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We are dedicated to making Medicare's program work well for all beneficiaries. Your feedback from your own or your client's concerns and experiences with Medicare, will guide our Medicare advocacy efforts with key policy and decision-makers in both California and nationally with the Centers for Medicare and Medicaid Services (CMS) and Congress.

  • 17Jun

    Below is a humorous but sadly too true commentary on the outrageous prices of drugs and how the pharmaceutical industry does everything in its power to avoid discussing prices….and to distract our attention by…looking at squirrels!

    Wow, this drug is really expens — Look! A squirrel!!

    For years, the pharmaceutical industry has had a pretty simple strategy for discussing the prices it charges for its drugs: don’t.

    Indeed, whenever the high price of pharmaceuticals is in the news, drugmakers try desperately to change the subject and distract from the issue. Now more than ever, that strategy is on full display as the industry is under increasing fire for the prices of specialty pharmaceuticals – some priced at more than $100,000 for a single course of treatment. Shifting blame may have been effective in the past, but when public health and access to life-saving drugs is being threatened by these increasingly outrageous prices, it just won’t do the trick anymore. As the drugmakers ramp up yet another campaign of distraction, here are some simple facts to consider:

    FACT: Astronomical prices for specialty drugs will blow up Medicare Part D budgets and force higher premiums for seniors

    An analysis in Health Affairs last week found that the price of the important hepatitis C drug Sovaldi could increase the cost of Medicare Part D and premiums for seniors by 8%. From this one drug alone, seniors on Part D could see an 8% premium hike.

    FACT: Astronomical prices for specialty drugs will devastate state Medicaid budgets and displace important priorities like education and infrastructure

    One recent analysis highlighted on Vox illustrated that, because Sovaldi is so expensive, California could potentially spend more administering the drug for people on Medicaid than it does for K-12 and secondary education combined. Yes, you read that correctly.

    FACT: Astronomical prices for specialty drugs put upward pressure on premiums for all consumers

    At its core, the cost of health insurance is a reflection of the cost of health care. The skyrocketing prices that drugmakers are charging has a ripple effect throughout the system, raising premiums and increasing health care costs for individuals, families, and employers.

    FACT: Health plans offer consumers a range of coverage options, including policies with lower cost-sharing

    To distract from their unjustifiable pricing, drugmakers have latched onto distorted coverage comparisons that ignore the range of cost-sharing options consumers can choose from. Hey, anything beats talking about the actual price.

    FACT: Consumers have out-of-pocket limits that mean health plans and state and federal governments rather than patients are paying the vast majority of the cost of these stratospherically priced drugs

    Pharmaceutical companies know that consumers’ out-of-pocket costs are capped under the Affordable Care Act, allowing them to ask for what amounts to a blank check from insurers and government programs. Not surprisingly, drugmakers are making the law work for them.

    BONUS FACT: Drugmakers have no straight-face explanation to justify the increasingly astronomical prices they have been charging for their medications

    That’s why they want to talk about anything – ANYTHING – other than the prices they are charging.

    The most important fact is that we all want patients to have access to the best treatments. That’s why we cannot afford to allow pharmaceutical companies to have us simply look the other way any longer when it comes to pricing. These unsustainable drug prices threaten our health care system – public and private – access for patients, as well as the very innovation that pharmaceutical companies relish. We cannot have sustainable innovation without sustainable prices to support it, and that’s why health plans and a diverse set of stakeholders have called on drugmakers to come to the table to find a private sector solution to this challenge before the government feels like it needs to.

  • 29May

    “Part D already costs about $80 billion a year and is on track to double by 2022 as benefits improve and Baby Boomers retire. For two reasons, a significant chunk of that money is wasted on overpayments to drug companies: When Part D began, millions of patients were shifted over from Medicaid, the state-federal program for low-income people that gets far lower drug prices than Medicare. Suddenly, the cost of providing drugs to the same people shot up. Congress barred Medicare from negotiating the way Medicaid and the Department of Veterans Affairs do with drug makers to get lower prices. Instead, lawmakers insisted the job be done by private insurance companies.”

    This is a quote from a USA Today editorial and it highlights the absurdity of prohibiting Medicare from negotiating prescription prices with drug makers, especially in a time  when government calls for cuts in Medicare and ways to reduce Medicare spending. Both Medicaid and the Department of Veteran Affairs negotiate for lower prices, but Medicare Part D, from it’s inception in 2006, is barred from doing this.

    This is a very different scenario than in other countries, like Canada and Europe, where all government health plans bargain with the drug companies to protect their citizens. “Per capita drug spending in the U.S. is about 40% higher than in Canada, 75% greater than in Japan and nearly triple the amount spent in Denmark,” according to an article in Health Care for America Now.

