Managing Your Medicare: 2011

Monday, July 4, 2011

Medigap Policies Available in Florida

I am doing an extensive analysis of the Medigap (Medicare supplement) policies currently available to Medicare beneficiaries. This is because the structure of new policies available to beneficiaries changed last June, and by now there is enough information to give some guidance on both the availability and prices of the newly structured policies. The full analysis will take me quite awhile, but I already producing some helpful information for certain states, and it makes sense to begin sharing this now rather than waiting until my full analysis is complete.

There is no need to go into explaining the new structure; this is all spelled out in Managing Your Medicare, on page 157. And even better, you can access, thorough the CD that comes with the book, a “2011 Medigap Standard Policies Worksheet” to help guide you through the process of selecting a Medigap policy during this current year. (Click on the “check for any updated forms” button on the introduction screen to the CD.)

But what I have available here is information, first, for those age 65, which is when most beneficiaries get a Medigap policy, on the number of policies available, the lowest priced one available, the highest priced one available, and the average price. Even better, this information is given for each policy type. Also, there is a quick comparison of the average price of each policy type to type “A”, the “basic” policy, so you can easily determine roughly how much more or less the policy type you are looking at compares to the basic one, or indeed, to any other policy type. All this is harder to explain than it is to show. In addition, where one or more SELECT policies is available, I include information on these. Recall that these Medigap policies require you to go to physicians and providers which are in the Medigap insurance company’s network of providers; on the other hand, they may be a little cheaper than non-SELECT policies.

You should understand that I have draw information for the prices in Hillsboro County as this is somewhat representative of the state of Florida as a whole. Prices are substantially higher if you live in the Miami area; if you live in Walton County they are the same or a bit less. The information for beneficiaries age 65 is then followed by that for disabled beneficiaries (that is, those under age 65) as Florida law mandates that insurance companies make one Medigap policies available to them. All this information comes from the Florida Office of Insurance Regulation website, www.floir.com, which has more detailed information on these policies.

Again, remember that for each policy type, the benefits are exactly the same no matter who sells it, and you should aggressively look for the best price. It is interesting to note, that for beneficiaries age 65, there are not huge differences in the prices of Medigap policies as there are in other states. (This is not true for beneficiaries under age 65.) Please understand that the prices shown here and what you are quoted will vary somewhat because of how and how often you pay your premium, whether you smoke, where you live in Florida, etc., etc., so use these as guides rather than exact “matches.” The dollar amounts shown below are the annual cost of the policies. And note that in some cases more policies are available than are noted here, but are available only to narrow groups, so I have not included them.

Medigap Policies Females, Age 65

(Note that the prices for these will be about 15% higher at age 70, and about 33% higher at age 75.)

Policy A:
The lowest price available is $1,270, the highest is $1,956, and the average is $1,657.
This is the “basic” policy. Some 25 different policies are available. No SELECT “A” policies are available.

Policy B:
The lowest price available is $1,712, the highest is $2,604, and the average is $2,036.
On the whole, these cost about 23% more than Policy A. 17 different policies are available.
One SELECT policy ($1,507) is also available.

Policy C:
The lowest price available is $1,971, the highest is $2,717, and the average is $2,323.
On the whole, these cost about 36% more than Policy A. 17 different policies are available.
Four SELECT policies are also available; the lowest price is $1,635, the highest is $2,451.

Policy D:
The lowest price available is $1,813, the highest is $2,435, and the average is $2,159.
On the whole, these cost about 26% more than Policy A. 12 different policies are available.
Three SELECT policies are also available; the lowest price is $1,624, the highest is $2,188.

Policy F:
The lowest price available is $1,982, the highest is $2,896, and the average is $2,362.
On the whole, these cost about 38% more than Policy A. 25 different policies are available.
Five SELECT policies are also available; the lowest price is $1,647, the highest is $2,458.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $624, the highest is $1,020, and the average is $839.
On the whole, these cost about 51% less than Policy A. 10 different policies are available.
No SELECT “F – High Deductible” policies are available.

Policy G:
The lowest price available is $1,825, the highest is $2,471, and the average is $2,154.
On the whole, these cost about 26% more than Policy A. 14 different policies are available.
Two SELECT policies are also available; the lower price is $1,683, the higher is $1,995.

Policy K:
The lowest price available is $816, the highest is $1,274, and the average is $1,064.
On the whole, these cost about 38% less than Policy A. 4 different policies are available.
No SELECT “K” policies are available.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $1,227, the highest is $1,879, and the average is $1,545.
On the whole, these cost about 10% less than Policy A. 6 different policies are available.
No SELECT “L” policies are available.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $1,777, the highest is $2,116, and the average is $1,973.
On the whole, these cost about 15% more than Policy A. 7 different policies are available.
One SELECT policy ($1,613) is also available.
This policy is very new.

Policy N:
The lowest price available is $1,485, the highest is $2,325, and the average is $1,857.
On the whole, these cost 8% more than Policy A. 15 different policies are available.
No SELECT “N” policies are available.
This policy is very new.

Medigap Policies Males, Age 65
Note: These tend to be just a little more expensive than those for females, but many companies sell their policies for the same price, and, almost without exception, the lowest price available for each policy type for a female is also available to a male. The prices for these will be about 15% higher at age 70, and about 33% higher at age 75.

Policy A:
The lowest price available is $1,270, the highest is $2,213, and the average is $1,784.
This is the “basic” policy. Some 25 different policies are available.
No SELECT “A” policies are available.

Policy B:
The lowest price available is $1,712, the highest is $2,996, and the average is $2,188.
On the whole, these cost about 23% more than Policy A. 17 different policies are available.
One SELECT policy ($1,507) is also available.

Policy C:
The lowest price available is $1,971, the highest is $3,025, and the average is $2,471.
On the whole, these cost about 39% more than Policy A. 17 different policies are available.
Four SELECT policies are also available; the lowest price is $1,635, the highest is $2,640.

Policy D:
The lowest price available is $1,813, the highest is $2,858, and the average is $2,334.
On the whole, these cost about 31% more than Policy A. 12 different policies are available.
Three SELECT policies are also available; the lowest price is $1,624, the highest is $2,357.

Policy F:
The lowest price available is $1,982, the highest is $3,333, and the average is $2,537.
On the whole, these cost about 42% more than Policy A. 25 different policies are available.
Five SELECT policies are also available; the lowest price is $1,647, the highest is $2,647.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $717, the highest is $1,173, and the average is $938.
On the whole, these cost about 47% less than Policy A. 10 different policies are available.
No SELECT “F – High Deductible” policies are available.

Policy G:
The lowest price available is $1,825, the highest is $2,869, and the average is $2,345.
On the whole, these cost about 31% more than Policy A. 14 different policies are available.
Two SELECT policies are also available; the lower price is $1,934, the higher is $2,268.

Policy K:
The lowest price available is $816, the highest is $1,274, and the average is $1,083.
On the whole, these cost about 39% less than Policy A. 4 different policies are available.
No SELECT “K” policies are available.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $1,227, the highest is $1,879, and the average is $1,588.
On the whole, these cost about 11% less than Policy A. 6 different policies are available.
No SELECT “L” policies are available.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $1,777, the highest is $2,404, and the average is $2,158.
On the whole, these cost about 21% more than Policy A. 7 different policies are available.
One SELECT policy is available; it costs $1,613.
This policy is very new.

