - http://new.cms.hhs.gov/center/ombudsman.asp

• Develop training materials and programs to meet identified needs

• Establish a system to track performance metrics

• Develop standard operating procedures

• Train people and organizations on using the new standard operating procedures

Communicate with Beneficiaries and their Advocates

ImplementPerformance Management

System

Report to Congress

• Gather quantitative data from internal CMS systems

• Gather qualitative data from local/regional partners and beneficiaries

• Develop a set of data-driven recommendations to Congress


Beneficiary Outreach

Regional/Local Advocate Meetings

Open Door Forums

Beneficiary Feedback Meetings

Opportunity for beneficiaries, their caregivers and advocates to publicly interact with the Medicare Beneficiary Ombudsman to identify, discuss and

address opportunities to improve the systems and processes within the Medicare program.

National conference calls open to beneficiaries, their caregivers and advocates beginning February 15, 2006

Targeted discussions with regional and local advocates within the beneficiary communities that they support

Roundtable discussions with small groups of beneficiaries within their community


Working with the Ombudsman

• The Medicare Beneficiary Ombudsman Will:

– Work with CMS and partners to implement service improvements

– Take action on issues under its purview

– Refer questions/issues to CMS leadership for awareness as appropriate

– Provide updates on major CMS initiatives

• The Medicare Beneficiary Ombudsman Will Not:

– Make agency decisions

– Duplicate existing processes for resolving issues

– Lobby Congress or intervene in legal action



The OMO is seeking input on issues that:

• Affect large numbers of beneficiaries

• Involve unique or exceptional circumstances

• Fall under the Ombudsman’s purview (systems/processes v. policy/statute)

• Are actionable

• Enhance awareness



• Partners have actively communicated situations arising from Part D implementation

• These are the types of things that the OMO wants to hear

• CMS has established mechanisms for resolving specific circumstances. The OMO should not duplicate those, but should understand the underlying, systemic issues



• CMS Role:– Resolve Specific Situations

• Existing Mechanisms: – Tools for Verifying Plan Enrollment/LIS

Status– Procedures to Provide Immediate Access

to Medications– Escalation of Emergency Situations to

CMS Regional Offices



Example: A dual-eligible beneficiary does not know if he or she has been enrolled in a plan:

– Pharmacist should send an E1 Query to

determine plan enrollment– If no match, the pharmacist should verify

Medicare and Medicaid eligibility – If dual-eligibility has been determined, but

no plan has been identified, the pharmacist can use the Point-of-Sale facilitated enrollment option



If a beneficiary is still unable to obtain medications, and the backup systems are not working:

– Call 1-800-Medicare

– Medicare has special caseworkers in each of the CMS Regional Offices who will provide individualized help in getting prescriptions filled

– Medicare is here to help – 24 hours/day, 7 days/week



• The Ombudsman’s role:

– Understand what beneficiaries are experiencing

– Identify underlying systemic issues and make recommendations to Congress for long-term resolution

– Communicate findings with CMS leadership

– Connect partners and beneficiaries to appropriate resources



• Today’s session is an opportunity for you to share your experiences

• I don’t have all the answers!

• I will listen to your feedback, and follow up with the appropriate resources


Ombudsman Resources

The following Ombudsman resources are available. Please help us promote these resources within the beneficiary and advocacy communities:

• OMO Website - http://www.cms.hhs.gov/center/ombudsman.asp

• Contact the Ombudsman - Refer to the link on the above website

• Listserv - To subscribe to the Medicare Beneficiary Ombudsman Listserv - BENEOMBUDODF-L, visit http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=4 and follow the instructions

• Medicare Beneficiary Ombudsman Open Door Forum – Wednesday, February 15, 2006 from 2:00p.m.-3:30p.m.– Call in number: 1-800-837-1935, Conference ID: 3102342

Documents

January 27, 2006 FAMILIES USA 2006 HEALTH ACTION CONFERENCE Daniel J. Schreiner Medicare Beneficiary Ombudsman CMS Office of the Medicare Ombudsman Meet