Jan Neal Law Firm, LLC

Alabama Estate, Elder and Special Needs Law

Tag Archives: Medicare


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Beware Deceptive Marketing of Medicare Advantage Plans

Medicare Advantage Plans (MA) are a good fit for many people, while they may not be a good idea for others.  I have no problem with Medicare Advantage, but I do have a problem with the deceptive ways these plans are marketed. 

Earlier this year The Center for Medicare and Medicaid Services (CMS) revealed that from 2020 to 2021 the agency received double the complaints from Medicare eligible persons about private sector marketing of MA plans.  These complaints launched a Senate Finance Committee majority staff inquiry in August 2022.  The committee reviewed complaints from 14 states and found that Medicare eligible persons were being “inundated with aggressive marketing tactics as well as false and misleading information, such as:

Seniors shopping at their local grocery store are approached by insurance agents and asked to switch their Medicare coverage or MA plan.

Insurance agents selling new MA plans tell seniors that their doctors are covered by the new plans. Seniors who switch plans find out months later that their doctor is actually out-of-network, and they have to pay out-of-pocket to visit their doctor.

Seniors receive mailers that look like official business from a Federal agency, yet the mailer is a marketing prompt from an MA plan or its agent or broker.


An insurance agent calls seniors 20 times a day, attempting to convince them to switch their Medicare coverage.


Widespread television advertisements with celebrities claim that seniors are missing out on benefits, including higher Social Security payments, in order ot prompt seniors to call MA plan agent or broker hotlines.”

These deceptive Medicare Advantage marketing practices are especially pervasive during open enrollment (October 15 – December 7).  The committee recommends that CMS warn seniors and people living with disabilities of the following:


“Warning 1: USE CAUTION IF CALLING A TV HELPLINE . The Federal Medicare program does not advertise MA plans or benefits on television. These so-called helplines will connect you with an agent or broker. That agent or broker does not have to tell you about all of your options in the Medicare program and does not have to ensure that your plan will meet your needs.


Warning 2: IF YOU THINK YOU HAVE BEEN ENROLLED IN A NEW PLAN THAT DOESN’T WORK FOR YOU, CALL 1-800-MEDICARE FOR HELP. Seniors and people living with disabilities can also get no-cost counseling from the local State Health Insurance Assistance Program (SHIP) or Senior Medicare Patrol (SMP office). In some situations you may be eligible for a special enrollment period to switch back into your original plan During the first three months of the year you can also change your enrollment.


Warning 3: BE CAREFUL WHAT YOU CLICK. Third-Party Marketing Organizations are using sneaky tactics to get your information and then sell your information to agents or brokers who can call you. When in doubt, don’t provide your information on unfamiliar websites or to unfamiliar people. The Medicare Call Center (1-800-MEDICARE) and your local State Health Insurance Assistance Program (SHIP) office can help you understand your Medicare choices and enroll in a plan that will meet
your needs.”

There are multiple policy recommendations made in this report including reinstating requirements over marketing MA plans that were loosened during the Trump Administration. 

The full report, Deceptive Marketing Practices Flourish in Medicare Advantage, can give you good insight on how to protect yourself while shopping for the right Medicare coverage that meets your individual needs.


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Medigap Coverage

Medigap premiums for plans from insurance companies offering the same benefits vary widely, so it pays to be a smart shopper.

So why do you need a Medigap? You need this supplemental coverage to cover the Medicare gaps in coverage.  With all the deductibles, copayments and coverage exclusions, Medicare pays for only about half of the medical costs for Medicare eligible persons.  Much of the balance not covered by Medicare can be covered by purchasing a Medigap insurance policy.

As always with Medicare, timing is important.  A Medicare recipient cannot be denied a Medigap policy if he or she applies for one within six months of enrolling in Medicare Part B. Otherwise, claims relating to pre-existing conditions can be denied only during the first six months that the policy is in effect. However, federal law does not require that fee-for-service Medigap policies be offered to those who enroll in Medicare Part B because they are disabled, although some states require the insurance companies to offer at least one kind of Medigap policy to people with Medicare under 65.   Alabama is not one of those states.

Medigap policies do not fill all the gaps in Medicare coverage. The biggest gap they fail to bridge is for custodial care in a nursing facility or for skilled care in a nursing home beyond the first 100 days. For coverage of this type of care, you must either purchase long-term care insurance or qualify for Medicaid coverage.

Federal law requires that each insurance company offers the same benefits for each of the Medigap plans lettered A through M, but each company sets its own premium rates.  The 8 available Medigap policy packages are identified by the letters A, B, D, G, K, L, M, and N. Plans E, H, I, and J are no longer sold, but, if those who already had that plan when discontinued were allowed to keep that coverage. As of January 1, 2020, Medigap plans sold to people new to Medicare were not allowed to cover the Part B deductible. Because of this, Plans C and F were no longer available to people who are new to Medicare on or after January 1, 2020, but those who already had either of these two plans were able to keep their plans.   

