All About Medicare S

• By Bob CarlsonEditor, Retirement Watch
• By Bob Carlson

July 10, 2018

Most Americans in, or near, retirement know too little about Medicare, causing them to pay far more out-of-pocket for retirement medical care than they should and make big Medicare mistakes.

Many people believe Medicare — the federal health insurance program for people 65 and older — covers all or most retirement medical expenses. It doesn’t. The average Medicare beneficiary pays $8,000 or more for medical expenses annually, or about half the medical costs he or she incurs. And at least 90 percent of Medicare beneficiaries pay more out-of-pocket for their medical care than necessary, according to Katy Votava of Goodcare.com, an independent consulting firm specializing in the economics of health care.

Fortunately, you can reduce out-of-pocket payments for retirement medical care whether you enroll in traditional Medicare (also known as Medicare Part B) or in a Medicare Advantage plan (also known as Medicare Part C), offered by private companies to cover Medicare benefits.

Traditional Medicare

Let’s first look at the Traditional Medicare option.

Traditional Medicare has premiums, deductibles, co-payments and co-insurance. But dental, vision, prescription drugs and some other types of care aren’t covered.

You can decide to enroll only in Medicare Part B. Then, you’ll pay out of pocket for everything it doesn’t cover. You’ll also have a lot of uncertainty about your future health care spending.

Before deciding to sign up for only Medicare Part B, consider its two biggest gaps: prescription drugs and co-insurance (when you and your insurance plan share the cost of a medical service; for most Medicare Part B services, you pay 20 percent and Medicare pays 80 percent) .

Prescription medicine is the most significant medical expense for most beneficiaries, and the fastest rising. Over the past five years, according to a 2018 report from Sen. Claire McCaskill (D-Mo.), the prices for each of the 20 most prescribed brand-name drugs for Medicare Part D beneficiaries increased 12 percent a year, on average — about 10 times higher than inflation.

Even if you don’t need prescription medicines now, you’re likely to in the future. You’ll be on your own for those costs if you have only Medicare Part B.

The co-insurance gap also is potentially substantial. When you need an expensive procedure, such as a hip replacement or heart surgery, you owe 20 percent of the total cost. That can be tens of thousands of dollars, or more.

Two Steps to Cover Gaps in Health Coverage in Retirement

Two steps can help you cover a large part of these two gaps as well as other gaps in traditional Medicare:

Step 1: Purchase a Medicare Supplement (or Medigap) insurance policy.

There are 10 standardized Medigap plans, identified by letters, with varying amounts of coverage. Choose the plan that meets your needs and budget.

For example, Plan F provides the broadest coverage, which means you’ll have few out-of-pocket expenses with this one. Medicare Plan F will be eliminated beginning in 2020, but you’ll be able to renew an existing Plan F if you enroll before 2020.

Plan G has the next broadest coverage and will continue in 2020 and after. The only difference between Plan F and Plan G is that Plan G doesn’t cover the annual Part B deductible, which is $183 in 2018. Other Medigap plans cover fewer of the gaps, but they are likely to charge lower premiums.

After deciding on the Medigap plan you want, shop around. Since the plans are standardized, insurers compete on premiums and service, not coverage. Surveys have found that premiums on identical Medigap policies differ by as much a 100 percent.

Step 2: Purchase a Medicare Part D Prescription Drug policy.

Part D policies aren’t standardized. In most areas of the country, you can find policies with a range of premiums, deductibles, and co-payments. But the most important feature is the covered medications, known as the formulary. Insurers decide which medicines they’ll cover, so you need to compare the specific medications covered by a policy with those you are taking or think you might need in the future.

Details about Medigap and Part D policies available in your area can be found at www.medicare.gov or by calling 800-MEDICARE. You also might receive help from your local Area Agency on Aging or you can consider working with a financial professional with expertise in Medicare.

Medicare Advantage Plans

Now back to Medicare Advantage plans: Enrolling in a Medicare Advantage plan is the alternative to traditional Medicare. About a third of Medicare beneficiaries are enrolled in Medicare Advantage plans, and that’s expected to grow to 40 percent in the next few years.

Most Medicare Advantage plans offer in one package all the elements of traditional Medicare, Medigap and Part D. Many also add vision and dental benefits and often other benefits. Medicare Advantage plans tend to be managed care plans in which doctors and care are more coordinated and proactive than under traditional Medicare.

Importantly, a Medicare Advantage plan has an annual limit on a beneficiary’s out-of-pocket spending for covered care.

With Medicare Advantage plans, you’re likely to receive broader coverage than Traditional Medicare at a lower cost. But you’ll also give up some flexibility and choice.

Under Medicare Advantage plans, you generally see doctors and other health providers that are in the plan’s network. Care by specialists usually isn’t covered unless it is approved in advance. When you see an out-of-network provider or seek care without prior approval, you might pay extra or find the care isn’t covered by the plan at all.  (Under Traditional Medicare, the plan pays the doctor of your choice if the physician participates in Medicare. You can also decide whether to see a specialist and which specialist to see. If Medicare Part B covers the treatment, Medicare pays its share.)

Prescriptions are covered under Medicare Advantage plans, but with the same caveats as for Part D plans. Before choosing a Medicare Advantage plan, review the formulary and other details to ensure that your prescriptions will be covered.

Medicare Advantage plans aren’t all the same, so if you’re attracted to the concept and more than one is offered in your area, compare their coverage and cost details.

Also, be aware that Medicare Advantage plans aren’t available nationwide. If you move, your plan might not be available in the new area. You’ll then have to find a new Medicare Advantage plan or opt for Traditional Medicare.

Whichever route you choose, keep in mind that neither Medicare option covers much long-term care. You’ll need to make other plans to pay for long-term care costs.

By Bob Carlson

Bob Carlson is the editor of Retirement Watch and the author of several books, including The New Rules of Retirement-Revised Edition.

