Senior Medicare Patrol (SMP) State Project Grants - Vermont

SMP MissionThe mission of the SMP program is to empower and assist Medicare beneficiaries to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education. To further this mission, all SMP program activities are organized around four strategic program objectives:Provide group education and one-on-one assistance to Medicare beneficiaries on a statewide basis, with a specific emphasis on those with greatest need.Recruit, train, and retain a diverse, sufficient, effective, and representative workforce equipped to provide high-quality education and one-on-one support.Monitor and assess SMP results through operational and quality measures.Position SMP to nimbly and effectively respond to changes in the programmatic landscape.Program HistoryThe Department of Health and Human Services Office of Inspector General (HHS-OIG) estimates that Medicare loses billions of dollars each year due to errors, fraud, and abuse. The 1997 Senate Report 104-368 noted that “senior citizens are our best front-line defense against these losses, but they often don’t have the information and experience needed” to recognize and accurately report cases of error, fraud, and abuse. These losses are due, to a considerable extent, to the many ways in which the funds are disbursed as well as to the sheer magnitude surrounding the dynamics of healthcare expenditures. Both factors increase the probability of errors while opening wider opportunities for fraud and abuse.To address this growing issue the Health Care Fraud and Abuse Control (HCFAC) Program was created to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse. Now in its 25 year of operation, the HCFAC Program continues to demonstrate its success in protecting beneficiaries by identifying and prosecuting the most egregious instances of healthcare fraud and preventing future fraud and abuse. As partner in these efforts ACL administers the Senior Medicare Patrol (SMP) program which funds a nationwide network of local community-based partners and team members to provide outreach and education to Medicare beneficiaries about how to prevent, detect, and report healthcare fraud. The SMP program plays an important role in the broader HCFAC Program by focusing on community outreach and Medicare beneficiary empowerment with the goal of stopping fraud before it occurs.SMP Program TodayACL funds 54 state SMP projects, including grantees in all 50 states, the District of Columbia, Puerto Rico, Guam, and the US Virgin Islands. The SMP projects use this funding to provide local outreach, education, and assistance to Medicare beneficiaries through a trained volunteer and in-kind workforce. SMP projects teach Medicare beneficiaries to take proactive steps to protect themselves and the Medicare program from potential fraud, errors, and abuse. SMP projects actively disseminate fraud prevention and identification information through the media, outreach campaigns, community events, and one-on-one beneficiary support. SMPs help individuals and their loved ones understand how to review their health care statements and bills for accuracy, as well as how to identify and avoid potential fraud schemes. If suspicious activity is identified or suspected, SMPs can help answer questions, resolve errors, or report suspicious activity for further investigation.One key role of the SMP projects is to assist beneficiaries by referring potential fraud complaints on to other investigate entities, as appropriate. This process can include facilitating referrals to the Department of Health and Human Services (HHS)-Office of Inspector General (HHS-OIG), the Centers for Medicare & Medicaid Services (CMS), Federal Bureau of Investigations (FBI), Federal Trade Commission (FTC), state Medicaid fraud control units (MFCUs), state attorneys general, and other organizations. Capturing SMP program activity data is also a key function of the projects, including tracking, analyzing, and reporting of beneficiary complaints, referrals, potential savings, and other outcomes.Annual OIG Report on SMP ProgramEach year, the HHS-OIG completes an annual performance report on the SMP projects. In 2021, the 54 SMP projects had a total of 5,346 active team members who conducted a total of 12,660 group outreach and education events, reaching an estimated 556,980 people. In addition, the projects had 239,625 individual interactions with, or on behalf of, Medicare beneficiaries.According to the annual OIG Report, the program has educated over 44 million beneficiaries since its inception through 491,000 group education and outreach sessions. The true value of the program and primary focus of SMP grantee work is on education, prevention, and teaching beneficiaries how to protect themselves and avoid fraud in the first place. The impact of these education and prevention activities is extremely difficult to quantify in dollars and cents. As HHS-OIG indicated in their 2022 report on the SMP program:We note that the projects may not be receiving full credit for recoveries, savings, and cost avoidance attributable to their work. It is not always