Life After 50 Expo

Dear Marci,

By

Dear Marci,

I have some chronic health care conditions, and have to take several prescription drugs to manage them. I spend a lot of money on Medicare prescription drug copays each month, and I’m struggling to keep up with these costs. My friend told me that I should see if I can apply for the Extra Help program. What is the Extra Help program?

–  Barbara (San Francisco, CA)

Dear Barbara,

Extra Help is a federal program that helps people with limited incomes to pay the costs associated with Medicare prescription drug coverage (Medicare Part D). Extra Help is administered by the Social Security Administration. To qualify, you must meet income and asset guidelines that are determined by the federal government each year. If you are single in 2015, your monthly income must be below $1,471 ($1,991 for couples), and your assets must be up to $13,640 ($27,250 for couples) in order to qualify for Extra Help.

In order to have Extra Help, you must get your prescription drug coverage through Medicare Part D. You can get this coverage through a stand-alone Part D plan that works with Original Medicare, or through aMedicare Advantage plan that includes prescription drug coverage. Extra Help does not work with other forms of prescription drug coverage, such as coverage from an employer. If you do not have a Part D plan, Extra Help gives you a Special Enrollment Period to enroll in a Part D plan outside of typical enrollment periods.

Depending on your income and assets, you may qualify for either full or partial Extra Help. With either program, you will never have to pay the full cost of your drugs as long as you take medications that are on your plan’sformulary—its list of covered drugs—and you buy them at a pharmacy in your plan’s network. You also can use a mail-order pharmacy with Extra Help. Extra Help can also assist with your monthly Part D premium and annualdeductibles.

Apply for Extra Help through the Social Security Administration. You can call the National Hotline at 800-772-1213, or visit your local Social Security office. You also can apply online athttp://www.ssa.gov/medicare/prescriptionhelp/.

Know that some people may get Extra Help automatically; people who have a Medicare Savings Program, receive Supplemental Security Income (SSI), or have Medicaid all receive Extra Help.

If you do not qualify for Extra Help, your state may have a State Pharmaceutical Assistance Program (SPAP) that can assist with prescription drug costs. Eligibility requirements and program benefits may vary, depending on the program. Contact your local State Health Insurance Assistance Program (SHIP) to see if there is one available in your state. To find your SHIP, visitwww.shiptacenter.org or call 877-839-2675.

Doc Fix Passes House !

By

House of Representatives Votes to Fix Medicare Payments for Doctors

Today the House passed a bill, the Medicare Access and CHIP Reauthorization Act of 2015 (H.R.2), to repeal the formula for physician payment under Medicare and extend the Children’s Health Insurance Program (CHIP) for two years. Congress has acted 17 times to temporarily prevent the formula, called the Sustainable Growth Rate (SGR), from going into effect. H.R.2 would replace the SGR with alternative, value-driven payment strategies. The bill also permanently funds the Qualified Individual (QI) program that helps low-income Medicare beneficiaries afford Part B premiums.

Medicare Rights supports this bipartisan effort to repeal and replace the SGR. Yet, Medicare Rights and other beneficiary advocates are concerned that the current replacement proposal asks beneficiaries to shoulder too much of the cost of this legislation—$30 billion in higher costs would be shifted to some beneficiaries. Reflecting that concern, Medicare Rights wrote a letter to House Speaker John Boehner and Democratic Leader Nancy Pelosi, expressing the need for additional improvements for low-income beneficiaries as the Senate takes up the legislation.

Click here to read Medicare Rights’ letter to House leadership on H.R. 2.

Click here to read Medicare Rights’ statement about H.R. 2.

Click here to read the text of the House bill H.R. 2.

Medicare Rights Asks CMS to Improve the Part D Appeals Process

Every year, Medicare Rights helps thousands of individuals navigate the complicated Medicare Part D appeals process, which allows beneficiaries to challenge a prescription drug plan’s coverage decision. Because the process is the equivalent of a nonsensical maze, it leaves beneficiaries confused, frustrated, and unable to adhere to prescribed treatment plans.

The most recent audit conducted by the Center for Medicare and Medicaid Services (CMS) of Part D and Medicare Advantage (MA) plan sponsors showed that:

  • 89% issued denial letters to beneficiaries that either failed to include an adequate rationale or contained incorrect information
  • 78% failed to demonstrate sufficient outreach to obtain additional information necessary to make an appropriate clinical decision
  • 56% made inappropriate denials when processing coverage determinations
  • 61% were shown to apply unapproved quantity limits
  • 50% were shown to apply unapproved utilization management practices

The Medicare Rights Center is asking CMS to immediately implement reforms to help people with Medicare better navigate Part D denials and appeals.

Click here to join Medicare Rights and take action today.

Volume 6, Issue 11

Medicare Interactive logo

Medicare Reminder

The coverage gap, also known as the doughnut hole, is a period of time during your Part D prescription drug coverage when the amount you pay for your drugs suddenly increases. The coverage gap starts when your total drug costs—including what you and your plan have paid for drugs—reaches $2,960 in 2015.

