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CMS delivers a punch to the jaw

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I think officials at the Centers for Medicare & Medicaid Services (CMS) should start over, hold a teleconference with long-term care services outreach experts and insurance agents, and come up with a better set of outreach rules for its Programs for All-Inclusive Care for the Elderly, commonly called PACE.

The authors of the current draft are probably nice, smart people who meant well and may have a point, but the current wording just reads like a punch in insurance agents’ jaw.

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

A PACE plan is a nonprofit organization, with a closed provider panel, that provides soup-to-nuts health care, long-term care and support services for people 55 and older who already need the equivalent of nursing home care and still live in the community.

The idea is that a PACE plan will use Medicare and Medicaid money to fight to keep people who have severe health problems, severe disabilities, or both severe health problems and severe disabilities, in the community as long as possible. But a PACE plan is supposed to pay for nursing home care for enrollees who end up having to move into a nursing home.

Many PACE enrollees meet their states’ normal Medicaid eligibility standards, but some are not eligible for Medicaid. Some PACE programs use waivers to serve people with incomes up to 300 percent of the federal poverty level.

When your clients ask you for ideas about how to pay for long-term care for parents or other loved ones who already need long-term care services, a PACE plan might be something to talk about.

In a set of new draft PACE regulations, CMS officials say they want to ban PACE plans from working with any outside sales agents or marketing organizations. Officials note that all 116 PACE plans in the country serve only about 35,000 people; that the people in the plans are often extremely fragile; that the plans limit enrollees to using the plans’ own providers; and that CMS is worried that even well-intentioned, honest agents may somehow give the prospective enrollees and their families an incorrect impression about what being in the plan would be like.

Officials do ask for public comments on whether the ban on use of independent agents, brokers and marketing organizations is appropriate.

I have no objection to the idea of CMS setting strict rules for PACE plan marketing, but I don’t think CMS has made a good argument for an outright ban on PACE plan use of outside agents, brokers and marketing organizations.

Why I’m unconvinced

First, I write news articles about CMS just about every day. Of course, the way news (at least: interesting news) works, my stories about CMS often involve CMS doing something that insurance agents and brokers might view as irritating. It’s important to acknowledge that the people at CMS do a heroic job of helping people get access to health care and long-term care services.

No matter what you think of the current programs and rules, and how you think the U.S. health care delivery and finance systems should work in the future, the people at CMS help millions of people use the programs that exist now to get necessary care every day.

Even if the agent ban might rub agents the wrong way, the CMS officials were just trying to protect older people from getting stuck in the wrong plans. I think everyone can agree that this is a good goal.

Second, it seems possible that CMS officials had specific horror stories in mind when they wrote the regulations. Maybe CMS officials know about agents ruining people’s lives by giving them inaccurate information about PACE plans. If so, it would be great if they could find a way to publish information about those problems.

Third, I don’t personally have anything against the idea of CMS imposing strict rules for PACE plan marketing efforts.

But, at this point, the officials don’t seem to be doing a good job of documenting why a complete ban on PACE plan use of agents and marketing organizations is necessary.

The National PACE Association, an Alexandria, Virginia-based trade group for PACE plans, includes a chapter in its member guide on the marketing materials and services provides, and it includes a PACE education section for consumers on its own public website. I think those are signs the PACE plans have to market their services to get people in the door, not just passively sit around waiting for gerontologists to send patients their way.

The number of people using PACE plans might be too small to be of much interest to typical insurance agents and brokers, and it’s possible that the compensation PACE programs are willing to pay outside marketers is too small to get many outside marketers’ attention.

But, at the same time, I know what a PACE plan is because some long-term care planners and Medicare plan marketers thought it was important to mention PACE plans when they were talking to me, a reporter who writes for insurance agents, about long-term care options.

The SCAN Foundation, a Long Beach, California-based group, has used funding from a PACE plan to try to find ways to improve all kinds of public and private long-term care financing options, including private long-term care insurance.

Related: SCAN Arizona reaches out to Hispanic seniors

So, it seems as if at least some PACE plans are open to reaching out to insurance agents, and some insurance agents are interested in knowing at least a little about PACE plans.

Getting in-depth knowledge about more than one or two nearby PACE plans might be difficult for the typical long-term care planner, but, on the other hand, CMS is the agency that was out there encouraging consumers to shop for individual major medical plans based on monthly out-of-pocket premiums, and only monthly out-of-pocket premiums, from October 2013 until, roughly November 2015. 

Insurance agents were the ones screaming, as if into the wind, “Don’t you remember all of those awful front-page horror stories from the 1980s about the closed-panel staff-model health maintenance organizations? Don’t you? Don’t you?”

Given that agents were the ones bringing up the provider network issue in the major medical market, maybe CMS officials could trust most agents to bring up the topic of provider networks in the Medicare product and long-term care planning markets.

Kind long-term care planners might tell clients who seem to need PACE plans about the plans for free, but I don’t know why giving PACE plans the option of at least paying agents for referrals is such a terrible thing.

If CMS still wants to impose an outright ban on existing agent-based marketing strategies, then I think it should provide concrete evidence showing how the existing strategies have caused problems, not just suggest that prospective PACE users are frail and that PACE plans are too small and strange for agents to understand them.


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