Policy N:
The lowest price available is $1,485, the highest is $2,676, and the average is $2,041.
On the whole, these cost 14% more than Policy A. 15 different policies are available.
No SELECT “N” policies are available.
This policy is very new.

Disabled Female Beneficiaries Under Age 65(These are NOT available to beneficiaries entitled because of ESRD.)

Policy A:
The lowest price available is $2,928, the highest is $9,489, and the average is $4,211.
This is the “basic” policy. Some 23 different policies are available. No SELECT “A” policies are available.

Policy B:
The lowest price available is $3,492, the highest is $5,259, and the average is $4,259.
On the whole, these cost about 1% more than Policy A. 15 different policies are available.
One SELECT policy ($3,706) is also available.

Policy C:
The lowest price available is $4,069, the highest is $12,572, and the average is $5,990.
On the whole, these cost about 42% more than Policy A. 15 different policies are available.
Four SELECT policies are also available; the lowest price is $3,861, the highest is $5,945.

Policy D:
The lowest price available is $3,900, the highest is $11,681, and the average is $5,704.
On the whole, these cost about 35% more than Policy A. 10 different policies are available.
Three SELECT policies are also available; the lowest price is $3,992, the highest is $5,306.

Policy F:
The lowest price available is $3,598, the highest is $12,659, and the average is $5,651.
On the whole, these cost about 34% more than Policy A. 23 different policies are available.
Five SELECT policies are also available; the lowest price is $3,483, the highest is $5,961.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $1,692, the highest is $2,636, and the average is $2,111.
On the whole, these cost about 50% less than Policy A. 8 different policies are available.
No SELECT “F – High Deductible” policies are available.

Policy G:
The lowest price available is $3,449, the highest is $5,064, and the average is $4,314.
On the whole, these cost about 2% more than Policy A. 12 different policies are available.
Two SELECT policies are also available; the lower price is $3,069, the higher is $3,791.

Policy K:
The lowest price available is $1,926, the highest is $2,796, and the average is $2,435.
On the whole, these cost about 42% less than Policy A. 4 different policies are available.
No SELECT “K” policies are available.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $2,898, the highest is $4,125, and the average is $3,403.
On the whole, these cost about 19% less than Policy A. 6 different policies are available.
No SELECT “L” policies are available.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $3,516, the highest is $10,266, and the average is $5,765.
On the whole, these cost about 37% more than Policy A. 7 different policies are available.
One SELECT policy is available; it costs $3,966.
This policy is very new.

Policy N:
The lowest price available is $3,066, the highest is $10,223, and the average is $4,788.
On the whole, these cost 14% more than Policy A. 13 different policies are available.
No SELECT “N” policies are available.
This policy is very new.

Disabled Male Beneficiaries Under Age 65 (These are NOT available to beneficiaries entitled because of ESRD.)

Policy A:
The lowest price available is $3,137, the highest is $10,220, and the average is $4,478.
This is the “basic” policy. Some 23 different policies are available.
No SELECT “A” policies are available.

Policy B:
The lowest price available is $3,640, the highest is $6,051, and the average is $4,505.
On the whole, these cost about 1% more than Policy A. 15 different policies are available.
One SELECT policy ($3,706) is also available.

Policy C:
The lowest price available is $4,069, the highest is $13,540, and the average is $6,303.
On the whole, these cost about 41% more than Policy A. 15 different policies are available.
Four SELECT policies are also available; the lowest price is $3,861, the highest is $6,403.

Policy D:
The lowest price available is $3,900, the highest is $12,512, and the average is $6,056.
On the whole, these cost about 35% more than Policy A. 10 different policies are available.
Three SELECT policies are also available; the lowest price is $3,992, the highest is $5,714.

Policy F:
The lowest price available is $4,078, the highest is $13,634, and the average is $5,992.
On the whole, these cost about 34% more than Policy A. 23 different policies are available.
Five SELECT policies are also available; the lowest price is $3,891, the highest is $6,420.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $1,946, the highest is $3,038, and the average is $2,324.
On the whole, these cost about 48% less than Policy A. 8 different policies are available.
No SELECT “F – High Deductible” policies are available.

Policy G:
The lowest price available is $3,911, the highest is $5,200, and the average is $4,613.
On the whole, these cost about 3% more than Policy A. 12 different policies are available.
Two SELECT policies are also available; the lower price is $3,558, the higher is $4,309.

Policy K:
The lowest price available is $1,926, the highest is $2,796, and the average is $2,476.
On the whole, these cost about 45% less than Policy A. 4 different policies are available.
No SELECT “K” policies are available.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $2,898, the highest is $4,125, and the average is $3,492.
On the whole, these cost about 22% less than Policy A. 6 different policies are available.
No SELECT “L” policies are available.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $4,037, the highest is $11,056, and the average is $6,215.
On the whole, these cost about 39% more than Policy A. 7 different policies are available.
One SELECT policy is available; it costs $3,966.
This policy is very new.

Policy N:
The lowest price available is $3,456, the highest is $11,021, and the average is $5,153.
On the whole, these cost 15% more than Policy A. 13 different policies are available.
No SELECT “N” policies are available.
This policy is very new.

Tuesday, June 21, 2011

Medigap Policies Available in New York

Wednesday, June 8, 2011

Medigap Policies Available in California

I am doing an extensive analysis of the Medigap (Medicare supplement) policies currently available to Medicare beneficiaries. This is because the structure of new policies available to beneficiaries changed last June, and by now there is enough information to give some guidance on both the availability and prices of the newly structured policies. The full analysis will take me quite awhile, but I already producing some helpful information for certain states, and it makes sense to begin sharing this now rather than waiting until my full analysis is complete.

There is no need to go into explaining the new structure; this is all spelled out in Managing Your Medicare, on page 157. And even better, you can access, thorough the CD that comes with the book, a “2011 Medigap Standard Policies Worksheet” to help guide you through the process of selecting a Medigap policy during this current year. (Click on the “check for any updated forms” button on the introduction screen to the CD.)

But what I have available here is information, first, for those age 65, which is when most beneficiaries get a Medigap policy, on the number of policies available, the lowest priced one available, the highest priced one available, and the average price. Even better, this information is given for each policy type. Also, there is a quick comparison of the average price of each policy type to type “A”, the “basic” policy, so you can easily determine roughly how much more or less the policy type you are looking at compares to the basic one, or indeed, to any other policy type. All this is harder to explain than it is to show.

The information for beneficiaries age 65 is then followed with that for disabled beneficiaries, that is, those under age 65, as California mandates that insurance companies make Medigap policies available to them. While the state mandates only certain policy types, some companies also make other policy types available. (And be aware that the mandate applies only six months AFTER you get Part B, and even then waiting periods for pre-existing conditions may apply.)

Note that for both groups the information is given first for females and then for males. All this information comes from the California Department of Insurance website, www.insurance.ca/gov, which has more detailed information on these policies.