A Medigap insurance company sets premiums in three ways:

  • Community-rated, where the premiums are the same, regardless of age
  • Issue or entry age-related, where premiums are cheaper if purchased at a younger age
  • Attained-age-related, where premiums are based on your age at the time of purchase

When choosing a Medigap plan, compare the different benefits each plan offers and the price for each company’s plan. Consider your current health status, what your health care needs might be in the years to come, as well as your future health care budget.

Premiums vary drastically from state to state.  For instance, The American Association for Medicare Supplement Insurance found that in 2022 the lowest costs for a female age 65 ranged from $99.24 per month in Dallas to $278.25 per month in New York City.

When shopping for a Medigap policy, get quotes from two or more insurance agents working for different insurance brokers. Every insurance broker may not represent all of the insurers offering a plan in the state or city where you live.

It will take time to shop around, but the money you save will be worth it.


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Beware Medicare Advantage

Medicare Advantage plans flood the market with advertising leading consumers to believe that they are missing out on the best coverage possible without an Advantage plan as opposed to Original Medicare.

True, Medicare Advantage plans often look attractive because they offer the same basic coverage as original Medicare at a seemingly lower cost, plus some additional benefits and services like vision and dental care that traditional Medicare doesn’t offer. One reason Medicare Advantage plans can offer such enhanced services is because the federal government gives them additional payments compared to Original Medicare.

But, according to the Department of Health and Human Services’ Office of Inspector General, there is a downside to signing up for Medicare Advantage. In an alarming number of instances, private Medicare Advantage plans are denying coverage for medical services that would be covered under original Medicare, according to a federal investigation.  These denials are likely preventing or delaying medically necessary care for tens of thousands of Medicare Advantage beneficiaries each year.

The investigation by the inspector general found that 13 percent of Medicare Advantage plan denials should have been covered under Medicare.  The findings were based on a review by doctors and coding experts of service denials by 15 of the largest Medicare Advantage plans during the first week of June 2019.   Extrapolating from their findings, investigators estimate that nearly 85,000 beneficiary requests for medical care — everything from MRIs to skilled nursing facility care — could have been wrongly denied in 2019.

In an even higher proportion of cases, plans are incorrectly refusing to pay claims. Nearly one-fifth of claims that Medicare Advantage plans initially declined to pay were for services that met Medicare coverage and plan billing rules.  This translates to an estimated 1.5 million refused payments for all of 2019, which delayed or prevented payments for services that providers had already delivered.

Hidden Barriers to Care

Some 26 million Medicare beneficiares were in Medicare Advantage plans as of 2021, more than double the figure a decade ago.  The Congressional Budget Office projects that by 2030 more than half of Medicare beneficiaries will be in a private Medicare plan. Unlike original Medicare, where the federal government is the insurer, Medicare Advantage plans are run by private insurance companies. The government pays the plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. The less money the plans spend on patient care, the more they and their investors make. In this way, plans have an incentive to keep costs down.

For many beneficiaries, Medicare Advantage plans’ most disagreeable cost-cutting strategy is “preauthorization” — the common requirement that doctors and other medical providers obtain the plan’s approval before a beneficiary can receive certain medical services. If the plan administrators disagree that a procedure is medically necessary, the plan may refuse to pay for it.

“[B]eneficiaries enrolled in Medicare Advantage may not be aware that there may be greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare,” the report states.

One example highlighted in the report tells of a Medicare Advantage plan that refused to approve a followup MRI to find out whether an adrenal lesion was malignant because the lesion was allegedly too small. In fact, Medicare’s rules do not restrict the use of followup MRIs based on the the size of a lesion. (The plan reversed its initial denial on appeal.)

Denial Appeals Can Work

The report identified two common causes of service denials. First, even though Medicare Advantage plans’ clinical criteria cannot be “more restrictive” than Medicare’s coverage rules, plans often used tighter clinical criteria, such as requiring an x-ray before approving more advanced imaging. Second, plans often claimed that the request for services lacked sufficient documentation, even though investigators who reviewed the denied claims found that the existing medical records were sufficient to support the request.

When a Medicare Advantage plan denies a preauthorization or payment request, the beneficiary can file an appeal with the plan.  The inspector general found that when a beneficiary or provider appealed or disputed the denial of a service that met Medicare’s coverage rules, plans sometimes reversed the denial.  And in certain cases, Medicare Advantage plans corrected their own errors.

The inspector general’s report offers several recommendations for the Centers for Medicare and Medicare Services, which oversees Medicare Advantage plans, including better auditing of plans.   

To read the inspector general’s report, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” click here.  