Next Avenue Editors Also Recommend:

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• What Are Private Medicare Advantage Plans?
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On – 10 Jul, 2018 By Richard Eisenberg

Alexandria Ocasio-Cortez beat 10-term House Democrat Joe Crowley in New York’s 14th District — the political upset of the year — in part because she championed Medicare-for-all (in addition to free college tuition and a jobs guarantee, among other progressive policies).

Immediately, some pundits began to try their best to explain her victory in a light most favorable to moderate liberals.

Part of their agenda involved watering down what “Medicare-for-all” means. It is very important that Medicare-for-all advocates resist these efforts and clarify exactly what we’re fighting for.

Vox’s Dylan Scott recently quoted one activist (Adam Green, co-founder of the Progressive Change Campaign Committee), describing the “pleasant ambiguity of Medicare-for-all.” Green suggested that there was no downside to letting voters hold different definitions of the phrase in their minds, at least during campaign season. Meanwhile, Paul Krugman described Medicare-for-all, in his New York Times column, as a “deliberately ambiguous phrase.”

“In practice,” Krugman wrote, presumably to reassure centrist readers, “[Medicare-for-all] probably wouldn’t mean pushing everyone into a single-payer system. Instead, it would mean allowing individuals and employers to buy into Medicare — basically a big public option. That’s really not radical at all.”

It’s correct that Democrats diverge on the issue of health care. Yet despite the musings of Krugman and others, there’s nothing ambiguous about the Medicare-for-all legislation Ocasio-Cortez supports and that appealed to the people who voted for her. She was referring to two specific bills, Rep. Keith Ellison’s H.R. 676 and its companion, Sen. Bernie Sanders’s S. 1804, both of which would create a single-payer health care system and both of which share clear principles.

Yet as public support for Medicare-for-all rises, establishment think tanks and lobbyists are floating proposals designed to capitalize on its momentum while diluting its content.

In February, the Center for American Progress released a plan called “Medicare Extra for All,” a particularly shameless attempt to co-opt Medicare-for-all’s popularity. It would create a public option similar to what Krugman describes — it would allow people to buy into a public “Medicare Extra” plan while leaving in place the privatized, multi-payer system that drives our health care struggles.

Obama administration alumnus Andy Slavitt’s United States of Care initiative, on the other hand, promises to “put health care over politics” — an obvious impossibility — with three extremely vague “principles”: giving Americans “an affordable regular source of health care”; protecting them from “financial devastation” as a result of medical bills; and, the giveaway that Slavitt’s organization will settle for less than what voters are demanding, requiring legislation to be “economically responsible” to “win … political support.”

Benchmarks as vague as that prevent any accountability, ensuring that, whatever inadequate plan might be passed, these experts will be able to congratulate themselves.

In contrast to such vagueness, Democratic Socialists for Medicare for All (for whom we work) — a campaign organized and paid for by Democratic Socialists of America, working in coalition with National Nurses United and Labor Campaign for Single Payer — has defined its five core demands as follows. They dovetail with the Sanders and Ellison bills.

There should be a single, federal program

We need a true single-payer system, not a patchwork. Unlike our current fragmented mess of a health care system, Medicare-for-all would ensure that Americans no longer have their health outcomes determined by the free market’s whims.

It would expand Medicare to everyone as a single, public program and prohibit private insurers from offering competing services, effectively abolishing the private health insurance industry altogether and democratizing approximately one-sixth of the US economy.

Health insurance CEOs currently make an average of over $20 million per year by profiting off the sick; Medicare-for-all will redirect the money that currently goes to them toward its intended purpose: providing health care.

With all Americans on the same program, every doctor and hospital will be in-network, giving patients complete freedom to choose from whom and from where they receive care. Unlike tiered systems in which the wealthy are able to purchase a higher standard of care — the kind that CAP and United States of Care advocate for — Medicare-for-all will extend high-quality care to everyone.

As Nye Bevan, architect of Britain’s National Health Service, argued in 1958, “you can’t have different treatment in order of contribution. You can’t perform a second-class operation on a patient if they aren’t paid up.”

Coverage should be comprehensive

The program will provide comprehensive coverage that exceeds the services currently covered by Medicare. Dental, vision, and mental care will be covered, as will inpatient care, outpatient care, primary care, preventative care, palliative care, ambulatory care, emergency care, maternal care, and newborn care.

It will eliminate the need for supplemental insurance, expanding the benefits of expensive “Medigap” plans to everyone. Sanders’s bill will also cover contraceptives and abortion, as well as repeal the Hyde Amendment, which largely bars the use of federal funds to pay for abortion; that would make it one of the strongest reproductive rights bills in US history.

Health care should be free at the point of use

Everything covered under Medicare-for-all will be provided without cost, meaning no fees, no copays, and no deductibles. Medicare-for-all isn’t “affordable access” or the opportunity to pay for care; it’s care without any financial hurdles at the doctor’s office, clinic, or hospital.

The program will be funded by progressive taxation — in other words, by primarily taxing corporations and the rich. American residents and employers would pay a tax that would effectively replace their current health care expenses; it would be modest for most and rise according to ability to pay.

Sanders projects that his bill will mean substantial savings for 95 percent of Americans. The average working-class family currently pays nearly $6,300 a year in premiums — not to mention unpredictable out-of-pocket spending. Under Medicare-for-all, such a family would pay less than $500 in taxes, saving well more than $5,000 per year.

Medicare-for-all will be a program by and for the people, one based on neither charity nor sacrifice. It will benefit everyone, guaranteeing that none of us ever has to worry about affording a medical emergency. Such a program will eliminate the number one cause of bankruptcy in the country and remove the unnecessary stress of dealing with the insurance market, decommodifying one of our most basic human needs.

The program would be universal

Medicare-for-all will cover all American residents, regardless of income, age, employment, medical history, or immigration status.

“Health care is a right” has become such a common catchphrase that proponents of all kinds of health care plans have adopted it. Yet any health care proposal that maintains unequal coverage and cost-sharing — the requirement that patients foot part of the bill — can never be truly universal. Even meager copays deter patients from receiving care. And forcing people to choose between competing insurance plans, even with a robust public option on the table, will inevitably leave many underinsured.

