AAA Medicare Improvements for Patients & Providers Act

The Medicare Improvements for Patients and Providers Act (MIPPA) [PDF] expands, extends and enhances outreach efforts to beneficiaries on Medicare Part D and for those with limited income. The State Health Insurance Program (SHIP), the Area Agencies on Aging (AAA) and the Aging and Disability Resource Centers (ADRC) are coordinating efforts to provide outreach to Texas beneficiaries with limited incomes statewide, and for general Part D outreach and assistance to beneficiaries in rural areas.

In 2009, Texas was awarded the first MIPPA grant, funded by the Centers of Medicare and Medicaid (CMS) and the Administration on Aging (now called the Administration for Community Living), totaling more than $1.2 million with a goal of submitting 3,000 new Low Income Subsidy or Medicare Savings Program applications. DADS provided funds to 6 ADRCs.

In 2010, a second MIPPA grant was awarded totaling more than $2.7 million. The agency plans to reach 1.5 million beneficiaries and submit 5,000 new Low Income Subsidy or Medicare Savings Program applications. All 28 AAAs and 9 ADRCS received funding.

MIPPA Questions & Answers

What documentation do we need to have in our client files relating to our enrollment goal?

To meet the MIPPA application goal, a AAA must assist a person with completing an application for Low Income Subsidy (LIS) or Medicare Savings Programs (MSP). The application does not have to result in an enrollment.

AAAs and ADRCs will, as a part of their standard processes, document contacts as Legal Assistance or Legal Awareness in State Unit on Aging Programs Uniform Reporting System/State Health Insurance Program National Performance Report (SPURS/SHIPnpr). In addition, AAAs and ADRCs will submit a MIPPA Quarterly Report in accordance with grant guidelines. The quarterly report will identify applications and "touches" to beneficiaries through outreach efforts.

AAAs and ADRCs are expected to submit applications and perform outreach activities or touches; both areas are included in the DADS MIPPA Quarterly Report to the Centers for Medicare and Medicaid Services (CMS). In addition, the state established performance measures for the AAAs and ADRCs. The AAAs performance measure is based on the number of applications they submit and the ADRCs measure is based on the number of touches. AAAs and ADRCs have funding obligations linked to a specific date.

On some of the referrals, some individuals come into the office and complete the application online — those will be easily documented. However, sometimes we send the person an LIS application and he or she takes it from there. We can follow up but the documentation would only be a notation in the persons file.

AAA staff consulted with the National Council of Aging (NCoA) regarding the documentation necessary to support counting an application, when the application is sent home with an individual to be completed.

The primary goal of MIPPA is to encourage person-centered assistance. For MIPPA, benefits counselors should not count any application where they did not have direct involvement in completing and submitting the application. The guiding principle should always be the certainty that an application was or will be submitted.

In a previous response, Health and Human Services (HHS) indicated a AAA could follow-up with the individual to confirm the application was submitted and simply notate in the file. As a result of our most recent conversation with NCoA, this documentation will not be allowed because it does not meet the test of "certainty" of a submission.

Files that support counting an application must contain a copy of any submission confirmation provided to the individual, such as a copy of the "application was received" letter, copy of the submission confirmation email sent to the individual or a print screen of the submission.

If the above described documentation can not be obtained, the activity would be counted as a "touch" for the MIPPA Quarterly Report to DADS. For the SHIP/NPR Report, on the ICC enter it as a contact. The time spent could also be included in your Administration for Community Living (ACL) reporting if the client was older than 60.

How will the number of enrollments be reported to you?

CMS tracks the LIS/MSP enrollments/applications. The number of applications submitted will be reported to DADS by CMS, which comes from the data entered into SHIPnpr. When entering the data into SHIPnpr for LIS only, enter the information in the MIPPA 1 area of the ICC form. For MSP only enter the information in the MIPPA 2 area of the ICC form. For both LIS/MSP enter data into MIPPA 3. In addition, be sure to check the applicable category for application assistance.

The MIPPA Quarterly Report submitted by the state will include space for the AAA/ADRC to enter the number of LIS/MSP applications they have assisted with.

Will we be able to count the applications that were completed but, for whatever reason, were not approved?

Yes. NCoA does not require confirmation that an individual has successfully enrolled in the LIS or MSP. The application must be submitted but does not have to result in an enrollment.

Or will the goal be verified through CMS enrollments, by HHS comparing enrollment numbers for the AAA before the grant started to enrollment when the grant ended.

No. HHS will track progress through the CMS quarterly report. This makes it vitally important everything is accurately reported through SHIPnpr. If the benefits counselors need technical assistance with reporting, contact Patsy Fernandez at patsy.fernandez@hhsc.state.tx.us or at 512-438-4205.

