Category Archives: Medicare

Medicare Now Covers Outpatient Treatment for Opioid Addiction

February 28, 2020

Recognizing the huge problems caused by opioid addiction in the United States, Medicare is adding a new outpatient opioid treatment benefit, paying for methadone and related treatment in certain facilities.

Under a new rule taking effect in January 2020, Medicare will now provide payment to opioid treatment programs (OTPs), also known as methadone clinics, as part of Medicare Part B. OTPs are the only locations where people addicted to opioids can receive methadone as part of their treatment.

Under the new OTP benefit, Medicare covers:

  • U.S. Food and Drug Administration (FDA)-approved opioid treatment medications (such as methadone)
  • Dispensing and administration of the treatment medications (if applicable)
  • Substance use counseling
  • Individual and group therapy
  • Toxicology testing
  • Intake activities
  • Periodic assessments

For beneficiaries who are eligible for both Medicare and Medicaid, Medicaid paid for methadone treatment. Now, once the OTP is enrolled in Medicare, Medicare will become the primary payer for these beneficiaries. Medicaid should continue to cover the service during the transition. Medicare Advantage plans should also allow coverage of OTPs that are not in their network while they assist beneficiaries in transitioning to an in-network OTP.

For a fact sheet from Justice in Aging, click here.

Now’s the time to switch or ditch your Medicare Advantage Plan if you don’t like it

February 27, 2020

courtesy of NAELAeBulletin:

by Sarah O’Brien

KEY POINTS
  • You can only make one change during the current three-month window, which makes it important to be aware of any potential snags or restrictions you may encounter.
  • Of Medicare’s 61 million or so beneficiaries, roughly 38% (23 million) choose to get their coverage through an Advantage Plan.
  • Separately, if you missed your initial Medicare enrollment period and don’t qualify for an exclusion, you can sign up through March 31.

If your 2020 Medicare coverage includes an Advantage Plan that’s not a great match, you might be able to part ways with it.

During an enrollment window that opened Jan. 1 and closes March 31, you can swap your plan for another or drop it and return to basic Medicare (Part A hospital coverage and Part B outpatient coverage). Yet, before you make a change, be sure you’re aware of potential snags and any restrictions involved.

“Do your due diligence before you switch, because if you make another mistake in your choice, you’ll be stuck with it for the rest of the year,” said Danielle Roberts, co-founder of insurance firm Boomer Benefits in Fort Worth, Texas.

Also possible through March 31: If you missed your initial Medicare enrollment period and don’t qualify for an exception, you can sign up now. If this is your situation, coverage won’t start until July 1, said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans.

Of Medicare’s 61 million or so beneficiaries, more than a third choose to go with an Advantage Plan, which delivers Parts A and B and usually Part D prescription drug coverage, along with extras such as dental and vision. While most recipients tend not to change their plan, experts generally agree that evaluating whether there’s a more cost-effective option should be a yearly process.

The current three-month opportunity to change or drop your Advantage Plan comes just a few weeks after the close of Medicare’s annual fall open enrollment, when a variety of options were available for those who wanted to make changes to their coverage.

For this current period, however, there are restrictions.

For starters, you can only switch once. This means that once you move to a different Advantage Plan or drop it for basic Medicare, the change is locked in for 2020 (unless you meet an exclusion that qualifies you for a special enrollment period).

Additionally, this three-month window does not allow you to switch from one stand-alone Part D prescription drug plan to another.

If you picked a Part D plan in the fall open enrollment period based on faulty or misleading information, you can call 1-800-Medicare at any point during the year to see if your situation would allow you to make a change.

Meanwhile, dropping an Advantage Plan in favor of basic Medicare typically means losing prescription drug coverage — which means you would have to enroll in a stand-alone Part D plan. This matters, because if you go 63 days without the coverage, you could face a lifelong penalty that gets tacked on to your premiums.

Also, if you switch back to original Medicare and want to get a supplemental policy (also called Medigap), you may not get guaranteed coverage, depending on various factors that include where you live and exactly how long you’ve had your Advantage Plan. These policies either fully or partially cover cost-sharing of some aspects of parts A and B, including deductibles, copays and coinsurance.

“You might have to go through medical underwriting and answer health questions from the insurer and you might not get coverage,” said Gavino, of Lewin & Gavino.

If you’ll be subject to a health check, be sure to apply for the supplement before you drop your Advantage Plan.

“The worst-case scenario is that you go back to original Medicare and then no company takes you for Medigap, and you’re stuck for the rest of the year,” said Roberts, of Boomer Benefits. “So the order of events is really important.”

If you want to switch to a different Advantage Plan, your options largely depend on where you live.

The average Medicare beneficiary has 28 plans available to them this year, up from 24 in 2019, according to the Kaiser Family Foundation. However, 77 counties — generally in rural areas — have no Advantage Plan available.

If you want to switch to a different Advantage Plan, remember to make sure your doctors and other providers are in-network, Roberts said. And, assuming the plan includes Part D prescription drug coverage (most do), be sure that any medications you take are covered.

 

Medicare Part D: A First Look at Prescription Drug Plans in 2020

December 24, 2019

courtesy of NAELA eBulletin:

During the Medicare open enrollment period  from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D drug coverage, either a stand-alone prescription drug plan (PDP) as a supplement to traditional Medicare, or a Medicare Advantage prescription drug plan (MA-PD), which covers all Medicare benefits, including drugs.

Click here for the entire article and the issue brief

Medicare Premiums to Increase By Almost $10 a Month in 2020

December 24, 2019

After small or no increases the past couple in of years, Medicare’s Part B premium will rise sharply 2020. The basic monthly premium will increase $9.10, from $135.50 a month to $144.60.

