CHA Blog

A provision in the 2010 federal health care reform law calls for changes in Medigap policies that essentially shift the burden of health care costs more onto the hands of beneficiaries. Several members in Congress have come to the unsubstantiated conclusion that because some Medigap plans (the most popular ones, C and F) cover most of the costs Medicare doesn’t — hence this insurance is referred to as MediGAP, beneficiaries use more services than they need. Therefore, they claim that Medicare pays more health care costs for these beneficiaries than others. To to help reduce these costs and hence the federal deficit, Congress has asked the National Association of Insurance Commissioners (NAIC) to propose changes to these Medigap plans so that beneficiaries pay more out-of-pocket for their health care.  The Congressional Budget Office estimated in March that such changes could save the government $53 billion in Medicare spending over a decade by strengthening incentives “for more prudent use of medical services.”

Yet despite this request, as written in the health care reform law, an unlikely group of health insurance regulators, insurers and consumer advocates are raising opposition to these Medigap changes. In several interviews with reporters, Bonnie Burns, our Training and Policy Specialist who also serves on the NAIC, points out some substantial flaws or blind spots in Congress’ thinking. First, she strongly questions the idea that beneficiaries need an incentive not to use services. After all, physicians are the ones who order services, not the beneficiaries. Also, although some studies have found that seniors with Medigap policies use more Medicare services, they may be sicker than the average Medicare beneficiary, which is why they bought Medigap coverage in the first place.

“To suggest that Medicare beneficiaries overutilize services on a whim because they don’t have ‘skin in the game,’ is pretty disturbing,” says Burns, as quoted in a recent article on Kaiser Health News.

Second, Mary Beth Senkewicz, Florida’s deputy insurance commissioner, who chairs the NAIC’s senior issues committee, which includes the Medigap group, questions the legality of making changes that apply to Medigap policies beneficiaries have already purchased. The policies are contracts between the insurer and the beneficiary which contain certain promises of coverage. When state regulators require changes in insurance, those typically apply to future policies only, not to existing ones as well.

Similar to Burns’ point of Medicare beneficiaries not being directly responsible for their higher health costs noted above, several members of this group have also suggested that Medigap policies are not responsible for Medicare’s growing costs. These carriers, the Medigap plans, only pay for services that Medicare deems to be medically necessary. Those determinations are not made by the Medigap insurance company.

In Conclusion

Some of Congress’ proposed Medigap changes dramatically shift costs onto seniors, leaving members of diverse interest groups concerned for good reasons. Medigap insurance has long been a product that has worked well for many benficiaires, currently 7 million, which comprise about 1/6 of the population with Original Medicare. These policies have helped maintain beneficiaries’ peace of mind, knowing that they have coverage for the gaps in Medicare. Putting this coverage in jeapordy may not be the best or even a mediocre move to help save some money to help the federal budget deficit, especially when savings aren’t even a guaranteed outcome.

For more information on this issue, see the following articles:

• Changes to Medigap Plans Meet Resistance
• Lawmakers Propose Cuts to Medicare and Medigap Coverage

Did you know that by calling a special 1-800 number you may qualify to receive $500 from the American Opportunity Act?  By providing your Social Security number, date of birth and other personal information, in just 4 weeks you will receive a Visa Check card ready to be loaded with money.  Sound too good to be true?  Well it is!

Scam artists are continually misusing real information in an effort to steal beneficiaries’ money and their personal information.  There is no program called the American Opportunity Act that just gives away money.  But as part of the American Recovery and Reinvestment Act, parents and students can qualify under the American Opportunity Tax Credit to pay for college expenses.

We encourage people to never give their personal information out to strangers.  This type of information is used to not only commit identity theft but also to commit medical identity theft as well as stealing money from the health care system in the form of Medicare fraud.

To learn more about our California SMP and how you can prevent Medicare fraud and abuse, see our Medicare Fraud section.

If you help people with Medicare, watch for Medicare’s “Help Prevent Fraud” Campaign on TV and in newspapers in your area, especially if you live near Los Angeles, Miami or New York.

Similar to our Senior Medicare Patrol’s (SMP) “Stop Medicare Fraud” campaign, this one tells people how they can protect themselves against fraud by checking their billing statements and reporting suspicious charges. People should also report other suspicious activities, like being asked over the phone for their Medicare/Social Security number or banking information.  Remember that Medicare will NEVER call for this information.

People can report suspicious activities by calling our California SMP helpline at 1-855-613-7080, or 1-800-MEDICARE (1-800-633-4227).

You Can Help!

You can help, by making sure people with Medicare have the information they need to identify and report fraud.  Check out our Medicare Fraud and Resources sections on our website. Medicare also has ample materials in their Fraud Prevention Toolkit.

Thank you in advance for your help in spreading the word and awareness on Medicare fraud and prevention!

The Centers for Medicare and Medicaid Services (CMS) removed its marketing and enrollment sanctions on Universal American on 8/5/2011.  Universal American offers the Today’s Options plans in California.  As of now, Quality Health Plan (QHP), a Tampa, Florida based insurer is the only organization that’s still under sanction.

With its sanctions removed, Universal is permitted to market and advertise their 2011 Medicare Part C and D products. They can also accept enrollments from beneficiaries with valid election periods, with the earliest effective enrollment date being 9/1/2011.

Universal had been under sanction for marketing violations by their agents and brokers, including prohibited marketing practices, resulting in delays in access to care.

CMS is reasonably assured that the issues that gave rise to the company’s sanction are not likely to reoccur. However, if they do resurface, CMS will consider additional compliance and enforcement actions. CMS will also continue to closely monitor Universal American’s performance.

