Your Weekly Medicare Consumer Advocacy Update
Testimony Highlights Complex Medicare Coverage Rules for Hospital Stays
Medicare Rights Submits Testimony on Current Hospital Issues in Medicare
This week, the Medicare Rights Center submitted written testimony to the US House Committee on Ways & Means, Subcommittee on Health for a recent hearing entitled: “Current Hospital Issues in the Medicare Program.” In the prepared testimony, Medicare Rights argues that a range of complex Medicare coverage rules for hospital stays can be difficult to navigate and taxing for people with Medicare. The growing use of observation status, allowable hospital rebilling practices, and the currently delayed “two midnights” policy are three policies pertaining to Medicare hospital stays that are particularly challenging for beneficiaries.
As reflected by the experiences shared by callers to the Medicare Rights helpline, much can be done to improve policies concerning hospital stays for older adults and people with disabilities. Medicare Rights urges Congress to pass H.R. 1179 and S. 569—to count time spent in observation status towards post-acute Medicare coverage for skilled nursing care. In addition to this legislation, reforms are needed to improve beneficiary notice and appeals related to observation status as well as to ease the burden of higher cost sharing for routine medicines administered during outpatient hospital stays.
Medicare Rights also urges Congress and the Centers for Medicare & Medicaid Services (CMS) to revisit the agency’s current policies related to beneficiary liability for hospital rebilling of denied Part A claims. People with Medicare should be held harmless from higher cost sharing associated with hospital rebilling that occurs months following a hospital discharge.
Finally, the time-based, arbitrarily defined “two midnights” rule for assessing patient status fails to facilitate transparent communications by hospitals and health care providers to beneficiaries about their status and cost sharing responsibilities. Medicare Rights urges CMS to reach out to both beneficiaries and especially clinicians, who are experienced in emergency medicine, geriatrics, and inpatient hospital care, to advise on how policies related to observation status can be modified or altered to better address beneficiaries’ needs.
Proposed Legislation Protects Beneficiaries from Charges after Receiving Colon Cancer Screening
This month, Senator Sherrod Brown (OH) proposed legislation to protect older Americans receiving colon cancer screenings from “unfair” costs when their screening becomes diagnostic. The Removing Barriers to Colorectal Cancer Screening Act aims to improve the preventive care landscape by ensuring that colon cancer screenings that become diagnostic remain cost free. Medicare covers colon cancer screenings as preventive care as well as annual mammograms, heart disease screenings, flu shots, and others. Thanks to the Affordable Care Act (ACA), most preventive care is covered without cost sharing for people with Medicare; however, if a preventive screening (like a colonoscopy) requires a physician to intervene, the screening becomes diagnostic and the beneficiary must pay a copay or coinsurance for both the screening and the intervention.
The best example of a free colon cancer screening becoming diagnostic is when a polyp is discovered and removed during a preventive colonoscopy. In many cases, removing a cancerous polyp prevents colon cancer from forming or spreading. When a polyp is removed, the patient is charged cost sharing for procedure to remove the polyp. If no polyp is removed, the very same screening would otherwise be free of cost sharing.
Senator Brown believes that this discrepancy discourages Medicare beneficiaries from following through with preventive colon cancer screenings, which could have catastrophic consequences. “Colorectal cancer is the third leading cause of cancer death in the country,” Brown said. “But too many seniors who go in expecting a free, preventive screening, wake up to an unexpected and significant bill.” The senator went on to say that over 60 percent of colon cancer deaths could be prevented through colonoscopies and other colorectal cancer screening measures. He hopes this new legislation encourages people with Medicare to seek out preventive colon cancer screenings.
Volume 5, Issue 22
Medicare covers many preventive services. As long as you meet basic eligibility standards, you have the right to receive these services no matter if you have Original Medicare or a Medicare Advantage plan (Medicare private health plan).
If you have Original Medicare you will have no coinsurance or deductible for certain preventive care services recommended by the U.S. Preventive Services Task Force if you see a doctor or other health care provider who accepts assignment. Doctors who accept assignment cannot charge you more than the Medicare approved amount.
Although the preventive services itself may be free, you may be charged additional fees for certain services related to preventive care.
- You may have costs for some of these preventive services if your doctor makes a diagnosis during the service or does additional tests or procedures. Doctors do diagnostic tests and procedures when patients have distinct symptoms of a condition or a history of that condition. For example, if your doctor finds and removes a polyp during a colonoscopy, the colonoscopy is diagnostic and costs will apply. Also, if during your annual wellness visit, your doctor needs to investigate or to treat a new or existing problem, costs may apply.
- You may have to pay a facility fee depending on where you receive the service. For example, certain hospitals will often charge separate facilities fees when you are receiving a preventive service.
- You may be charged for a doctor’s visit if you meet with a physician before or after the service.
If you are in a Medicare Advantage plan, your plan will not be able to charge you for preventive care services that are free for people with Original Medicare as long as you see in-network providers. If you see providers that are not in your plan’s network, charges will typically apply.
Original Medicare still requires its normal deductible and/or a 20 percent coinsurance for some preventive services. Some of these services are glaucoma screenings, diabetes self-management trainings, barium enemas (to detect colon cancer), and digital rectal exams (to detect prostate cancer).
Be sure to follow the Medicare guidelines for receiving these services in order to ensure that Medicare will cover them since some are covered only once every few years and others are only covered if you meet specific criteria.
This week, Marilyn Moon, the Director of the Center on Aging at the American Institutes for Research (AIR) and a member of Medicare Rights’ board of directors, accepted the 2014 Robert M. Ball Award for Outstanding Achievements in Social Insurance. This award is given out every year by the National Academy of Social Insurance (NASI) to an individual who has made a significant impact on the social insurance system in the United States.
According to NASI, Dr. Moon is being honored for her “extraordinary record of public service and effectiveness in furthering public understanding of Medicare and its role in our nation’s social insurance system, including its interaction with Medicaid and Social Security.”
Medicare Rights congratulates Dr. Moon on this honor and thanks her for her ongoing dedication to strengthening Medicare and other social insurance programs.