The Centers for Medicare and Medicaid Services (CMS) announced the premium increase on November 8, 2019. Not everyone will pay the whole increase, however. Due to a “hold harmless” rule around 70 percent of Medicare recipients’ premiums will not increase more than Social Security benefits, and Social Security benefits are increasing only 1.6 percent in 2020. This “hold harmless” provision does not apply to about 30 percent of Medicare beneficiaries: those enrolled in Medicare but who are not yet receiving Social Security, new Medicare beneficiaries, seniors earning more than $87,000 a year, and “dual eligibles” who get both Medicare and Medicaid benefits.

Meanwhile, the Part B deductible will go from $185 to $198 in 2020, while the Part A deductible will go up by $44, to $1,408. For beneficiaries receiving skilled care in a nursing home, Medicare’s coinsurance for days 21-100 will increase from $170.50 to $176. Medicare coverage ends after day 100. CMS attributed the sudden steep rise in Part B premiums and deductibles on the increased costs of physician-administered drugs.

Here are all the new Medicare payment figures:

  • Part B premium: $144.60 (was $135.50)
  • Part B deductible: $198 (was $185)
  • Part A deductible: $1,408 (was $1,364)
  • Co-payment for hospital stay days 61-90: $352/day (was $341)
  • Co-payment for hospital stay days 91 and beyond: $704/day (was $682)
  • Skilled nursing facility co-payment, days 21-100: $176/day (was $170.50)

So-called “Medigap” policies can cover some of these costs.

Premiums for higher-income beneficiaries ($87,000 and above) are as follows:

  • Individuals with annual incomes between $87,000 and $109,000 and married couples with annual incomes between $174,000 and $218,000 will pay a monthly premium of $202.40.
  • Individuals with annual incomes between $109,000 and $136,000 and married couples with annual incomes between $218,000 and $272,000 will pay a monthly premium of $289.20.
  • Individuals with annual incomes between $136,000 and $163,000 and married couples with annual incomes between $272,000 and $326,000 will pay a monthly premium of $376.00.
  • Individuals with annual incomes above $163,000 and less than $500,000 and married couples with annual incomes above $326,000 and less than $750,000 will pay a monthly premium of $462.70.
  • Individuals with annual incomes above $500,000 and married couples with annual incomes above $750,000 will pay a monthly premium of $491.60.

Rates differ for beneficiaries who are married but file a separate tax return from their spouse. Those with incomes greater than $87,000 and less than $413,000 will pay a monthly premium of $462.70. Those with incomes greater than $413,000 will pay a monthly premium of $491.60.

The Social Security Administration uses the income reported two years ago to determine a Part B beneficiary’s premiums. So the income reported on a beneficiary’s 2018 tax return is used to determine whether the beneficiary must pay a higher monthly Part B premium in 2020. Income is calculated by taking a beneficiary’s adjusted gross income and adding back in some normally excluded income, such as tax-exempt interest, U.S. savings bond interest used to pay tuition, and certain income from foreign sources. This is called modified adjusted gross income (MAGI). If a beneficiary’s MAGI decreased significantly in the past two years, she may request that information from more recent years be used to calculate the premium. You can also request to reverse a surcharge if your income changes.

Those who enroll in Medicare Advantage plans may have different cost-sharing arrangements. CMS estimates that the Medicare Advantage average monthly premium will decrease by 14 percent in 2020, from an average of $26.87 in 2019 to $23 in 2020.

For Medicare’s press release announcing the new premium and deductible amounts, click here.

Medicare would cover dental and vision if these bills pass Congress

November 18, 2019

courtesy NAELAeBulletin:

by Sarah O’Brien

  • Right now, Medicare’s 60 million beneficiaries can only get dental, vision and hearing coverage through supplemental options such as Advantage plans or standalone insurance policies.
  • Original Medicare — Part A hospital coverage and Part B outpatient care — excludes those services except in limited circumstances.
  • Allowing Medicare to negotiate with drugmakers as outlined in one of the bills would save the government $345 billion from 2023 through 2029, according to an estimate from the Congressional Budget Office.

Medicare beneficiaries would get dental, vision and hearing coverage if several bills now before Congress pass.

In addition, the government would get authority to negotiate prices with drugmakers and create a cap for Medicare out-of-pocket spending on prescription drugs. All have cleared the necessary committees over the last couple of weeks and now await full House action.

“There have been proposals over the years that would do this, but in the past they haven’t gone anywhere,” said David Lipschutz, associate director at the Center for Medicare Advocacy. “It looks like this time something could get passed in at least one chamber of Congress.”

The bills (summarized further below) are generally supported by Democrats and opposed by Republicans. This means that even if the measures get approved in the Democrat-controlled House, they would would face an uphill battle in the Republican-dominated Senate.

Roughly 10,000 baby boomers turn 65 each day and can sign up for Medicare. While the program’s 60 million beneficiaries can access dental, vision and hearing through supplemental options such as Advantage plans or standalone insurance policies, original Medicare — Part A hospital coverage and Part B outpatient coverage — excludes them except in limited circumstances.

Some of the Advantage plans now include comprehensive dental coverage as part of the plan or as an optional supplemental benefit, said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans.

However, those benefits also might be limited to the carrier’s dental network or require prior authorization that the treatment is medically necessary, Gavino said.

H.R. 3: Includes provisions to allow the Medicare program to negotiate with drugmakers, cap out-of-pocket spending by beneficiaries on prescriptions at $2,000 and expand the low-income subsidy program, which helps cover Part D premiums and out-of-pocket costs.

H.R. 4650: Would add preventive and screening dental services, including oral exams and cleanings under Part B. It would also cover procedures such as tooth restorations and extractions, bridges, crowns, root canal treatments and implants and dentures. Beneficiaries would chip in the standard 20% for basic treatments and 50% for major treatments.