If we are truly committed to the idea of health care as a right, then we will eliminate the profit motive and guarantee that all patients receive the same standard of treatment and breadth of coverage. Real universal programs foster solidarity by bringing people together under equal treatment for the benefit of the common good. Medicare-for-all will be the first program of its kind in the United States, and will change Americans’ understanding of what they can and should demand from their government.

It would provide a just transition for workers currently employed by the private insurance industry

Both the Sanders and Ellison bills include severance, placement assistance, and job training for those affected by the abolition of the private insurance industry. Many people will still be needed to administer Medicare-for-all, but it will result in a massive reduction in administration work, eliminating the need for many insurance workers and administrative staff in hospitals.

More health care providers will be needed, and health care professionals currently working for insurance companies can find work in the field. But a training and placement program is absolutely necessary to protect the incomes of insurance and administrative workers for whom the transition proves more challenging. Our Medicare-for-all proposal will provide this.

A mass movement for Medicare-for-all is emerging around these five principles, with groups like the Democratic Socialists of America and National Nurses United running nationwide campaigns built on door-knocking and public advocacy. In April, the Democratic Socialists of America hosted its first Weekend of Action, during which dozens of chapters in more than 20 states canvassed and organized town halls or rallies; an even bigger weekend event is planned for August 11-12.

Last month, Healthcare NOW and Labor Campaign for Single Payer held a single-payer strategy conference in Minneapolis, attended by dozens of unions and single-payer advocacy groups from around the country.

These campaigns are working. A recent Morning Consult/Politico poll shows that 63 percent of American voters support a “Medicare-for-all health care system, where all Americans would get their health insurance from the government.” Just 26 percent were opposed.

Clear, honest messaging will help us build on this popularity and prevent lookalike proposals from sowing confusion.

Let there be no doubt — Medicare-for-all is a universal, public program that would provide comprehensive medical care to all American residents, totally free at the point of use. Any attempt by pundits or lobbyists to muddy the waters around this proposal is an obvious attempt to co-opt the campaign’s momentum with an eye toward weakening future legislation and protecting the interests of health-industry profiteers.

Ocasio-Cortez’s moral clarity on the campaign trail worked to great effect with New York City voters. Medicare-for-all reflects that resolute vision, one in which our common well-being and dignity take obvious precedence over the profits of a few. For millions of American voters, there’s nothing ambiguous about it.

Tim Higginbotham and Chris Middleman are organizers with the Democratic Socialists for Medicare for All campaign. Find them on Twitter @singlepayertom and @_Middleman

The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

https://www.vox.com/the-big-idea/2018/7/13/17567952/medicare-for-all-centrists-copycat-plans-water-down-left-center-sanders

On – 13 Jul, 2018 By Tim Higginbotham and Chris Middleman

Medicare for All Isn’t Single-Payer Health Care

http://nymag.com/daily/intelligencer/2018/07/medicare-for-all-wont-bring-medicare-to-all.html

On – 13 Jul, 2018 By Ed Kilgore

https://www.statnews.com/2018/07/23/medicare-catastrophic-insurance-a-catastrophe-for-some/

On – 23 Jul, 2018 By Erin E. Trish

https://www.tennessean.com/story/news/2018/07/03/comprehensive-pain-specialists-closes-clinics-after-ceo-indicted/754904002/

On – 03 Jul, 2018 By Brett Kelman

https://www.washingtonpost.com/blogs/post-partisan/wp/2018/07/05/i-cant-afford-that-a-viral-tweet-shows-why-we-need-medicare-for-all/

On – 05 Jul, 2018 By Helaine Olen

One in four people in traditional Medicare (25 percent) had private, supplemental health insurance in 2015—also known as Medigap—to help cover their Medicare deductibles and cost-sharing requirements, as well as protect themselves against catastrophic expenses for Medicare-covered services. This issue brief provides an overview of Medigap enrollment and analyzes consumer protections under federal law and state regulations that can affect beneficiaries’ access to Medigap. In particular, this brief examines implications for older adults with pre-existing medical conditions who may be unable to purchase a Medigap policy or change their supplemental coverage after their initial open enrollment period.

• The share of beneficiaries with Medigap varies widely by state—from 3 percent in Hawaii to 51 percent in Kansas.
• Federal law provides limited consumer protections for adults ages 65 and older who want to purchase a supplemental Medigap policy—including, a one-time, 6-month open enrollment period that begins when they first enroll in Medicare Part B.
• States have the flexibility to institute consumer protections for Medigap that go beyond the minimum federal standards. For example, 28 states require Medigap insurers to issue policies to eligible Medicare beneficiaries whose employer has changed their retiree health coverage benefits.
• Only four states (CT, MA, ME, NY) require either continuous or annual guaranteed issue protections for Medigap for all beneficiaries in traditional Medicare ages 65 and older, regardless of medical history (Figure 1). Guaranteed issue protections prohibit insurers from denying a Medigap policy to eligible applicants, including people with pre-existing conditions, such as diabetes and heart disease.
• In all other states and D.C., people who switch from a Medicare Advantage plan to traditional Medicare may be denied a Medigap policy due to a pre-existing condition, with few exceptions, such as if they move to a new area or are in a Medicare Advantage trial period.

Medicare beneficiaries can choose to get their Medicare benefits (Parts A and B) through the traditional Medicare program or a Medicare Advantage plan, such as a Medicare HMO or PPO. Roughly two-thirds of Medicare beneficiaries are in traditional Medicare, and most have some form of supplemental health insurance coverage because Medicare’s benefit design includes substantial cost-sharing requirements, with no limit on out-of-pocket spending. Medicare requires a Part A deductible for hospitalizations ($1,340 in 2018), a separate deductible for most Part B services ($183), 20 percent coinsurance for many Part B (physician and outpatient) services, daily copayments for hospital stays that are longer than 60 days, and daily copays for extended stays in skilled nursing facilities.