Again, remember that for each policy type, the benefits are exactly the same no matter who sells it, and you should aggressively look for the best price. You will be shocked by the difference in prices for the same policy type. Please understand that the prices shown here and what you are quoted will vary because of how and how often you pay your premium, your exact age, whether you smoke, where you live in California, if it is a SELECT policy (that is, you are limited to a network of providers), etc., etc., so use these as guides rather than exact “matches.” (These happen to be based on the populous Los Angeles County area.) The dollar amounts shown below are the annual cost of the policies.

Medigap Policies – Females – Age 65

Policy A:
The lowest price available is $864, the highest is $5,323, and the average is $1,694.
This is the “basic” policy. Some 29 different companies offer these.

Policy B:
The lowest price available is $1,427, the highest is $4,915, and the average is $2,167.
On the whole, these cost about 28% more than Policy A. 19 different companies offer these.

Policy C:
The lowest price available is $1,655, the highest is $6,143, and the average is $2,551.
On the whole, these cost about 51% more than Policy A. 19 different companies offer these.

Policy D:
The lowest price available is $1,509, the highest is $4,500, and the average is $2,451.
On the whole, these cost about 45% more than Policy A. 13 different companies offer these.

Policy F:
The lowest price available is $1,629, the highest is $5,467, and the average is $2,428.
On the whole, these cost about 43% more than Policy A. 29 different companies offer these.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $395, the highest is $1,422, and the average is $875.
On the whole, these cost about 48% less than Policy A. 7 different companies offer these.

Policy G:
The lowest price available is $1,461, the highest is $4,591, and the average is $2,434.
On the whole, these cost about 44% more than Policy A. 16 different companies offer these.

Policy K:
The lowest price available is $611, the highest is $954, and the average is $809.
On the whole, these cost about 52% less than Policy A. 5 different companies offer these.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $1,006, the highest is $1,855, and the average is $1,308.
On the whole, these cost about 19% less than Policy A. 7 different companies offer these.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $1,239, the highest is $1,901, and the average is $1,611.
On the whole, these cost about 5% less than Policy A. 3 different companies offer these.
This policy is very new.

Policy N:
The lowest price available is $911, the highest is $1,981, and the average is $1,550.
On the whole, these cost about 9% less than Policy A. 9 different companies offer these.
This policy is very new.

Medigap Policies – Males – Age 65

Policy A:
The lowest price available is $864, the highest is $6,064, and the average is $1,854.
This is the “basic” policy. Some 29 different companies offer these.

Policy B:
The lowest price available is $1,427, the highest is $5,480, and the average is $2,232.
On the whole, these cost about 20% more than Policy A. 19 different companies offer these.

Policy C:
The lowest price available is $1,655, the highest is $6,849, and the average is $2,622.
On the whole, these cost about 41% more than Policy A. 19 different companies offer these.

Policy D:
The lowest price available is $1,524, the highest is $5,018, and the average is $2,564.
On the whole, these cost about 38% more than Policy A. 13 different companies offer these.

Policy F:
The lowest price available is $1,629, the highest is $6,096, and the average is $2,522.
On the whole, these cost about 36% more than Policy A. 29 different companies offer these.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $395, the highest is $1,422, and the average is $892.
On the whole, these cost about 52% less than Policy A. 7 different companies offer these.

Policy G:
The lowest price available is $1,461, the highest is $5,119, and the average is $2,526.
On the whole, these cost about 36% more than Policy A. 16 different companies offer these.

Policy K:
The lowest price available is $611, the highest is $956, and the average is $809.
On the whole, these cost about 56% less than Policy A. 5 different companies offer these.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $1,006, the highest is $1,855, and the average is $1,381.
On the whole, these cost about 26% less than Policy A. 7 different companies offer these.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $1,239, the highest is $1,901, and the average is $1,611.
On the whole, these cost about 13% less than Policy A. 3 different companies offer these.
This policy is very new.

Policy N:
The lowest price available is $911, the highest is $1,981, and the average is $1,550.
On the whole, these cost about 16% less than Policy A. 9 different companies offer these.
This policy is very new.

Disabled Beneficiaries Under Age 65 Females
(These are NOT available to beneficiaries entitled because of ESRD.)

Policy A:
The lowest price available is $1,067, the highest is $10,686, and the average is $3,132
This is the “basic” policy. Some 25 different companies offer these.

Policy B:
The lowest price available is $1,556, the highest is $9,876, and the average is $4,226.
On the whole, these cost about 35% more than Policy A. 18 different companies offer these.

Policy C:
The lowest price available is $1,730, the highest is $12,339, and the average is $4,982.
On the whole, these cost about 59% more than Policy A. 17 different companies offer these.

Policy D:
The lowest price available is $2,430, the highest is $7,776, and the average is $4,527.
On the whole, these cost about 45% more than Policy A. 5 different companies offer these.

Policy F:
The lowest price available is $1,746, the highest is $10,974, and the average is $4,551.
On the whole, these cost about 45% more than Policy A. 26 different companies offer these.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $692, the highest is $3,436, and the average is $2,082.
On the whole, these cost about 34% less than Policy A. 3 different companies offer these.

Policy G:
The lowest price available is $3,348, the highest is $5,406, and the average is $3,989.
On the whole, these cost about 27% more than Policy A. 5 different companies offer these.

Policy K:
The lowest price available is $1,112, the highest is $4,308, and the average is $2,303.
On the whole, these cost about 26% less than Policy A. 5 different companies offer these.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $1,756, the highest is $3,484, and the average is $2,649.
On the whole, these cost about 15% less than Policy A. 5 different companies offer these.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $4,152, the highest is $4,152, and the average is $4,512.
On the whole, these cost about 33% more than Policy A. Only 1 company offers this.
This policy is very new.

Policy N:
The lowest price available is $2,163, the highest is $3,900, and the average is $3,056.
On the whole, these cost about 2% less than Policy A. 4 different companies offer these.
This policy is very new.

Disabled Beneficiaries Under Age 65 Males
(These are NOT available to beneficiaries entitled because of ESRD.)

Policy A:
The lowest price available is $1,067, the highest is $11,915, and the average is $3,242
This is the “basic” policy. Some 25 different companies offer these.

Policy B:
The lowest price available is $1,556, the highest is $11,012, and the average is $4,355.
On the whole, these cost about 34% more than Policy A. 18 different companies offer these.

Policy C:
The lowest price available is $1,730, the highest is $13,757, and the average is $5,149.
On the whole, these cost about 59% more than Policy A. 17 different companies offer these.

Policy D:
The lowest price available is $2,794, the highest is $7,776, and the average is $4,559.
On the whole, these cost about 42% more than Policy A. 5 different companies offer these.

Policy F:
The lowest price available is $1,746, the highest is $12,236, and the average is $4,695.
On the whole, these cost about 45% more than Policy A. 26 different companies offer these.
These cover all Medigap benefits and are popular.

Policy F – High Deductible:
The lowest price available is $692, the highest is $3,436, and the average is $2,163.
On the whole, these cost about 33% less than Policy A. 3 different companies offer these.

Policy G:
The lowest price available is $3,348, the highest is $5,406, and the average is $3,989.
On the whole, these cost about 23% more than Policy A. 5 different companies offer these.