H.R. 4665: Would add routine eye exams to coverage through Part B, with beneficiaries generally paying 20% of the cost. It also would provide some coverage — $100 — toward contact lenses or eye glasses.

H.R. 4618: Would provide coverage under Part B for hearing exams and hearing aids, with beneficiaries contributing 20%.

This expanded coverage also might come with a cost. While some Advantage plans have no premium, the average is expected to be $23 in 2020, according to the Kaiser Family Foundation. Although down from $27 this year, any amount paid for a premium is on top of what Medicare enrollees pay for Part B: $135.50 is the standard for 2019 and forecast to be $144.30 next year. (Higher earners pay more).

Roughly 22.2 million, or 37%, of Medicare beneficiaries have Advantage plans. The remainder stick with original Medicare, which they can pair with a supplemental policy (i.e., Medigap) and a standalone Part D plan for prescription drug coverage (which also is typically included with Advantage plans).

“The majority of people on Medicare still choose to be in [original] Medicare, so having an expansion of benefits would accrue to everyone,” Lipschutz said. “It would be a significant improvement to the program and fill holes that have been there since its inception.”

The Congressional Budget Office has not yet released an estimate on how the three bills that expand benefits would impact Medicare’s budget. It did, however, offer a preliminary estimate of $345 billion in government savings from 2023 through 2029 if negotiating with drugmakers were allowed under the fourth bill.

At the same time, though, the budget office report notes the bill’s negative effects may include reduced spending on research and development.

In 2018, Medicare spent about $740 billion on 59.9 million beneficiaries through its hospital, outpatient care and prescription drug benefits, according to the latest report from the program’s trustees.

Total Medicare costs are expected to rise to 5.9% of gross domestic product by 2038, up from 3.7% in 2018, the report says. The more immediate concern among opponents of the measures now headed for a possible House vote is that the trust fund for Part A (hospital coverage) is anticipated to be depleted in 2026 unless Congress acts before then. At that point, the program would be able to fund 89% of promised Part A benefits, the trustees report says.

“We are … considering four bills that expand Medicare benefits as this important program is facing bankruptcy and have no responsible way to pay for them,” said Kevin Brady, R-Texas, in his opening remarks during a hearing on the bills in a recent House Ways and Means Committee, where he is the lead Republican.

Providing Medicare Beneficiaries with Complete, Objective Information to Help Them Make the Best Enrollment Decision

November 18, 2019

NAELAeBulletin: UPDATED FOR 2109
The Center for Medicare Advocacy and the National Committee to Preserve Social Security and Medicare have partnered once again on an education and outreach project to support Medicare beneficiaries and those who assist them enroll and re-enroll in Medicare. The Medicare Fully Informed Project provides a variety of unbiased, accurate and comprehensive information about the full range of Medicare coverage options, and includes an array of tools to assist in making the best individual enrollment choices.

Making Medicare coverage decisions is a complex task with multiple personal factors that must be taken into account. Beneficiaries need help in understanding all their complex options including all the pros and cons of traditional Medicare and private Medicare Advantage. They need to make fully informed choices given their likely health needs, personal and financial circumstances, and possible cost-sharing assistance. Our organizations and other beneficiary advocates have been concerned about the objectivity of some Centers for Medicare & Medicaid Services (CMS) enrollment materials. We hope to help fill some of the gaps.

In preparing for this project, we polled over 2,000 members of the National Committee to Preserve Social Security and Medicare in August 2018 in order to better understand Medicare beneficiaries, their unique needs, Medicare choices, and how we can better serve them. The responses helped us identify knowledge gaps and develop the suite of materials developed for this project. Key survey results that informed this project include:

    • 61% of respondents are in traditional Medicare
    • 54% of respondents make enrollment decisions through on-line research
    • Half of all respondents said they want more information about their enrollment choices
    • 77% receive the annual Medicare & You handbook from CMS
    • Less than half of respondents comparison shop between Medicare Advantage and Part D prescription drug plans
    • Only 13% changed their Medicare Advantage plan or Part D plans in the last year
    • 57% have one or more pre-existing health condition
    • 57% are not aware of Medicare’s Extra-Help program
    • Male respondents made up about 45%; female respondents comprised 54%
    • 54% live in suburban areas while 25% live in rural areas and 20% in urban areas

The results of the poll confirm that Medicare beneficiaries need additional, objective tools and information to make informed decisions about their Medicare options. They are also a diverse group who often face significant barriers when switching between plans or navigating these complex programs.

The goal of the Medicare Fully Informed Project is to help by providing a variety of educational tools for beneficiaries, and those who help beneficiaries, make enrollment decisions. We hope these various formats will help beneficiaries make fully informed Medicare and related health care coverage decisions. Project materials updated for 2019 include the following:

Don’t Let Medicare Open Enrollment Go By Without Reassessing Your Options

November 18, 2019

Medicare’s Open Enrollment Period, during which you can freely enroll in or switch plans, runs from October 15 to December 7. Don’t let this period slip by without shopping around to see whether your current choices are the best ones for you.

During this period you may enroll in a Medicare Part D (prescription drug) plan or, if you currently have a plan, you may change plans. In addition, during the seven-week period you can return to traditional Medicare (Parts A and B) from a Medicare Advantage (Part C, managed care) plan, enroll in a Medicare Advantage plan, or change Advantage plans. Beneficiaries can go to www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to make changes in their Medicare prescription drug and health plan coverage.