To help with these expenses and limit their exposure to catastrophic out-of-pocket costs for Medicare-covered services, a quarter of beneficiaries in traditional Medicare (25 percent) had a private, supplemental insurance policy, known as Medigap in 2015 (Figure 2). Medigap serves as a key source of supplemental coverage for people in traditional Medicare who do not have supplemental employer- or union-sponsored retiree coverage or Medicaid, because their incomes and assets are too high to qualify. Medicare beneficiaries also purchase Medigap policies to make health care costs more predictable by spreading costs over the course of the year through monthly premium payments, and to reduce the paperwork burden associated with medical bills.

Medigap policy benefits were standardized through the Omnibus Budget Reconciliation Act of 1990, which also included additional consumer protections discussed later in this issue brief. Of the 10 standard Medigap policies available to beneficiaries, Plan F is the most popular, accounting for over half of all policyholders in 2016, because it covers the Part A and B deductibles (as does Plan C), and all cost-sharing for Part A and B covered services.

The share of all Medicare beneficiaries with Medigap coverage varies widely by state—from 3 percent in Hawaii to 51 percent in Kansas in 2016 (Figure 3, Appendix Table). In 20 states, at least one-quarter of all Medicare beneficiaries have a Medigap policy. States with higher Medigap enrollment tend to be in the Midwest and plains states, where relatively fewer beneficiaries are enrolled in Medicare Advantage plans.

Medigap coverage is substantially more common for Medicare beneficiaries ages 65 and older than it is for younger Medicare beneficiaries, many of whom qualify for Medicare because of a long-term disability. Only 5 percent of traditional Medicare beneficiaries under age 65 had Medigap in 2015—considerably lower than the shares in older age brackets (Figure 4). The low enrollment in Medigap by beneficiaries under age 65 is likely due to the absence of federal guarantee issue requirements for younger Medicare beneficiaries with disabilities (discussed later in this brief) and higher rates of Medicaid coverage for people on Medicare with disabilities who tend to have relatively low incomes.

In general, Medigap insurance is state regulated, but also subject to certain federal minimum requirements and consumer protections. For example, federal law requires Medigap plans to be standardized to make it easier for consumers to compare benefits and premiums across plans. Federal law also requires Medigap insurers to offer “guaranteed issue” policies to Medicare beneficiaries age 65 and older during the first six months of their enrollment in Medicare Part B and during other qualifying events (listed later in this brief). During these defined periods, Medigap insurers cannot deny a Medigap policy to any applicant based on factors such as age, gender, or health status. Further, during these periods, Medigap insurers cannot vary premiums based on an applicant’s pre-existing medical conditions (i.e., medical underwriting). However, under federal law, Medigap insurers may impose a waiting period of up to six months to cover services related to pre-existing conditions, only if the applicant did not have at least six months of prior continuous creditable coverage. As described later in this brief, states have the flexibility to institute Medigap consumer protections that go further than the minimum federal standards.

Federal law also imposes other consumer protections for Medigap policies. These include “guaranteed renewability” (with few exceptions), minimum medical loss ratios, limits on agent commissions to discourage “churning” of policies, and rules prohibiting Medigap policies to be sold to applicants with duplicate health coverage. (For further details on these requirements and a history of federal involvement in the Medigap market, see Medigap: Spotlight on Enrollment, Premiums, and Recent Trends, April 2013.)

Federal law provides guaranteed issue protections for Medigap policies during a one-time, six-month Medigap open enrollment period for beneficiaries ages 65 and older when enrolling in Medicare Part B, and for certain qualifying events. These limited circumstances include instances when Medicare beneficiaries involuntarily lose supplemental coverage, such as when their Medicare Advantage plan discontinues coverage in their area, or when their employers cancel their retiree coverage. Beneficiaries who are in a Medicare Advantage plan also have federal guaranteed issue rights when they move to a new area and can no longer access coverage from their Medicare Advantage plan. In these qualifying events, people ages 65 and older in Medicare generally have 63 days to apply for a supplemental Medigap policy under these federal guaranteed issue protections.

Federal law also requires that Medigap polices be sold with guaranteed issue rights during specified “trial” periods for Medicare Advantage plans. One of these trial periods is during the first year older adults enroll in Medicare. During that time, older adults can try a Medicare Advantage plan, but if they disenroll within the first year, they have guaranteed issue rights to purchase a Medigap policy under federal law. Another trial period applies to Medicare beneficiaries who cancel their Medigap policy to enroll in a Medicare Advantage plan. These beneficiaries have time-limited guaranteed issue rights to purchase their same Medigap policy if, within a year of signing up for a Medicare Advantage plan, they decide to disenroll to obtain coverage under traditional Medicare.

States have the flexibility to institute Medigap consumer protections that go further than the minimum federal standards, such as extending guaranteed issue requirements beyond the open enrollment period or adding other qualifying events that would require insurers to issue policies, as discussed later in this brief.

Broadly speaking, after 6 months of enrolling in Medicare Part B, older adults do not have federal guaranteed issue protections when applying for Medigap, except for specified qualifying events described earlier (Table 2). Therefore, older adults in traditional Medicare who miss the open enrollment period may, in most states, be subject to medical underwriting, and potentially denied a Medigap policy due to pre-existing conditions, or charged higher premiums due to their health status.

Medical Underwriting. Insurance companies that sell Medigap policies may refuse to sell a policy to an applicant with medical conditions, except under circumstances described above. The Text Box on this page provides examples of health conditions that may lead to the denial of Medigap policies, derived from underwriting manuals/guides from multiple insurance companies selling Medigap policies. Examples of conditions listed by insurers as reasons for policy denials include diabetes, heart disease, cancer, and being advised by a physician to have surgery, medical tests, treatments, or therapies.

Barriers for Beneficiaries Under Age 65 with Disabilities. Under federal law, Medigap insurers are not required to sell Medigap policies to the over 9 million Medicare beneficiaries who are under age of 65, many of whom qualify for Medicare based on a long-term disability. (However, when these beneficiaries turn age 65, federal law requires that they be eligible for the same six-month open enrollment period for Medigap that is available to new beneficiaries age 65 and older.)