Could you clarify the period for the Application/Enrollment goal. Is it 1 year or 2?

The period for the goal is 2 years, the same as the grant. The date to achieve one-half of your goal is Oct. 10, 2011. One-quarter of your funding must also be obligated by Oct. 1, 2011.

What is the beginning date?

The beginning date is the start date of the grant — Sept. 30, 2010. The ending date is Sept. 29, 2012.

Do LIS enrollments completed this fall count toward our goal?

Yes. NCoA has informed HHS that beginning Oct. 1, 2010, all applications will be credited to the MIPPA #2 Grant.

Are AAAs automatically given credit for MIPPA applications completed by other organizations or an individual?

No. Per NCoA, applications submitted by the Social Security Administration (SSA) and the Texas Medicaid office cannot be counted toward the local MIPPA partners' (AAAs and ADRCs) numbers, even if the applications were submitted as a result of a referral made by the AAA or ADRC. Unless one of two conditions apply:

The AAA or ADRC makes referrals to SSA with the agreement the SSA office will assist with the application completion.
The AAA or ADRC outsources staff to the SSA or Medicaid office to assist referrals with the application completion.

The agreement must be that the application is counted only once.

For MIPPA, only applications completed by AAA or ADRC staff, under personalized assistance, are credited to the AAA or ADRC. The definition of personalized assistance is an application for which the AAA had some direct involvement in completing and submitting.

Applications handed out by a AAA, where the individual takes the application and at a later time completes and submits the application via the web or mail may not be counted as completed applications for MIPPA reporting. However, the number of applications distributed to potentially eligible individuals may be counted as touches for MIPPA reporting and is applied to the DADS performance goal of 1.5 million touches during the grant period.

Further guidance from NCoA.

The new SHIPnpr enables each AAA to count specific data, which is required by CMS.

LIS application — Mark direct client assistance when counting an application as being completed.
MSP applications — NCoA uses Form 1200-EZ from HHSC.

When a AAA assists an individual over the phone and then mails them an application, how can the AAA be sure the individual will return the application to the Social Security Office?

The only way to be sure the application was turned in to the Social Security office is to get documentation of the submission.

The primary goal of MIPPA is to encourage person-centered assistance. For MIPPA, benefits counselors should not count any application where they did not have direct involvement in completing and submitting the application. The guiding principle should always be the certainty that an application was or will be submitted.

As a result of our most recent conversation with NCoA, verbal follow-up with the individual to confirm the application was submitted is not sufficient to support "certainty" an application was or will be submitted.

If the above described documentation cannot be obtained, the activity would be counted as a touch for the MIPPA Quarterly Report to HHS. For the SHIP/NPR Report, on the ICC you enter it as a contact. The time spent could also be included in your ACL reporting if the client was over 60.

Does HHS have an agreement with the SSA to share Section B information?

HHS does not, at this time, have an agreement with SSA to share the information provided in Section B. The MIPPA grant does encourage the development of partnerships with all the state and local agencies involved with services and counseling for aging and disability populations. HHS encourages AAAs to develop a relationship with the local SSA office and possibly enter into an agreement with the local SSA office to share this information with the AAA. HHS will continue to work with our SSA contacts at the state level, ACL, NCoA and CMS to encourage information sharing and combined outreach and enrollment efforts.

Can I use an estimated audience for touches when using TV ads, radio or print media, such as newspaper and magazines? How do I estimate the size of an audience?

For MIPPA Quarterly reporting ONLY — Yes, you can use an estimated audience for the number of beneficiaries touched using this outreach method. If the TV, radio or print media cannot provide a breakdown of their audience demographics, such as the number of viewers, readers or listeners who are over age 65, then NCoA advises the number of Part D eligibles or number of LIS eligibles who are not enrolled be used as the basis of your estimate.

HHS is allowing the use of the weighted LIS eligibles percentage (for AAAs) or weighted Medicare eligibles (for ADRCs) percentage used in the grant funding formula to determine the estimated audience for mass media outreach. An email will be sent to each AAA and ADRC providing that percentage.

Example: If the estimated audience for a radio program designed for seniors contains an advertisement for the LIS or Extra Help is 50,000 listeners, and your LIS eligibles weighted percentage is 2.5 percent, the total estimated audience that can be reported for that airing on the MIPPA Quarterly Report is 1,250 listeners or touches. If the program is aired twice a week, the total would be 2,500 listeners or touches.

Remember, this is only for the MIPPA Quarterly Report. This does not apply to CMS reporting (SHIPnpr reporting).

