CHA Blog

A new federal regulation issued by Medicare in November as part of health care reform’s Affordable Care Act will affect approximately 4.5 million beneficiaries receiving home health and/or hospice benefits. Starting on January 1, homebound elderly and disabled patients as well as hospice patients will require having a “face-to-face encounter” with a physician or nurse practitioner if they want to receive care under Medicare. For hospice patients, this “encounter” must happen prior to the 180^th day recertification for continued hospice benefits and for each subsequent recertification. The certifying hospice physician must also attest that such a visit took place.

The intent of the new rule is to maintain benefit integrity by ensuring strong physician involvement in care planning and authorization. Yet advocates are strongly encouraging Medicare to examine the implementation process. They advise having a transitional period of no less than 6 months after the rule is enacted, wherein Medicare can monitor for compliance, provide notice of noncompliance where appropriate, provide continuing education on the requirements, and institute changes in instructions and guidelines where needed.

Advocates are concerned about possible disruptions in access to hospice and home health care as most likely most affected people, doctors included, have not heard of the new rule yet.

Elderly and disabled Medicare beneficiaries who are confined to their homes for medical reasons or hospice patients in the midst of end of life care will need to find a way to either get to the doctor or get the doctor to come see them. This is the predicament that will result if considerations for home care and hospice needs are not made.

You can read the full text (PDF) of the new Medicare rule.

This article was edited in part from a National Association for Home Care and Hospice press release.

We’ve heard from the Centers for Medicare and Medicaid Services (CMS) that they are still having some problems with their personalized health plan search tool on Medicare.gov. This is a critical time for accurate information as beneficiaries are still in their Annual Election Period (AEP) and have the right to join, switch or disenroll from Part D plans and/or Medicare Advantage plans. After making a choice, they must stay in that plan for the following year (with a few exceptions, including being about to disenroll from an MA plan and return to Original Medicare during the Annual Disenrollment Period from Jan. 1 – Feb. 14).

Because of this critical choice time, we’ve asked CMS to give any beneficiaries who join a plan that does not best suit their needs because of inaccurate information provided on Medicare.gov a Special Election Period (SEP) to choose another plan.

CMS expects to have this problem resolved by Thursday 12/23. In the meantime, beneficiaries can still use the Medicare Plan Finder tool to complete general plan searches and enroll in 2011 plans. Beneficiaries can complete general plan searches by entering their health coverage and Part D low-income subsidy information, as well as a Drug List ID and password date to retrieve a previously saved drug list. Beneficiaries can continue to enroll in 2011 plans using either the general search feature of the Medicare Plan Finder or the Enroll Now tool.

We will keep you updated of any new developments.

For more info on other situations that trigger a SEP, see our section Special Election Periods for Parts C and D.

Under a little-known provision of the health overhaul law, insurers will be required to provide their benefits information on a standardized chart using the same plain English terms as other companies to help shoppers understand and compare complicated policies.

This will make choosing a health insurance policy easier and “will force the insurance companies to reveal information in a consistent way,” says Bonnie Burns, our Training and Policy Specialist. “It should make it easier for people to understand what they’re getting and not getting.”

In the provision, Congress even listed some of the insurance jargon – including terms such as deductible, preferred provider, excluded services and UCR (usual, customary and reasonable) – that must be defined in a glossary that will accompany the benefit summary.  It directed the National Association of Insurance Commissioners to form a group to develop the materials and specified that the group include state insurance regulators, consumer and patient advocates (such as Bonnie Burns), insurance companies and health care providers.

These materials will be sent to the Department of Health and Human Services and Department of Labor. Those departments will issue regulations spelling out how insurance companies and employers must use the materials. The new system must be in place by March 2012.

Right now it’s hard for consumers to shop for coverage, compare plans and make good choices. For example, one study compared breast cancer treatments under 3 different California policies. It found that a patient would spend nearly $4,000 for a typical treatment under one policy and as much as $38,000 under another policy, both of which had similar deductibles and out-of-pocket limits. These changes will make a significant difference in helping people compare coverage plans with ease and prevent such a potential consequence of choosing the “wrong” plan.

The law even prohibits the use of “fine print” by mandating at least a 12-point type size. In addition, any exceptions or limitations to coverage must be included along with the out-of-pocket costs that plan members can expect to pay. Examples of the costs for some common medical treatments must also be provided in a separate “coverage facts label” modeled after the nutrition facts label that appears on prepared foods.

Karen Pollitz, the deputy director for consumer support in the HHS Office of Consumer Information and Insurance Oversight, helped develop the concept of a coverage facts label when she was a research professor at Georgetown University’s Health Policy Institute. She is one of the officials who will review the materials. Pollitz co-wrote a report last year that highlighted consumers’ need for better insurance information.

It has been challenging for the group to decide what information consumers needed when choosing a policy and to translate insurance jargon so that a normal person understands what it is. The group’s nearly 4 dozen members held 25 meetings and conference calls, some as long as 6 hours.

For general information on health care reform, see www.healthcare.gov, or for Medicare-specific info, see our Health Care Reform section.

This article was edited in part from a Kaiser Health News article, 12/15/10.