Beneficiaries Choosing to Switch from Medicare Advantage to Traditional Medicare. There are no federal guarantee issue protections for individuals who choose to switch from a Medicare Advantage plan to traditional Medicare and apply for a Medigap policy, except under limited circumstances described in Table 2. In most states, therefore, beneficiaries who want to switch from their Medicare Advantage plan to traditional Medicare may be subject to medical underwriting and denied coverage when they apply for a Medigap policy because they do not have guaranteed issue rights, with some exceptions (e.g., if they have moved or if they are in a limited trial period). In states that allow medical underwriting for Medigap, Medicare Advantage enrollees with pre-existing conditions may find it too financially risky to switch to traditional Medicare if they are unable to purchase a Medigap policy. Without Medigap, they could be exposed to high cost-sharing requirements, mainly because traditional Medicare does not have a limit on out-of-pocket spending (in contrast to Medicare Advantage plans).

States have the flexibility to institute Medigap consumer protections that go further than the minimum federal standards. While many states have used this flexibility to expand guarantee issue rights for Medigap under certain circumstances, 15 states and the District of Columbia have not, relying only the minimum guarantee issue requirements under federal law (Table 3).

Only four states require Medigap insurers to offer policies to Medicare beneficiaries age 65 and older (Figure 5). Three of these states (Connecticut, Massachusetts, and New York) have continuous open enrollment, with guaranteed issue rights throughout the year, and one state (Maine) requires insurers to issue Medigap Plan A (the least generous Medigap plan shown earlier in Table 1) during an annual one-month open enrollment period. Consistent with federal law, Medigap insurers in New York, Connecticut, and Maine may impose up to a six-month “waiting period” to cover services related to pre-existing conditions if the applicant did not have six months of continuous creditable coverage prior to purchasing a policy during the initial Medigap open enrollment period. Massachusetts prohibits pre-existing condition waiting periods for its Medicare supplement policies.

Some states provide additional guaranteed issue rights for current Medigap policyholders. Two states (CA and OR) allow beneficiaries to switch each year to a different Medigap plan with equal or lesser benefits within 30 days of their birthday, and another state (MO) allows policyholders to switch to an equivalent plan within 30 days before or after the annual anniversary date of their policy. Medigap policyholders in Maine can switch to a policy with equal or less generous benefits at any time during the year (not only during the annual open enrollment period) if there is less than a 90 day gap in coverage. Some Medigap insurers may also provide guaranteed issue rights to their policies that go beyond the state requirements. In Illinois, Blue Cross Blue Shield of Illinois and Health Alliance provide ongoing guaranteed issue rights for all beneficiaries ages 65 or older.

Many other states have expanded on the federal minimum standards in more narrow ways by requiring Medigap insurers to offer policies to eligible applicants during additional qualifying events (Table 3). For example, 28 states require Medigap insurers to issue policies when an applicant has an involuntary change in their employer (retiree) coverage. (This qualifying event is more expansive than federal law, which applies only when retiree coverage is completely eliminated.) Nine states provide guaranteed issue rights for applicants who lose their Medicaid eligibility.

As noted above, federal law does not require Medigap insurers to issue policies to Medicare beneficiaries under the age of 65, most of whom qualify for Medicare because of a long-term disability. However, 31 states require insurers to provide at least one kind of Medigap policy to beneficiaries younger than age 65 (typically through an initial open enrollment period).

States also have the flexibility to establish rules on whether or not Medigap premiums may be affected by factors such as a policyholder’s age, smoking status, gender, and residential area. Federal law allows states to alter premiums based on these factors, even during guaranteed issue open enrollment periods.

There are three different rating systems that can affect how Medigap insurers determine premiums: community rating, issue-age rating, or attained-age rating (defined in the Text box below). States can impose regulations on which of these rating systems are permitted or required for Medigap policies sold in their state. Of the three, community rating provides the strongest consumer protection for Medigap policies because it does not allow premiums to be based on the applicant or policyholder’s age or health status. However, insurers in states that require community rating may charge different premiums based on other factors, such as smoking status and residential area. In states that allow attained age rating, older applicants and policyholders have considerably less protection from higher premiums because premiums may increase at unpredictable rates as policyholders age.

Currently, eight states (AR, CT, MA, ME, MN, NY, VT, and WA) require premiums to be community rated among policyholders ages 65 and older. This means that Medigap insurers cannot charge higher premiums to people because they are older or sicker, and therefore, must charge an 80-year old policyholder the same as a 70-year old policyholder regardless of health status (Table 4). Insurers may still adjust premiums based on other factors, including smoking status, gender, and residential area. A state’s community rating requirement does not, in itself, guarantee that applicants will be issued a policy in the state. However, as described earlier, four of the states that have community rating (CT, MA, ME, NY), have guarantee issue protections and require insurers to issue Medigap policies to eligible applicants either continuously during the year, or during an annual enrollment period.

The remaining 38 states and the District of Columbia do not require premiums to be community rated; therefore, Medigap premiums in these states may be subject to issue-age and attained-age rating systems, depending on state regulation. Medigap insurers are permitted to offer community rated policies in these states, but most do not. Additionally, Medigap insurers may increase premiums due to inflation, regardless of the premium rating system.

Medigap plays a major role in providing supplemental coverage for people in traditional Medicare, particularly among those who do not have an employer-sponsored retiree plan or do not qualify for cost-sharing assistance under Medicaid. Medigap helps beneficiaries budget for out-of-pocket expenses under traditional Medicare. Medigap also limits the financial exposure that beneficiaries would otherwise face due to the absence of an out-of-pocket limit under traditional Medicare.

Nonetheless, Medigap is not subject to the same federal guaranteed issue protections that apply to Medicare Advantage and Part D plans, with an annual open enrollment period. As a result, in most states, medical underwriting is permitted which means that beneficiaries with pre-existing conditions may be denied a Medigap policy due to their health status, except under limited circumstances.

