Life After 50 Expo

Dear Marci,

I recently applied to the Medicare Savings Program and was enrolled in the QMB program. Can you explain improper billing and how it will affect me now?

-Henrik (Billings, MT)



Dear Henrik,

Congratulations on successfully enrolling in the QMB program. I am so glad you applied and will receive help paying your Medicare costs.

In Medicare, the term improper billing refers to a provider inappropriately billing a beneficiary for Medicare cost-sharing. Cost-sharing can include deductibles, coinsurance, and copayments. Federal law prohibits Medicare providers from billing people enrolled in the Qualified Medicare Beneficiary (QMB) program for any Medicare cost-sharing. This means that if you have QMB, Medicare providers should not bill you for Medicare copays or deductibles for any Medicare-covered services. *

If you have QMB and are enrolled in Original Medicare, you should not be billed for Medicare cost-sharing when receiving a Medicare-covered service from either:

A participating provider (one who takes assignment)
A non-participating provider If you have QMB and are enrolled in a Medicare Advantage Plan, you should not be billed for Medicare cost-sharing when receiving a plan-covered service from in-network providers, as long as you meet your plan’s coverage rules, such as getting prior authorization to see certain specialists.
To protect yourself from improper billing, be aware that:

Original Medicare and Medicare Advantage providers who do not accept Medicaid must still comply with improper billing protections and cannot bill you for Medicare cost-sharing.

You keep your improper billing protections even when receiving care from Medicare providers in other states (Note: You can be billed if you are enrolled in a Medicare Advantage Plan and see an out-of-network provider, or if you have Original Medicare and see an opt-out provider).

You cannot choose to waive these protections and pay Medicare-cost sharing, and a provider cannot ask you to do this.



Remember that if you have QMB, the Medicare providers you see must accept Medicare payment and any QMB payment as the full payment for any Medicare-covered services you received. Providers who violate improper billing protections may be subject to penalties. If you are having issues with a provider who continually attempts to bill you, or if you have unpaid cost-sharing bills that have been sent to collection agencies, call 1-800-MEDICARE or contact your Medicare Advantage Plan.

*Note: Some states may impose Medicaid copays for certain Medicare-covered services. Medicare and Medicaid should pay the majority of the cost, leaving you a smaller copay. Contact your local Medicaid office to learn more about Medicaid copays in your state.

-Marci

Dear Marci,

It has been challenging to live on a fixed income recently. A friend told me she has the Medicare Savings Program and that it really helps her financially. What should I know about this program?

-Sabrina (Randleman, SC)



Dear Sabrina,

Medicare Savings Programs help pay your Medicare costs if you have limited income and savings. Medicare Savings Programs are also called MSPs, Medicare Buy-In programs, or Medicare Premium Payment Programs. There are three main programs, with different benefits and eligibility requirements. *

Qualifying Individual (QI) Program: Pays for Medicare Part B premium. Also reimburses for premiums paid up to three months before your MSP effective date, and within the same year of that effective date.

Specified Low-income Medicare Beneficiary (SLMB): Pays for Medicare Part B premium. Also reimburses for premiums paid up to three months before your MSP effective day, but unlike QI, you may be reimbursed for premiums from the previous calendar year.

Qualified Medicare Beneficiary (QMB): Pays for Medicare Parts A and B premiums. If you have QMB, typically you should not be billed for Medicare-covered services when seeing Medicare providers or providers in your Medicare Advantage Plan’s network. This means you should not owe Medicare deductibles, copayments, and coinsurances, as long as you see the right providers.

*There is a fourth MSP called the Qualified Disabled Working Individual (QDWI), which pays for the Medicare Part A premium for certain people who are eligible for Medicare due to disability. Contact your local Medicaid office to learn more.

There are even more benefits to enrolling in an MSP. MSP enrollment:

Allows you to enroll in Part B outside of the regular enrollment periods

Eliminates your Part B late enrollment penalty if you have one

Automatically enrolls you in Extra Help, the federal program that helps pay your Medicare prescription drug (Part D) plan costs

To qualify for an MSP, you must have Medicare Part A and meet income and asset guidelines.

If you do not have Part A but meet QMB eligibility guidelines, your state may have a process to allow you to enroll in Part A and QMB outside of the General Enrollment Period.

It also may be helpful to note that income and asset guidelines vary by state. Certain income and assets may not count and some states do not count assets at all when assessing MSP eligibility. You can contact your State Health Insurance Assistance Program (SHIP) to learn more about MSPs in your state and to receive assistance with the application process.

