Life After 50 Expo

Doc Fix Passes House !

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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

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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

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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 !

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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 !

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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.

Dear Marci,

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Dear Marci,

When I last visited my doctor, she said that we should schedule my Annual Wellness Visit soon to discuss my health. I have never had an Annual Wellness Visit before, and I am not sure what this visit is about. Is it just a regular physical exam? What happens during an Annual Wellness Visit?

–  Jackie (Lexington, KY)

Dear Jackie,

The Annual Wellness Visit is an annual appointment with your primary care doctor to develop your plan of preventive care for the upcoming year. This visit is not a head-to-toe physical; rather, it is an opportunity to discuss your current health with your doctor and create a plan for promoting your health and wellness. The Annual Wellness Visit is similar to your Welcome to Medicare visit, the one-time appointment with your doctor that takes place within the first twelve months after you enroll into Medicare. Know that you cannot have your Annual Wellness Visit within the same year that you have your Welcome to Medicare exam.

Since this will be your first Annual Wellness Visit, you and your doctor will create a prevention plan based on your needs. You will likely discuss your medical and family history, complete a health-risk assessment that considers your health status, injury risks, and any health needs, and compile a list of all of your current medical providers and medications. You can start to consider these things in advance of your appointment to prepare for the visit.

Depending on your health care needs and history, you and your doctor might do any of the following tasks during your Annual Wellness Visit:

  • Create a checklist or screening schedule for various preventive health care screenings. Medicare covers many preventive care services, and this checklist will depend on your health status and what services you are eligible to receive;
  • Identify risk factors and current medical and mental health conditions along with related current or recommended treatments;
  • Check your height, weight, blood pressure, and body mass index;
  • Screen for cognitive impairment, including diseases such as Alzheimer’s or other forms of dementia;
  • Review risk factors for depression;
  • Review your functional ability and level of safety, including screening for hearing impairments and for your risk of falling; or
  • Give health advice and referrals to education or preventive counseling services or programs aimed at reducing identified risk factors and promoting wellness, such as weight loss, physical activity, smoking cessation, fall prevention, and nutrition.

You will not have a full physical as part of your Annual Wellness visit. Rather, the visit is used to assess your overall state of health and put a plan in place to maintain and promote your well-being.

Original Medicare covers the Annual Wellness Visit with no coinsurance or deductible as long as you see doctors or other health care providers who accept Medicare assignment. Medicare Advantage plans cover all preventive services the same as Original Medicare, so your plan is not allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that Original Medicare does not charge for as long as you see in-network providers. If you see providers that are not in your plan’s network, charges will typically apply.

It’s very important to keep in mind that, while the Annual Wellness visit itself is free, out of pocket costs can apply for additional care you receive during or following the visit. If your primary care provider explores or treats a new or existing health issue or runs test separate from those listed above during the Annual Wellness Visit, you may be charged. Services not included in the Annual Wellness Visit are billed separately and are subject to the usual copays and deductibles.

-Marci