Category Archives: Medicare

There’s Still Time to Go Back to Traditional Medicare or Change MA Plans

February 27, 2019

Annual Enrollment has ended, but the Medicare Advantage Open Enrollment Period, allowing plan changes or a return to traditional Medicare continues through March 31 – Make sure you are fully informed about the Medicare that is right for you.

When?

  • January 1–March 31

What Can I Do?

  • If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage).
  • You can disenroll from your Medicare Advantage Plan and return to Original Medicare. If you choose to do so, you’ll be able to join a Medicare Prescription Drug Plan.
  • If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without drug coverage) within the first 3 months you have Medicare.

What Can’t I Do?

  • Switch from Original Medicare to a Medicare Advantage Plan.
  • Join a Medicare Prescription Drug Plan if you’re in Original Medicare.
  • Switch from one Medicare Prescription Drug Plan to another if you’re in Original Medicare.

Get Medicare’s New, And First Official, “What’s Covered” App!

February 27, 2019

Is your medical item or service covered by Medicare Part A and/or Part B? Now there’s a quick way to check!

Medicare’s free “What’s Covered” app delivers accurate cost and coverage information right on your smartphone. Now you can quickly see whether Medicare covers your service in the doctor’s office, the hospital, or anywhere else you use your phone. The “What’s Covered” app is the only official U.S. government Medicare app.

The app delivers general cost, coverage and eligibility details for items and services covered by Medicare Part A and Part B.  Search or browse to learn what’s covered and not covered; how and when to get covered benefits; and basic cost information. You can also get a list of covered preventive services.

The “What’s Covered” app helps you understand the health care coverage offered by Original Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).

Use this federal government app to:

  • Get answers to your Medicare coverage questions
  • See how much you’ll pay
  • Learn about the covered items and services
  • See helpful notes and where to get more information
  • Browse free preventive services

Original Medicare Items & Services: Find out exactly what your Medicare coverage has to offer by getting answers to questions like:

  • When are mammograms covered?
  • Are specialists or home health care covered?
  • Will Medicare pay for crutches, walkers, or diabetes testing supplies?

Preventive Health Coverage: Medicare coverage includes many common preventive services at no cost to you. Preventive services can help keep you healthy by finding health problems early, when treatment works best, and can keep you from getting certain diseases.

What’s covered will help you answer questions like:

  • Will my Medicare benefits cover a service to help me stop smoking?
  • Can I get a regular cervical cancer screening?
  • How often will my Medicare coverage allow me to get a bone mass measurement?
  • Ask your doctor or other health care provider which preventive services (like screenings, shots, and tests) you need to get.

Part A & Part B Costs: Medicare Part A and Part B cover certain medical services and supplies in hospitals, doctors’ offices, and other health care settings.

Part A hospital insurance coverage helps pay for inpatient care in a hospital, inpatient care in a skilled nursing facility, hospice care, home health care, or inpatient care in a religious non-medical health care institution. Copayments, coinsurance, or deductibles may apply for each service covered by Part A.

Part B medical insurance coverage supports medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, mental health services, preventive services, and other medical services. Under Original Medicare, if the Part B deductible applies, you must pay all health care costs (up to the Medicare-approved amount) until you meet the yearly Part B deductible. After your deductible is met, Medicare begins to pay its share and you typically pay 20% of the Medicare-approved amount of the service, if the doctor or other health care provider accepts assignment. There’s no yearly limit for what you pay out-of-pocket.

For some items and services, you must meet eligibility criteria or you may be responsible for paying all costs. Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Use the “What’s Covered” app to answer questions like:

  • How much will I pay for prescription drugs included in Medicare Part B coverage?
  • Does the Part B deductible apply for cardiac rehabilitation?
  • What percentage of the Medicare-approved amount will I need to pay for colorectal cancer screenings?

Medicare Advantage Plans: If you have a Medicare Advantage Plan or other Medicare health plan, you have the same basic health care coverage as people who have Original Medicare, but the rules vary by plan. Some Medicare Advantage Plans offer extra benefits that Original Medicare doesn’t cover – like vision, hearing, or dental. Check with the plan or search in the App Store to see if the plan has a similar mobile application.

Download Medicare’s official “What’s Covered” app — available for free in both the Apple App Store and Google Play.    The “What’s Covered” is part of the agency’s eMedicareinitiative—launched in 2018—which is aimed at empowering beneficiaries with cost and quality information.