    And, it’s no accident that the law prohibits Medicare to negotiate lower drug prices. A recent article by the National Committee to Preserve Social Security & Medicare points out that “the drug lobby worked hard to ensure Medicare wouldn’t be allowed to cut into the profits which would flow to big Pharma thanks to millions of new customers delivered to them by Part D.”

    For years these big Pharma companies have used the argument that negotiating lower drug prices would actually hurt seniors in the long run because it would take away the necessary funds for innovative research and development to “save lives.” Yet, this just isn’t true. “Half of the scientifically innovative drugs approved in the U.S. from 1998 to 2007 resulted from research at universities and biotech firms, not big drug companies, research shows,” according to an article in Health Care for America NOW. The article also notes that “despite their rhetoric, drug companies spend 19 times more on marketing than on research and development.” In fact, 5 pharmaceutical companies have reported million-dollar increases in their spending on lobbying the federal government during the 1st quarter of 2014 alone.

    Join us and many other advocacy groups in helping Americans and our government save money by urging Congress to allow Medicare the same drug negotiate powers as Medicaid and Veterans Affairs.

    For more information see, Negotiating for Lower Drug Costs in Medicare Part D.

  • 13Mar

    Here’s a short video from the Kaiser Family Foundation on the Centers for Medicare and Medicaid Services’ proposed changes to the Part D prescription drug benefit. Currently CMS requires Part D plans to cover the vast majority of drugs in 6 specific classes. One proposed change is to drop 2 of these categories next year (anti-depressants and immunosuppressant drugs) and then drop anti-pyschotics a year later. Several advocacy groups are concerned that this change would reduce people’s access and ability to get the drugs they require. They point out that not all drugs are the same and it’s important to have a wide range of drugs available. Another proposal is to limit the number of plans each plan sponsor can offer. Research shows that more choices aren’t necessarily better for seniors; it can actually be more overwhelming. Many beneficiaries tend to stick with a plan they originally pick.

    Watch the short video below for more information on these changes…

  • 04Mar

    Below is an infographic with some disturbing facts about the cost and numbers of prescriptions Americans are taking. This article, Pill Nation: Are Americans Over Medicated? is provided by The Nursing Bible blog.


    Pill Nation

  • 30Jul

    A day before Medicare’s 48th birthday, the Department of Health and Human Services (HHS) released new information confirming a strong Medicare program. Over 6.6 million people with Medicare have saved over $7 billion on prescription drugs as a result of the Affordable Care Act (ACA). These savings average $1,061 per beneficiary in drug costs while a beneficiary is in the “donut hole” coverage gap that the law closes over time.

    In addition, 16.5 million people with traditional Medicare took advantage of at least one free preventive service in the first six months of 2013.

    This news also comes at a time of historically low levels of growth in Medicare spending. From 2010 to 2012, Medicare spending per beneficiary grew at 1.7% annually, more slowly than the average rate of growth in the Consumer Price Index, and substantially more slowly than the per capita rate of growth in the economy. All of this good news is a direct result of the the health care reform law.

    Savings on Prescription Drugs

    Because of the Affordable Care Act, beneficiaries’ out-of-pocket savings on medications continue to grow. As mentioned, over 6.6 million beneficiaries have saved over $7 billion on prescription drugs in the Medicare Part D donut hole since the law was enacted, for an average of $1,061.

    People with Medicare in the donut hole now receive discounts and some coverage when they purchase prescription drugs at a pharmacy or order them through the mail, until they reach the catastrophic coverage phase. The Affordable Care Act gave those who reached the donut hole in 2010 a one-time $250 check, then began phasing in discounts and coverage for brand-name and generic prescription drugs beginning in 2011. The law will provide additional savings each year until the coverage gap is closed in 2020.

    For more information on how the Affordable Care Act closes the donut hole, see our article: What’s New for Part D in 2013? Lowered Costs, New Covered Drugs, Appeal Changes.

    Preventive Services

    By making certain preventive services available with no cost-sharing obligations, the ACA also helps Americans take charge of their own health.  People can now better afford to work with health care professionals to prevent disease, detect problems early when treatment works best, and monitor health conditions.

    In Medicare, the ACA eliminated coinsurance and the Part B deductible for recommended preventive services, including many cancer screenings and other important benefits. For example, before the law’s passage, a person with Medicare could pay as much as $160 in cost-sharing for some colorectal cancer screenings. Today, that screening is free.