possible to track referrals to Medicare contractors or law enforcement from beneficiaries who have learned to detect fraud, waste, and abuse from the projects. In addition, the projects are unable to track the potentially substantial savings derived from a sentinel effect whereby Medicare beneficiaries’ scrutiny of their bills reduces fraud and errors.The SMP program has been extremely effective in its mission to protect Medicare beneficiaries, their family members, and caregivers against fraud, errors, and abuse. However, not all beneficiaries obtain access to available SMP services. One of the populations identified as being most vulnerable to falling victim to fraud, errors, and abuse are those who are uninformed about available supports. To address this systemic inequity, the White House released an Executive Order on Diversity, Equity, Inclusion, and Accessibility in the Federal Workforce in June 2021. To further advance equity within the Federal Government, this order established that it was the policy of the Administration to cultivate a workforce that drew from the full diversity of the Nation. HHS and ACL took immediate steps to ensure that federal staff and grantees’ priorities included an intentional diversity, equity, and inclusion focus in order to strengthen their existing programmatic efforts. These aspects are reflected throughout this funding opportunity.Strategic Program ObjectivesThis opportunity will fund SMP work done in the state of Vermont only. Applicants must address each of the following strategic program objectives as part of their project narrative to further the goal of preventing Medicare fraud in Vermont:Provide group education and one-on-one assistance to Medicare beneficiaries on a statewide basis, with a specific emphasis on those with greatest need.Recruit, train, and retain a diverse, sufficient, effective, and representative workforce equipped to provide high-quality education and one-on-one support.Monitor and assess SMP results through operational and quality measures.Position SMP to nimbly and effectively respond to changes in the programmatic landscape.Project narratives should propose specific goals and activities to address each component of the four strategic program objectives as follows:Provide group education and one-on-one assistance to Medicare beneficiaries on a statewide basis, with a specific emphasis on Vermonters with greatest need. Applicants must describe a comprehensive plan to achieve statewide SMP coverage. Statewide coverage means the applicant must have the capacity to provide SMP services, including group education and one-on-one assistance, in each county within the state. In the project narrative, applicants must:Demonstrate knowledge of the geographic service area, including barriers to program access and strategies specifically designed to overcome these barriers.Identify populations with greatest historical and current need within the state, any barriers to program access specific to these populations, and plans for addressing those barriers.Explain plans to provide one-on-one assistance, both in-person and virtually. Applicants must describe the types and levels of service to be provided as well as the approaches to achieve or enhance services, such as the development of web sites and web-based strategies, the use of toll-free lines, ability to flexibly shift to atypical service provision as public need requires, and/or the development of sub-grants, contracts, or partnerships with other local, regional, or statewide organizations.Explain plans to provide in-person group education sessions to teach beneficiaries to prevent, detect, and report Medicare fraud, errors, and abuse. Applicants must describe the types and levels of service to be provided, as well as the approaches to achieve or enhance services, such as the development of sub-grants, contracts, or partnerships with other local, regional, or statewide organizations. Describe plans to build on existing partnerships and the development of new partnerships to establish a strong network to deliver SMP services. Examples of potential partners could include, but are not limited to:Other local or state programs receiving ACL funding to provide services to older adults and people with disabilities, including but not limited to: State Health Insurance Assistance Programs (SHIPs), Long-Term Care Ombudsman programs, Elder Abuse Prevention programs, Benefits Enrollment Centers, Centers for Independent Living (CILs), Aging and Disability Resource Centers/No-Wrong Door (ADRC/NWD), Assistive Technology programs, Traumatic Brain Injury Programs, State Councils on Developmental Disabilities, State Protection and Advocacy Systems, Nutrition Services, Chronic Disease Self-Management Programs, and Legal Assistance programs.Local, state, and national organizations within the law enforcement and health care networks which may include state attorneys general, state MFCUs, CMS, HHS-OIG, FBI, and FTC.Partnerships to intentionally focus on reaching those in greatest need of assistance such as:Organizations or groups who have demonstrated previous success