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Medicare Coverage for COVID-19 Vaccine

While Medicare would cover a coronavirus vaccine approved through normal channels, there was concern that because the Food and Drug Administration approves the vaccine through an emergency use authorization (EUA), Medicare might not cover it. Governmental action was needed to assure that Medicare beneficiaries could receive the vaccine without charge.

Fortunately, The Centers for Medicare and Medicaid Services released an interim final rule Oct. 28 saying that Medicare would cover vaccines that receive U.S. Food and Drug Administration authorization — including those available through emergency use authorization — at no cost to beneficiaries. This will remove any concern or barriers to Medicare beneficiaries receiving the COVID-19 vaccine.

CMS will pay about $28 to administer single-dose vaccines. For vaccines that require two or more doses, it will pay around $17 for the first dose or the first few doses and $28 for the final dose in the series. According to CMS, the cost to vaccinate the roughly 67 million seniors enrolled in Medicare will be about $2.6 billion.

 


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New Medicare Rule May Have Negative Impact on Home Health Care Services

Starting in January 2020, Medicare will reimburse home health agencies at a lower rate when they provide care for patients who have not been admitted to a hospital first. Does this sound familiar? It should because it is a continuation of the observation status problem faced by Medicare patients who are not formally admitted to hospitals for at least three nights. Those patients who only stay at the hospital on an observation status are not eligible for limited skilled care Medicare coverage in long-term care facilities following hospital discharge.

Now the problem extends to people trying to obtain home health care services paid by Medicare. The new rule will require reimbursement for home health care agencies at a significantly lower rate for patients who do no satisfy the hospitalization admission standard. CMS estimates that it will pay home health agencies approximately 19 percent more for a patient who hires the home health agency directly after leaving a hospital than a patient who was never in the hospital or was only an outpatient on observation status.  That estimate may be low. The Center for Medicare Advocacy estimates a 25 percent lower payment for patients who do not satisfy the hospital admission requirement.

This lower reimbursement rate means that home health agencies may be reluctant to provide care for patients who were under observation status or who haven’t been in a hospital at all. 

Hospitals are required to provide notice to patients if they are under observation for more than 24 hours. 

For more information about the new rule from the Center for Medicare Advocacy, click here. 


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Getting Part B Without Penalty After Moving From Marketplace to Medicare

Medicare is extending its offer of relief from penalties for certain Medicare beneficiaries who enrolled in Medicare Part A and had coverage through the individual marketplace. Beneficiaries who qualify will be able to enroll in Medicare Part B without paying a penalty for late enrollment if they enroll by September 30, 2018.

Individuals who do not enroll in Medicare Part B when they first become eligible face a stiff penalty, unless they are still working and their employer’s plan is considered “primary.” For each year that these individuals put off enrolling, their monthly premium increases by 10 percent — permanently. Some people with marketplace plans – that is, plans purchased by individuals or families, not through employers — did not enroll in Medicare Part B when they were first eligible. Purchasing a marketplace plan with financial assistance from the Affordable Care Act can be cheaper than enrolling in Medicare Part B. However, Medicare recipients are not eligible for marketplace financial assistance plans. And because marketplace plans are not considered equivalent coverage to Medicare Part B, signing up late for Part B will result in a late enrollment penalty.

To address this problem, the Centers for Medicare and Medicaid Services (CMS) is allowing individuals who enrolled in Medicare Part A and had coverage through a marketplace plan to enroll in Medicare Part B without a penalty. It is also allowing individuals who dropped marketplace coverage and are paying a late enrollment penalty for Medicare Part B to reduce their penalty. CMS is now expanding the offer of possible relief to people who should have signed up for Part B during a special enrollment period that ended Oct. 1, 2013, or later but instead used exchange plans. It is also extending the deadline to September 30, 2018 (the earlier deadline was September 30, 2017). To be eligible for the relief, the individual must: Have an initial Medicare enrollment period that began April 1, 2013 or later; or have been notified on October 1, 2013, or later that they were retroactively eligible for premium-free Medicare Part A; or have a Part B Special Enrollment Period that ended October 1, 2013, or later. This offer is available for only a short time. To be eligible for the relief, individuals must request it by September 30, 2018.

Gather any documentation you have to prove that you are enrolled in a marketplace plan. Individuals who are eligible should contact Social Security at 1-800-772-1213 or visit their local Social Security office and request to take advantage of the “equitable relief.”

 


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January 2018 Newsletter Available

Our January 2018 Newsletter, Bookmarks, has been published , and you can view it online at the link provided.  Several articles are included covering Medicare, Medicaid, nursing home resident dumping, and the new tax law.  Let us know if you want to be added to the email list.


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Medicare Improvement Standard

Have you or a loved one been denied Medicare-covered services because you’re “not improving”? Many health care providers are still not aware that Medicare is required to cover skilled nursing and home care even if a patient is not showing improvement. If you are denied coverage based on this outdated standard, you have the right to appeal.