Federal law requires Medigap guaranteed issue protections for people age 65 and older during the first six months of their Medicare Part B enrollment and during a “trial” Medicare Advantage enrollment period. Medicare beneficiaries who miss these windows of opportunity may unwittingly forgo the chance to purchase a Medigap policy later in life if their needs or priorities change. This constraint potentially affects the nearly 9 million beneficiaries in traditional Medicare with no supplemental coverage; it may also affect millions of Medicare Advantage plan enrollees who may incorrectly assume they will be able to purchase supplemental coverage if they choose to switch to traditional Medicare at some point during their many years on Medicare.

Only four states (CT, MA, NY, ME) require Medigap policies to be issued, either continuously or for one month per year for all Medicare beneficiaries age 65 and older. Policymakers could consider a number of other policy options to broaden access to Medigap. One approach could be to require annual Medigap open enrollment periods, as is the case with Medicare Advantage and Part D plans, making Medigap available to all applicants without regard to medical history during this period. Another option would be to make voluntary disenrollment from a Medicare Advantage plan a qualifying event with guaranteed issue rights for Medigap, recognizing the presence of beneficiaries’ previous “creditable” coverage. For Medicare beneficiaries younger than age 65, policymakers could consider adopting federal guaranteed issue protections, building on rules already established by the majority of states.

On the one hand, these expanded guaranteed issue protections would increase beneficiaries’ access to Medigap, especially for people with pre-existing medical conditions. They would also treat Medigap similarly to Medicare Advantage in this regard, and make it easier for older adults to switch between Medicare Advantage and traditional Medicare if their Medicare Advantage plan is not serving their needs in later life. On the other hand, broader guaranteed issue policies could result in some beneficiaries waiting until they have a serious health problem before purchasing Medigap coverage, which would likely increase premiums for all Medigap policyholders. A different approach altogether would be to minimize the need for supplemental coverage in Medicare by adding an out-of-pocket limit to traditional Medicare.

Ongoing policy discussions affecting Medicare and its benefit design could provide an opportunity to consider various ways to enhance federal consumer protections for supplemental coverage or manage beneficiary exposure to high out-of-pocket costs. As older adults age on to Medicare, they would be well-advised to understand the Medigap rules where they live, and the trade-offs involved when making coverage decisions.

https://www.kff.org/medicare/issue-brief/medigap-enrollment-and-consumer-protections-vary-across-states/

On – 11 Jul, 2018 By

CHICAGO (Reuters) – (The writer is a Reuters columnist. The opinions expressed are his own.)

Navigating Medicare can be complicated, but one big change recently introduced requires that you do absolutely nothing beyond opening an envelope. In fact, doing just about anything else could open the door to a damaging identity-fraud scam.

Medicare is mailing out new identification cards to 59 million Americans this year and in early 2019. The old Medicare cards use Social Security numbers as identifiers; the new cards use a unique, randomly assigned number. The changeover is part of a sweeping federal initiative to bolster defenses against fraud by reducing the widespread use of Social Security numbers as identifiers throughout the government.

Trouble is, phone scammers are taking the card replacement program as an opportunity to target seniors. The most common trick is to call Medicare enrollees and tell them they must pay for their new cards, then request their bank account information or Social Security numbers.

That opens the door to identity theft.

“We are hearing from people who have been told their Social Security payments will stop coming unless they give the caller their personal information, or that they can’t send the new Medicare card unless they get a payment,” said Amy Nofziger, a fraud expert with AARP.

In fact, the new card is free, and you do not need to do anything to get it. The new card does not change your Medicare coverage in any way. And Medicare will not be calling you about this. Just keep an eye out for an envelope containing the new card, and then give the new number to your healthcare providers. Then stash the card away for safekeeping, since carrying it around creates yet another theft risk. Finally, destroy the old card.

Simple, right?

Unfortunately, we’ve got a failure to communicate, to paraphrase the 1967 film classic “Cool Hand Luke.”

An AARP survey conducted in March found that 76 percent of adults aged 65 and older had not seen, read or heard “much of anything at all” about the new Medicare cards, or were not sure if they had. Three-quarters could not correctly identify the key change coming with the new Medicare identification numbers.

Nearly two-thirds were unsure or incorrect in thinking that Medicare would be charging beneficiaries a $25 processing fee for the new cards. And 56 percent were unsure or incorrect in thinking that Medicare would be calling to verify their Social Security number before they could receive their new card.

THE ROLLOUT SCHEDULE

Anyone signing up for Medicare now automatically receives the new card. Mailing of replacement cards already is complete in some eastern states (Delaware, Maryland, Pennsylvania, Virginia, West Virginia and the District of Columbia). The cards are in the mail now for most Midwestern states, plus California and Oregon. All new cards will be sent by next April. Details on the status of every state can be found on the Medicare website (bit.ly/2Jlf3Dm)

Most of the fraud schemes are being conducted by phone, Nofziger said. So understanding Medicare phone protocols is key.

As a general matter, the Centers for Medicare & Medicaid Services (CMS) does not contact enrollees for Medicare numbers or other personal information, unless they have granted permission in advance. The only time you might receive a legitimate phone call from Medicare is if you have given CMS permission to call in advance; also, Medicare Advantage or prescription drug plans may call if you already are a member of that plan.

You also might get a call from Medicare if you have left a message requesting a call-back. More information on preventing Medicare fraud can be found at the CMS website: (bit.ly/1QneOn0). The Social Security Administration does sometimes call beneficiaries for customer service purposes, but representatives never ask for personal information.

If you are not certain that a call from Medicare or Social Security is legitimate, hang up and call the agency back on the customer service lines: 1-800-633-4227 or 1-800-772-1213 for Social Security.

If you have been victimized by a Medicare fraud scam, put a freeze or fraud alert on your credit with one of the three major credit reporting companies (Experian, TransUnion and Equifax). Nofziger notes you need call only one of these companies, which will in turn alert the others. Also notify your bank and credit card providers.