Policy K:
The lowest price available is $1,112, the highest is $4,308, and the average is $2,303.
On the whole, these cost about 29% less than Policy A. 5 different companies offer these.
This is the 50% catastrophic policy.

Policy L:
The lowest price available is $1,756, the highest is $3,484, and the average is $2,649.
On the whole, these cost about 18% less than Policy A. 5 different companies offer these.
This is the 75% catastrophic policy.

Policy M:
The lowest price available is $4,152, the highest is $4,152, and the average is $4,512.
On the whole, these cost about 28% more than Policy A. Only 1 company offers this.
This policy is very new.

Policy N:
The lowest price available is $2,163, the highest is $3,900, and the average is $3,056.
On the whole, these cost about 6% less than Policy A. 4 different companies offer these.
This policy is very new.

Monday, June 6, 2011

Medigap Policies Available in Texas

Friday, June 3, 2011

Monday, May 30, 2011

Article on Your Home Health Rights

I recently wrote an article on the special rights Medicare beneficiaries have with their Home Health Agency (HHA) benefits. In it, I point out that because of the way Medicare pays agencies for care, they tend to minimize the number of visits they make to you, while you, because these visits are absolutely free to you, want to maximize visits. The article is posted on the Self-Counsel Press web site at:

http://www.self-counsel.com/news/reference/family/452-your-rights-when-receiving-home-health-agency-care-in-the-us.html

Tuesday, April 26, 2011

Some Changes in Medicare Advantage and Part D Plans

The Centers for Medicare & Medicaid Services (CMS) officially published a long set of final regulations having to do with Part C (Medicare Advantage) and Part D (prescription drugs) of the Medicare program on April 15, 2011. Many of these directly affect beneficiaries. A number of these are already in effect because of statute or temporary regulation, and there is no need to rehash them. And a majority of the changes that these rules make will not go into effect until 2012 or 2013, and I’ll blog about them when they are closer to their actual implementation. But a few of them go into effect on June 6, which is 60 days after they were first “displayed,” and you should be aware of the changes that directly affect you.

Senior Housing Facility Plans – The regulations make permanent a fairly new option in Medicare managed care (Medicare Advantage) called a “Senior Housing Facility Plan,” which has been available only as a demonstration. It further stipulates that these plans, which may enroll only beneficiaries who reside in a continuing care retirement community, must provide primary care services on-site, and also provide transportation to specialty care, as well as meet all other requirements to be a Medicare Advantage Plan. (This transportation requirement is an exception to the general rule that Medicare does not cover routine medical transportation.) It also clarifies that if a beneficiary moves out of the community, this is an “out-of-area” move, and the beneficiary must be disenrolled from the Plan, but are also entitled to a “special enrollment period” (SEP) to choose another managed care plan and/or to continue in Part D.

Disenrollment for Failure to Pay Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA) – This clarifies what happens when beneficiaries fail to their Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA). I call this the Part D high-income premium surcharge, because that’s what it is. And this basically applies to beneficiaries who are not getting monthly Social Security, Railroad Retirement, or Office of Personnel Management (federal pensions) benefits, as these amounts are normally deducted from those payments. If you fail to pay your “monthly adjustment amount,” that is, your surcharge, you are given a three-month grace period. In these cases you will receive an initial bill, a second notice, and a delinquent notice; these will come from the Centers for Medicare & Medicaid Services (CMS). At that point, if you have not paid, you will receive your disenrollment notice, but this will come from your drug plan, not from CMS. This notice is called a “Notification of Involuntary Disenrollment by the Centers for Medicare and Medicaid Services for Failure to Pay the Part D-IRMAA.”

One very important point to understand is that if your get your Part D prescription drug benefit though a Medicare Advantage Plan, and your don’t pay your Part D monthly adjustment amount, that is, your surcharge, you will be disenrolled from your Medicare Advantage Plan and put into Original Medicare.

You will be given a three-month grace period after your disenrollment during which, if you show “good cause” for failure to pay your monthly adjustment amounts/surcharges, you can be reinstated into your Plan. By good cause is meant that there were “unusual and unavoidable circumstances beyond your control” which caused you not to pay. (An example of good cause might be that you were hospitalized with a bad stroke, and your family didn’t understand that your monthly adjustment amounts/surcharges had to be paid while you underwent extensive rehabilitation.) If good cause is found, and you pay all your past due Part D premiums and your adjustment amounts/surcharges, you can be reinstated. So if you are disenrolled, and you think you may have good cause to be reinstated, you should call 1-800-MEDICARE and ask to be put in touch with a caseworker in the CMS regional office which serves your state.

Good Cause Reinstatement of a Beneficiary Who Fails to Pay Plan Premiums – This applies both to Part C Medicare Advantage Plans and Part D prescription drug plans. If you fail to pay your premium to your Plan, it may disenroll you. They have to give you a grace period of at least two months after they notify you of your delinquency before they do this. You will receive a “Notice of Failure to Pay Plan Premiums.” But now, similar to the discussion above, you will be given a three-month period after your disenrollment during which, if you show “good cause” for failure to pay your premiums, that is, there were “unusual and unavoidable circumstances beyond your control” which caused you not to pay, and if you now pay all of your premiums which you failed to pay, and any arrearages, you can be reinstated by your plan. So if you are disenrolled, and you think you have “good cause” to be reinstated, call your plan and request this.

Coverage Gap – No Discount on Vaccine Administration Fees – Beginning this year, 2011, beneficiaries who do not receive the low income subsidy and who go into the coverage gap (“donut hole”), get a 50 percent discount on their brand name medicines, and a 7 percent off their generics. This regulation clarifies that that this discount does not apply to any vaccine administration fee. So you will be fully responsible for this, as well as, as has been previously established, any dispensing fee and any sales tax while you are in the coverage gap or “donut hole.”

Call Center Interpreters Required – As the Centers for Medicare & Medicaid Services (CMS) found that a number of call centers were not providing interpreter services, it has now required in regulation that both Part C Medicare Advantage Plans and Part D prescription drug plans provide these to non-English speaking and limited English proficiency callers. If your Plan does not provide an interpreter to translate your language, you should notify CMS at once.

Notification Calls – If at some point your Part C Medicare Advantage Plan or your Part D prescription drug plan finds that one of its agent is unqualified (for example, they are not properly licensed), and that agent enrolled you in their Plan, it must call you and explain the situation to you. The purpose of this call is to be honest with you, to answer any questions you have about your enrollment and the plans benefits, and to give you the opportunity to confirm your enrollment or to change Plans if you believe you were disadvantaged or misled in any way.

Note that this “notification call” is in addition to the “enrollment verification call” that you should routinely receive whenever you sign up with any Plan. This call is supposed to be made to all new enrollees to clearly establish that they have enrolled in the Plan, and to make sure you understand its benefits, and to make a change if you did not understand that you were enrolling or what the benefits are.

