Medicare Watch

Medicare Rights Center Submits Testimony on Care Integration for Dual-Eligibles

This week, the Medicare Rights Center submitted testimony to the U.S. Senate Special Committee on Aging in response to a recent hearing on state demonstrations designed to test managed care models for dual-eligibles, or beneficiaries enrolled in both Medicare and Medicaid. Thanks to the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) is implementing a multi-state demonstration intended to enhance the quality of care for dually eligible individuals and achieve cost savings in both the Medicare and Medicaid programs.

In its testimony, Medicare Rights voiced support for the effort to improve care for the dual-eligible population, but expressed concerns about the size and scope of the projects, as well as the timelines associated with creating, approving and implementing these proposals. The testimony also highlights best practices for rolling out state demonstrations, based on the experiences of New York State thus far.
 
Five New York-based organizations representing older adults and people with disabilities joined Medicare Rights in identifying three practices worth replicating in other state-based demonstrations. The practices include allowing existing care models to function alongside demonstration models, appointing an ombudsman to protect dually eligible individuals affected by the demonstrations, and involving stakeholders in the creation and implementation of the demonstrations.

Read Medicare Rights’ testimony.

New Kaiser Report Compares Premium Support Proposals

This week, the Kaiser Family Foundation (KFF) released a report comparing policy proposals that would transform Medicare as we know it into a voucher, or premium support, program. In the context of recent deficit-reduction debates, policymakers have proposed reducing federal spending on Medicare and other public programs. Several of their proposals intend to end Medicare as it currently exists, replacing Medicare’s guaranteed benefits with a capped voucher. The Kaiser report provides a side-by-side comparison of five such premium support proposals and the current Medicare program.

According to the Kaiser report, most of the premium support proposals would provide beneficiaries with a voucher from the federal government that they could use to purchase Original Medicare or health insurance from a private plan. The private plan’s benefits would be actuarially equivalent to those offered under Original Medicare. However, the majority of the proposals discussed in the Kaiser report would not guarantee that private plans include a standardized set of benefits, or the same benefits as Original Medicare provides. Additionally, four of the five proposals would not require private plans to limit out-of-pocket spending for beneficiaries, which is currently a requirement for Medicare private health plans, also known as Medicare Advantage plans.

The proposals vary widely in their protections for people who are eligible for both Medicare and Medicaid, also known as dual-eligibles. Two of the proposals would provide premium and cost-sharing assistance for dual-eligibles either through Medicaid or Medical Savings Accounts (MSAs). However, the proposals do not specify when Medicaid would cover out-of-pocket expenses, and when or how MSAs would cover these costs. One of the proposals, part of Congressman Paul Ryan’s House budget for 2013, would provide federal Medicaid payments, including payments for dual-eligibles, to states in a block grant. The proposal would cut Medicaid to a point where states would likely be forced to reduce coverage, restrict eligibility, and increase costs to beneficiaries, resulting in reduced access to care.

According to the Kaiser report, these premium support proposals assume that competition between private plans, or between private plans and Original Medicare, would be the primary mechanism for achieving savings. However, analysis shows that these proposals would shift significant costs to Medicare beneficiaries. Over time, the vouchers provided to older adults and people with disabilities would be insufficient to purchase health coverage as good as that which Medicare currently provides. As a result, people with Medicare, half of whom live on annual incomes of $25,000 or less, and who, on average, already spend 15 percent of their incomes on health care costs, would be required to make up the difference with their own money. Policies that aim to save money in the Medicare program should be based on solutions that preserve access to affordable health care and protect beneficiaries from shouldering even more health care costs.

Medicare Reminder

Medicare Part B usually covers outpatient doctor’s visits to diagnose or treat a medical condition at 80 percent after you have met your Part B deductible. There are a couple of things you can do if you believe that Medicare should pay for a service that it is denying. 

First, find out if it is possible that there was a billing mistake. You may not need to challenge Medicare if the service was billed incorrectly. Medicare uses a set of codes for processing medical claims. Each medical service is given a specific code. Sometimes doctors’ offices or hospitals accidentally use the wrong codes when filling out Medicare paperwork. This can result in Medicare denying the service. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct codes. Your doctor's billing office can call 800-MEDICARE to get in touch with the company that processes Medicare claims (carrier or intermediary). If the wrong code was used, ask your doctor to resubmit the claim with the correct code.

If your doctor’s office does not think there was a billing problem or is unwilling to re-submit the bill to Medicare, your next step is to appeal. Appealing to Medicare is simple and most people win their appeals in the early stages. To appeal a denial, circle the service you want to appeal on your Medicare Summary Notice (MSN), write "Please Review" on the bottom and sign the back. Make a copy for your files. Then mail the signed original to Medicare at the address on the MSN. Make sure you mail your appeal within 120 days of receiving the MSN. It’s very important to get a letter of support from your doctor or other health care provider that explains why you needed the service. Send this with your MSN. You should keep photocopies and records of all communication, whether written or oral, with Medicare concerning your denial. Send your appeal certified mail or delivery confirmation.

There four additional levels of appeals you can use if Medicare still will not pay for services. There are four additional levels of appeals you can use if Medicare will still not pay for services. Click here for a full timeline of Original Medicare appeals.  
Remember, you cannot appeal to Medicare to cover services that are never covered. For example, you can never ask Medicare to cover more than 100 days in a skilled nursing facility.

For more information, visit www.medicareinteractive.org or call our helpline at 800-333-4114.

Spotlight

Earlier this month, the Medicare Rights Center joined 33 national aging and disability rights organizations in submitting a comprehensive set of recommendations to the Centers for Medicare and Medicaid Services’ (CMS’) Medicare-Medicaid Coordination Office (MMCO). The recommendations address the integration of dual-eligibles, or people with both Medicare and Medicaid, in state-based managed care demonstrations.

The letter brings to light a number of areas in which state demonstration proposals lack necessary detail, including those of beneficiary education, plan capacity and benefit adequacy. Medicare Rights will continue working with its national partners and CMS to address these issues as the demonstrations unfold.

Read the consumer recommendations and sign-on letter.