This really is a great program that helps so many beneficiaries with their Medicare costs! Again, contact your local SHIP to see if you’re eligible for an MSP in your state. Best of luck!

-Marci

Dear Marci,

My mother recently received a misdiagnosis, resulting in unnecessary and painful treatment. We are so upset about her situation but are not sure what to do about it. Is there anything Medicare beneficiaries can do when they receive poor quality of care?

-Vincent (Abbeville, SC)


Dear Vincent,

I am so sorry to hear about your mother’s situation. If you have a concern about the quality of care she received from a Medicare provider, your concern can be directed to the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for your area. The BFCC-QIOs are made up of practicing doctors and other health care experts. Their role is to monitor and improve the care given to Medicare enrollees. BFCC-QIOs review complaints about the quality of care provided by physicians, hospitals, skilled nursing facilities, home health agencies, and ambulatory surgery centers. 
 
Examples of situations about which you might wish to file a quality-of-care complaint include: 

A medication mistake 
Developing an infection during a stay in a facility
Receiving the wrong care or treatment 
Running into barriers to receiving care 
 
You can file a quality-of-care complaint by calling your QIO or submitting a written complaint. When the BFCC-QIO gets your complaint:
They should call you to ask clarifying questions about your complaint and to get the contact information for your provider.
A physician of matching specialty will review the medical record to determine whether the care provided met the medical standard of care, or whether the standard of care was not met.
You and your doctor will be notified by phone and in writing when the review is over (the review process can take up to a few months).
 
Livanta and KEPRO are currently the two BFCC-QIOs that serve the entire country. To find out which BFCC-QIO serves your state or territory and how to contact them, visit www.qioprogram.org/locate-your-bfcc-qio or call 1-800-MEDICARE. 
 
If you have a Medicare Advantage Plan, you can choose to make complaints about the quality of care you receive through your plan’s grievance process, through the BFCC-QIO, or both.

Your state may have other ways for you to file a complaint about a provider or facility You may be able to file a complaint through the consumer or patient protection sections within your state’s office of the Attorney General. You can also consider filing a complaint through the state licensing boards that oversee providers, for example, the Board of Medicine or the Nursing Board.

I hope your mother is doing better and that this information is helpful to you all.

-Marci

Dear Marci,

I received a favorable decision on an appeal to my Medicare Advantage Plan to cover the cost of a doctor’s office visit. I had already paid for the cost of the visit out of pocket, and my plan notified me that I would receive a reimbursement. It has been months and I have still not received one. What should I do?

-Shruthi (Los Angeles, CA)


Dear Shruthi,

If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is a formal complaint that you file with your plan. It is not an appeal, which is a request for your plan to cover a service or item it has denied. Times when you may wish to file a grievance include:

If your plan has poor customer service
You face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund)
You believe the plan’s network of providers is inadequate

To file a grievance:
Send a letter to your plan’s Grievance and Appeals department. Check your plan’s website or contact them by phone for the address.
You can also file a grievance with your plan over the phone, but it is best to send your complaints in writing.
Be sure to send your grievance to your plan within 60 days of the event that led to the grievance.
You may also want to send a copy of the grievance to your regional Medicare office and to your representatives in Congress, if you feel they should know about the problem. Go to www.medicare.gov or call 1-800-MEDICARE to find out the address of your regional Medicare office.
Keep a copy of any correspondence for your records.

Your plan must investigate your grievance and get back to you within 30 days. If your request is urgent, your plan must get back to you within 24 hours. If you have not heard back from your plan within this time, you can check the status of your grievance by calling your plan or 1-800-MEDICARE.

Best of luck filing your grievance and getting your reimbursement!

-Marci

Dear Marci,

My sister just went to her doctor for an Annual Wellness Visit and recommended I do the same. I don’t think I’ve had this type of appointment before, though. What is it and what should I expect?

-Douglas (Westminster, CO)


Dear Douglas,

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit.

During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:

Check your height, weight, blood pressure, and other routine measurements
Give you a health risk assessment
Review your functional ability and level of safety
Learn about your medical and family history
Make a list of your current providers, durable medical equipment (DME) suppliers, and medications
Create a written 5-10 year screening schedule or check-list
Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia
Screen for depression
Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness

AWVs after your first visit may be different. At subsequent AWVs, your doctor should:
Check your weight and blood pressure
Update the health risk assessment you completed
Update your medical and family history
Update your list of current medical providers and suppliers
Update your written screening schedule
Screen for cognitive issues
Provide health advice and referrals to health education and/or preventive counseling services

Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s requirements for the service.

Contact your healthcare provider if you want to schedule your Annual Wellness Visit!

-Marci