According to the New York Times, few Medicare beneficiaries take advantage of open enrollment, but of those that do, nearly half cut their premiums by at least 5 percent. Even beneficiaries who have been satisfied with their plans in 2019 should review their choices for 2020, as both premiums and plan coverage can fluctuate from year to year. Are the doctors you use still part of your Medicare Advantage plan’s provider network? Have any of the prescriptions you take been dropped from your prescription plan’s list of covered drugs (the “formulary”)? Could you save money with the same coverage by switching to a different plan?

For answers to questions like these, carefully look over the plan’s “Annual Notice of Change” letter to you. Prescription drug plans can change their premiums, deductibles, the list of drugs they cover, and their plan rules for covered drugs, exceptions, and appeals. Medicare Advantage plans can change their benefit packages, as well as their provider networks.

Remember that fraud perpetrators will inevitably use the Open Enrollment Period to try to gain access to individuals’ personal financial information. Medicare beneficiaries should never give their personal information out to anyone making unsolicited phone calls selling Medicare-related products or services or showing up on their doorstep uninvited. If you think you’ve been a victim of fraud or identity theft, contact Medicare.

Here are more resources for navigating the Open Enrollment Period:

  • Medicare Plan Finder, which helps you find a plan to match your needs: www.medicare.gov/find-a-plan
  • Medicare coverage options: https://www.medicare.gov/medicarecoverageoptions/
  • The 2020 Medicare & You handbook, which all Medicare beneficiaries should have received. The handbook can also be downloaded online at: medicare.gov/forms-help-resources/medicare-you-handbook/download-medicare-you-in-different-formats
  • The Medicare Rights Center: www.medicareinteractive.org
    Your State Health Insurance Assistance Program, which offers independent counseling: https://www.shiptacenter.org

How Will Medicare-for-all Proposals Affect Medicaid?

October 15, 2019

Summary

As the debate over the future direction of our health care system heats up leading into the 2020 Presidential election, several Democratic proposals to create a single, federal, universal health insurance program known as Medicare-for-all have garnered significant attention. These proposals would replace most current public and private health insurance with a new federal program that would guarantee health coverage for all or nearly all U.S. residents. However, many details about how a new public program would be implemented and financed are not yet known. While much attention has focused on the implications of ending private insurance and Medicare, the debate has largely ignored the effects on the low-income and vulnerable populations covered by Medicaid and the broader implications for states of eliminating the Medicaid program. Key changes related to Medicaid under current proposals include:

The Medicare-for-all debate has largely ignored the effects on the low-income and vulnerable populations covered by Medicaid and the broader implications for states of replacing the Medicaid program.

Medicare-for-all proposals would generally eliminate current variation in eligibility, enrollment and renewal processes, benefits, and payment and delivery systems that are part of the current structure of Medicaid where states have considerable flexibility to design programs within broad federal rules.

Proposals would extend coverage for certain Medicaid services important to vulnerable populations (such as comprehensive benefits for children and non-emergency medical transportation) to other populations. The proposals would continue Medicaid protections against high out-of-pocket costs.

One of the most fundamental changes under Medicare-for-all would be uniform coverage of community-based long-term care services for all Americans. Medicaid is the primary payer for these services today, with substantial state variation in eligibility and coverage. Under current Medicare-for-all proposals, these services would be required and explicitly prioritized over institutional services. Medicare-for-all proposals vary as to whether they would include institutional long-term care, such as nursing homes, or instead continue the current Medicaid coverage of these services, locking in state spending, variation in benefits across states, and limited access to populations beyond Medicaid.

Some proposals would have the federal government assume all or a significant share of the nearly $222 billion in state spending on Medicaid, leading to significant state savings, while other proposals call for a maintenance of effort for all or some current state Medicaid spending.

The proposals would shift responsibility for designing and implementing much of health policy from states to the federal government, in contrast to states’ role under Medicaid today.

Introduction

As the debate over the future direction of our health care system heats up leading into the 2020 Presidential election, several Democratic proposals to create a single, federal, universal health insurance program known as Medicare-for-all have garnered significant attention. These proposals would replace most current public and private health insurance with a new federal program that would guarantee health coverage for all or nearly all U.S. residents, though many details about how a new public program would be implemented and financed are not yet known. While much attention has focused on the implications of ending private insurance and Medicare, the debate has largely ignored the effects on the low-income and vulnerable populations covered by Medicaid and the broader implications for states of eliminating the Medicaid program.

Multiple Medicare-for-all proposals have been introduced in Congress and advanced by Presidential candidates. Currently, the proposals are characterized by two main approaches: proposals that create a single-payer system and eliminate other forms of coverage, including employer-sponsored insurance, Medicare and Medicaid; and proposals that eliminate the Medicare and Medicaid programs but maintain a role for private insurance. Medicare-for-all bills proposed by Rep. Pramila Jayapal (HR 1384) and Sen. Bernie Sanders (S. 1129) and endorsed by Presidential candidates Sen. Elizabeth Warren, Sen. Cory Booker, and Andrew Yang adopt the former approach. A Medicare-for-all proposal offered by Sen. Kamala Harris takes the latter approach. Each of these proposals differs in some way from the others. However, for purposes of this brief, we refer to these proposals collectively as Medicare-for-all, though we note where important differences in the proposals may have different implications for Medicaid.

Medicaid is administered by the states, and each state’s program is unique, reflecting states’ use of existing program flexibility and waiver authority to design their programs. Because of this variation, the specific implications of a shift from Medicaid to a Medicare-for-all program would vary across states. However, in all states, Medicaid plays a key role by providing affordable health coverage for vulnerable populations that includes a wide range of medical, behavioral health, and long-term care benefits. It also is the largest source of federal funds to states. This issue brief explores key ways in which a shift to Medicare-for-all could affect current Medicaid enrollees, future enrollees (such as those who may need long-term care coverage at a later time), and states, which jointly finance the Medicaid program along with the federal government. Table 1 summarizes key similarities and differences regarding eligibility, benefits, affordability, provider payment and delivery systems, and state financing in the main Medicare-for-all proposals and Medicaid.