For ACL and CMS reporting, each mass media event is considered a contact.

Seminar Q&A

Note: These are questions and comments from the April 2011 MIPPA seminar in Austin.

How much longer do we do double entry into State Health Insurance Program (SHIP) and Social Assistance Management System (SAMS) for individual client contacts (ICCs)?

Unfortunately, we do not have a concrete time for the end of the double entry of ICCs and PAMs. Two criteria must be met before we discontinue the double entry. The first is the patch for the MIPPA data field in the State Unit on Aging Programs Uniform Reporting System (SPURS). The second is a confirmation that data entered into SPURS matches with the State Health Insurance Program National Performance Report (SHIPnpr). Once this is confirmed, and DADS is confident that all data can be uploaded accurately, we can end the double entry process.

We understand this is extra work and tedious but it must be done to ensure the process and system are consistent. We appreciate your understanding and patience.

How do I get MIPPA credit from a call center call? There needs to be a template that will count a contact for either an information and referral (I&R) call or a call from an enrolled individual.

We suggest that the call center have a log to serve as source documentation of any calls reported. Each area agency on aging SAMS system administrator can set up a template. For assistance with creating the template, please send a request to the Help Desk.

I tried doing a batch of ICCs but my "dual eligibles — mental health" were all kicked out because they were less than 65 years old.

The system becomes confused when you enter an individual who is 65 or older and who has a disability. When an individual is 65 or older, you should not also select disabled. When a person is under 65, you select "disabled." So, you only enter "disabled" if the person is under age 65.§

SAMS' ICC does not handle Spanish speakers properly.

The benefits counselors would be the people completing the ICC form. This statement needs further clarification. Please submit additional details to the Help Desk.

My ICC batch (from SAMS to NPR) has many "anonymous" contacts. Can I get a list of every ICC to find and correct the offensive "anonymous?"

There are two key criteria here:

How did it get into the system? (Such as an anonymous call, an individual or a consumer group enter.)
The AAA needs to set up every benefits counselor as a provider; such as "AAA-(name of benefits counselor). This setup allows a list by provider to be generated.

Another item to consider is the display on the screen. When you open a batch error list, you need to take note of the following:

Open error report — this will list the errors in the export. You want to look at the last updated field.
Go back to the call log, consumer list or consumer group List, depending on where you put the entry.
Filter the list using the last updated date/time.

Answering these questions will help you generate the list.

Please contact Harmony Support should you need assistance with the steps to generate the listing.

Is the $240 allowance for Low Income Subsidy (LIS)/Extra Help?

Yes, this is standard LIS (Extra Help) income allowance.

Who made the rule that we can't count more than one contact per day? Why can't we change that rule and count all substantive contacts?

The counting of only one contact per person per day, regardless of the number times the AAA/aging and disability resource center (ADRC) had contact with the person, is a Centers for Medicare and Medicaid Services (CMS) parameter, not a DADS criteria. CMS does allow for the recording the total time spent with the person.

Why use 8888888 for all unknown information? Why not use 9s, which is the standard convention for missing data?

The use of the 888888 convention is per CMS specifications.

The Service Definitions explain that a certified benefits counselor is required for Legal Assistance but not Legal Awareness. So why can't an information and assistance agent do an ICC?

An information and assistance agent can complete an ICC form. However, they must select the name of one of their certified benefits counselors, which are listed in the drop-down box.

If 2 people take calls from the same person on the same day, and they need to document their calls, how come both can't use the same description title, e.g. telephone call?

The counting of only 1 contact per person per day, regardless of the number times the AAA/ADRC had contact with the person, is a CMS parameter. CMS does allow for the recording the total time spent with the person.

Can you please review the topics for Legal Assistance and Legal Awareness?

We have completed our check and have found that the topics are not switched. If we are not understanding your concern or you want to provide an example, please contact the Help Desk.

How do you enter or record time in SPURS/ICC form? Do we enter in minutes or military time?

Please refer to the PowerPoint presentation given at the MIPPA Training Seminar during the "Completing the ICC and SPURS Forms" session. The specific page number is 55.

In SAMS/SPURS when you have a person that you previously entered as a Legal Assistance are they entered as Legal Assistance if they call back another time?

The service delivery entered for the person will depend on the issue and the type of service provided. For example: A person who asks for Legal Assistance may potentially have a need for care coordination service at a later date.

In reality, you would be spending double the time with individuals if you are working directly in SAMS due to slowness of the system — sometimes up to 30 seconds between screens. We need faster system to do all recording required.