Monday, April 11, 2011

Face-to-Face Requirement for Home Health Agency and Hospice Services Effective April 1, 2011

Beneficiaries should be aware that a new requirement stemming from the Health Care Reform legislation went into final force and effect on April 1, 2011. This requires that, with regard to home health agency (HHA) services, a physician must actually see a beneficiary face-to-face prior to certifying their need for home health agency care. This face-to-face encounter must occur within a 120-day window which begins 90 days prior to the start of care and ends 30 days after the start of care. In addition to a physician, a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant may perform this encounter under certain circumstances. Additionally, the “face-to-face” may be performed via telemedicine, again, in certain circumstances.

And for hospice services, the new legislation requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient's 180th-day recertification and at each subsequent recertification. (Hospices are periodically required to recertify a Medicare patient’s eligibility for hospice care.)

Beneficiaries need to be aware of some of the implications of this. For beneficiaries in hospice care, it’s pretty straightforward. It’s up to the hospice to make sure this is done, and done by one of their own physicians or practitioners. So you will not be liable for the cost of this encounter. And, if it is not done, and done timely, and the hospice continues to treat you, Medicare will not pay them, but they and not you bear the cost for any care you receive.

For home health agency care, it’s more complicated. For one, and this is not expected to be the norm, if the encounter is the only reason you need to see a physician, or other qualified practitioner, you are responsible for your share of the cost the encounter, which is a covered Part B service. On the other hand, it is up to the Home Health Agency serving you to make sure this new requirement is met. If for some reason they begin visiting you, and the encounter does not take place, they must notify you that you will become liable for all of their services (as Medicare cannot pay them unless this requirement is met). And if they do not notify you, you are not liable for the costs of their services.

Home Health Agencies have been instructed to notify you using the Home Health Advance Beneficiary Notice (HHABN), and more specifically, Option 2 of that notice. They are supposed to do this in advance of their stopping care so you can make arrangements for the encounter.

Saturday, April 9, 2011

Special Medigap Suspension Right for Disabled Medicare Beneficiaries

Few federal Medicare supplement insurance (Medigap) rights exist for you beneficiaries who are under 65 and have Medicare because of a disability. (This does not apply to those of you who are under 65 and have Medicare because you have End Stage Renal Disease.) However, one little known right you have is that, if you have a Medigap policy, you may suspend your Medigap policy, without penalty, for up to 24 months, while you are enrolled in your or your spouse’s employer or union group health plan. (Typically, because you are disabled, you would get this coverage through your spouse’s employment.) That is, you can get your coverage through that plan but at the same time keep your right to get your Medigap policy back if you loose your employer or union coverage for any reason in that 24 months. You have to notify your Medigap insurer that you want your coverage back within 90 days of loosing your employer or union coverage. Your Medigap coverage will start the day your employer or union coverage stops, and you can’t be made to wait because of preexisting conditions, and your Medigap policy has to have the same benefits and premiums as if it had not been suspended. (Of course, if the same policy had its rates raised and/or its benefits changed for everyone, yours will change too.)

Thursday, March 31, 2011

Beneficiary Beware – Your Liabilities with Hospital “Observation” Services

Late last year Susan Jaffe of the Kaiser Health News wrote an excellent article in The Washington Post (September 7, 2010) concerning a significant increase in the use of “observation services” by hospitals for Medicare beneficiaries. Of course, many patients who show up or who are brought to hospitals are treated and then held for observation, not only because the hospital physicians and staff need to be sure their diagnoses are correct and that the treatments are working, but also because they often know absolutely nothing about the patient when they arrive in the emergency room or at an outpatient clinic. So their being cautious is quite understandable. But, as Ms. Jaffe so clearly points out, this appears to have gotten out of hand; indeed, she cites the case of an 85-year old beneficiary who broke a number of ribs and was held in observation for six days! This was in spite of the fact that Medicare says observations stays should be limited to 24 hours, and, with rare exceptions, to 48 hours. And, as her article further points out, beneficiaries who are put in this limbo often do not understand that they have not been admitted as an inpatient, as they are assigned a bed and get one of those plastic bracelets and are fed their meals and seem to be regarded as any other inmate.

But from the beneficiary point-of-view, there are two big downsides to this whole trend. One of them is not what you will directly owe the hospital for your observation care. This is because although you are responsible for a Part B co-payment for your observation care, this is limited to the amount of the Part A inpatient deductible, that is, what you would have owed the hospital for your inpatient care if you had been admitted. So you are protected on your hospital bill whether or not you are admitted as an inpatient. [Well, mostly protected; see the note at the end of this posting.*]

But you will be liable for two other expenses, which can be huge. In Medicare, recall that your Skilled Nursing Facility (SNF) care is covered only if you were admitted to a hospital as an inpatient for at least three days. So if you get put in “observation care,” no matter how long you are there, you will NOT qualify for Medicare to cover your Skilled Nursing Facility care if you go to one of these facilities after your hospital treatment. (While some of your care there may be covered, that is, your Part B will have to pay for “ancillary services” such as physical or occupational therapy, your basic room and board charges, which are the big part of the bill, will not be covered at all.) In Ms. Jaffe’s article, she points out that the beneficiary ended up owing well over $10,000 out-of-pocket to a Skilled Nursing Facility.

The Centers for Medicare & Medicaid Services has begun to realize that this is quite a problem, and is working on it. Perhaps they will issue a requirement that hospitals give beneficiaries in observation status an “Advanced Beneficiary Notice” clearly telling them that their care is covered under Part B and not Part A and what the implications of this are. But unless there is a way to instantly appeal this, I’m not sure where it leaves the beneficiary. Probably still in limbo.

My only suggestion at this point is that if your are put into a protracted observation status at a hospital, and you think you should be admitted, immediately call, or have a family member or caregiver call, your Quality Improvement Organization (QIO) and formally complain to them about the quality of care you are receiving. Perhaps they can intervene. These outfits are discussed on page 215 of Managing Your Medicare; you can get your organization’s number by calling the 1-800-MEDICARE number or by going on www.medicare.gov.

And while this will not help you while you are in the hospital, you can always appeal your Medicare Summary Notice about the hospital observation services, and insist that you should have been admitted as an inpatient. If you are successful, you can demand that any subsequent Skilled Nursing Facility also be covered by Medicare. The Center for Medicare Advocacy, a strong proponent of beneficiary rights, has excellent suggestions on its website www.medicareadvocacy.org on how to do this. It advises that you may need help from an organziation such as itself or from your State Health Insurance Counseling Program (SHIP).

The other liability arises when, while you are in observation status, you have to take prescription drugs you take everyday, and which may have nothing to do with your being at the hospital. You may have neglected to take your drugs with you, or perhaps the hospital wouldn’t let you take what you did bring. Or perhaps you have to take a prescription that you have but which you don’t usually take everyday. In cases where the hospital gives you these drugs, you will be in a bind as generally Part B will not pay for self-administered drugs in a hospital outpatient setting unless they are part of the hospital’s therapy. And so the hospital will bill you, and not Medicare, for these drugs.

If you have Part D, your drug plan MAY pay for what the hospital billed you. Particularly because most hospital pharmacies do NOT participate in Part D, the hospital will likely bill you for these drugs, you will have to pay them, and you should submit the bills to your Part D plan. You can call them to find out how to do this. Your plan may inquire about the reasons for your hospital visit, or if you could have gotten the medicine in another way, or from an in-network pharmacy. If your drug plan does reimburse you, it will probably be only at the level that it would have paid if you got the medicine at a network pharmacy, taking Part D deductibles, coinsurance and co-payments into account. The amount it establishes will count toward your Part D true out-of-pocket costs (TrOOP).