Medicaid’s Role Today

Medicaid covers 75 million low-income adults, children, pregnant women, seniors, and people with disabilities. The Affordable Care Act (ACA) expanded Medicaid eligibility to serve as the basis of its larger set of coverage and affordability reforms. As of August 2019, 37 states including DC have adopted the ACA’s Medicaid expansion. In 2017, the Medicaid expansion group included more than 12 million newly eligible low-income adults. However, 2.5 people remain in a coverage gap, with income too high to qualify for Medicaid but too low to receive Marketplace subsidies in the 14 states that have not yet adopted the expansion. Medicaid also covers 45% of nonelderly adults with disabilities and millions more people with chronic conditions for whom private insurance, designed for a generally healthy population, is inadequate and/or unaffordable.

Medicaid covers a broad array of medical, behavioral health, and long-term care services. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children provides comprehensive coverage including preventive screenings, vision, dental, and hearing services, and any other medically necessary care. Federal standards outline minimum benefits for adults, such as hospital, physician, and nursing facility services. States also can cover a variety of optional benefits, such as prescription drugs and private duty nursing. Medicaid is the principal source of coverage for long-term services and supports (LTSS), including nursing home care as well as home and community-based services that enable seniors and people with disabilities to live independently. While all state Medicaid programs cover a comprehensive set of services, because states have flexibility to provide optional services for adults, there is significant variation across states.

Medicaid provides affordable coverage for its low-income enrollees. Federal standards prohibit states from charging premiums to those with incomes less than 150% of the federal poverty level (FPL), though some states impose premiums for certain adults through a Section 1115 waiver. Federal rules also limit cost-sharing to nominal amounts and entirely exempt certain groups and services from any cost sharing. Aggregate out-of-pocket costs for an individual may not exceed 5% of family income.

Medicaid provides access to a broad range of providers, including many with unique expertise in treating vulnerable and low-income populations. States set provider payment rates within broad federal guidelines, and as a result, there is significant variation across states in how provider rates are determined and in payment levels. Despite lower payment rates in Medicaid and gaps in access to some types of specialists, national data show that access to services for children and adults is comparable to private insurance and exceeds access for the uninsured. Medicaid programs contract with a broad range of providers, including many safety net clinics, hospitals, and other providers that have experience in meeting the needs of Medicaid’s vulnerable enrollees. Managed care has become the dominant Medicaid delivery system, though states have substantial flexibility in designing their delivery and payment systems.

Medicaid is financed jointly by the federal government and the states, guaranteeing federal matching payments to states with no pre-set limit. The matching structure of the program provides states with resources that automatically adjust for demographic and economic shifts, rising health care costs, and changing state priorities. This structure also enables the program to respond to public health emergencies and natural and other disasters. Examples of this response include providing a coverage safety net to people affected by the HIV/AIDS epidemic and expanding eligibility and benefits for children and pregnant women exposed to high levels of lead during the Flint water crisis. Recessions, rising costs of prescription drugs, and increasing needs for long-term care and behavioral health services are factors that put upward pressure on Medicaid spending growth. However, over time, Medicaid growth per enrollee has been lower than private health spending. Medicaid is a significant spending item in state budgets, but also the largest source of federal revenues due to the matching structure.

Implications of Medicare-for-all for Medicaid
Eligibility, Coverage, and Enrollment

Medicare-for-all programs would establish universal national health coverage for all or nearly all U.S. residents, eliminating the need for the specific eligibility pathways in the current Medicaid program. Medicare-for-all programs would establish uniform eligibility criteria across all states that are tied to U.S. residency and not based on income. Notably, Medicare-for-all would eliminate the current variability in eligibility for health coverage across states and fill in coverage gaps in states that have not adopted the ACA’s Medicaid expansion. Under Medicaid, states must cover certain populations, such as very low-income parents and children, pregnant women, and poor people with disabilities who receive federal Supplemental Security Income (SSI) benefits. States then choose from a variety of optional coverage pathways and waiver authorities to expand coverage, especially for children with significant disabilities and seniors and adults with disabilities who need long-term care. While all states currently adopt at least one of these optional expansions, Medicaid eligibility criteria differ across states. Medicare-for-all programs would eliminate the need for specialized eligibility determinations based on disability or functional status. How current Medicaid enrollees, particularly those with complex health care needs, would be transitioned to a new coverage plan, is an important policy and implementation issue in the new proposals.

Immigrants’ eligibility for coverage under Medicare-for-all is unclear, while their coverage under Medicaid today is subject to limitations. Medicare-for-all proposals grant authority to the Health and Human Services Secretary to define residency when determining eligibility for coverage, so it is not yet known how undocumented immigrants would be treated, though some proposals specifically cover legal immigrants and certain undocumented immigrants. Many Democratic candidates running for President say they support coverage for undocumented immigrants. Most legal immigrants are barred from Medicaid coverage for five years after entering the United States (except in the 35 states that have taken up the option to eliminate the five-year waiting period for Medicaid/CHIP coverage for lawfully-residing immigrant children and/or pregnant women). Undocumented immigrants are not eligible for Medicaid coverage, although state Medicaid programs reimburse providers for emergency care for individuals who are otherwise eligible for Medicaid except for their immigration status.

