Role of Medicare Beneficiary Ombudsman

Explore the vital role of the Medicare Beneficiary Ombudsman in addressing beneficiary inquiries, providing education, and recommending improvements in Medicare administration. Discover when to contact the Ombudsman for systemic issues, research topics, or feedback on Medicare experiences, including the Special Enrollment Period for formerly incarcerated individuals starting January 1, 2023.

• Medicare Beneficiary Ombudsman
• Healthcare
• Medicare Administration
• Special Enrollment Period
• Formerly Incarcerated

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1. Medicare Beneficiary Ombudsman Overview 1

2. Agenda CMS Offices of Hearings and Inquiries (OHI) Medicare Beneficiary Ombudsman (MBO) & Associate Ombudsmen (AO) Medicare Ombudsman Group (MOG) From Incarcerated to Insured Efforts Incarceration SEP Re-Entry Challenges From Incarcerated to Insured Workgroup Improving Transitions Informing Policy Best Practices 2

3. Role of the Medicare Beneficiary Ombudsman The Medicare Beneficiary Ombudsman (MBO) was established by Congress to Receive and respond to beneficiary inquiries and complaints Work with partners to provide outreach and education to beneficiaries Provide recommendations for improving the administration of Medicare Report its activities to Congress1 Associate Ombudsman Medicare Ombudsman Group (MOG) 1Social Security Act 1808(c), 42 U.S.C. 1395b-9. 3

4. Medicare Beneficiary Ombudsman The Role of the OHI Ombudsmen in the Medicare Customer Assistance Process The figure is a circular diagram that demonstrates the role the OHI ombudsmen have in the Medicare customer service process. There is an inner and outer circle in the diagram. The figure illustrates the cyclical nature of ombudsmen activities as part of the customer service process, as each activity leads the next and occurs on an ongoing basis. The outer circle depicts the three aspects of ombudsmen activities in the customer service process. These activities include responding to inquiries and complaints, communicating opportunities for program improvement, and facilitating solutions based on feedback. The inner circle outlines three activities that relate to facilitating the ombudsmen's engagement with the three areas in the outer circle. These include: engaging stakeholders as part of responding to inquiries and complaints; collaborating with partners as part of communicating opportunities for program improvement; and improving experiences as part of facilitating solutions based on feedback. 4

5. When to Contact the MBO/MOG If you have a systemic issue potentially affecting multiple beneficiaries. If you have a topic of interest for research. To provide feedback about beneficiary experiences with Medicare. 5

6. Medicare Special Enrollment Period for Formerly Incarcerated Consumers Effective January 1, 2023 Prior to establishment, incarcerated beneficiaries were subject to: Late enrollment & other financial penalties Limited enrollment timeframes Gaps in coverage Other enrollment issues 6

7. Re-Entry Challenges Incarceration can negatively impact mental and physical health By 2030, aged 55+ will be 30% of the carceral population Access to discharge planners varies Medicare enrollment is not always automatic, enrollment rules apply, and current discrepancy between CMS definition of incarceration and how it works operationally Must contact SSA to inquire about eligibility and apply Medicaid suspension/termination rules vary by state 7

8. From Incarcerated to Insured Workgroup External Stakeholders Purpose Internal Stakeholders To promote awareness of the SEP SHIPs (HI and AZ) OHI Federal BOP CM Encourage information sharing among stakeholders VA Re-entry Group OPOLE HHS Re-entry Group OMH CMCS Successful Reentry, LLC Identify areas of underutilization Justice in Aging 8

9. Improving Transitions 1115 Medicaid Demonstration Waivers Returning to the Community: Health Care After Incarceration Consolidated Appropriations Act, 2024 SHIP Pilot 9

10. Informing CMS Policy and Programs Improvements to materials Gained insights into design & accessibility Acquired example materials to use as a model for future promotion materials Identified new stakeholders/ outreach opportunities Established pathway for reporting coverage/ enrollment issues Informing policy-Changing definition of incarceration for Medicare 10

11. Best Practices Communicate with target population and/or those working directly with the justice-involved population, addressing gaps in engagement, equity, and uptake Establish & maintain relationships, and be proactive Consider other barriers justice-involved populations encounter* Use terms that have less stigma: i.e. re-entry, incarcerated individual, justice involved population, and carceral 11

12. Resources Incarcerated Medicare Beneficiary Outreach and Education page: https://www.cms.gov/training-education/look-up- topics/special-populations/incarcerated-medicare- beneficiaries#considerincarcerated Signing up for Medicare after incarceration: https://www.medicare.gov/media/publication/12182-signing- up-for-medicare-after-jail-or-incarceration.pdf Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances): https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms- list/cms10797 Proposed Rule for Medicare s definition of incarceration: https://www.federalregister.gov/documents/2024/07/22/2024- 15087/medicare-and-medicaid-programs-hospital-outpatient-prospective- payment-and-ambulatory-surgical 12

13. Resources Continued Medicare coverage of items and services furnished to beneficiaries in custody under a penal authority: https://www.cms.gov/files/document/mln908084-patients- custody-under-penal-authority.pdf Program Operations Manual Systems (POMS) for Payment of Premium Arrearage: https://secure.ssa.gov/poms.nsf/lnx/0600805180 Request for Termination of Part A, B, or PBID Coverage: https://www.cms.gov/medicare/cms-forms/cms- forms/downloads/cms1763.pdf Options for Financial Relief from Retroactive Part B Billing: https://secure.ssa.gov/poms.nsf/lnx/0600815042#:~:text=Advise %20beneficiaries%20they%20have%20two,SSA%2D632%2DBK) 13

14. Contact Information & Resources Barbara McCoy, Associate Medicare Ombudsman Email: Barbara.mccoy1@cms.hhs.gov Catherine Rippey, Medicare Beneficiary Ombudsman E-mail: Catherine.Rippey@cms.hhs.gov Website:Get help with your rights & protections | Medicare 14