Medicare Watch

Health Reform Q&A

People with Medicare still have many outstanding questions about the Affordable Care Act (ACA), as evidenced by the response to last week’s Medicare Watch. By far the most frequently asked question about health reform by Medicare Watch readers was some variation of the following:

Q: What services are included in the new “annual wellness visit”?

A: During the annual wellness visit, you and your doctor will create and update a preventive care plan. Your doctor will also update your medical history; make a list of your current doctors and medications; create a 5- to 10-year screening schedule; identify health risk factors and discuss ways to possibly avoid them; check your height, weight, blood pressure and body mass index; and screen for cognitive issues. In addition to what is covered at no cost to consumers during the annual wellness visit, other preventive services will also be free of charge under Medicare, including mammograms, colonoscopies and diabetes screenings.

There are a few nuances about the wellness visit that Medicare consumers should understand.

First, the ACA creates the annual wellness visit under Original Medicare only, and does not require Medicare private health plans, also known as Medicare Advantage (MA) plans, to cover such visits in full. However, in the proposed rules it released recently, the Centers for Medicare & Medicaid Services (CMS) is considering requiring MA plans to provide the same preventive benefits, including an annual wellness visit, free of charge to consumers, beginning in 2012. The final rule has not yet been released. Second, while the annual wellness visit is free of charge, you may still be required to pay something out of pocket if you receive other services from your doctor during the same visit. Lastly, Medicare will cover 100 percent of the cost of the wellness visit only if you go to a doctor who accepts assignment, which means they accept Medicare rates as payment in full.

Read more about the annual wellness visit on Medicare Interactive.

Read HealthCare.gov’s fact sheet on preventive services.

Read Medicare Rights Center’s chart on preventive services.

Please keep your questions coming. If you have a personal story about Medicare or health reform, positive or negative, please share that, too. In future issues of Medicare Watch, we will continue to answer readers’ questions about the ACA and how it affects people with Medicare.

Click here to send us your questions.

Please tell us your story.

Medicare Rights Calls for Reforms to the Drug Appeals Process

In comments on Part D appeals guidance submitted last week, the Medicare Rights Center urged the Centers for Medicare & Medicaid Services (CMS) to require Medicare Prescription Drug plans (PDPs) to provide more detailed information in denial notices to enrollees. In the Medicare Rights Center’s experience of representing clients in appeals cases, we have found that plans’ notices do not always include all of the reasons why they are denying coverage for a drug or service, and it is often only in later stages of the appeal that a plan reveals that there is more than one reason for the denial. In addition, Medicare Rights requested that CMS make it easier for Medicare consumers and their physicians to initiate appeals, escalate appeals to the next level if a plan fails to make a timely coverage decision, and access information related to their appeals, such as case files, free of charge.

The appeals guidance is part of the Medicare Prescription Drug Benefit Manual, which interprets regulations that govern the appeals process and plans’ obligations under the appeals process. The guidance appears in Chapter 18 of the Manual.

Read Medicare Rights Center’s comments on the guidance.

Read the draft guidance.

Explore CMS’s Internet-Only Manuals.

Medicare Reminder:
Q&A Edition

We also received many questions about Medicare that are not directly related to health reform. This week, we answer one of them. Look for more answers in the coming weeks.

I am turning 65, and I have applied for Medicare Part A. I am still working and am covered in full by my employer insurance. Should I enroll in Part B?

—Mr. T

Dear Mr. T,

If you are 65 or older and there are fewer than 20 employees in the company you work for, Medicare is your primary coverage. If you have not yet enrolled, you should enroll in Medicare Part B during your Initial Enrollment Period. If you decline Part B, neither Medicare nor your job coverage (with limited exceptions) will pay for your doctors' services and other medical care.

If you are 65 or older and there are 20 or more employees in the company you work for, your employer’s group health plan is your primary insurer. You do not need to enroll in Medicare if you are satisfied with your coverage.

In either case, you qualify for a Special Enrollment Period, which means you can delay enrollment in Part B without penalty if you were covered by employer health insurance through your or your spouse’s current job when you first became eligible for Medicare. You can enroll in Medicare without penalty at any time while you have group health coverage and for eight months after you lose your group health coverage or you (or your spouse) stop working, whichever comes first.

Learn more about enrolling in Medicare with employer insurance at www.MedicareInteractive.org.

Spotlight

In a recent blog post, the Commonwealth Fund cautioned against deficit-cutting proposals that focus on reducing federal health spending without considering the impact those reductions might have on consumers, or without addressing the underlying problem of health care spending overall.

Read the blog post.