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Feds may ban agents from selling Medicare long-term care plans

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Federal regulators want to expand access to an unusual, Medicare-related program that can pay for enrollees’ long-term care costs — then prohibit insurance agents and other outside entities from marketing the organizations in the program.

Officials at the Centers for Medicare & Medicaid Services (CMS) put the proposed ban on agent involvement in a new set of draft regulations. The draft regulations would update the rules governing the Programs of All-Inclusive Care for the Elderly.

Medicare does not normally pay for long-term care services in a nursing home.

A PACE program is supposed to provide comprehensive care for people ages 55 and older who live at home but who already have disabilities or health problems severe enough that they need the equivalent of the kind of nursing home care a state’s Medicaid program would normally cover. A PACE program tries to use its own network of providers to try to provide all of the health care and support services needed to keep the patient at home. If the patient does end up needing hospital care, or nursing home care, the PACE program is supposed to provide the facility-based care.

Related: H.R. 3243 could expand federal LTC role

PACE program organizers have to go through a CMS application process to start the programs. In November 2015, organizers were running 116 PACE programs in 32 states, and those programs were providing care for about 35,000 people, according to the Alexandria, Virginia-based National PACE Association.

Some PACE programs now use agents, brokers or outside marketing firms to market their services to the patients, and the patients’ families, officials write in a preamble to the proposed regulations.

“We believe it is in the best interest of the program to permit only [PACE organizations] to market their programs through their own employees,” officials say in the preamble.

A PACE program’s enrollees have to use the program’s care providers, and enrollment in any one PACE program is usually small, officials say.

Those factors may “make it difficult for agents and brokers that are not employed by [PACE organizations] to fully understand and explain the PACE program to potential participants,” officials say.

CMS does not want to see a marketer’s efforts to maximize enrollment numbers be a patient’s primary reason for signing up for a PACE program, officials say.

“This is especially important given the vulnerable nature of the PACE population, which is elderly and frail and often has more complex health care needs than Medicare or Medicaid managed care populations,” officials say.

“We are seeking comment as to whether CMS’s proposed prohibition on the use of independent agents and brokers is appropriate,” officials say. “If commenters believe that this prohibition is not appropriate, we ask for specific reasons for allowing their use, descriptions of how [PACE organizations] contemplate using agents and brokers, and the protections [PACE organizations] have in place to ensure accurate information is provided to potential PACE participants.”

The regulations are set to appear in the Federal Register Aug. 16. Comments will be due 60 days after the official publication date.

CMS lists Martha Hennsessy as its main contact for the proposal.

Andy Slavitt, the acting director of CMS, wrote about the proposed PACE regulations in a blog entry Thursday. Slavitt said the main goal of the draft regulations is to strengthen program enrollee protections and give PACE organizations more administrative and operational flexibility.

“While PACE serves a relatively small number of people today, our proposal is intended to encourage states to further expand these programs,” Slavitt wrote in the blog entry.


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