    In the first 6 months of 2013, 16.5 million people with traditional Medicare took advantage of at least 1 free preventive service. For more information on the additional coverage for preventive services, see our article: Heath Care Reform Brings Changes to Medicare.

    For more information on the health care reform law, visit: healthcare.gov.

    This article was edited from a press release from the Department of Health and Human Services.

  • 10Apr

    This article is written by Ethan Rome, Executive Director, Health Care for America Now

    Here’s an outrage that must be changed: Big Pharma has been systematically price-gouging the Medicare program for seniors and people with disabilities — and raking in billions in excessive profits. The 11 largest global drug companies made an astonishing $711 billion in profits over the 10 years ending in 2012, and they got a turbo-charged boost when the Medicare Part D prescription drug program started in 2006, according to an analysis of corporate filings by Health Care for America Now (HCAN). ??The drug companies hold the power to charge America’s consumers whatever they want. Worse, Medicare — the nation’s largest purchaser of drugs — is prohibited by law from seeking better prices. The result of this shortsighted policy is dramatic. In 2006, the first year of Medicare’s prescription drug program, the combined profits of the largest drug companies soared 34 percent to $76.3 billion. And unlike other industries, such as Big Oil, drug companies get something even better than a tax subsidy — they get a government program.

    There is nothing wrong with a company making profits — that’s what they’re supposed to do. But the drug industry’s profits are excessive as a result of overcharging American consumers and taxpayers. We pay significantly more than any other country for the exact same drugs. Per capita drug spending in the U.S. is about 40 percent higher than in Canada, 75 percent greater than in Japan and nearly triple the amount spent in Denmark.

    HCAN reviewed the last decade’s financial filings from the 11 prescription drug giants: Pfizer, Johnson & Johnson, Novartis, Merck, Roche, Sanofi-Aventis, GlaxoSmithKline, Abbott Laboratories, AstraZeneca, Eli Lilly and Bristol-Myers Squibb. Even as millions of Americans struggle to afford their medicines and as Republicans in Congress threaten to cut seniors’ benefits, these corporate behemoths have extracted $711.4 billion in profits for Wall Street investors. The drug companies’ annual profits reached $83.9 billion in 2012, a 62 percent jump from 2003.

    Combined Net Profits

    The drug companies, of course, say they have no choice and need to charge outrageous prices to pay for research that enables them to innovate and develop new drugs that save our lives. But that’s not true. Half of the scientifically innovative drugs approved in the U.S. from 1998 to 2007 resulted from research at universities and biotech firms, not big drug companies. And despite their rhetoric, drug companies spend 19 times more on marketing than on research and development.

    There are two reasons why it matters that the drug industry is booking eye-popping profits. First, American consumers and taxpayers are footing the bill, and second, we could do something about it. ??It’s against federal law for Medicare, the nation’s biggest health plan, to use its unparalleled market power to reduce the cost of prescription drugs. This makes no sense. If the policy were changed, taxpayers and consumers would save huge amounts of money.

    Simply empowering Medicare to get the same bulk purchasing discounts on prescription drugs as state Medicaid programs would save the federal government $137 billion over 10 years, according to the Congressional Budget Office. Eliminating price-gouging on that scale would go a long way toward addressing the fiscal challenges that are constantly under discussion in Washington — without harming seniors and middle-class families. This proposal has been supported by President Obama and is in the House Democrats’ budget plan. It is reportedly in the president’s 2014 budget plan as well.

    Our politicians give all kinds of tax breaks and subsidies to big corporations that don’t need them: Big Oil. Wall Street. Companies that ship our jobs overseas. Every gift to a special interest, including allowing Big Pharma to overcharge Medicare, is an expenditure of scarce tax dollars. That’s called wasteful spending.
    When it comes to addressing our country’s fiscal challenges, we shouldn’t even talk about cutting Medicare or any services people depend on, as the Republicans have proposed. Instead, we should eliminate indefensible special-interest tax breaks and subsidies for big corporations that don’t need them.

  • 01Apr

    Medicare has only a few clearly defined periods where people can enroll into, switch or disenroll from Medicare Advantage and/or Medicare Part D prescription drug plans. Yet, just as in life, there are also many exceptions. These exceptions are called Special Election Periods (SEPs). On our website we have a section that reviews many of the most commonly used SEPs. Recently, however, we received a question about another little used Part D SEP, which is introduced below.

    The question received was:

    “Does someone who moved from Idaho to California, who didn’t have a Part D drug plan in Idaho, have a Special Election Period to enroll into a Part D plan in California?”

    Answer:

    Yes, if a beneficiary moves to another state and did not previously have Part D coverage, they have an SEP when they relocate.