in focusing on diversity, equity, inclusion, and/or accessibilityOrganizations or groups who have expertise focused around cultural competency and/or intentionally serving those in greatest need.Outline a statewide media and outreach plan based on a preliminary assessment of state and national health care fraud trends and issues, including focus on targeting those in greatest need of SMP program services and those traditionally underserved. Recruit, train, and retain a diverse, sufficient, effective, and representative workforce equipped to provide high quality education and one-on-one support. Applicants must provide a plan to ready a nimble workforce to provide high quality service to beneficiaries including, but not limited to, the following:Describe a plan to initially and continually train and certify all SMP team members (staff, in-kind, and volunteers) with the information necessary to perform the work of the SMP program:At the most basic level including:Basic mission and functions of the SMP program;Medicare basics; andHealth care fraud, errors, and abuse.At a more advanced workforce training level including:Development of effective skills in conducting educational presentations and outreach;Resolution of beneficiary inquiries and complaints;Referrals for further action, when appropriate; andUnderstanding and implementation of cultural competency and inclusion practices and activities to ensure equitable access to SMP program services.The training plan should also cite the training materials and resources to be used to achieve the training objectives. NOTE: The National SMP Resource Center develops and provides training materials that are available for use to all successful SMP awardees. Non-incumbent applicants may contact the SMPRC for access to basic training-related material information.Minimum initial and ongoing training requirements, knowledge testing, and certification of all SMP team member roles must be clearly defined by the grantee and consistently applied to all team membersDescribe a plan to recruit, retain, and manage paid, volunteer, and in-kind team members throughout the state. The plan should include implementation of ACL’s Volunteer Risk and Program Management (VRPM) policies and the ACL Conflict of Interest guidance for the SHIP, SMP, and MIPPA Programs. Identifying and appropriately managing risks related to team member involvement and service delivery is an important aspect of effective program management. Proposals should include approaches to ensure team members are:Appropriately recruited and screened to ensure ability to perform assigned duties and to identify potential conflicts of interest;Thoroughly trained to provide effective service, and enhance the quality of the SMP program;Consistently provided ongoing supervision, management, and support to ensure the safety, integrity, and professionalism of the SMP workforce;Habitually compliant with procedures and practices to ensure that confidentiality of program information is maintained; andSupported to ensure retention and continued high morale.In every case, applicants should propose activities that will effectively employ the unique skills, varied experiences, good will, and availability of team members in assisting beneficiaries to become more educated about Medicare fraud, errors, and abuse.ACL’s VRPM policy and procedure resources are available on ACL’s website: https://acl.gov/programs/senior-medicare-patrol/volunteer-risk-and-prog…. The VRPM policies provide a framework that allows each individual SMP project to have the flexibility and responsibility to develop volunteer risk and program management policies and procedures. NOTE: Any new (non-incumbent) SMP project grantees will receive a reasonable amount of time to implement these policies. Successful non-incumbent applicants will be asked to negotiate this timeline with ACL individually after awards are made.ACL’s Conflict of Interest: Identification, Remedy, and Removal guidance found here: https://acl.gov/programs/senior-medicare-patrol/managing-conflicts-inte…. This guidance was developed to provide technical assistance to the SMP, SHIP, and Medicare Improvements for Patients and Providers Act (MIPPA) programs and their community-based partners on how to avoid actual and perceived conflicts of interest and mitigate risk. ​​​​​​3. Monitor and assess SMP results through operational and quality measures. ACL requires SMP projects to use the SMP data system, known as the SMP Information and Reporting System (SIRS), to collect, track, assess, and measure program performance data. SIRS data is summarized annually in an HHS-OIG report titled Performance Data for the Senior Medicare Patrol Projects. Recent reports are available on ACL’s website: https://acl.gov/programs/protecting-rights-and-preventing-abuse/senior-… must describe plans to comply with SMP reporting requirements including:1. Timely data entry of SMP activities into SIRS, including one-on-one interactions with beneficiaries, group education and outreach events, media education and outreach events, SMP team members, and SMP team member activities.2. Participation