The migration to the next generation of SAMS will occur sometime later this calendar year. This generation does not rely on the Citrix client, which is believed to be the cause of the slow speed. AAAs can expect improvement in the overall performance, including screen refresh speed.

What is the difference in "call" and ICC in SAMS/SPURS?

Please be more specific in your question. Forward your revised question to the Help Desk.

I thought I heard Patsy say dual eligibles could not be counted in/as MIPPA. What if they call with questions or issues related to MIPPA?

If a person is already enrolled in an MSP, they are considered dual eligible; therefore, since it is not a new application, it is not counted in MIPPA. If, for example, a person comes to you for recertification, then this would be a new application and you can count it in MIPPA

The handouts you provided were hard to read. Your slides with lots of information should be printed two slides per page. I could not follow with such small print.

Thank you for your input.

Please go over the Excel spreadsheet with that includes the MIPPA draft scenarios.

If you are referring to the Administration for Community Living (ACL)/Centers for Medicare and Medicaid Services Crosswalk, this spreadsheet will be covered at the July T4A meeting. (ACL formerly was the Administration on Aging.)

On the PowerPoint slides, MIPPA is MIPPA 48x and CMS is CMAx2.

Thank you for your input.

What is "one-one-pharmaceutical benefits counseling?"

This is for individuals who do not qualify for LIS but may qualify for a specific drug manufacturer's assistance program.

Are we allowed to use online certification from another state to certify benefits counselors?

No. Texas does not recognize benefit counselor certifications from another state; the benefits counselor training is specific to Texas law. We are considering the pros and cons of having a web-based benefits counselor training module.

When assisting a client with a Do Not Resuscitate Order, do you count is as ACL?

You would count it in ACL reporting. You can also count it in CMS reporting (Topics Discussed - Other) if the individual meets CMS requirements, such as a Medicare beneficiary.

On page 35 of the Benefits Counselor Job Aid, 391 people means 391 units not 2.75. Which is time for 2 events?

The intent in the Job Aid was to illustrate one way to capture the time for a Legal Awareness event for the PAM. However, we will revisit this to remove the confusion. Thank you for calling our attention to this matter.

With regard to pharmacy bags, HEB statewide could be contacted to agree to LIS/MSP participation as a whole.

Thank you for the suggestion.

What is a "touch" and how is it recorded?

A touch (or reach) is how many individuals you touched/reached with your outreach. Here are some examples of how to record it:

The AAA/ADRC had a booth at a health fair and took 250 flyers with them. At the end of the day, they had 50 flyers left. The AAA/ADRC touched/reached 200 people.
The AAA/ADRC sent letters to the people whose names were on the interest lists DADS sent them. This is considered a mass mailing. A total of 500 letters were sent out. That is 500 touches/reaches.
The AAA/ADRC goes to a senior center to present information about Medicare and included information about LIS and MSP. There were 15 people present at the presentation. The AAA/ADRC touched/reached 15 people.

Hope this helps. If not, please contact the Help Desk.

With regard to multiple providers, can you enter contacts per each provider on the same day?

We need more information to answer properly. Please forward further information to the Help Desk.

During first contact with an information and referral agent, who gets the credit?

It depends on the service and information that was provided. If the information was about Homemaker, the Care Coordination program would get credit. If it was about Extra Help (LIS), it would be Legal Awareness.

During first contact about CMS, who gets credit?

It would be Legal Awareness or Legal Assistance depending on the depth of information or assistance provided.

If someone contacts us more than once on the same day it counts as 1 contact. If a person contact us on two different days is it counted as two contacts?

Yes, in CMS — same day, same person, no matter the numbers times assisted on that day is one contact. Same person, two different days is two contacts.

We sent a letter to a client, but there was no case opened. Advising client unable to reach — will close case. (example page 87)

Example #1: If a case was not opened on the inquiry and a person-to-person contact, although attempted, was not made, the AAA sends a letter advising an attempt to reach the inquirer was made and includes the AAA contact information for the inquirer to contact the AAA. The AAA closes the inquiry. Since a case (completed intake) was not opened, there is no case to close.
Example #2: If a file (completed an intake) is opened on this inquirer (a client) and the AAA was not able to reach the client (person-to-person) so a letter is sent to the inquirer. The AAA sends the letter, puts a note in the narrative, and closes the file.—

Can we capture caregiver information on Service Delivery without opening a case?

You cannot provide service without completing an intake for the caregiver and care recipient, thus opening a case.

Do you count an application for Medicaid for a nursing facility as a MIPPA contact?

You would not count the application. The nursing home is a community-based facility; hence, they are responsible for their own Medicaid/Medicare paperwork.