AARP maintains a fraud hotline that can provide help: 1-877-908-3360.

Editing by Matthew Lewis

Our Standards:The Thomson Reuters Trust Principles.

https://www.reuters.com/article/us-column-miller-medicare/new-u-s-medicare-cards-prompt-warnings-about-phone-scams-idUSKBN1JT2FG

On – 03 Jul, 2018 By Mark Miller

 

July 12, 2018

 

Quotes for attribution to National Kidney Foundation

 

Yesterday evening the Centers for Medicare & Medicaid Services (CMS) issued the annual proposed rule governing Medicare payments to dialysis facilities and the quality measures for which the dialysis facilities are held accountable. 

 

The National Kidney Foundation (NKF) is pleased that CMS has included key issues that we, and the patients we represent, have spoken out on for many years such as lack of innovation in therapies for dialysis patients, improving access to kidney transplants, and empowering patients to choose the type of kidney replacement therapy that best aligns with their individual goals, preferences and values.

 

CMS is proposing to pay separately for all new dialysis medications and biologics for a period of two years.  The intent is to improve patient access to new therapies and improve innovation in treatments for patients on dialysis, however the National Kidney Foundation will be carefully reviewing this new proposed rule to ensure that it indeed will be good for dialysis patients. 

 

CMS shares our concerns that dialysis patients must appropriately be educated about kidney transplantation, referred to the organ donation waitlist and tracked for waitlist status.  CMS is searching for solutions to ensure that dialysis facilities are adequately helping patients receive this information and that patients are given a chance to receive a kidney transplant.  Informing patients about their waitlist options and helping patients learn about living organ donation, which can greatly reduce their time waiting for a kidney transplant, are essential to improving the quality of life for dialysis patients. No patient should believe that they must face a lifetime of dialysis if they are eligible for a transplant. NKF will work closely with our patients, transplant professionals and dialysis care professionals to develop robust, feasible recommendations to CMS and we look forward to helping CMS on this issue. 

 

Additionally, NKF is pleased that CMS is soliciting input on ways to correct the disparities that exist in patients receiving home dialysis. NKF will work closely with our patients and our professionals to develop patient-centered recommendations on how to ensure that all patients fully understand their dialysis options and are empowered to select the treatment that best aligns with their individual goals, preferences and values. Home dialysis is a viable option that must be made more widely available to end stage renal disease patients.  It can greatly lesson the burden of dialysis, have clinical outcome benefits and provide better quality of life and increased independence for many patients. 

 

Through the ESRD Quality Incentive Program (QIP) CMS is seeking to further promote patient access to transplantation by measuring the percent of dialysis patients on the waitlist starting in 2022.  The QIP also will promote better care coordination and safety for dialysis patients with another new quality measure used to improve medication reconciliation by clinics. These important steps will help ensure that dialysis facilities have better information on the medications and the doses that dialysis patients are currently taking, and also ensure that dialysis facility staff work to update any changes in medications after patients return from a hospital stay.

 

National Kidney Foundation Home Dialysis Resources

Dialysis modality planning and decision-making is integral to the treatment process for many CKD patients, and home dialysis has the potential to address some of the quality of life issues experienced by dialysis patients. The barriers to accessing home dialysis, and remaining on it, are largely known: the time and costs of home dialysis training for the patient, family member, and caregiver; the lack of care partner support; lack of patient and clinician familiarity with the home dialysis prescription and follow-up care; and late diagnosis which requires a rapid start of hemodialysis in–center with a catheter. The KDOQI Home Dialysis Controversies Conference  is a multi-year project for home dialysis which will foster collaboration among a multi-stakeholder group of patients, clinicians, care partners, researchers, health payers and healthcare industry representatives to facilitate the development of research designs to measure home dialysis quality and create interventions to overcome the barriers of maintaining dialysis treatment at home.

 

National Kidney Foundation Living Donation Resources

THE BIG ASK: THE BIG GIVE platform, which provides nationwide outreach, is designed to increase kidney transplantation through training and tools that help patients and families find a living donor. It includes direct patient and caregiver support through our toll-free help line 855-NKF-CARES, peer mentoring from a fellow kidney patient or a living donor, online communities, an advocacy campaign to remove barriers to donation, and a multi-media public awareness campaign. All of these resources are free and designed to teach kidney patients, or their advocates, how to make a “big ask” to their friends, loved ones, or community to consider making a “big give,” a life-saving living organ donation.  For more information visit www.kidney.org/livingdonation.

 

Kidney Disease Facts

In the United States 30 million adults are estimated to have chronic kidney disease—and most aren’t aware of it.  1 in 3 American adults are at risk for chronic kidney disease. Risk factors for kidney disease include diabetes, high blood pressure, heart disease, obesity and family history. People of African American, Hispanic, Native American, Asian or Pacific Islander descent are at increased risk for developing the disease.  African Americans are 3 times more likely than Whites, and Hispanics are nearly 1.5 times more likely than non-Hispanics to develop end stage renal disease (kidney failure).

 

The National Kidney Foundation (NKF) is the largest, most comprehensive and longstanding organization dedicated to the awareness, prevention and treatment of kidney disease. For more information about NKF visit www.kidney.org.

https://www.kidney.org/news/nkf-statement-centers-medicare-medicaid-services-rule-medicare-payments-to-dialysis-facilities

On – 12 Jul, 2018 By

Editor’s Note: Journalist Philip Moeller is here to provide the answers you need on aging and retirement. His weekly column, “Ask Phil,” aims to help older Americans and their families by answering their health care and financial questions. Phil is the author of “Get What’s Yours for Medicare,” and co-author of “Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security.” Send your questions to Phil; and he will answer as many as he can.

Peggy – Ariz.: My husband is at the point with health issues where I need help with his bathing and going to bathroom. He has been diagnosed with prostate cancer, AFib [atrial fibrillation], and severe breathing problems with fluid retention, all of which are being treated somewhat. What are the steps for getting home care with Medicare?