    Below are excerpts from the Medicare Prescription Drug Benefit Manual (§30.3.1, Chapter 3). The 4th scenario applies in the case in question above. And in Example 2 below, the beneficiary was not enrolled in a prescription drug plan (PDP) before the relocation.

    Excerpts from §30.3.1:

    An SEP for changes in residence exists for these scenarios:

    1. Individuals who are no longer eligible to be enrolled in a PDP due to a change in permanent residence outside of the PDP’s service area.
    2. Individuals who were not eligible for Part D because they have been out of the U.S. and have now moved back to the U.S.
    3. Individuals who were not eligible for Part D because they were incarcerated and have now been released.
    4. Individuals who will have new Medicare health or Part D plans available to them as result of a permanent move.

    Example 2:

    A beneficiary resides in Florida and is currently in Original Medicare and not enrolled in a PDP.  The individual intends to move to Maryland on August 3.  An SEP exists for this beneficiary from July 1 through October 31.

    At the time the individual enrolls in a PDP, the individual must provide the specific address where s/he will permanently reside upon moving into the service area, so that the PDP sponsor can determine that the individual meets the residency requirements for enrollment in the plan.

    For more information on Part D SEPs, see our website.

     

  • 19Feb

    Last month an editor at Caring.com contacted Elaine Wong Eakin, our Executive Director with a host of questions about CHA, what we do, California-specific Medicare issues, common mistakes or misconceptions beneficiaries have about Medicare, current advocacy issues to know about, thoughts on health care reform and info on health care fraud. Well Elaine could have easily written a book, yet below are her responses on the following questions that provide good insight on these questions and issues. You can also view the complete article, Interview with Elaine Wong Eakin: What We All Need to Know About Medicare.

    Here are the questions:

    1. In terms of Medicare advocacy, what are the hot button issues of which Medicare recipients and their families should be aware?

    2. CHA provides a plethora of information for both Medicare beneficiaries and their families and those professionals, providers and advocates who serve them. What types of information does CHA provide?

    3. As the name implies, CHA focuses primarily on Medicare issues as they relate to California residents. What issues involving Medicare are specific to Californians or tend to impact Californians differently than in other states?

    4. What are the most common misconceptions Medicare recipients and their families have in terms of utilizing Medicare?

    5. What are the key factors regarding prescription drug coverage that Medicare recipients and their families should know?

    6. What are the most common mistakes Medicare recipients and their families make when choosing Medigap coverage?

    7. Health care reform is a high profile issues these days. In terms of the Affordable Care Act, what are the advantages and disadvantages for Medicare recipients?

    8. Medicare fraud is unfortunately common. What advice do you have for Medicare recipients and their families when it comes to identifying and reporting possible fraud or abuse?

     

    And here are Elaine’s answers:

    1.In terms of Medicare advocacy, what are the hot button issues of which Medicare recipients and their families should be aware?

    For all Medicare beneficiaries, but especially those new to Medicare, they should be aware that they have different options to receive their Medicare benefits and understand the differences and consequences of each choice. For example, Medicare beneficiaries can choose to receive their Medicare through Original Medicare, which is fee-for-service, or through a Medicare Advantage plan depending on where a beneficiary lives. Whichever they choose, they are in the Medicare program, but there are some differences including their choice of providers and cost-sharing. For example, a beneficiary who chooses Original Medicare can go to any doctor who accepts Medicare assignment, but the beneficiary has to find these doctors. A beneficiary who enrolls in a Medicare Advantage plan, depending on the type of plan, may choose doctors within the plan’s network (usually listed in the provider directory), and if he or she wants to see a doctor outside the network, the plan most likely will not cover.

    Another difference is cost-sharing. A beneficiary in Original Medicare has a deductible ($147 in 2013) for most outpatient medical services (Medicare Part B), and after the deductible is met, the coinsurance is 20% of the Medicare-approved amount. Depending on the Medicare Advantage plan a beneficiary chooses, there may or may not be a deductible, and many plans have a copayment rather than coinsurance. A beneficiary’s decision is not for life but can be changed annually. During the Annual Election Period (Oct 15 to Dec 7), beneficiaries can make changes such as enroll in a Medicare Advantage plan from Original Medicare or disenroll from a Medicare Advantage plan and return to Original Medicare. In making such changes, a beneficiary should consider how his/her access to care may change, for example if he/she must change providers (doctors and/or hospitals), if his/her prescriptions will be covered, etc. The Health Insurance Counseling & Advocacy Program (HICAP), the Medicare benefits counseling program, can help a beneficiary who is considering such changes. HICAP is the State Health Insurance Assistance Program (SHIP) in California and can be reached at 1-800-434-0222.