This issue has become such a problem that the Centers for Medicare & Medicaid Services had a “tip sheet” about it. You can download it, “How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings,” CMS Product No. 11333 (January. 2010), from their website, www.medicare.gov.

Perhaps the “moral of this story” is that you should always try to have a small supply of your prescription drugs with you, and your schedule for taking them, with you. And while this perhaps this can’t be done in all emergencies, it is just a good habit. For example, recently I was unexpectedly stranded overnight in an airport due to a flight cancellation; I was not happy that I did not have my meds with me.

I would be interested in any experiences you may have had with this issue. Please email me at managingyourmedicare@gmail.com.

[*Well, you are mostly protected. But you should also be aware that if you are not admitted, your Part A “benefit period” or “spell of illness” will not begin. Recall that once that happens, that is, you are admitted as an inpatient, you are liable for the Part A deductible of $1,132 (in 2011). And that’s all you pay for your first 60 days of hospital inpatient care. So, for example, if you are admitted as an inpatient, and then discharged, let’s say five days later, and you are readmitted four weeks later, your benefit period (spell of illness) is still in effect and you do NOT have to pay the inpatient deductible again. (Your benefit period or spell generally does not expire until you have been out of a hospital or a Skilled Nursing Facility for 60 days.) But, if you were held in observation status for four days and then released, and then readmitted four weeks later, but now as an inpatient, you would be liable not only for the Part B copayment for the observation stay, but also for the Part A deductible for the new, inpatient stay.]

Tuesday, March 29, 2011

2011 Medicare Cheat Sheet

2011 Medicare Cheat Sheet

Years ago, when I worked for the Social Security Administration, and it ran the whole Medicare program, we would go out and give talks about Medicare. For ready reference, we would always keep a 3x5 index card in one hand, and on it we wrote all the numerical information that changed from year to year. It wasn’t much, usually the Part A inpatient hospital deductible would change, and the other Part A deductibles, and also the Part B premium, and rarely, the Part B deductible. But the point being, every variable could fit on one side of one little index card.

No more! Not only are there more Parts to Medicare now, but the program has become very, very complex. And with this, there are many, many variables which typically change from year to year, and which no one, and certainly not me, can easily remember. To help me, especially when I do counseling, I keep a “cheat sheet” which I update each year. And, to warn you, it’s six pages in an Excel spreadsheet! Goodbye index card!

You can access this by going to the CD that comes with Managing Your Medicare, clicking on the check for any updated forms and instructions link, and printing it out. I keep it color-coded not only to highlight the changes from last year to the current year, but also to help separate the many different topics it covers, and so I strongly recommend that you print it out in color. And note that the last two pages cover only Alaska and Hawaii, respectively, so you probably don’t need to print those pages unless you live in one of those two states. Helpful printing instructions are at the very end of the sheet.

Finally, you should be aware that the information for the next year starts coming out early in the current year, and various items for the next continue to be released as the current year goes along, and even into the next year. So I will begin posting the next year’s cheat sheet late in the current year, but it won’t be fully complete until early in the year it covers. At that point it will be named “Final Cheat Sheet for 2012,” or whatever the year is.

Thursday, March 24, 2011

Hurry, the 2011 General Enrollment Period Ends March 31

As we come upon March 31, beneficiaries without Part B who wish to get it must enroll by that date. You can do this by calling the Social Security Administration (1-800-772-1213). Your enrollment will not be effective until July 1, 2011. Your base premium will be $115.40 per month; if you get Social Security, this will automatically be deducted from your monthly payment. But remember that you are, as a late enrollee, subject to a penalty; it is 10% (or $11.50 a month) of the base premium for each 12 months you could have been enrolled but were not. (And, if you have a high income, generally $170,000 for a couple or $85,000 for an individual, you will also be subject to the high income surcharge. But the penalty applies only to the base premium, not to any surcharge.)

(For those very few of you who do not have Part A but can qualify for “Premium Part A”, you can also sign up now, with the same effective date. Your monthly premium will probably be $495.00, if you have fewer than 30 “quarters of coverage,” or $272.80, if you have at least 30.

If you do sign up for Part B and you also have had or get Part A, two important events occur:

If you are 65 or older, and this is the very first time you have Part B, you will have a guaranteed issue right to any Medigap policy sold in your area beginning July 1st. This is true no matter how much older than 65 you are, although there may be some temporary preexisting condition exclusions. This is the federal law; your state may have additional protections. This right exists for only six months, so act before December 31.

For a beneficiary of any age (but not if you have End Stage Renal Disease), you also may, effective with July 1st, join a Medicare Advantage Plan as you now have both Part A and Part B, a requirement to join such a Plan. You must sign up within three months of July 1, that is, by September 30. You may not, in doing this, change your Part D status. If you don’t have Part D, you must sign up for a Plan which does not offer it; if you do have Part D, you can either do that and keep your current Part D stand-alone plan, or you can join any Plan which does include Part D coverage.

So act quickly if you want to enroll in more of Medicare! Call Social Security by Friday, March 31 and don’t wait ‘til the last minute. More detailed information on all these topics is available in Managing Your Medicare.

And, as I blogged on January 9, when enroll in Part B you know you will get it on July 1, so aggressively begin to schedule all applicable preventive and educational services beginning with that date, as these are all Part B services. It may take you months to schedule your “Welcome to Medicare” exam with your physician, so begin lining it up as soon as you enroll. Same for all the other preventive and educational services. My blog of November 29, 2010 explains everything available in 2011. And go over chapter 4 of Managing Your Medicare to see what else Part B covers. Perhaps you have put off some physical therapy that you really need, or some mental health services; line these up, too.

Tuesday, March 1, 2011

Part D Formulary Changes after March 1

After March 1, 2011, drug plans can make “negative” changes to their formularies during most of the remainder of the year. By negative changes we mean they can remove a drug from their formulary, that is, no longer cover it; or remove a particular dosage of a drug from their formulary; or they can change a drug from one price tier to another tier where a beneficiary has to pay more; or they can impose utilization controls (such as step therapy) which had not previously been in place. In other words, “negative” changes are those which either restrict a beneficiary from getting a drug, or which cause a drug to be more costly to a beneficiary. (Part D drug plans are always able to add drugs to their formulary, or put a drug in a lower cost tier, or remove utilization controls.)

And there is a general rule that a plan cannot actually make these negative changes until 60 days after giving notice of the change. The exceptions are that an immediate change can be made if the FDA issues a warning about a drug or if a manufacturer stops making a drug.

Some Medicare guidance talks about what a beneficiary’s rights are when these changes are made (“maintenance” vs. “non-maintenance” changes), but a beneficiary has no real way of knowing what kind of change has been made other than that their plan has to notify them of it if they are affected by it, and tell them what their rights are.

