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Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

Critical Benefit for People with Medicare at Risk

December 12, 2013

The Fate of the QI Benefit up in the Air as Congress Weighs “Doc-Fix” 

Today, both the Senate Finance Committee and the House Committee on Ways & Means considered legislation to permanently repeal and replace the Sustainable Growth Rate (SGR) formula. Without Congressional action, the SGR calls for sizable cuts to Medicare reimbursements to physicians and other providers. For the last decade, Congress has acted on an annual basis to avert these drastic cuts, commonly known as the “doc-fix.”

The legislation considered today would gradually transition Medicare to a system where doctors are paid on the basis of the value of care provided, as opposed to the volume of services ordered. Medicare Rights Center supports transitioning to a reformed payment system that emphasizes value—essentially better quality care at a lower price.

Yet, Medicare Rights remains deeply concerned about the future of critical Medicare benefits annually extended alongside the annual SGR patch. Critical among these is the Qualified Individual (QI) program. The QI benefit covers the cost of the Part B premium for Medicare beneficiaries with limited incomes, from about $14,000-$15,500 a year, and less than $7,080 in assets. Amounting to about $105 per month in 2013, this vital assistance helps vulnerable seniors and people with disabilities afford health care costs and other basic needs that they might otherwise go without.

Legislation approved by the House Committee on Ways & Means earlier today does not yet address the QI program and other extender programs, while the Senate Finance Committee framework only extends the QI program through 2018. Earlier this week, 112 organizations, including Medicare Rights, urged members of Congress to ensure QI is made permanent alongside a permanent SGR fix.

In addition to leaving concerns regarding critical extender programs unresolved, the House and Senate Committees have yet to address how the SGR repeal and replacement policy will be paid for. As these negotiations move ahead, Medicare Rights urges Congress not to shift added costs to people with Medicare.

Read a letter in support of QI to the Senate.

Read a letter in support of QI to the House.

New KFF Issue Brief Shows High Majority of People with Medicare have Good Access to Doctors

According to a new issue brief released by the Kaiser Family Foundation (KFF), 96 percent of Medicare beneficiaries say they have a “usual source of care” at a doctor’s office or clinic. Many have speculated about the number of doctors accepting Medicare, largely due to the looming annual threat of cuts to Medicare physician reimbursements. In order to evaluate patient access to physicians, the brief looks at results from patient and physician surveys, published studies, and physician data from Medicare.

In addition to a high rate of beneficiaries reporting good access to physicians, the brief also finds that about 90 percent of people with Medicare are able to schedule timely appointments with their doctors, and they are more likely than adults age 50 to 64 in private plans to report “never” having to wait longer than they would like for routine care. Only two percent of people with Medicare say they have issues finding a physician when they need one.

On the physician side, survey data shows that 91 percent of non-pediatric physicians take new Medicare patients; however, the data also shows that physician acceptance of new Medicare patients varies across states and may be related more to circumstances in each market than to issues with the Medicare program overall. However, less than one percent of physicians in clinical practices have stopped taking Medicare, with physiatrists making up 42 percent of “opt-out” doctors.

Read the issue brief.

Volume 4, Issue 47

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Medicare Reminder

Your costs can be significantly impacted by what doctor you visit. The rules to follow differ if you have your coverage through Original Medicare or a Medicare Advantage plan.

If you have Original Medicare, you want to make sure you go to a doctor who accepts Medicare. There are two types of doctors who accept Medicare – participating providers and non-participating providers. Participating providers accept Medicare and accept the amount that Medicare approves for a service as full payment, which is called accepting assignment. They also agree to charge you no more than the Medicare coinsurance, which is usually 20 percent. Non-participating providers are providers who accept Medicare, but who don’t accept the amount Medicare approves as full payment. This doctor is allowed to bill you the 20 percent coinsurance you typically owe, plus up to 15 percent extra. Some doctors do not accept Medicare at all. These are called opt-out providers. You will have to pay for the full cost of any services you receive from an opt-out provider. With Original Medicare, you will usually pay the least if you go to a participating provider, also known as a doctor who accepts Medicare assignment.

If you have a Medicare Advantage plan, you will pay the least if you only go to doctors in your network. Depending on your plan’s rules, you may receive little or no coverage if you go to a doctor who is out-of-network. Contact your Medicare Advantage plan to find out its specific cost and coverage rules.

Read more about how Original Medicare covers outpatient doctor visits on Medicare Interactive.



A recent Gallup poll shows that 30 percent of Americans delay treatment due to high medical costs. Those who have no insurance are more than twice as likely to delay treatment as those with Medicare, Medicaid or private insurance. Further, those least likely to have insurance—younger Americans aged 19 to 29 and those with lower incomes—are considerably more likely to put off treatment than older, wealthier Americans.

As the Affordable Care Act rolls out, most Americans will be required to purchase insurance in 2014 or pay a fine in the form of a tax. According to additional polling data, most uninsured Americans say they will get insurance, which should reduce the amount of people delaying treatment.

View the poll results.


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Get answers to your Medicare questions from Medicare Interactive at www.medicareinteractive.org.

© 2013 by Medicare Rights Center. All rights reserved.

For reprint rights, please contact Mitchell Clark.