As a result of the Affordable Care Act, you get discounts to help you pay for your drugs during the coverage gap. In 2015, there is a 55 percent discount on brand-name drugs and a 35 percent discount on generic drugs while you are in the coverage gap. These discounts will gradually increase each year until 2020, when you will typically pay no more than 25 percent of the cost of your drug.

In 2015, once you have paid $4,700 out-of-pocket, you reach catastrophic coverage. During catastrophic coverage, your costs will be significantly less.

Learn more about the coverage gap on Medicare Interactive.

Learn more about catastrophic coverage on Medicare Interactive.

 

Spotlight

Five years ago this week, the Affordable Care Act (ACA) was passed into law, bringing real benefits to the tens of millions of Americans who have Medicare. Older adults and people with disabilities are now receiving low-to-no cost preventive services as well as more affordable prescription drugs in the coverage gap.

In a statement, Medicare Rights Center President Joe Baker said, “The ACA tackles the systemic causes of rising costs in the Medicare program, and so far the results continue to be promising. Most importantly, the ACA demonstrates that the federal government can contain costs without shifting even higher health care costs to beneficiaries, all while improving Medicare benefits. Continued implementation of the ACA is essential to preserving and strengthening Medicare for today’s and future beneficiaries.”

Click here to read the statement.

 

Dear Marci

By

Dear Marci,

I recently went to see my doctor to receive some preventive care screenings, and wanted to get an EKG test. My doctor said that Medicare might not cover this test, and gave me something to sign called an Advance Beneficiary Notice. I’m unsure whether I should sign this notice. What is the purpose of an Advance Beneficiary Notice?

– Charles (Phoenix, AZ)

Dear Charles,

An Advance Beneficiary Notice (ABN) is a notice you should receive when a provider or supplier offers you a service or item that Medicare normally covers but may not cover for you. Know that ABNs only apply to people with Original Medicare; people with Medicare Advantage plans will not receive an ABN.

The ABN must list the reason that your doctor thinks Medicare will not cover the EKG. The notice serves as a warning that Medicare might not pay for your care; it is not an official determination from Medicare about whether or not care is covered. It may still be possible to get Medicare to cover your care if you agree to pay for it if Medicare formally denies payment.

If you receive an ABN but decide to move forward with the item or service, you must select Option 1 on the ABN form. Option 1 says you agree to pay for care in the event Medicare denies coverage. It also requires your provider to submit the bill to Medicare after providing you care. If you do not select Option 1, you will have no chance of Medicare coverage because your provider will not be required to submit the bill to Medicare.

You will know if the service is covered by checking the claim on your Medicare Summary Notice (MSN). An MSN is a summary of the health care services you have received over the past three months, and it describes whether Medicare has covered these services. If the claim is denied, you can appeal by following the directions on the MSN. If the claim is approved, the MSN will say how much you owe. If you paid the provider more than that, the provider must refund you the excess amount.

Keep in mind, by agreeing to get care and signing Option 1 on ABN, you must be willing to pay upfront for care at the time you get it and you risk being responsible for all charges if Medicare denies payment. In some cases, this can amount to a significant bill. If you receive an ABN, be sure to discuss your options for care with your provider.

– Marci

“Doc Fix” for Medicare up for renewal !

By

 

The Kaiser Family Foundation (KFF) recently released a report examining the likely cost to people with Medicare of permanently replacing the Sustainable Growth Rate (SGR) formula, otherwise known as the “doc fix.” Enacted in 1997, the SGR places a cap on Medicare payments to health care providers. Since then, Congress has been forced to enact 17 temporary legislative patches to avoid drastic cuts in physician payments. Once again, due to the SGR, Medicare providers are facing a significant pay cut—21 percent unless Congress acts before the April 1st deadline.

Temporary actions by Congress have only delayed SGR. Last year, members of Congress reached consensus on a bipartisan, long-term alternative for setting Medicare provider payments through a value-based system. Yet, lawmakers have yet to come to an agreement on how to pay for this change.

According to the KFF report, beneficiaries wouldautomatically contribute to the cost of repealing and replacing the SGR, through higher Part B premiums and cost sharing. KFF estimates that Medicare beneficiaries would pay $58 billion in higher Part B premiums over ten years if last year’s bipartisan package to permanently fix the SGR were adopted. Despite this automatic increase, some lawmakers continue to support proposals to additionally increase Medicare beneficiaries’ premiums, deductibles and cost sharing as a way to pay for a permanent SGR fix.

Yet, most people with Medicare simply cannot afford to pay more for health care. Half of all people with Medicare—more than 25 million seniors and people with disabilities—live on annual incomes of $23,500 or less, and already contribute a sizable share of their income towards out-of-pocket health care costs. In fact, the average Medicare household spends nearly three times what the average non-Medicare household spends on health care expenses.

 

 

 

 

Medicare Reminder !

By

Medicare’s General Enrollment Period (GEP) is coming to an end on March 31. If you did not enroll in Medicare when you originally became eligible for it, you can sign up during the GEP, which is from January 1st through March 31st of every year. Your coverage will begin July 1st of the year you sign up. You will have to pay a Part B premium penalty for every year you delayed enrolling in Medicare Part B.