    A couple of hot button issues are observation status and the improvement standard. Observation status has to do with how a hospital classifies a patient depending on the patient’s condition. Is the beneficiary admitted as an inpatient and billed for inpatient services, or is the beneficiary put under “observation” as an outpatient and billed differently from an inpatient? In recent years, an increasing number of beneficiaries are being classified as under “observation” past the 24 to 48 hour time limit for observation status, which can have grave financial consequences for Medicare beneficiaries. Besides having different out-of-pocket costs, a beneficiary who is an outpatient under observation does not have Medicare coverage for a subsequent skilled nursing facility (SNF) stay. For Medicare to cover a SNF stay, a beneficiary must be admitted as an inpatient in a hospital, have stayed in the hospital for at least 3 consecutive days, and need SNF care for the same condition and be admitted within 30 days of discharge from the hospital. A beneficiary who is under observation as an outpatient does not satisfy the requirements and would have to pay for the SNF stay out-of-pocket. A couple of Medicare advocacy groups have jointly filed a lawsuit on behalf of 7 beneficiaries who represent a nationwide class of beneficiaries negatively impacted by this policy and practice. See our blog article for more info on this issue.

    The improvement standard was the target of a class action lawsuit which challenged the practice of denying necessary skilled nursing care to beneficiaries because they showed no improvement. A proposed settlement agreement was reached in November 2012, which confirms that skilled services are covered by Medicare if they are required to maintain a patient’s condition, or prevent or slow further deterioration. In other words, skilled services cannot be denied because the beneficiary does not show improvement.

    Although the settlement must be finalized, we want Medicare beneficiaries, their families and especially their providers to know that Medicare does cover skilled nursing and therapy services if they are necessary, and the practice of denying services using the improvement standard must stop. If services are denied, a beneficiary can appeal.

    Another hot button issue that we all should be concerned about, not just Medicare beneficiaries, is how the Medicare program will survive attempts to cut federal spending to reduce the budget deficit. In light of the increasing costs of health care and a growing Medicare population as baby boomers become eligible, several Medicare “reform” proposals have been circulating, such as premium support and raising the eligibility age. California Health Advocates does not believe these proposals or others that cut benefits or raise beneficiary cost-sharing would be effective. We advocate for changing the health care system to aim for better health care that results in better health outcomes and controls health care costs. For instance: focusing on wellness and prevention, bundling payments, reducing waste, encouraging efficiency such as coordinating care and using electronic health records, and preventing fraud and abuse.

    The new health law, the Affordable Care Act, introduced initiatives to control costs as well as pay for value instead of volume.  Instead of focusing on cutting Medicare spending by shifting the cost to beneficiaries, lawmakers should build on the initiatives in the Affordable Care Act and address the challenge of taking care of a growing Medicare population without adding to the federal deficit. We encourage everyone to pay close attention to proposals being made and tell their Congress representative how important Medicare is to present and future beneficiaries.

     

    2. What types of information does CHA provide?

    CHA provides information for both beneficiaries and professionals who work with beneficiaries.  We have comprehensive and easy-to-read information on all parts of the Medicare program on our website (cahealthadvocates.org), including:

    • Medicare eligibility,
    • enrollment periods,
    • Medicare cost-sharing,
    • resources and FAQs for those new to Medicare,
    • prescription drug coverage,
    • Medicare Advantage plans,
    • ways to supplement Medicare including Medigap plans and retire plans,
    • appeal rights,
    • Medicare for people with disabilities,
    • long-term care options,
    • Medicare fraud and more.

    We also have extensive information on programs for people with low-income and assets, such as Medi-Cal, Medicare Savings Programs and Extra Help for Medicare Part D prescription drug coverage, a low-income subsidy program that pays the drug plan deductible and copays for people who qualify.

    CHA has a blog and newsletter articles with updates on current Medicare news and other health insurance related issues, including health care reform. And CHA provides 32 Medicare Fact Sheets covering 9 major topic areas for professionals working with beneficiaries available via an annual subscription.

    In addition, CHA provides Medicare training on all the above-mentioned topics for service providers.

    CHA’s website has the contact information for all the Health Insurance Counseling and Advocacy Program (HICAP) offices throughout the state. HICAP provides free, unbiased individual counseling on Medicare and related health insurance questions to California residents and can be reached at 1-800-434-0222. HICAP is California’s State Health Insurance Assistance Program (SHIP), and every state has a SHIP.