What is important is that some changes (the so-called “non-maintenance” changes) are not supposed to directly affect a beneficiary for the remainder of the calendar year in which they are made. So, for example, if you are taking a drug and your plan now decides (for its own reasons, and not, for example, because of an FDA warning) that it will require step therapy for it, you will not be affected as for the remainder of the year as this new requirement won’t apply to you. Nor will it apply to a beneficiary who first presents a prescription for the drug in the 60 days between when the plan announces the change and the change actually goes into effect. It will apply to a beneficiary in the plan that subsequently starts taking that drug after the change goes into effect.

(Importantly, if you stick with this plan for the next calendar year, you will then be subject to the change, but you, of course, will have to the opportunity, from October 15 to December 7, 2011 Note the new dates, the Annual Coordinated Election Period, which is sometimes called Fall Open Enrollment, is different this year. to switch plans in 2012. But what is a little tricky here is that your plan doesn’t have to notify you of the specific change if you are not affected by it, and so you may stick with your plan into the new year, when it will affect you. Again, this just reinforces the need for you to check your plan’s Annual Notice of Change you get in the fall to make sure that all your drugs will continue to be covered, or, even better, to go on Medicare’s Plan Compare feature and shop, each and every year, for the very best plan for you.)

The other changes (the so-called “maintenance” changes) will apply to you, but your plan has to give you a 60-day notice of what the change is before it goes into effect, and it has to allow you to have at least a 60-day supply of your drug. But from then on, you are subject to the change. So, for example, if a generic drug begins to be marketed, and your plan removes its brand name equivalent from its formulary, you have to get the notice 60 days before it actually does so, and your plan has to make sure you can get a 60-day supply of the brand name drug. The idea here is that the 60 days gives you time to check with your prescribing physician or health care provider about the change. And, if it is not suitable, the important paragraph below applies.

In these cases, because you are affected, your plan must tell you your rights. So in these cases you may ask for exception, which is really just another way of saying you can appeal. And this applies to any action which is negative to you: removal of a drug (or particular dosage of it) from their formulary; a change a drug from one price tier to another, higher tier; or the imposition of utilization controls. And the first appeals step is a “request for a drug coverage determination” in which you ask your plan for a formal decision on your request, in this case, for an exception.

Most beneficiary advocates prefer that you make your “request for a drug coverage determination” in writing; this is especially so because your prescribing physician or health care provider will have to endorse your exception request. You can easily download a form to so this on by searching for “Request for Medicare Prescription Drug Coverage Determination” on the net. Print this out and fill out all of it that you possibly can, and then take it to your prescriber to have them finalize it. They usually will fax it to the plan for you. Alternatively, you can ask your State Health Insurance Counseling Program (SHIP) to help you with this process. Their toll free phone number is on the back of your Medicare and You booklet.

If your plan’s decision is not acceptable to you, follow the rest of the appeals process as set out in Chapter 14 of “Managing Your Medicare.”

2011 Income Amounts for the Part D Prescription Drug Low Income Subsidy or “Extra Help”

The federal government recently released the federal poverty income levels (FPLs) for 2011, and they have increased slightly over 2010 levels, which will probably enable some beneficiaries to qualify for “Extra Help,“ particularly because Social Security payments did not automatically increase for 2011. The Low Income Subsidy or Extra Help allows Medicare beneficiaries with low incomes and resources who enroll in Part D to qualify for full or partial payment of their premiums, deductibles and reduces their co-payments on drugs. Full payment of the premium is restricted to plan premiums which are at or below the “benchmark” premium for your state.) This is fully explained in Chapter 7 (which begins on page 99) of Managing Your Medicare. (Finally, these income amounts apply to the contiguous 48 states and the District of Columbia, the income levels (but not the resources levels) are higher for Alaska and Hawaii.)

Those who qualify for Extra Help at these levels will pay no premium, and will not be subject to the deductible, and the cost of their drugs will be as follows:

If you have Medicaid AND:

You live in a nursing home:
You pay nothing.

Your income is at or below $10,890 (individual) or $14,710 (couple):
You pay $1.10 for a generic or preferred brand, and $3.30 for a non- preferred brand.*

Your income is above $10,890 (individual) or $14,710 (couple)
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*

You don't have Medicaid but your state helps you pay your Medicare premiums (that is, you are in the “Medicare Savings Program”) OR you get supplemental security income (SSI):
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*

You are not as above but qualify for Extra Help because of your income and resources levels as follows:

If your income is below $14,702 (individual) or $19,859 (couple) & resources are at or below $8,180 (individual) & $13,020 (couple):
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*

If your income is below $14,702 (individual) or $19,859 (couple) & resources are
at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible.**

If your income is at or below $15,246 (individual) or $20,594 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 25% of your premium.**

If your income is below $15,791 (individual) or $21,330 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 50% of your premium.**

If your income is below $16,335 (individual) or $22,065 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 75% of your premium.**

*If your “drug expenses” ever exceed $4,550 in 2011, you will pay nothing for any prescription.

**If your “drug expenses” in the year ever exceed $4,550 in 2011, you will pay not more than $2.50 for a generic or preferred brand, and $6.30 for a non-preferred brand.

2011 Income Levels for Medicare Savings Programs

The federal government recently released the official federal poverty levels or “FPLs” for 2011. These income levels are key in two areas of Medicare. Here we discuss their effect on the Medicare Savings Programs, sometimes abbreviated as “MSP.” These are discussed in full beginning on page 16 of Managing Your Medicare. A separate posting will be made of the other key area, the Low Income Subsidy for Part D, also known as “Extra Help.”

Remember that you apply for the Medicare Savings Programs with your state’s Medicaid program, and that the resources you are permitted to have and still qualify have not changed in many years and are usually shown as $6,600 for an individual and $9,910 for a couple, but there are many exceptions and disregards both for resources, and for the income limits given below.

As the new income limits are different in both Alaska and Hawaii from the rest of the United States, in makes sense to give the 2011 income limits in three separate segments, as follows:

For the lower 48 states and the District of Columbia:

For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:

For an individual, $10,890 annually, or $908 monthly.
For a couple, $14,710 annually, or $1,226 monthly.
For each additional person in a family, add $3,820 annually, or $318 monthly.

For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:

For an individual, $13,068 annually, or $1,089 monthly.
For a couple, $17,652 annually, or $1,471 monthly.
For each additional person in a family, add $4,584 annually, or $382 monthly.

For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:

For an individual, $14,702 annually, or $1,225 monthly.
For a couple, $19,859 annually, or $1,665 monthly.
For each additional person in a family, add $5,157 annually, or $430 monthly.

For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:

For an individual, $21,780 annually, or $1,815 monthly.
For a couple, $29,420 annually, or $2,452 monthly.
For each additional person in a family, add $7,640 annually, or $637 monthly.

For Alaska:

For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:

For an individual, $13,600 annually, or $1,133 monthly.
For a couple, $18,380 annually, or $1,532 monthly.
For each additional person in a family, add $4,780 annually, or $398 monthly.

For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:

For an individual, $16,320 annually, or $1,360 monthly.
For a couple, $22,056 annually, or $1,838 monthly.
For each additional person in a family, add $5,736 annually, or $478 monthly.