Phil Moeller: I am sorry to learn about your husband’s health problems, and hope things turn out as well as possible.

Medicare does cover at-home care services if they are prescribed by a physician or other licensed caregiver. So, this would be your first step. Medicare does not cover so-called custodial care, so your husband must require medical care.

Medicare requires that people use only agencies it has licensed to provide this care. This would be your next step. Here is an online search tool to help you find an agency near you. If your husband has a Medicare Advantage plan, you should call the plan to see if it has a list of approved home health providers.

There have been reports that people have either been improperly denied this benefit or have had trouble finding a home health agency who will work with them. I would appreciate you letting me know your experience in this regard.

Denise – Mo.: My husband is on my insurance through my employment. He has been approved for Social Security disability and I understand this means he will also be able to get Medicare in a couple of years. Should we drop him from my insurance then and just get a supplemental policy along with Parts A and B of Medicare? My cost for his insurance is about $300 a month.

Phil Moeller: Your question may seem fairly straightforward but what you’ve asked winds up requiring an examination of all Medicare coverage, not just the ones included in your question.

His Medicare Part B will cost $134 a month unless you make a lot of money. Part B only pays 80 percent of covered expenses, so one key question here is whether your employer plan would pay that 20 percent or if your husband would need a Medigap supplement plan to do so. Medigap plans are regulated at the state level. Many states do not require insurers to even sell Medigap plans to disabled persons younger than 65; fortunately, Missouri insurers are required to do so.

Most Medigap plans cost less than $166 a month, which is the difference between what his employer coverage costs and his Part B premium. You can call a local insurance broker and get Medigap quotes. The annual guide to Medigap explains the different types of Medigap plans.

Even if you would save some money by dropping his employer coverage in favor of Medicare, your work is not yet done! Your question did not include prescription drugs. I assume they are covered on the employer plan, but under Medicare, he would need to get a separate Part D drug plan. Monthly premiums vary and average a bit more than $30.

Your question also did not mention getting a Medicare Advantage plan. These plans would charge him a premium on top of his Part B payment, but they usually include drug coverage and also have annual ceilings on out-of-pocket medical expenses that avoid the need for a Medigap plan.

Premiums for most Medicare Advantage plans are cheaper than getting Medigap plus a stand-alone Part D plan. However, they usually require care be provided by doctors and hospitals in a plan’s provider network, and coverage may only be available near where you live.

By this time, you may have regretted even asking your question! I wish Medicare was easier to navigate but at least you still have two years to come up with the right answers. If you need more guidance, you can find it in my book.

Martha – N.Y.: I will soon turn 65. I am fully employed and, because my company has fewer than 20 employees, I plan to sign up for Part A and Part B of Medicare. When I stop working — and I hope to work into my 70s or beyond — will I face problems getting a Medigap supplemental policy? Also, Social Security says I have to pay $134 a month for Part B of Medicare. Since I am not getting Social Security yet, how will this supplemental payment get paid or billed?

Phil Moeller: You ask a great question. If your employer plan will be providing supplemental coverage to your Medicare, you really don’t have a need for a Medigap plan right now. However, the Medicare rules that provide you guaranteed issue rights for a Medigap policy normally expire six months after you get Medicare. If you lose these rights, insurers in some states may be able to charge you more for a policy because of any pre-existing health conditions you have, or even decline to sell you a policy at all.

Fortunately, Medicare rules do not start your Medigap “clock” ticking until you leave your current employer plan. At that time, you will have a Medigap enrollment period during which you will be guaranteed of getting a policy on favorable terms. Your situation is described in detail on page 22 of Medicare’s annual guide to Medigap.

Lastly, because you’re not yet receiving Social Security, you would pay your Medicare premiums directly to Medicare every three months. You should receive payment instructions and should call Social Security if you do not (Social Security handles Medicare premiums).

Eliza: We just found out that my husband needs heart surgery in the near future. He is on private health insurance now but will turn 65 in July and will be on Medicare. What happens effective July 1, since he’ll most likely still be under a doctor’s care and will still need treatment relative to the surgery? He is going to select a Medicare Advantage plan that his doctor and surgeons are in.

Phil Moeller: On paper, all will be fine. If his Medicare effective date is on or before he loses his current insurance, he will be covered for any post-operative care.
In the real world, you will need to spend a lot of time making sure his two insurance plans don’t drop the ball. Due to long delays between a care event and the subsequent insurance billing, you’ll need to make sure that his first insurer pays for covered charges that occurred before his first plan ended, and that such claims don’t get submitted to your MA insurer.

It sounds like his surgery will be done by the same surgeons who will be in his new MA plan, so this should make coordination easier. I’d call the MA plan you intend to join before the surgery, explain what’s going on, and ask for any suggestions or guidance to help you avoid unpleasant surprises.

Thanks for taking the time to write, and best of luck on the surgery.

Mark: My disabled adult son is on Medicaid. He does not work. He recently switched from SSI [Supplemental Security Income] to SSDI [Social Security Disability Income]. We were told he will be automatically signed up for Medicare in about one year, but we are happy with Medicaid and don’t need Medicare, especially the Part B premium, which will diminish his benefit. I am reading that some states’ Medicaid programs will pay the part B premium. I also read that declining Part B could have negative consequences in the long term. What should we do?

Phil Moeller: If your son’s income is low enough, he would be dually eligible for Medicare and Medicaid, and Medicaid should pay for any Medicare expenses. I don’t know where you live, but as you probably know, the states have different Medicaid eligibility rules. So, I would first check with your state’s Medicaid office and see whether your son’s shift from SSI to SSDI will have any impact on his Medicaid eligibility. If you need help understanding your state’s Medicaid eligibility rules, I’d get in touch with a local office of the State Health Insurance Assistance Program (SHIP), which provides free Medicare counseling.

https://www.pbs.org/newshour/economy/making-sense/my-husband-needs-at-home-health-services-where-do-i-start

On – 29 Jun, 2018 By Philip Moeller