Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

Balance Billing Explained in New Toolkit

February 25, 2016

New Justice in Aging Toolkit Helps Explain Balance Billing

This week, Justice in Aging, a non-profit organization focused on fighting senior poverty, released a toolkit to help people with Medicare and the professionals who assist them understand balance billing. Balance billing happens when doctors and hospitals charge you more than the amount approved by Medicare.

Balance billing is an issue low-income people with Medicare face, and as Justice in Aging explains, people who have both Medicare and Medicaid or the Qualified Medicare Beneficiary (QMB) Medicare Savings Program are protected under federal law from balance billing for services covered under Medicaid or Medicare.

According to Justice in Aging, “As more and more patients move to [Medicaid] managed care plans, balance billing may increase due to doctor and hospital confusion.” It is important for people to understand what balance billing is and how to recognize it.

For more information about balance billing, including fact sheets, webinars, and template letters to use when communicating with your providers, visit Justice in Aging’s website.

Kaiser Family Foundation Releases Primer on Alternative Payment Models and Medicare

Delivery system reforms—changes to the way health care is provided and paid for—look to address concerns about rising costs, quality of care, and inefficient spending underway in the Medicare program. The Affordable Care Act (ACA) recently established initiatives to identify and test new health care payment models in the program. These include medical homes, accountable care organizations (ACOs), and bundled payments.

This week, the Kaiser Family Foundation (KFF) released a primer describing these models, which affect about 10 million people with Original Medicare all together. KFF describes each models’ goals, financial incentives, size, and potential beneficiary implications. It also summarizes early results with respect to Medicare savings and quality.

KFF reports that preliminary results are somewhat mixed, with some models showing more promise than others. The report also finds that though many of the models are meeting quality targets and showing improvements in quality of care, to date, overall net savings to Medicare are relatively modest.

Visit to read the full primer and learn more about delivery system reforms being tested in Medicare.

Volume 7, Issue 7

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Medicare Reminder

If your Medicare Advantage plan (Medicare private health plan) or Medicare prescription drug plan makes any changes during the plan year they must notify you.

Network provider changes:

Most Medicare Advantage plans have networks of doctors, hospitals and other providers. You typically pay less if you see providers that are in your plan’s network. Most people can only change their plan once a year during the Fall Open Enrollment Period, but providers can leave a plan’s network at anytime.

When a provider is leaving a plan’s network, the plan must try and send all the plan members who use that provider a written notice at least 30 days before the provider leaves the network.

Mid-year formulary changes:

If your drug plan makes changes to its formulary during the year, you have certain rights depending on why the plan made the change.

If a drug is declared unsafe by the Food and Drug Administration (FDA) a plan can remove the drug from their formulary at anytime. When a drug is removed by the FDA the plan must notify anyone who might be affected.

If the plan is making maintenance changes, they must give you 60 days notice or provide you with a 60 day transition fill. Maintenance changes include covering a generic drug instead of a brand-name drug or adding quantity limits for drugs that the FDA adds warnings to, and making formulary changes based on clinical best practices and safety concerns.

If your plan is making non-maintenance changes, which is any other change, and you are already taking the drug you must be allowed to continuing taking that drug for the rest of the year as long as it is medically necessary. Your plan must also send you a notification in the mail stating that the drug is no longer on their formulary but it will be covered for you for the rest of the year.

When a plan makes any of these changes they are required to update both the online and print version of their formulary. If you are going to be affected by any of the changes to your plan’s formulary, they must send you a copy of the updated formulary in the mail.

Learn more at



Last week, the Leadership Council of Aging Organizations (LCAO) held a national forum featuring Senator Bernie Sanders and former Virginia Congressman Tom Davis, a representative from the presidential campaign of Governor John Kasich.

The forum, Seniors Decide, provided an opportunity for  presidential candidates to speak about many issues facing older adults and their families, including Medicare, Social Security, caregiving, and long-term care.

Read this Next Avenue article for a summary of the forum.


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