     

    3. As the name implies, CHA focuses primarily on Medicare issues as they relate to California residents. What issues involving Medicare are specific to Californians or tend to impact Californians differently than in other states? (We combined this question with question 6 as Californians have many additional Medigap rights under California law) 6. What are the most common mistakes Medicare recipients and their families make when choosing Medigap coverage?

    California has the largest Medicare population of any state. There are 5 million Medicare beneficiaries in California (10% of the total Medicare population), and the next state (Florida) has <4 million. Size matters when change affects so many people. An initiative from the Affordable Care Act to integrate care for individuals dually eligible for Medicare and Medicaid, commonly referred to as “duals” for short, illustrates the point. California has 1.2 million duals. The initiative in California, commonly called the Duals Demo, is estimated to affect 44% of duals for the first 3 years. However, the size of this population, 526,902 duals, is huge for a demonstration project and bigger than the populations that will be affected by approved demonstrations in 2 other states. As advocates, we are concerned that people might not understand how the Duals Demo would affect their access to benefits, lose access, disrupt their care and impact their health.

    Medigap, or formally Medicare supplemental insurance, policies are state regulated. California law provides certain extra rights and protections that are not found under federal law. Medicare beneficiaries sometimes experience changes to their coverage and want to buy a Medigap policy to supplement their benefits in Original Medicare.  In such situations, California law broadens existing federal protections and adds new ones to allow people to buy a Medigap policy without a health screening.

    For example, under federal law, Medicare beneficiaries at age 65 or older can get a Medigap policy without health screening for six months starting with the effective date of their Part B.  California extends this protection to disabled beneficiaries under age 65 when they first enroll in Part B. California law also requires companies to issue Medigap coverage to Medicare beneficiaries without health screening or exclusions for pre-existing conditions if they lose access to health care at military bases or their retiree benefits are reduced or eliminated.  In addition, beneficiaries can trade their Medigap policy for 30 days starting on their birthday each year for another Medigap from the same or different company for benefits that are the same or less than they already have in their current Medigap policy.

    Some common mistakes:

    • Buying a Medigap policy without comparing companies or rates. Tip: A person looking to buy a Medigap policy should know that there are 10 Medigap plans (one has a high deductible option) and compare the benefits among the different plans before deciding on a plan. Next they should find out which companies sell the Medigap plan they want. They should shortlist at least 3 companies and call each company about rates, customer service, etc., before deciding on the company. The Health Insurance Counseling & Advocacy Program (HICAP) provides information and guides people in the process to buy a Medigap policy. HICAP can be reached at 1-800-434-0222.
    • Buying a Medigap policy to help pay the cost-sharing in a Medicare Advantage plan. Tip: A Medigap policy will supplement only Original Medicare.
    • Buying the most basic plan when a beneficiary is younger. Tip: It is understandable why a Medicare beneficiary would choose a basic plan or a plan with fewer benefits when he/she is younger and feels healthy. If the beneficiary wants a Medigap plan with more benefits later when he/she needs more health care, he/she may be subject to health screening and/or medical underwriting or his/her Medigap application may be declined.
    • Assuming that the Medigap policy will cover the services of a doctor who has opted out of Medicare. Tip: If Medicare does not cover a service, neither will the Medigap policy.

     

    4. What are the most common misconceptions Medicare recipients and their families have in terms of utilizing Medicare?

    Some common misconceptions:

    • Medicare is all-inclusive and will cover all of beneficiaries’ health care costs and services. Fact: Although Medicare covers many hospital and medical services, it does not cover all services, and for the services that Medicare does cover, beneficiaries have cost-sharing.
    • A beneficiary who enrolls in a Medicare Advantage plan “signs over” or gives up their Medicare. Fact: A beneficiary who enrolls in a Medicare Advantage plan is still in the Medicare program and is not stuck in the Medicare Advantage plan for life. If he/she disenrolls from the Medicare Advantage plan (there are certain periods when a beneficiary can disenroll), the beneficiary goes back to Original Medicare. Beneficiaries in a Medicare Advantage plan have the same rights and protections as those in Original Medicare.
    • A beneficiary who enrolls in a Medicare Advantage plan does not have to pay the Part B premium. Fact: A beneficiary who enrolls in a Medicare Advantage plan continues to pay the Part B premium (to Medicare) plus the plan’s premium (to the plan if there is a premium).
    • Everyone who retires gets Medicare. Fact: A person who turns 65 becomes eligible for Medicare regardless of whether they are retired. People who retire before they turn 65 must wait until they turn 65 to get Medicare. People who continue to work past 65 and have health coverage from their employer (or their spouse works and gets employer health coverage for the couple) are eligible for Medicare when they turn 65 but they may delay enrolling in Medicare until they stop working.
    • Medicare covers nursing homes. Fact: Generally, care in a nursing home is custodial care which Medicare does not cover. Medicare does not cover long term care, such as in a nursing home or assistance living facility, to assist with activities of daily living (ADL). Medicare does cover a skilled nursing facility (SNF) stay if the requirements are met (see answer about observation status to question 1). If the requirements are met, Medicare pays 100% for Medicare-covered services the first 20 days of the stay. From the 21st to the 100th day of a SNF stay, the beneficiary has a daily copayment ($148/day in 2013). Medicare does not cover any services after 100 days.
    • People who have not worked enough to earn credits to get Part A “free” are not eligible for Part A. Fact: People who did not work 40 or more quarters are not entitled to “free” Part A, but they are eligible for Part A and can get coverage by paying a premium.