If you hear of any significant issues associated with Universal American, or any other of our Medicare Advantage or Prescription Drug Plans, please let CMS know by contacting your CMS Regional Office.

I’m re-posting this article by Maria Selor. She’s the Supervising Attorney at the Elder Law Center in Wisconsin and wrote this article early this summer…

On Jan. 1, 2011, the preventative services provision of the Affordable Care Act was extended, making all Medicare patients eligible for free, important preventive services – including colonoscopies. However, not all colonoscopies are created equal, and this could impact whether it is truly without cost to you. This article explains what you should be aware of when receiving this important and life-saving test.

Screening Colonoscopy vs. Diagnostic Colonoscopy
The free Medicare exam only covers screening colonoscopies – not diagnostic colonoscopies. A screening colonoscopy is a procedure performed on a patient of screening age in order to find colon polyps or cancer. A colonoscopy that is performed in order to explain symptoms (e.g. blood in stools, change in bowel movements, etc) is called a diagnostic colonoscopy, which is not covered under the Affordable Care Act. Patients are usually fully liable for at least 20% (and maybe more) of the cost related to a scheduled diagnostic colonoscopy.

There are some cases where a scheduled screening colonoscopy can become a diagnostic colonoscopy, and in those cases a patient becomes responsible for any out-of-pocket costs related to their deductible, co- insurance or co-pays for standard costs like physician and facility fees. A screening colonoscopy becomes a diagnostic colonoscopy when a physician removes a polyp or takes a biopsy during the procedure. For Medicare patients, a family history of colon cancer or polyps will not automatically transform a screening colonoscopy into a diagnostic one. Some private insurers, however, will do this.

Beware! Related Services Not Always Covered
Medicare patients who are eligible to have a colonoscopy screening will pay no deductible, co-pay or co-insurance. However, please be forewarned – Patients may still be responsible for other services, such as anesthesia or medication, associated with the procedure. Some of those who have taken advantage of the “free services,” have been unpleasantly surprised to receive hefty bills. If you receive a bill after a “free” Medicare exam, contact the Elderly Benefit Specialist in your county immediately. He or she can help you determine if these charges are allowable.

How often is it covered?
Medicare rules dictate how often you can get a free screening colonoscopy. If you get the test sooner that the time periods listed below, you will likely be fully responsible for the cost.

• Fecal Occult Blood Test: Once every 12 months.
• Flexible Sigmoidoscopy: Generally, once every 48 months, or 120 months after a previous screening colonoscopy for people not at high risk.
• Screening Colonoscopy: Generally once every 120 months (once every 24 months if you’re at high risk), or 48 months after a previous flexible sigmoidoscopy.
• Barium Enema: Your doctor can decide to use this test instead of a flexible sigmoidoscopy or colonoscopy. This test is covered every 24 months if you are at high risk for colorectal cancer and every 48 months if you aren’t at high risk.

How do I qualify?
A Medicare patient can qualify for a screening colonoscopy if they:

1. Are of the recommended screening age (for people of average risk = age 50 or over, though recent studies indicate that African-Americans may need to start screening at age 45.)
2. Do NOT have any symptoms
3. Do NOT have personal history of colon polyps or colon cancer

A Medicare patient can still qualify for a screening colonoscopy despite having a family history of colon cancer or colon polyps.

Costs: Screening Colonoscopy

• Clarifying “Free” Screening Colonoscopies for Medicare Patients
  $0 annual deductible for procedure
• $0 co-insurance for procedure

Costs: Diagnostic Colonoscopy

• $0 annual deductible for procedure
• 20% co-insurance must be paid for procedure

Why Should I Get a Screening Colonoscopy?
Colorectal cancer is the third most commonly diagnosed cancer and the 3rd leading cause of cancer death in both men and women in the US. The great majority of these cancers and deaths could be prevented with early screening. This is because most colorectal cancers develop from
adenomatous polyps. Polyps are noncancerous growths in the colon and rectum. Detecting polyps through screening and removing them can actually prevent cancer from occurring. Furthermore, being screened at the recommended frequency improves the chance that colorectal cancer will be detected at an earlier stage, when it is more likely to be cured by surgery alone, the surgical procedure is less extensive, and the recovery is much faster.

(statistics excerpted from AMERICAN CANCER SOCIETY, Colorectal Cancer Facts & Figures 2008-2010.)

Inspector General Levinson testifies about the HHS Office of Inspector General’s (OIG) efforts to monitor and make recommendations to reduce Medicare improper payments last week.  He describes the scope of the problem, OIG’s oversight of the Department’s measurement of Medicare improper payments, and OIG’s role in preventing, detecting, and reducing improper payments.

Here are some excerpts from his 4-page testimony:

• In 2010, the Centers for Medicare & Medicaid Services (CMS) reported Medicare improper payments totaling $47.9 billion. Of that total, $34.3 billion is attributable to Medicare Fee-for-Service (10.5% error rate) and $13.6 billion is attributable to Medicare Part C (14%% error rate).
• Some but not all improper payments are the result of fraud. Improper payments can also result from medically unnecessary claims, miscoded claims, eligibility errors, or insufficient documentation. Examples of improper payments include payments made to an ineligible recipient, duplicate payments, or payment for services not received. For example, my office recently identified $3.6 million in improper Medicare Part D payments on behalf of deceased beneficiaries.
• Although not all improper payments are fraudulent, all payments resulting from fraud are improper. There is no precise measure of the magnitude of health care fraud, but we know that it is a serious problem that demands an aggressive response.

Read the full testimony (PDF) for more information.

Also, find the most recent OIG testimonies and speeches on the OIG website.