Key Elder Law Numbers for 2019: Our Annual Roundup

February 4, 2019

Below are figures for 2019 that are frequently used in the elder law practice or are of interest to clients.

Medicaid Spousal Impoverishment Figures for 2019

The new minimum community spouse resource allowance (CSRA) is $25,284 and the maximum CSRA is $126,420. The maximum monthly maintenance needs allowance is $3,160.50. The minimum monthly maintenance needs allowance remains $2,057.50 ($2,572.50 for Alaska and $2,366.25 for Hawaii) until July 1, 2019.

Medicaid Home Equity Limits

Minimum: $585,000

Maximum: $878,000

For CMS’s complete chart of the 2019 SSI and Spousal Impoverishment Standards, click here.

Income Cap

The income cap for 2019 applicable in “income cap” states is $2,313 a month.

Gift and estate tax figures

Federal estate tax exemption: $11.4 million for individuals, $22.8 million for married couples

Lifetime tax exclusion for gifts: $11.4 million

Generation-skipping transfer tax exemption: $11.4 million

Annual gift tax exclusion: $15,000 (unchanged)

Long-Term Care Premium Deductibility Limits for 2019

The Internal Revenue Service has announced the 2019 limitations on the deductibility of long-term care insurance premiums from income. Any premium amounts above these limits are not considered to be a medical expense.

Attained age before the close of the taxable year Maximum deduction
40 or less $420
More than 40 but not more than 50 $790
More than 50 but not more than 60 $1,580
More than 60 but not more than 70 $4,220
More than 70 $5,270

Benefits from per diem or indemnity policies, which pay a predetermined amount each day, are not included in income except amounts that exceed the beneficiary’s total qualified long-term care expenses or $370 per day (for 2019), whichever is greater.

For these and other inflation adjustments from the IRS, click here.

Medicare Premiums, Deductibles and Copayments for 2019

  • Part B premium: $135.50/month (was $134)
  • Part B deductible: $185 (was $183)
  • Part A deductible: $1,364 (was $1,340)
  • Co-payment for hospital stay days 61-90: $341/day (was $335)
  • Co-payment for hospital stay days 91 and beyond: $682/day (was $670)
  • Skilled nursing facility co-payment, days 21-100: $170.50/day (was $167.50)

Part B premiums for higher-income beneficiaries:

  • Individuals with annual incomes between $85,000 and $107,000 and married couples with annual incomes between $170,000 and $214,000 will pay a monthly premium of $189.60.
  • Individuals with annual incomes between $107,000 and $133,500 and married couples with annual incomes between $214,000 and $267,000 will pay a monthly premium of $270.90.
  • Individuals with annual incomes between $133,500 and $160,000 and married couples with annual incomes between $267,000 and $320,000 will pay a monthly premium of $352.20.
  • Individuals with annual incomes between above $160,000 and married couples with annual incomes above $320,000 will pay a monthly premium of $433.40.
  • Individuals with annual incomes above $500,000 and married couples with annual incomes above $750,000 will pay a monthly premium of $460.50

High-earner premiums differ for beneficiaries who are married but file a separate tax return from their spouse. Those with incomes greater than $85,000 and less than $415,000 will pay a monthly premium of $433.40. Those with incomes greater than $415,000 will pay a monthly premium of $460.50.

For Medicare’s “Medicare 2019 costs at a glance,” click here.

Social Security Benefits for 2019

The new monthly federal Supplemental Security Income (SSI) payment standard is $771 for an individual and $1,157 for a couple.

Estimated average monthly Social Security retirement payment: $1,461 a month for individuals and $2,448 for couples

Maximum amount of earnings subject to Social Security taxation: $132,900 (was $128,400)

For a complete list of the 2019 Social Security figures, go to: https://www.ssa.gov/news/press/factsheets/colafacts2019.pdf

Understanding Medicare’s Hospice Benefit

February 4, 2019

Medicare’s hospice benefit covers any care that is reasonable and necessary for easing the course of a terminal illness. It is one of Medicare’s most comprehensive benefits and can be extremely helpful to both the terminally ill individual and his or her family, but it is little understood and underutilized. Understanding what is offered ahead of time may help Medicare beneficiaries and their families make the difficult decision to choose hospice if the time comes.

The focus of hospice is palliative care, which means helping people who are terminally ill and their families maintain their quality of life. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs while also supporting the terminally ill individual’s independence, access to information, and ability to make choices about health care.