     

    5. What are the key factors regarding prescription drug coverage that Medicare recipients and their families should know?

    Medicare Part D is a voluntary prescription drug insurance program available to everyone who has Medicare, regardless of income or health status. Private companies contract with Medicare to offer insurance plans for prescription drugs, and beneficiaries choose the drug plan and pay a monthly premium. Beneficiaries with low-incomes may qualify to get Extra Help to pay for most of their drug costs. Although Medicare Part D is optional, people who don’t sign up for a drug plan when they are eligible and don’t have other creditable drug coverage (coverage that is actuarially equivalent or better than the Medicare Part D standard benefit), will be charged a penalty if/when they do eventually sign up for a Medicare Part D plan.

    Medicare beneficiaries can get Part D coverage through a stand-alone prescription drug plan or a Medicare Advantage plan with prescription drug benefits.

    There are certain periods where one can enroll into, disenroll from or switch Part D plans. When a person first becomes eligible for Medicare, he/she has a 7-month Initial Election Period to enroll in a Part D plan. Every year during the Annual Election Period between Oct 15 and Dec 7, people can enroll, disenroll or change Part D plans, and the change becomes effective the following Jan 1. See our website section on Enrollment into Part D for more information.

    Part D plans contract with Medicare yearly. Sponsors of Part D plans (private insurance or health plans) can change plan costs and formularies for the next contract year, if the plan renews. Therefore, it is important for each enrollee to review their plan’s changes for the coming year in the fall, and evaluate whether to switch plans during the Annual Election Period. The Health Insurance Counseling & Advocacy Program (HICAP) provides information and help people compare Medicare Part D plans. HICAP can be reached at 1-800-434-0222.

     

    7. Health care reform is a high profile issues these days. In terms of the Affordable Care Act, what are the advantages and disadvantages for Medicare recipients?

    The Affordable Care Act (ACA) offers many advantages to Medicare beneficiaries, including:

    • No deductibles or copayments for many Medicare-covered preventive services
    • New preventive benefits such as: an annual wellness visit, cancer screenings, smoking cessation counseling, obesity screening and counseling, alcohol misuse screening and counseling, counseling to reduce the risk of cardiovascular disease and screening for depression.
    • Lower out-of-pocket Part D prescription drug costs for those with large medication expenses. Beneficiaries who reach the coverage gap (also known as the donut hole) now pay 47.5% of their brand name drug costs and 79% of their generic costs and not 100% as before the ACA. This amount will decrease gradually until 2020 when beneficiaries will pay 25% of their drug costs until they reach catastrophic coverage. As of June 2012, nearly 4 million Medicare beneficiaries had saved more than $2.1 billion on prescription drugs while in the coverage gap (for year 2012).
    • An end to overpayments to Medicare Advantage (MA) plans, saving both taxpayers and the Medicare program millions of dollars. By 2014, MA plans will be required to invest at least 85% of all the funds they collect in premiums and copayments back into quality health care services for beneficiaries versus high administrative costs and profits.
    • More tools to prevent and fight Medicare fraud and abuse. The ACA allocates more resources and facilitates data-sharing to fight and prevent Medicare fraud; expands efforts to prevent and recover overpayments; enhances penalties to deter fraud and abuse; imposes tougher new rules and sentences for criminals convicted of Medicare fraud; and requires providers and suppliers to establish ethics and compliance plans as a condition of enrollment to participate in Medicare.

    The main disadvantage of the ACA for the lay public is that it is a long piece of legislation (>2,000 pages) and covers many topics. Many people learn about the ACA through another source and, unfortunately, the ACA is often presented with a political bias rather than objectively. Do people who oppose the ACA, especially Medicare beneficiaries, understand what is in the law?