in quality assurance activities:Successful applicants must participate in an SMP Customer Satisfaction Survey which requires evaluation of both one-on-one interactions and group education events. To satisfy this requirement SMPs will be asked to:Ensure proper collection and reporting of beneficiary information so ACL may conduct post-service satisfaction surveys of a random sample of SMP clients.Periodically administer pre- and post- surveys at group education events, as requested by ACL. Each SMP project will be surveyed twice annually.Describe any additional quality assessment activities proposed outside the required surveys described above.Ongoing performance management, including regular assessment of progress toward goals and objectives, growth areas and obstacles, and strategies for performance improvement on the SMP performance measures listed below, as well as any other applicant-identified measures of success. Applicants are expected to provide a plan to continually assess gaps in program reach in order to strengthen provided servicesPerformance Measure (PM)Definition1. TOTAL NUMBER OF ACTIVE SMP TEAM MEMBERSTotal number of individuals who spent time on the SMP program, including SMP-paid, in-kind paid, and volunteer team members2. TOTAL NUMBER OF SMP TEAM MEMBER HOURSTotal number of hours contributed by team members while performing SMP work and receiving training to perform SMP work, including time spent by SMP-paid, in-kind paid, and volunteer team members3. NUMBER OF GROUP OUTREACH AND EDUCATION EVENTSTotal number of community outreach events, education activities, and presentations to educate beneficiaries, family members, caregivers, and others about SMP services and detecting health care fraud, errors, and abuse4. ESTIMATED NUMBER OF PEOPLE REACHED THROUGH GROUP OUTREACH AND EDUCATION EVENTSTotal estimated number of people reached as a result of SMP group outreach and education activities5. NUMBER OF INDIVIDUAL INTERACTIONS WITH, OR ON BEHALF OF, A MEDICARE BENEFICIARYTotal number of individual interactions between SMP team members and beneficiaries, family members, caregivers, or others for the purpose of discussing or gathering information about potential health care fraud, errors, or abuse6. COST AVOIDANCE ON BEHALF OF MEDICARE, MEDICAID, BENEFICIARIES, OR OTHERSHealth care expenditures for which the government, a beneficiary, or other entity was relieved of responsibility for payment7. EXPECTED MEDICARE RECOVERIESActual and expected Medicare recoveries from criminal actions, settlements, civil judgments, or overpayments that resulted from the referral. Includes recoveries associated with a project’s referral that resulted in the opening of an investigation or where the SMP made a meaningful contribution to an existing investigation8. ADDITIONAL EXPECTED MEDICARE RECOVERIESActual and expected Medicare recoveries from criminal actions, settlements, civil judgments, or overpayments that resulted from the referral. Includes recoveries associated with a project’s referral to an existing investigation where the SMP’s information validated existing information9. EXPECTED MEDICAID RECOVERIESActual and expected Medicaid recoveries from criminal actions, settlements, civil judgments, or overpayments that resulted from the referral. Includes recoveries associated with a project’s referral that resulted in the opening of an investigation or where the SMP made a meaningful contribution to an existing investigation10. ADDITIONAL EXPECTED MEDICAID RECOVERIESActual and expected Medicaid recoveries from criminal actions, settlements, civil judgments, or overpayments that resulted from the referral. Includes recoveries associated with a project’s referral to an existing investigation where the SMP’s information validated existing information11. ACTUAL SAVINGS TO BENEFICIARIESAmount of money recouped to beneficiaries12. OTHER SAVINGSAmount of money recouped to an entity other than Medicare, Medicaid, or a beneficiary4. Position SMP to nimbly and effectively respond to changes in the programmatic landscape. Applicants must propose a plan to adapt to changes in the programmatic landscape, such as the increasing Medicare beneficiary population, changes in the geographic distribution of beneficiaries, changes in public health need, varied beneficiary needs by age, and traditionally underserved populations that may need additional assistance understanding how to prevent, detect, and report Medicare fraud, errors, and abuse. Specifically, applicants must:Identify any anticipated changes in the programmatic landscape and explain how these changes will be addressed by the SMP project;Address readiness to nimbly and effectively shift as unanticipated changes in the programmatic landscape are identified;Describe the target populations to be served, including;identifying the target populations and the reasons why the applicant has chosen to target the specific populations;addressing barriers in access or provision of program services to the target populations; anddetailing proposed innovative and collaborative methods to reach the target populations.​​​​​​