Your Weekly Medicare Consumer Advocacy Update
New Report Recommends Ways to Improve the Medicare Enrollment System
Medicare Rights Center Identifies Pitfalls and Problems with Enrolling in Medicare Part B
This week, the Medicare Rights Center released a report detailing common enrollment challenges facing people new to the Medicare program. As the Baby Boom generation ages into Medicare, an estimated 10,000 people become Medicare eligible each day, while an increasing share of older adults are delaying retirement beyond age 65.
In the report, Medicare Part B Enrollment: Pitfalls, Problems and Penalties, a compelling story is shared by a caller to the Medicare Rights Center helpline. Believing that he had adequate health coverage when he turned 65, the caller chose to delay enrolling in Medicare Part B. Unwittingly—and based on confusing information received from his health plan—he made a choice that caused him to be without adequate health coverage and will require him to pay a lifetime premium penalty for Medicare Part B. Unfortunately, this caller is not alone. In 2012, 740,000 beneficiaries were reported to be paying Part B late enrollment penalties.
The report recommends that Congress, the Social Security Administration and the Center for Medicare & Medicaid Services prioritize key solutions to simplify Medicare enrollment and ensure that fewer people make costly enrollment mistakes, including:
- Enhancing notification and education for people new-to-Medicare.
- Reforming the Medicare enrollment periods to eliminate needless gaps in the start of health coverage.
- Strengthening avenues for relief, giving greater opportunity for retroactive enrollment and the elimination of premium penalties.
- Conducting more research on how many people are affected by Medicare enrollment challenges and how many will be potentially affected in the future.
Medicare Rights Center Comments on Quality Ratings and Sociodemographic Status
Earlier this month, the Medicare Rights Center (Medicare Rights) responded to a Request for Information (RFI) issued by the Centers for Medicare & Medicaid Services (CMS) regarding the enrollment of low-income beneficiaries in Medicare Advantage (MA) and Part D plans as well as lower Star Ratings in some of those plans. Medicare Rights commented on whether MA and Part D plans’ Star Ratings—scores that can be used to show the quality of care a plan provides its enrollees—should be risk adjusted based on sociodemographic (SDS) characteristics (such as low-income status) of their enrollees.
According to Medicare Rights, proposals to risk adjust, or modify plans’ Star Ratings based on enrollees’ SDS factors should be considered very cautiously, and only after a data-oriented review conclusively links low-income beneficiaries’ enrollment in MA and Part D plans to plans’ lower Star Ratings.
In its comments, Medicare Rights asks “CMS to carefully consider…potential pitfalls as it evaluates whether SDS risk adjustment is appropriate for the Star Ratings Program.” Medicare Rights is concerned that risk adjusting plans’ Star Ratings based on SDS could:
- “[M]ask existing disparities in care for low-income beneficiaries enrolled in plans that primarily serve disadvantaged populations, rather than expose and address these disparities. …This type of adjustment to Star Ratings may allow unequal quality standards for low-income patients versus wealthier patients.”
- Risk adjusting Star Ratings based on SDS factors could also “raise performance status from ‘standard’ to ‘average’ or from ‘average’ to ‘good,’ without actually making any improvements in the quality of care,” enrollees receive.
Data has shown that disadvantaged patients may be more likely to receive poor quality health care. These data, however, do not conclusively indicate that “substandard care is caused or precipitated by the actions or circumstances of patients,” with low incomes and other SDS factors. Even if CMS were to risk adjust Star Ratings, the agency’s ability to do that successfully could be limited by the difficulty associated with collecting and applying data related to SDS factors.
Making changes to the Star Ratings program could also halt improvements in plan quality that the current Star Ratings program appears to be influencing. According to an Avalere report on CMS’ quality data, “approximately 60 percent of MA enrollment is in four or five star plans, in increase from 53 percent of beneficiaries enrolled in four or five star plans in 2014.”
Volume 5, Issue 45
There are a number of ways to get coverage to fill gaps in Medicare or to get assistance with Medicare costs:
- Employer Insurance: If you or your spouse is still working, and you have insurance through that job, it will work with Medicare to cover your health care costs. You should know whether your employer insurance is primary or secondary to Medicare. Primary insurance is health insurance that pays first on a claim for medical and hospital care. Secondary insurance pays after primary insurance.
- Retiree Insurance: Some employers provide health insurance to retirees and their spouses to fill in the gaps of Medicare coverage. Retiree insurance always pays secondary to Medicare.
- Supplemental Insurance (Medigap): Insurance that you can buy from a private insurance company to fill in the gaps in Original Medicare coverage by paying for your Medicare deductibles, coinsurances and copayments. Premiums vary, depending on the plan you choose and the company you buy it from.
- Medicare Advantage: You can also get your Medicare benefits through a Medicare Advantage plan (such as an HMO or PPO). These plans contract with the government to provide Medicare benefits. They must provide at least the same set of benefits offered by Original Medicare, but may have different rules, costs and restrictions.
The Centers for Medicare & Medicaid Services (CMS) recently issued a draft decision memo outlining coverage for a new preventive service for lung cancer screening using a low-dose computed tomography scan. According to the proposed decision, those eligible for coverage of this preventive service should be:
- Enrolled in Medicare;
- Between 55 to 74 years old;
- A current smoker or has quit smoking in the last 15 years; and
- Showing no signs of lung disease.
Eligible beneficiaries should also have at least “30 pack-years” of tobacco smoking history. One pack-year is defined by CMS as smoking one pack, or 20 cigarettes, per day for one year.
CMS is currently seeking comments on the proposed decision.