     

    8. Medicare fraud is unfortunately common. What advice do you have for Medicare recipients and their families when it comes to identifying and reporting possible fraud or abuse?

    The days of being a passive health care consumer are over.  Today’s Medicare beneficiaries must be informed about their benefits and alert to possible schemes that compromise their health care identity. There are many schemes that try to steal Medicare numbers (which for most beneficiaries is the same as their Social Security number).  Medicare beneficiaries must treat their Medicare card like a credit card.  Our motto is “Guard the Card” and that means not giving their Medicare number out to anyone other than the health care entity they have chosen to work with. We tell beneficiaries to never give out their Medicare number to a stranger calling over the phone.  Many scammers call Medicare beneficiaries claiming to be from Medicare or Social Security and ask for the beneficiary’s Medicare number and/or their bank routing number.  If someone is unsure of a phone solicitation, they can simply hang up and call 1-800 MEDICARE for verification.  Beneficiaries should beware of FREE medical services or people touting new services/regulations under “Obamacare.”  Medicare benefits are fundamentally unchanged by the Affordable Care Act (see answer to question 7) and no new Medicare cards are issued to replace old ones.  People who have received calls or mail or any solicitations that seem suspicious should contact CHA’s Senior Medicare Patrol at 1-855-613-7080.

     

    For those who are unfamiliar, tell us about California Health Advocates.

    California Health Advocates (CHA) is an independent not-for-profit organization. Our mission is to provide quality Medicare and related healthcare coverage information, education and policy advocacy. CHA was founded in 1997 by managers of the Health Insurance Counseling & Advocacy Program (HICAP), the Medicare benefits counseling program. CHA continues to support the work of HICAP by providing training, technical assistance and policy advocacy. CHA has a website for both beneficiaries and professionals at www.cahealthadvocates.org (see answer to question 2). CHA sponsors California’s Senior Medicare Patrol which educates the public on how to protect themselves from health care fraud and abuse.

  • 24Oct

    The 2013 quality ratings for Medicare Advantage and Part D prescription drug plans were posted on Medicare.gov in early October. The Centers for Medicare and Medicaid Services (CMS) rates plans on a variety of quality care measures with 1 star being the lowest rating and 5 stars the highest. As Medicare’s fall Open Enrollment (also called Annual Election Period) is now through December 7, this is a good tool for beneficiaries to use when choosing whether to change their health coverage for the new year. This rating system is also one way CMS is encouraging and rewarding plans that provide quality care.

    In addition, beneficiaries who are in a low-rated plan, one that has received less than 3 stars for 3 consecutive years, now have the right to switch to another, higher rated plan. CMS has sent out over 500,000 notices to such beneficiaries in October, encouraging them to consider switching plans. Beneficiaries in low-rated plans who do not make a change within the Annual Election Period (Oct 15- Dec 7), and decide later that they would like to, can call 1-800-MEDICARE to do so.

    Also, if beneficiaries live in an area with a 5 star rated plan, they have the right to switch to that 5 star plan anytime between December 8 and November 30. Their coverage will begin on the first of the following month. Note that not all areas have 5 star rated plans. In fact, there are very few plans with such high ratings. In 2013, only 9 out of 555 Medicare Advantage contracts are with 5 star plans, and only 4 out of 74 Part D contract are with 5 star plans. California does have some MA 5 star plans but no Part D 5 star plans for 2013.

    For more info on other periods when beneficiaries can change coverage, see our section Special Election Periods (SEPs) for Parts C & D.

  • 25Sep

    Earlier this month the Federal Trade Commission announced that it is refunding close to 13,000 beneficiaries who paid significantly more than they should have for their prescription drugs in their CVS Caremark Part D plans. In January, the FTC sued CVS Caremark for allegedly charging beneficiaries deceptive prices on a variety drugs, including those used for breast cancer and epilepsy.  These high prices caused many beneficiaries to pay much more out of pocket than they should have, forcing some into the “donut hole”, or coverage gap where they are required to pay 50% of their drug costs much sooner than they otherwise would have. This recent settlement requires CVS Caremark to pay $5 million to reimburse those Medicare Part D beneficiaries affected by the price discrepancy. It also barres CVS from any such deceptive pricing strategies in the future.

    Reimbursement checks were sent out early September to affected consumers; the checks are good for 60 days. If you know anyone who was affected by this, make sure they have received and cashed their check before early November 2012. More details on this settlement can be found on the FTC website.

    People with questions on this issue can call an FTC toll-free hotline at 1-888-773-8392.

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