For decades Medicare, skilled nursing facilities, and visiting nurse associations applied the so-called “improvement” standard to determine whether residents were entitled to Medicare coverage of the care. The standard, which is not in Medicare law, only permitted coverage if the skilled treatment was deemed to contribute to improving the patient’s condition, which can be difficult to achieve for many ill seniors.

Three years ago in the case of Jimmo v. Sebelius the Centers for Medicare & Medicaid Services (CMS) agreed to a settlement in which it acknowledged that there’s no legal basis to the “improvement” standard and that both inpatient skilled nursing care and outpatient home care and therapy may be covered under Medicare as long as the treatment helps the patient maintain her current status or simply delays or slows her decline. In other words, as long as the patient benefits from the skilled care, which can include nursing care or physical, occupational, or speech therapy, then the patient is entitled to Medicare coverage.

Medicare will cover up to 100 days of care in a skilled nursing facility following an inpatient hospital stay of at least three days and will cover home-based care indefinitely if the patient is homebound.

Unfortunately, despite the Jimmo settlement, the word hasn’t gotten out entirely to the hospitals, visiting nursing associations, skilled nursing facilities, and insurance intermediaries that actually apply the rules. As a result, the Jimmo plaintiffs and CMS have now agreed to a court-ordered corrective action plan, which includes the following statement:

“The Centers for Medicare & Medicaid Services (CMS) reminds the Medicare community of the Jimmo Settlement Agreement (January 2014), which clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met). Specifically, the JimmoSettlement required manual revisions to restate a “maintenance coverage standard” for both skilled nursing and therapy services under these benefits:

Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.

Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.

The Jimmo Settlement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve. The Settlement is consistent with the Medicare program’s regulations governing maintenance nursing and therapy in skilled nursing facilities, home health services, and outpatient therapy (physical, occupational, and speech) and nursing and therapy in inpatient rehabilitation hospitals for beneficiaries who need the level of care that such hospitals provide.”

While this doesn’t change the rights Medicare patients have always had, it should make it somewhat easier to enforce them. If you or a loved one gets denied coverage because the patient is not “improving,” then appeal.

To read the court order implementing the new corrective action plan click here.


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Quarterly Newsletter Available

shutterstock_63936919Our quarterly newsletter, Elder Law Bookmarks, was sent today.  Articles included in the newsletter are:

  • People with Disabilities Can Now Create Their Own Special Needs Trusts
  • Is it Better to Remarry or Just Live Together?
  • Repealing Obamacare Will Have Consequences for Medicare
  • For Better or Worse, States Are Turning to Managed Care for Medicaid Long-Term-Care
  • Make Reviewing Your Estate Plan One of Your New Year’s Resolutions

If you want to be added to the mail list, send an email to neal@janneallaw.com.

 


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Case Study: The Value of Medicare Open Enrollment Plan Comparisons

medical technology concepts illustration designThe importance of Medicare plan comparisons during Open Enrollment are published everywhere you look, but sometimes I think that those warnings go unheeded because folks just do not understand how drastically coverage by the same plan can change year to year.

I saw up close and personal how beneficial the SHIP program is and the importance of Open Enrollment this week.  A gentleman we will call Mr. A came to a State Health Insurance Assistance Program (SHIP) Open Enrollment event in the South Central Alabama Development Commission region.  He drove 20 miles to check out his coverage because he was unsure of whether he needed to keep or change his Medicare Part D prescription drug plan (PDP) for 2017.  He opted to do the safe thing and  check it out.  Thank goodness he did.

Mr. A’s prescription drug plan for 2016 had a zero premium and covered his 10 medications prescribed by his doctor.  That all worked out well, and during 2016 Mr. A’s total out of pocket expenses related to his prescription drug plan totaled $542.00.  This was a manageable arrangement for him.

When a comparison of plans was run Mr. A was shocked to learn that his 2016 prescription drug plan would have a premium of $26.80,  a deductible of $400.00, and his 10 medications had been reconfigured on the plan formulary resulting in 2 of his medications no longer being covered and 3 of his medications reclassified as Tier 3 medications, meaning that his copayments would be higher. In all, Mr. A would have had to pay $3276.00 in out of pocket expenses related to his prescription drug plan during 2017 if he made no changes in coverage.

The comparison provided Mr. A with several options, and he selected a plan that would result in $360.00 in total out of pocket expenses for 2017, saving him $2916.00 over what he would have had to pay if he had not had a comparison run.

While Medicare enrollees can run their own comparisons, they will need to use the online plan finder provided by Medicare.  Comparisons are performed free and counseling provided through the SHIP program funded through the Alabama Aging and Disability Resource Centers.  To learn more call 1-800-AGE-LINE.