The House has passed the Medicare and Medicaid Extenders Act of 2010 (by a vote of 409-2), a day after it was unanimously passed by the Senate.  The “doc fix” provision has gotten the most media coverage, though the bill also extends other items that are slated to expire Dec 31, 2010.  President Obama signed this legislation on Dec 15, 2010.

Below is a brief summary of 3 Medicare-related provisions:

1.     The physician payment cut of 25%, scheduled to be effective Jan 1, 2011, is blocked, and the current payment rate is extended until Dec 31, 2011.  Congress is expected to come up with a long term solution to the sustainable growth rate.  Note: they are offsetting this expenses by asking for a repayment from some who would get a subsidy to buy health care insurance.  To read more, here is an article from the California Healthline.  Two California House reps are quoted in that article: Tom McClintock, who voted against the bill, and Wally Herger.

2.     The Qualified Individual (QI) program is extended until Dec 31, 2011.  Advocates have been asking that this Medicare Savings Program (MSP) be made permanent, like QMB and SLMB, but that won’t be accomplished with this bill.

3.     The exceptions process to the Medicare Part B outpatient therapy caps is extended until Dec 31, 2011.  Beneficiaries who are likely to exceed the therapy caps for physical therapy and speech therapy combined or occupational therapy can continue to get an exception.

See the text of the Medicare and Medicaid Extenders Act of 2010 for more information.

Beneficiaries enrolled in AARP Medicare Complete, a Medicare Advantage HMO sponsored by Secure Horizon have reported being back-billed for past months and/or years of premiums they did not know they owed. This has caused some panic and much distress for beneficiaries receiving bills for hundreds, sometimes thousands of dollars of premiums and no extra money with which to pay. California Health Advocates alerted the Centers for Medicare and Medicaid (CMS) about the problem, and CMS and United (Secure Horizons’ parent company) have recently come to a resolution. Below is a summary of the 2 kinds of back-billing problems, United’s actions and terms of resolution for each kind of problem, and a discussion regarding some of our ongoing concerns.

Two Kinds of Back Billing Problems

The 2 kinds of back-billing problems had to do with enrollees with dental benefits, and enrollees dually eligible for both Medicare and Medi-Cal.

Dental benefits – Some Secure Horizons enrollees signed up to receive an optional dental benefit and to have their premiums deducted from their Social Security checks.  Yet, as it turns out, Secure Horizons was not set up to deduct the additional dental benefit premiums from their Social Security checks, and therefore none of their premiums were paid. Secure Horizons did not bill members for the dental premium until recently, back-billing for several months’ or years’ premium. United (Secure Horizons’ parent company) agreed to write off the premiums for the months when members were not billed.  These cases were closed a few weeks ago.

Beneficiaries on Medicare and Medi-Cal – Many of these cases were first reported to us from the Health Insurance Counseling and Advocacy Program (HICAP), and CHA in turn inquired of CMS.  Some of the cases involved beneficiaries who were in a Secure Horizons plan even before 2006 when Medi-Cal paid the monthly premium.  These beneficiaries did not receive an invoice or coupon book until recently.  The invoices ranged from $990 to almost $3,000.

More than 18,000 beneficiaries were affected, yet it is still unclear whether all affected beneficiaries were in California. As United investigated the problem, they found that members fell into 4 categories depending on different dates, and United’s action was tailored accordingly.  Common to all cases, United agreed to write off balances during periods when United failed to bill or billed incorrect amounts.  However, for periods when United billed correctly, United expects to collect these amounts going forward.  If members cannot pay several months’ premium (for periods when United billed correctly and in a timely manner), United will offer payment plans.

For all categories, United developed appropriate communications to members, which were submitted for CMS approval and were sent to affected members in late November. According to CMS, they have also re-trained their staff to properly address this issue.  If United members have complaints related to this back-billing problem, they should call the plan and also 1-800-Medicare to log the complaint.

Additional Issues of Concern

Some issues we continue to be concerned about include:

1.     For some beneficiaries, when they called Secure Horizons about the lump sum invoice, the plan representative negotiated and reduced the amount due.  If a beneficiary paid the reduced amount, he or she should get a refund (or credit) if what he/she paid was for a period that United has agreed to write off. We are concerned about if, how and when they will receive this refund and whether CMS is monitoring this process.

2.     Beneficiaries with Medicare and Medi-Cal (also known as “dual eligibles”) may not know that they have a Special Election Period (SEP) to disenroll from their Secure Horizons plan.  We communicated our concern to CMS and they responded that they would ask United inform these beneficiaries of their SEP rights.

3.     Some dual eligibles were enrolled in their Secure Horizons plan before 2006, when Medi-Cal paid the premium.  When the policy changed and Medi-Cal no longer paid the premium, these beneficiaries may not have been notified that they would now be responsible for their MA plan premium.

4.     A related issue is dually eligible beneficiaries who were told by sales reps that they would not have to pay a premium because they have Medi-Cal.  As mentioned above, Medi-Cal does not pay the premium of Medicare Advantage plans for beneficiaries who are dually eligible for Medicare and Medi-Cal.  If a beneficiary cannot afford  the premium, they can disenroll or change to a plan with a lower premium.  They have an SEP to disenroll or change plans.

If you hear of any additional cases regarding this back-billing issue, please contact your local HICAP at 1-800-434-0222.

See Special Election Periods for Parts C and D for more information on SEPs.