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.
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.
