Orange County Health Authority’s CalOptima OneCare Medicare Advantage plan was served a notice of immediate sanctions by the Centers for Medicare and Medicaid Services (CMS) on January 24, 2014. The immediate sanctions mean that CalOptima can’t market or enroll new members into their OneCare Special Needs Plan until the sanctions are lifted. CMS cited “widespread and systemic failures impacting CalOptima’s enrollees’ ability to access health care services and prescription medications” as a summary for issuing immediate sanctions.
OneCare serves most Orange County’s most vulnerable
The OneCare Medicare Advantage Special Needs Plan (SNP) (See: What is a Special Needs Plan?) is offered to Orange County residents through CalOptima which as a division Orange County Health Authority (OCHA). CalOptima, a county organized health system, also offers a Medi-Cal managed health plan and Medicare PACE plan, neither of which will be effected by the CMS sanctions.
Long list of failures for CalOptima
Some of the deficiencies CMS noted in their audit pertaining to the medical administration of OneCare. Download the entire CMS letter at the end of the post.
- Failure to process provider payment requests within the required timeframes.
- Failure to pay for emergency medical services.
- Failure to properly distinguish between on organizational determination, an appeal and a grievance.
- Failure to include the specific reason(s) for an adverse decision in denial letters to beneficiaries.
Deficiencies within the prescription drug portion of the OneCare plan included.
- Failure to notify beneficiaries (or prescribers) of their applicable appeal rights for coverage determinations and redetermination when denying them coverage.
- Failure to notify the beneficiary of its decision within 72 hours of receipt of the expedited redetermination request.
- Failure to establish an adequate process for tracking and maintaining records about the receipt and disposition of grievances.
- Failure to appropriately process grievances.
Specific problems related to OneCare’s focus on the special needs of its members, CMS noted.
- Failure to verify the beneficiary’s dual eligibility prior to enrollment in the D-SNP.
- Failure to administer the initial health assessment to beneficiaries within 90 days of their enrollment.
- Failure to provide documented evidence and maintain records of an individualized care plan for beneficiaries.
Serious threat to enrollees’ health and safety
CMS also included a whole list of failures relating to CalOptima’s compliance program. All of these failures led CMS to write –
CalOptima’s Deficiencies Create a Serious Threat to Enrollee Health and Safety
CalOptima has experienced widespread and systemic failures impacting CalOptima’s enrollees’ ability to access health care services and prescription medications. Enrollee access to services and prescribed medications is the most fundamental aspect of the Part C and Part D programs because it most directly affects clinical care. CalOptima is denying enrollees access to drugs and services at the point of sale and within their appeals and coverage/organization determinations process. The severity of CalOptima’s conduct is magnified by the fact that more than 99% of its enrollees are beneficiaries who receive the low income subsidy (LIS) and who are likely unable to afford to buy medication that is not covered by their insurance.
The nature of CalOptima’s noncompliance provides sufficient basis for CMS to find the presence of a serious threat to enrollees’ health and safety, supporting the immediate suspension of CalOptima’s enrollment and marketing activities. Consequently, these sanctions are effective on January 24, 2014 at 11:59 p.m. EST, pursuant to the authority provided by 42 C.F.R. § 422.756(c)(2) and 423.756(c)(2).
OneCare SNP to new to rate
The OneCare MA-PD SNP is so new that there wasn’t enough data to assign a traditional Medicare star rating to the plan. (See: Medicare Star Ratings) Although, with the current failures found in a CMS audit last fall, it doesn’t look like they’ll be getting any happy stars soon. CMS noted numerous deficiencies with the health and prescription portion of the OneCare MA-PD SNP. Because these deficiencies were potentially threatening the health of the members, CMS determined immediate sanctions were necessary to force CalOptima to address the management problems found in the audit.
Medicare pays like an alarm clock
The announced CMS sanctions prohibit CalOptima from marketing or enrolling any new members into the OneCare plan. Medicare Advantage plans in Orange County are paid a minimum of $855.26 per month for each enrolled member up to $7,539.28 for Medicare beneficiaries with End Stage Renal Disease and need dialysis treatment. (See: How much will Medicare pay Advantage Plan in 2013) The OneCare plan was tailored to Orange county residents who were both Medicare and Medi-Cal eligible.
OneCare SNP backfires on members
The Special Needs Plan, or D-SNP, provides additional health care coordination for chronically ill members. CalOptima and OneCare were selected to be part of the California Financial Alignment Demonstration.
On March 27, 2013, the Department of Health and Human Services announced that the State of California will partner with the Centers for Medicare & Medicaid Services (CMS) to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience, along with access to new services.
Under the demonstration, also called “Cal MediConnect,” California and CMS will contract with Medicare-Medicaid plans to coordinate the delivery of and be accountable for covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees. – California Financial Alignment Demonstration (Cal MediConnect)
From the noted failures and deficiencies of CalOptima, it looks like this MA-PD SNP was actually retarding the delivery and accountability of services to dual eligible Medicare beneficiaries. CalOptima will have a period of time to respond to the sanctions and also correct the deficiencies. The CMS marketing and enrollment sanctions usually last up to a year before they are removed.
CMS action will delay launch of CalOptima Cal MediConnect
CalOptima’s press release about the CMS sanctions
FOR IMMEDIATE RELEASE
ENROLLMENT AND MARKETING ACTIVITIES
SUSPENDED FOR CALOPTIMA ONECARE
CMS action will delay launch of CalOptima Cal MediConnect
ORANGE, Calif. (January 24, 2014) — CalOptima received notification from the Centers for Medicare & Medicaid Services (CMS) regarding the final outcome of the first comprehensive audit of OneCare, which was conducted in November 2013. The scope of the audit included CalOptima, our health networks and our pharmacy benefits manager.
Based on the audit, CMS has directed that CalOptima suspend marketing and enrollment into OneCare effective today. This action does not affect the services CalOptima provides to existing OneCare members, although it does delay the launch of our Cal MediConnect plan. CMS plans to return to conduct a follow-up audit within the next six months.
“While there is a significant amount of work ahead for CalOptima and our health network partners, rest assured that there is no higher priority than ensuring access and quality of care for our members,” said Michael Schrader, CalOptima Chief Executive Officer. “We look forward to working collaboratively with CMS and the state to address the concerns.”
OneCare is a Medicare Advantage Special Needs Plan, which currently serves about 16,000 Orange County residents eligible for Medicare and Medi-Cal. This CMS action does not impact enrollment into CalOptima’s Medi-Cal or PACE programs, which currently serve nearly 500,000 Orange County residents.
A county organized health system, CalOptima provides publicly funded health plan coverage for low-income families, seniors and people with disabilities in Orange County, Calif. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. One in seven Orange County residents is a CalOptima member through Medi-Cal, OneCare (a Medicare Advantage Special Needs Plan) or PACE (Program of All-Inclusive Care for the Elderly). The dedication of more than 600 staff to ensure members have quality care earned CalOptima’s Medi-Cal plan National Committee for Quality Assurance “commendable” accreditation. In total, CalOptima serves more than 473,000 members with a network of more than 6,300 primary care doctors and specialists, as well as 30 hospitals.