A process for auto-enrolling individuals into coverage under Medicare-for-all programs would replace existing application and renewal processes in Medicaid. Once established, all of the Medicare-for-all proposals call for automatically enrolling individuals in coverage at birth. Auto-enrollment would result in higher coverage rates compared to the current Medicaid program, since not everyone who is eligible for Medicaid presently is enrolled. Each state administers its own Medicaid eligibility determination system. The ACA included new policies and strategies to streamline the eligibility and enrollment process, such as greater reliance on electronic data sources instead of paper verification, in an effort to keep eligible people enrolled in coverage. Nevertheless, the need to apply for and periodically renew Medicaid coverage can sometimes result in eligible individuals churning in and out of coverage.

Benefits

Medicare-for-all programs would cover a comprehensive set of health care services for adults that would eliminate the current variability in Medicaid benefit packages across states. For example, the Medicare-for-all proposals include some benefits that are optional in Medicaid for adults and consequently not available in all states, such as dental and vision care. The Medicare-for-all benefit package also would include mental health and substance use treatment services. While all state Medicaid programs cover mental health and substance use disorder services, the scope of coverage for adults can vary. Many states rely on Medicaid to cover specialized behavioral health services, and the Medicare-for-all proposals would include some of these benefits. For example, the Sanders and Jayapal proposals include day treatment and psychosocial rehabilitation for those with chronic mental illness. Also, although prescription drug coverage is not required by the Medicaid statute, all states cover this benefit. Medicaid must cover all drugs with a rebate agreement as medically necessary, but states may apply utilization controls such as prior authorization, a preferred drug formulary, or quantity limits on drug refills or pills per prescription, and those differ across states. While Medicare-for-all proposals would establish uniform coverage for prescription drugs across states, it is unclear if coverage would be as comprehensive. Under both Medicare-for-all and Medicaid, all covered services must be determined medically necessary.

Medicare-for-all would cover certain services important to vulnerable populations that currently are covered by Medicaid but not other payers. In current Medicare-for-all proposals, these include the EPSDT benefit that provides a comprehensive set of services for children as well as non-emergency medical transportation to access medical appointments, with the Sanders and Jayapal proposals limiting this benefit to those with low incomes and/or disabilities.

One of the most fundamental changes under Medicare-for-all would be uniform coverage of community-based long-term care services; Medicaid is the primary payer for these services today, with substantial state variation in eligibility and coverage. Medicare-for-all would cover many of the community-based long-term care services covered by Medicaid today. And, unlike Medicaid, where most community-based long-term care services are optional, these services would be required, and explicitly prioritized over institutional services, under Medicare-for-all. With community-based long-term care services included in the Medicare-for-all benefit package, everyone would be eligible to receive covered services without regard to income or assets, unlike in Medicaid today. The Jayapal proposal includes functional eligibility criteria (e.g. limitation in an activity of daily living) to qualify for LTSS; today, states set Medicaid LTSS functional eligibility criteria. Unlike other Medicaid services, states are allowed to cap enrollment for many community-based long-term care services, which means that some people who meet the eligibility criteria do not receive them. Including these services in Medicare-for-all could mean that individuals currently on state Medicaid waiver waiting lists as well as others who are not financially eligible for Medicaid could have access to these services. However, it could take time to develop adequate system capacity in terms of infrastructure and workforce to accommodate such an expansion in paid LTSS. Additionally, the cost of providing a universal long-term care benefit package could result in some limitations or restrictions on these benefits as more details are known and Medicare-for-all is implemented.

Medicare-for-all proposals vary as to whether they would include institutional long-term care, such as nursing homes, or instead continue the current Medicaid coverage of these services. Under a scenario where Medicare-for-all includes institutional long-term care, all enrollees would receive these services as part of their basic benefit package as medically necessary, without regard to income or asset limits. The Jayapal proposal includes functional eligibility criteria for institutional long-term care, as it does for HCBS. The Jayapal benefit package includes a range of institutional services, which could also include institutions for mental disease (IMDs) and intermediate care facilities for those with intellectual or developmental disabilities (ICF/DD). Medicaid currently covers ICF/DD services but generally does not cover services in IMDs for individuals ages 21-64. If institutional services are carved out of Medicare-for-all and instead continue to be provided through state Medicaid programs, as under the Sanders bill, then individuals would need to continue to meet current eligibility criteria for these services, which vary across states. Under this approach, states would also be required to continue to pay their state share of costs for these services based on the current federal Medicaid matching rules. Those not eligible for Medicaid would continue to have to pay for institutional long-term care out of their own income and assets or through private long-term-care insurance, or spend-down to be eligible for Medicaid. The Sanders Medicare-for-all program would require states to maintain their existing Medicaid eligibility standards and spending on institutional long-term care services and would continue to provide states with federal matching payments for these services, locking in variation in eligibility standards across states.

Premiums and Cost Sharing

Medicare-for-all would continue the protections that Medicaid provides against high out-of-pocket costs. Medicare-for-all programs would eliminate or reduce premiums and cost sharing. The Sanders and Jayapal proposals would eliminate premiums and deductibles, and the Jayapal proposal would eliminate cost sharing, while the Sanders proposal would include minimal copayments on prescription drugs for those with incomes above 200% FPL. Under these proposals, today’s Medicaid enrollees would continue to be protected from high out-of-pocket costs. While most Medicaid enrollees do not pay premiums and have limited out of pocket expenses, any who do would likely see these costs eliminated.

Payment and Delivery Systems

Similar to Medicaid, all licensed and certified providers would be eligible to participate in Medicare-for-all programs; however, given the scope of Medicare-for-all programs, it is likely a broader array of providers will participate, expanding the choice of providers for current Medicaid enrollees. State Medicaid programs are required to contract with federally qualified health centers, and most contract with other essential community providers, and consequently, these providers are an important source of care for Medicaid enrollees. While these contracting requirements are not part of current Medicare-for-all proposals, it is expected that health centers and other essential community providers would participate to the same extent they participate in Medicaid programs today.

