Your Weekly Medicare Consumer Advocacy Update
Medicare Rights Sheds Light on Common Beneficiary Challenges
New Report from Medicare Rights Details Common Challenges Faced by Helpline Callers
Today, the Medicare Rights Center released its first-ever report outlining the top concerns facing people with Medicare as told through the thousands of compelling stories heard on Medicare Rights’ national helpline.
The report, Medicare Trends and Recommendations: An Analysis of 2012 Call Data from the Medicare Rights Center’s National Helpline, includes an analysis of Medicare Rights’ 2012 national helpline data. Out of more than 14,000 questions posed by older adults and people with disabilities, their family members and the professionals serving them, three trends stood out among the questions posed by helpline callers:
- Affording coverage and care: Half of all Medicare beneficiaries live on less than $23,500 a year, yet Medicare households devote 14 percent of their budgets to health care, compared with just 5 percent among non-Medicare households.
- Transitioning into the Medicare program: Insufficient or inaccurate information can lead to late enrollment penalties, gaps in coverage, strained finances and delayed treatment for many people who are newly eligible for Medicare.
- Appealing denials of coverage: The lack of clear information, inefficient appeals systems, and changing coverage rules from year to year present barriers to accessing needed medical care.
Drawing directly from Medicare Rights’ almost twenty-five years of experience serving people with Medicare and their families, the report includes a comprehensive set of policy recommendations intended to improve access to affordable health coverage for beneficiaries. Among these are expanded access and automatic enrollment in Medicare low-income assistance programs, more streamlined and accessible appeals processes, improved communications for people transitioning into Medicare, and more.
GAO Examines Impact of Continuous Coverage Prior to Enrolling in Medicare
The US Government Accountability Office (GAO) recently published a report that examines how continuous health insurance before enrolling in Medicare relates to a beneficiary’s reported health status and use of medical services. The study included only people who were eligible for Medicare due to age, not people who were eligible due to disability. It examines the time span from six years before someone was eligible for Medicare to six years after someone had Medicare.
GAO found that people with prior continuous insurance reported being in better health throughout their first six years on Medicare. Additionally, they had lower Medicare spending during their first year on Medicare, translating to approximately $2,300 less in Medicare spending in their first year of coverage.
The study also found that beneficiaries with continuous prior insurance had less institutional outpatient care (e.g., hospital outpatient care) than those who did not during their first two years of Medicare coverage. Those with and without prior continuous insurance had similar noninstitutional outpatient care spending (e.g., physicians and labs) at first. However, beneficiaries with prior continuous insurance surpassed their counterparts in noninstitutional outpatient spending in the fourth and fifth year. This coincides with the finding that those with prior continuous insurance having more physician office visits during the first five years on Medicare.
GAO’s report suggests that beneficiaries with prior insurance are in better health and use fewer or less expensive Medicare services during their first years on Medicare. The care spending and usage patterns also suggest that people with and without prior continuous insurance may access healthcare in different ways. Overall, GAO’s report shows that, while Medicare can help those who are 65 and older access the care they need, their health status and use of services can be largely impacted by their health insurance status prior to Medicare.
Volume 5, Issue 3
If you switched your Part D prescription drug plan during Fall Open Enrollment or if your Part D plan changed its coverage rules, you are eligible for a transition refill. A transition refill is a one-time 30-day supply of a drug that Medicare drug plans must cover. Transition refills let you get temporary coverage for drugs that aren’t on your plan’s list of covered drugs (formulary) or that have restrictions on them. If you are requesting a transition refill, you must do so within the first 90 days of the year.
All Medicare Part D drug plans must cover transition refills. The rules apply to both Medicare Advantage plans that include drug coverage and Medicare stand-alone drug plans. However, transition refills aren’t for new prescriptions. You can only get them for drugs you were already taking before switching plans or before your existing plan changed its coverage.
If you get a transition refill, you should call your doctor right away to talk about switching to a drug that is on your plan’s formulary without restrictions. If no other drug will work for you, ask your doctor for help requesting an exception to your Medicare Part D drug plan’s formulary. Requesting an exception means to formally ask the plan to cover your drug.
As Congress seeks to permanently repeal and replace the sustainable growth rate formula (SGR), the formula used to control Medicare payments to physicians, Kaiser Health News recently released a Q&A answering common questions about the SGR and the various proposals that would replace the current formula with a system that rewards doctors based on the quality of care rather than the quantity of care. Some of the questions include:
- What is the sustainable growth rate?
- What is Congress doing to scrap the SGR and what would they replace it with?
- What do doctors say about the SGR?
- Will repealing and replacing the SGR change the way physicians treat Medicare patients?
- When is Congress expected to act?