To qualify for Medicare’s hospice benefit, a beneficiary must be entitled to Medicare Part A, and a doctor must certify that the beneficiary has a life expectancy of six months or less. If the beneficiary lives longer than six months, the doctor can continue to certify the patient for hospice care indefinitely. The beneficiary must also agree to give up any treatment to cure his or her illness and elect to receive only palliative care. This can seem overwhelming, but beneficiaries can also change their minds at any time. It’s possible to revoke the benefit and reelect it later, and to do this as often as needed.

Medicare will cover any care that is reasonable and necessary for easing the course of a terminal illness. Hospice nurses and doctors are on-call 24 hours a day, 7 days a week, to give beneficiaries support and care when needed. Services are usually provided in the home. The Medicare hospice benefit provides for:

  • Physician and nurse practitioner services
  • Nursing care
  • Medical appliances and supplies
  • Drugs for symptom management and pain relief
  • Short-term inpatient and respite care
  • Homemaker and home health aide services
  • Counseling
  • Social work service
  • Spiritual care
  • Volunteer participation
  • Bereavement services

Services are considered appropriate if they are aimed at improving the beneficiary’s life and making him or her more comfortable.

Because the beneficiary is electing palliative care over treatment, there are things the hospice benefit will not cover:

  • Treatment to cure the beneficiary’s illness.
  • Prescription drugs other than for symptom control or pain relief.
  • Care from a provider that wasn’t set up by the hospice team, although the beneficiary can choose to have his or her regular doctor be the attending medical professional.
  • Room and board. If the beneficiary is in a nursing home, hospice will not pay for room and board costs. However, if the hospice team determines that the beneficiary needs short-term inpatient care or respite care services, Medicare will cover a stay in a facility.
  • Care from a hospital, either inpatient or outpatient, or ambulance transportation unless it arranged by the hospice team. The beneficiary can use regular Medicare to pay for any treatment not related to the beneficiary’s terminal illness.

To download Medicare’s booklet on the hospice benefit, click here.

Jason Frank Presses Maryland Senate for “Aging in Place”

January 28, 2019

by Federico Salas, J.D.

On January 17, 2019, the Maryland Senate Finance Committee held a briefing that, among other topics, addressed the Home and Community Based Options Waiver (HCBOW). Jason A. Frank, Esq. specifically discussed the problems with the HCBOW that he expects will be fixed by current proposed legislation that:

  • Ensures that those people who lose Community First Choice services because of aging into Medicare can access the HCBOW and continue to receive services in the community; and
  • Eliminates the 22,000-person HCBOW Registry (waiting list) and serves eligible people who want services directly in the community without first entering a nursing home.

Resources from the Briefing

View the recording of the Senate Finance Committee briefing (presentations on the HCBOW begin at 1:23:00).

Download Mr. Frank’s presentation on Aging in Place (PDF, 24 pages).

Senate Bill 699

This is a summary of SB 699 regarding Maryland’s Community First Choice program:

The Problem

Marylanders who have community Medicaid, including Medicaid Expansion, and get long-term care services through the Community First Choice (CFC) program for as little help as having someone to assist in bathing and dressing at home, will lose all access to services if both: (1) they get Medicare and (2) they have too much income or assets. For individuals in 2019, CFC-Medicaid Expansion enrollees who have a monthly income between $791–$1,396 per month or assets greater than $2,000 are at risk of losing services. The Home & Community Based Options Waiver (HCBOW) program can provide the needed services to Marylanders with disabilities at home, but it has an 8-year, 22,000-person waiting list (“the Registry”).

Currently, there is no way for Marylanders living at home to bypass the 8-year, 22,000-person waiting list and stay at home, except by unnecessarily entering a nursing home. This means that the people who lose CFC when they get Medicare must choose between having to enter a nursing home or go without help for 8 years in order to continue getting the help that they need.

The Solution

Permit certain individuals who are affected, or will be affected, by “the CFC problem” to bypass the 8-year, 22,000-person waiting list in order maintain CFC services WITHOUT having to wait out the 8-year Registry or go through unnecessary and extremely costly nursing home admission just to transfer back out into the community.