Medicare-for-all programs would create a national fee schedule for paying providers, eliminating variation in payment rates across states and payers in Medicaid today. While few details are available, Medicare-for-all programs would establish payment rates for hospitals, physicians, and other providers, subject to a global budget process and negotiation under some proposals. In general, states have flexibility in setting Medicaid provider payment rates, leading for variation in payment rates across states. In general, Medicaid rates paid to physicians and some other providers are lower than Medicare rates, while other providers, such as safety net hospitals, may receive higher payments through Medicaid compared to Medicare due to supplemental payments. It is unclear whether payment rates under Medicare-for-all proposals would be based on Medicare rates or set using a different methodology. In addition, federal rules require special Medicaid payment rates for some providers, such as federally qualified health centers and rural health clinics that have contributed to their participation in the program. These providers are likely to see an increase in revenue from improved coverage under Medicare-for-all programs; however, given longstanding relationships Medicaid enrollees have with safety net providers, how they fare under a new program will matter.

The reliance on fee-for-service payments under current Medicare-for-all proposals may move away from current payment and delivery models adopted by state Medicaid programs. Medicare-for-all programs would pay physicians and other providers on a fee-for-service basis, while institutional providers would be paid through a global budget arrangement under some proposals or through fee-for-service under others. Medicaid initially relied on fee-for-service payments, but in recent years, states have experimented with innovative payment designs in their Medicaid programs that seek to improve quality of care, control costs, and address social determinants of health. In addition, through their contracts with managed care organizations as well as managed fee-for-service models, states have emphasized care management for people with complex health needs. Some proposals would allow for these types of payment and delivery models, including private managed care plans, while others would not. While moving to global budgets and a national fee schedule will likely lower costs, some of the benefits of care management strategies, particularly for people with multiple or complex conditions and other vulnerable patients, may be lost.

State Responsibilities

The state role in health care financing would change substantially under a Medicare-for-all program compared to Medicaid. The state share of spending for Medicaid was $222 billion in 2017. Medicare-for-all proposals vary in how much states could save and how much funding states would be required to contribute relative to current spending. For example, under the Jayapal proposal, states could see significant savings relative to current Medicaid spending because Medicaid would be eliminated, and there would be no state financing requirements. However, under other proposals, states would remain responsible through a maintenance of effort (MOE) requirement for all or part of current state spending on Medicaid. The Sanders Medicare-for-all program would require states to maintain their existing Medicaid eligibility standards and spending on institutional long-term care services and would continue to provide states with federal matching payments for these services, locking in variation in eligibility standards and financing across states. Long-term care accounts for more than one in five dollars of Medicaid spending and in 2016, community based long-term care services accounted for 57% of all Medicaid spending on long-term care nationally, although this varies by state. The level of state savings under the Sanders proposal will vary based on current state spending on institutional long-term care services. Under the Harris proposal, states would be required to make MOE payments to the new program equal to the amounts they currently spend on Medicaid and CHIP, increased over time by inflation. Since Medicaid costs have typically increased at higher rates than inflation, states could see some savings over time, but significantly less relative to the Jayapal and Sanders proposals. It is not clear in the Harris and Sanders proposals how state spending from provider fees or taxes (a mechanism used by nearly every state to finance the state share of Medicaid) would be factored in the MOE calculation.

In addition to transferring fiscal responsibility, the proposals would shift the role of designing and implementing much of health policy from states to the federal government. Under current programs, states have significant flexibility to design and administer Medicaid and other related health programs. Medicare-for-all programs would create more uniformity in eligibility and benefits and could result in state savings, but the proposals would also limit states’ ability to leverage Medicaid funding to implement innovative payment and delivery system reforms. Without a comprehensive Medicaid program – and the substantial financing of health care that comes along with it – state policymakers would have a much more diminished role in the health care system generally. Some role for states may remain. For example, the Sanders proposal calls for a regional administrative structure that would include state directors. While the proposals may open other avenues for innovation, the state role in administering all aspects of Medicaid and running insurance departments would diminish under Medicare-for-all programs as these functions shift to federal responsibility.

Looking Ahead

Many details about how a new Medicare-for-all program replacing all or most current public and private health insurance would be implemented and financed are not yet known. As proposals continue to emerge and develop, it is important to focus on the implications related to Medicaid, the program that currently covers 75 million low-income and vulnerable Americans. As with other parts of the health care system, there will be trade-offs. Medicare-for-all proposals would generally eliminate current variation in eligibility, enrollment and renewal processes, benefits, and payment and delivery systems that are part of the current structure of Medicaid, where states now have considerable flexibility to design programs within broad federal rules. However, the transition to a new program, even one with equally comprehensive benefits and cost sharing protections, could be particularly disruptive for current Medicaid enrollees who tend to be sicker with more complex health conditions, and for whom the ability to maintain relationships with current providers will be important. A smooth transition to any new system also will be critical for current Medicaid enrollees who rely on personal care and other services to meet daily self-care needs and maintain independent community living.

More broadly, Medicare-for-all programs would extend coverage for some Medicaid services to more Americans, most notably community-based long-term services and supports. For states, the role in health care financing would change substantially under a Medicare-for-all program. Some proposals would have the federal government assume all or a significant share of the nearly $222 billion in state spending on Medicaid, leading to significant state savings. However, other proposals call for a state maintenance of effort around spending broadly or for specific services. The details about how the MOE would be implemented are not clear. In addition, the proposals would shift responsibility for much of health policy from states to the federal government. As the debate continues and additional details emerge, it will be important to continue to evaluate how Medicare-for-all proposals affect coverage, benefits, out of pocket costs and access to care for the low-income and vulnerable populations currently covered by Medicaid.