Senate Bill 700

This is a summary of SB 700 regarding Maryland’s HCBOW:

The Problem

Most Marylanders who need as little help as having someone to assist them in bathing and dressing—but lack the money to pay for it—must choose between entering a nursing home or going without help for 8 years. The Maryland Medicaid Home & Community Based Services Options Waiver (HCBOW) program can provide the needed services to Marylanders with disabilities at home, but it has an 8-year, 22,000-person waiting list (“the Registry”). The HCBOW has an 8-year-long waiting list because the HCBOW is not required to meet the demand for services.

This year, the HCBOW can serve 5,659 individuals. When the Maryland Department of Health (MDH) readjusts HCBOW program availability every few years, it does not count eligible people on the 8-year, 22,000-person waiting list. In 2016, the MDH actually reduced program availability DESPITE the size of the 8-year, 22,000-person waiting list.

There is no way for Marylanders living at home to bypass the 8-year, 22,000-person waiting list and stay at home, except by unnecessarily entering a nursing home. While on the Registry, registrants are also in the dark for 8 years regarding where they are on the waiting list.

The Solution

  • Require registrants to come off the Registry at a rate that would eliminate the 8-year waiting list within 12 months;
  • Require the HCBOW to meet the projected “demand” for services;
  • Require services to HCBOW-eligible individuals within 30 days; and
  • Provide information for registrants about their exact place on the Registry or when they might expect to receive services.

CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories

December 26, 2018

NAELA News:

  1. Amidst Medicare Open Enrollment, CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories
  2. In Her Own Words: A Beneficiary’s Take On Medicare Advantage Steering
  3. Health Care Sabotage: Administration Doubles Down on States’ Ability to Undermine ACA

Amidst Medicare Open Enrollment, CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories

The Medicare Annual Coordinated Election Period (ACEP) is the most crucial time of year for Medicare beneficiaries to make decisions about how they wish to receive their Medicare coverage.  This year the Administration seems to be actively promoting Medicare Advantage plans. However, at the same time that this steering toward private plans is occurring, the Centers for Medicare & Medicaid Services (CMS) reported that Medicare Advantage  provider directories contain extremely inaccurate information, which could lead beneficiaries to sign up for plans that might not actually include their doctors.

This is CMS’ third round of provider directory review since initially being alerted by a beneficiary complaint. CMS Examined 5602 providers and their listed locations from 52 different Medicare Advantage organizations between November 2017 and July 2018.  Reviewers in the study called provider offices to verify the accuracy of the information in the provider directory. Information to be verified included names, address and phone numbers; whether the provider accepted the MA-PD in question at that location, and whether they accepted new patients with the MA-PD in question. CMS assigned each error a score, with incorrect locations, numbers and statements regarding accepting patients weighted highest.[1]

The CMS review found that:

  • Almost half (48.74%) had at least one inaccuracy.
  • Percentage of inaccuracies by MA organization ranged from 4.63% for the best network listing to 93.02% for the worst.
  • The majority of MA organizations had between 30% and 60% inaccuracies.
  • “Providers should not have been listed at 33.14% (3,481) of the locations…either because the provider did not work at the location or because the provider did not accept the plan at the location.”[2]
  • “85.64% of locations with deficiencies…had deficiencies of the highest weighted, most egregious errors.”[3]
  • 41.75% of all locations listed had inaccuracies “with the highest likelihood of preventing access to care.”[4]

Beneficiaries and caregivers rely on provider directories to make important choices about their care. In this era of overt steering toward Medicare Advantage by the Administration[5], accurate information has never been more crucial. Errors in provider listings “create a barrier to care and raise questions regarding the adequacy and validity of the MAO’s network as a whole.”[6] 

Despite these inaccuracies, according to the Washington Post, “[t]he Trump administration is holding off on punishing Medicare Advantage plans for error-ridden doctor directories — further evidence” that CMS “is showing special favor to the alternative program over traditional Medicare offerings.”[7]  The Post continues: “Last year, the agency threatened to impose fines on the plans if they didn’t clean up their act. While this year’s report shows no substantial improvement overlast year (or the year before that), CMS isn’t following through on the threat [emphasis in original].”