Beneficiary Advocates Raise Alarms Concerning Roll-Out of New Medicare Plan Finder and Revision of Medicare Marketing Rules

October 8, 2019

Washington, DC ─ Justice in Aging, Medicare Rights Center, Center for Medicare Advocacy and the National Council on Aging sent a joint letter to Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), on August 27, 2019, urging the agency to address concerns regarding changes to the Medicare Plan Finder (MPF) tool and the 2020 Medicare Communications and Marketing Guidance (MCMG).

The four organizations expressed appreciation for CMS’s efforts to update these resources to better support beneficiary decision-making, while raising concerns that the revisions may instead have the opposite effect. The groups urged CMS to mitigate adverse consequences by closely monitoring the roll out and functionality of the new MPF tool, providing enrollment relief as needed, and by rescinding the updated MCMG in its entirety.

Earlier today, CMS unveiled long-awaited updates to MPF—the federal government’s primary enrollment assistance tool for Medicare Advantage and Part D plans. While the new site includes a number of improvements, the groups are concerned that its late-August launch date may not give third-party assisters, like State Health Insurance Assistance Programs (SHIPs), adequate time to learn the new tool before Fall Open Enrollment begins. And that coupled with recent legislative and regulatory changes set to take effect this year, the truncated MPF launch timeline may generate demand for enrollment assistance that these chronically underfunded programs are unable to meet.  Further, CMS has stated that there will be no back-up system in place or ability to revert to the current “legacy” system during the upcoming Fall Open Enrollment period.

The Medicare Communications and Marketing Guidelines (MCMG) is a set of rules that govern the selling and promotion of Medicare Advantage and Medicare Prescription Drug plans. Revised each year, these guidelines help ensure that people with Medicare have accurate information about a plan’s costs and benefits as well as adequate protections against inappropriate marketing practices. The 2020 revisions, however, effectively disregarded the regular process for stakeholder input and introduce changes that primarily ease the burden on plans and downstream entities while at best doing little to benefit or protect consumers and at worst increasing the likelihood consumers will experience harm.

Apparently in direct conflict with current law, the revised MCMG weaken the distinction between “marketing” events, which are designed to steer or attempt to steer beneficiaries toward a plan or limited set of plans; and “educational” events, which are designed to inform beneficiaries about Medicare Advantage, Prescription Drug, or other Medicare programs. In addition, the revisions removed several disclaimers required of plans, including a short one alerting Spanish speakers of the availability of translations of certain important plan communications. The burden on plans of including the two-line notice was miniscule, but the need to alert limited-English proficient beneficiaries that they can receive help is great.  Further, the revision failed to include provisions outlined in the draft version that would have limited the aggressive marketing of plans referred to as D-SNP look-alikes. These Medicare Advantage plans, which are not subject to the oversight that CMS and states impose on plans designed to serve the complex needs of dual eligibles (people with both Medicare and Medicaid), are being marketed almost exclusively to this population. CMS has itself identified this marketing as a significant problem but abandoned its proposal to address its concerns in the guidelines.

Kevin Prindiville, Executive Director of Justice in Aging stated: “CMS’s harmful updates to the Marketing Guidelines are a step backward, leaving consumers more vulnerable to aggressive marketing tactics and making it more difficult for them to request important health information in their language. The hasty roll out of plan finder changes will only add to the challenges of this year’s Open Enrollment season.

Judith Stein, Executive Director of the Center for Medicare Advocacy, noted, “The revisions to the Marketing Guidelines cater to Medicare private plans and those who sell them, rather than being in the best interest of Medicare beneficiaries, those who assist them, or in furtherance of an equitable Medicare program. CMS should rescind these changes, and should ensure that beneficiaries are not hindered by a delayed roll out of a completely new Plan Finder format, with no back-up system in place.”

Frederic Riccardi, President of the Medicare Rights Center, stated: “Based on our experience assisting people with Medicare and their families, we know how challenging it can be for beneficiaries to make the best coverage decision for their unique circumstances. CMS must ensure that its tools and resources are developed, distributed and updated in ways that maximally support this decision-making process.”

Read the letter here.

New Rule May Make It Harder for Medicare Beneficiaries to Receive Home Care

October 8, 2019

It may become harder for Medicare beneficiaries to find home health care due to a new rule from the Centers for Medicare and Medicaid Services (CMS). Although the rule changes the way home health care providers are reimbursed, it could affect patient care as well.

Starting in January 2020, Medicare will reimburse home health agencies at a lower rate when they care for patients who have not been admitted to a hospital first. CMS estimates that it will pay home health agencies approximately 19 percent more for a patient who hires the home health agency directly after leaving a hospital than a patient who was never in the hospital or was only an outpatient.  (The Center for Medicare Advocacy calculates that the disparity could be as high as 25 percent.)

In part due to pressure from Medicare to reduce costly inpatient stays, hospitals often do not admit patients, but rather place them on observation status to determine whether they should be admitted. These patients, if not admitted to the hospital for at least three nights, are not eligible for Medicare reimbursement of a limited amount of skilled nursing care and typically head home instead to continue care with Medicare’s home health care benefit.

But a home health agency that cares for a patient who was in the hospital under observation will be reimbursed as if the patient had been an outpatient. This lower reimbursement rate means that home health agencies may be reluctant to provide care for patients who were under observation status or who haven’t been in a hospital at all.

If you are hospitalized, it is important to learn whether you are admitted or under observation. Hospitals are required to provide notice to patients if they are under observation for more than 24 hours.

For more information about the new rule from the Center for Medicare Advocacy, click here.