[1] Online Provider Directory Review Report (Centers for Medicare & Medicaid Services) (November 2018), available at: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf, p. 5, table 3.
[2] Id, p. 6
[3] Id, p. 8
[4] Id, p. 1
[5] In addition to previous Center Alerts, see, e.g. “Trump Administration Peppers Inboxes With Plugs for Private Medicare Plans” by Robert Pear, New York Times, (Dec. 1, 2018), available at: https://www.nytimes.com/2018/12/01/us/politics/trump-medicare-advantage-plans.html, and “The Health 202: Trump administration lets Medicare plans off the hook” by Paige Cunningham, (Dec. 4, 2018), Washington Post, available at:  https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/12/04/the-health-202-trump-administration-lets-medicare-plans-off-the-hook/5c058e4b1b326b60d12800f1/?utm_term=.072d2e85242c.
[6]Online Provider Directory Review Report , p. 1
[7] “The Health 202: Trump administration lets Medicare plans off the hook” by Paige Cunningham, (Dec. 4, 2018), Washington Post, available at:  https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/12/04/the-health-202-trump-administration-lets-medicare-plans-off-the-hook/5c058e4b1b326b60d12800f1/?utm_term=.072d2e85242c.

The Democrats Have Won The House. What Will They Do About Medicare For All?

December 26, 2018

By Howard Gleckman

The Democrats won control of the House, largely on the back of health policy. And many members of the caucus have gone on record in favor of what’s come to be known as “Medicare for all.”

The idea is hugely popular, backed by 58 percent of Americans in some polls and up to 70 percent in others. But what does that really mean? And is there a chance that such an idea will become law any time soon?

The last question is the easiest to answer; No. As long as Republicans control the Senate, where they increased their majority on Tuesday, and as long as President Trump remains in the White House, there is zero chance that Americans under age 65 will get access to Medicare.

What is Medicare for all?

But even answering the first question is complicated. It turns out that Medicare for all means many different things to different Democrats. Sometimes it doesn’t really mean Medicare. And it often doesn’t really mean for all.

Instead, the phrase has become short-hand for a wide range of ideas that really mean broader access to public insurance. But the design of that coverage is very different, depending on who you are talking to. The Kaiser Family Foundation has produced a very nice summary of the many plans here.

Start with the most far-reaching: Sen. Bernie Sanders (I-VT) plan to replace the entire health insurance system with a single public plan. No more employer-sponsored health coverage (which currently covers most Americans under age 65), no more Medicaid. No more ACA health exchanges for individuals. In fact, no more Medicare as we know it.  Just a single government payer for all Americans, no matter their age.

Then there is what was called the “public option” during the debate over the 2010 Affordable Care Act. A Medicare-like public plan would be offered on the ACA marketplace alongside private insurance. Individuals and, in some bills, even employers, could purchase coverage. While some backers use Medicare to frame these plans (they are sometimes called Medicare Part E or Medicare-X), they really are not Medicare at all. Their benefits would be different and so would their premiums.

The third variation on the theme, which harkens back at least to the Bill Clinton Administration, is a Medicare buy-in. Unlike the other ideas, this really is Medicare—just made available starting at, say, age 50 or 55. Like today’s Medicare beneficiaries, enrollees could choose traditional Medicare, Medicare supplemental (Medigap) coverage, Part D drug coverage, or Medicare Advantage managed care. Unlike, the over-65 enrollees, younger buyers would pay premiums that would cover the full cost of benefits.

What will Democrats do?

My Urban Institute colleagues have estimated that a Sanders-like plan would increase public costs by $32 trillion over 10 years. We don’t know what the other ideas would cost, but presumably it would be much less.

Because health care coverage, especially for those with pre-existing conditions, was such an important campaign issue, House Democrats will have to do something once they gain control of the chamber in January. But what?

The most likely bill is something to protect the ACA from the Trump Administration’s regulatory efforts to dismantle it and the multiple state legal challenges that put it at risk. Even Senate Majority Leader Mitch McConnell says he is willing to work with Democrats to fix the ACA, though his definition of fix and theirs may differ.

But the ACA never promised true universal coverage. Including its expansion of Medicaid (which not every state accepted), the ACA reduced the share of the unisured to about 12.7 percent before Trump began scaling it back (the uninsured rate has since risen to 15.5 percent).

The 2020 fight

House Democrats will also try to protect current Medicare from any administrative efforts by the Trump Administration to scale back benefits. At the same time, there is a chance, however remote, that they may find a work together with Trump to reduce Medicare drug costs.

But all of that falls far short of Medicare for all—no matter what you think it means.

So what will newly empowered House Democrats do? My best guess is that they pass a relatively modest buy-in bill. Then, it dies in the Senate. And everyone fights about it all over again in 2020.