For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:

For an individual, $18,360 annually, or $1,530 monthly.
For a couple, $24,813 annually, or $2,068 monthly.
For each additional person in a family, add $6,453 annually, or $538 monthly.

For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:

For an individual, $27,200 annually, or $2,267 monthly.
For a couple, $36,760 annually, or $3,063 monthly.
For each additional person in a family, add $9,560 annually, or $797 monthly.

For Hawaii:

For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:

For an individual, $12,540 annually, or $1,045 monthly.
For a couple, $16,930 annually, or $1,411 monthly.
For each additional person in a family, add $4,390 annually, or $366 monthly.

For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:

For an individual, $15,048 annually, or $1,254 monthly.
For a couple, $20,316 annually, or $1,693 monthly.
For each additional person in a family, add $5,268 annually, or $439 monthly.

For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:

For an individual, $16,929 annually, or $1,411 monthly.
For a couple, $22,856 annually, or $1,905 monthly.
For each additional person in a family, add $5,927 annually, or $494 monthly.

For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:

For an individual, $25,080 annually, or $2,090 monthly.
For a couple, $33,860 annually, or $2,822 monthly.
For each additional person in a family, add $8,780 annually, or $732 monthly.

Note on resources: Technically, the resource limits for these programs are $4,000 for an individual and $6,000 for a couple, but because of disregards and exceptions, they are usually shown as $6,600 and $9,910, respectively. Again, the best advice is, because of disregards and exceptions, not to speak of differing states’ interpretations and waivers, if a beneficiary is ANYWHERE near the income and resource limits, they should apply for these programs.

Special Election Period for Beneficiaries Who Lost Part D Prescription Drug Coverage on January 1, 2011 Because their Plan Left the Medicare Program

The Centers for Medicare & Medicaid Services has extended a special election period for Medicare beneficiaries whose Part D prescription drug coverage ended with December 31, 2010, either because their stand-alone prescription drug plan (PDP) or their Medicare Advantage Plan with prescription drug coverage (MA-PD) left the Medicare program on January 1, 2011. These beneficiaries now have until February 28, 2011 to sign up for either a Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with prescription drug coverage (MA-PD). Beneficiaries who do this will be enrolled effective with March 1, 2011. You can call 1-800-MEDICARE to do this.

Special Election Period Prescription Drug Coverage Part D

Wednesday, January 26, 2011

Special Election Period for Non-Renewals Ends January 31, 2011

Beneficiaries who were in a Medicare Advantage (MA) Plan which did not renew its contract with the Centers for Medicare & Medicaid Services on January 1, or which reduced their service area so that you are no longer in it, may enroll in a Medicare Advantage Plan until January 31, 2011. Your effective date of enrollment will be February 1, 2011.

By the same token, a Medicare beneficiary who was in a Part D prescription drug plan (PDP) which did not renew its contract with the Centers for Medicare & Medicaid Services on January 1, may enroll in a Part D prescription drug plan until January 31, 2011. Your effective date of enrollment will be February 1, 2011.

These special election periods are available because, with the deluge of Medicare information and advertisements you got toward the end of 2010 you might not have clearly realized your Medicare Advantage Plan or your Part D stand-alone drug plan would not be available to you in 2011.

So make haste: if you want to rejoin a Medicare Advantage Plan or a Part D stand-alone drug plan, do so quickly before the end of this month! You may wish to call 1-800-MEDICARE or your State Health Insurance Assistance Program. Its number is on the back of your Medicare & You 2011 handbook.

Sunday, January 16, 2011

Special Enrollment Period in Georgia and Tennessee

The Centers for Medicare & Medicaid Services recently announced a special enrollment period (SEP) for certain beneficiaries who reside in two states – Georgia and Tennessee. Both of these states have enacted legislation requiring Medicare supplement (also called Medigap) insurers to sell policies to Medicare beneficiaries under 65 – that is, those who have Medicare because they are disabled or have end stage renal disease. These Medicare supplement or Medigap policies are explained in chapter 11 of Managing Your Medicare.

Georgia has established a special open enrollment period for these individuals to buy a Medigap supplement policy effective from November 1, 2010 to May 1, 2011. In Tennessee, this runs from January 1, 2011 to June 30, 2011.

This Medicare special enrollment period is highly restrictive and is intended, solely for Medicare beneficiaries under age 65 who are now in a Medicare Advantage Plan, to be able to disenroll from their Plan, and, making use of this new state legislation, to go into Original (fee-for-service) Medicare with a Medigap supplement.

Medicare’s special enrollment period for these individuals is tailored to these states’ respective open enrollment periods. It will begin on February 15, 2011 (the day after the Medicare Advantage Annual Disenrollment Period ends, see my posting of January 4, 2011 on this) and will run to May 1, 2011 in Georgia and June 30, 2011 in Tennessee.

The special enrollment period allows a Medicare beneficiary under age 65 enrolled in a Medicare Advantage Plan to prospectively disenroll from that Plan and return to Original Medicare. Once the individual has Original Medicare, they will be eligible to purchase a Medigap supplement policy following their state’s Medigap open enrollment period guidelines. Disenrollment requests received by Medicare Advantage Plans are effective the first day of the month following the month the organization receives the request. Beneficiaries may not join or switch Medicare Advantage Plans under this special enrollment period. (You can disenroll by contacting your Plan or by calling 1-800-MEDICARE.)

Two important caveats. Technically, you can’t purchase a Medigap policy while you are in a Medicare Advantage Plan. That’s why Medicare says you must “prospectively disenroll.” One way around this is to see if your insurer will sell you the policy on the first day of your return to Original Medicare and make the policy effective with that day. Otherwise you face a period where you have no coverage for Medicare’s deductibles and coinsurances, which could be very expensive to you if you get seriously ill.

The other is that if you have Part D prescription drug coverage with your Medicare Advantage Plan, and you disenroll from your Plan, you will lose your Part D drug coverage unless you enroll in a stand-alone Part D drug plan. (Sometimes these are called a “PDP”.) Fortunately, this special enrollment period allows you to enroll in such a drug plan. Your enrollment will be effective with the first day of the month following the month you make your enrollment request. So you can keep your drug coverage without a break if you enroll in a drug plan the same month you give your disenrollment notice to your Medicare Advantage Plan. Be sure you do your homework ahead of time and find the best drug plan for you. And remember that if you happen to be in a Medicare Advantage Plan that requires no premium, you will have to pay a premium for a stand-alone drug plan.

If you do NOT have drug coverage at this time, you may NOT use this Special enrollment period to sign up for it. And if you have drug coverage with a stand-alone plan at this time, you may not disenroll from it or change plans. Only those that have drug coverage with their Medicare Advantage Plan and who disenroll from it can sign up for a stand-alone drug plan.

So if you are interested, you should contact your state department of insurance (for Georgia, this is the Office of Insurance and Safety Fire Commissioner, www.gainsurance.org or toll free1-800-656-2298; for Tennessee, it’s the Department of Commerce and Insurance, www.state.tn.us./commerce or toll-free 1-800-342-4029) and ask for information about Medigap policies for beneficiaries under age 65. Check out the benefits and premiums, and decide whether you want to go to Original Medicare with a Medigap supplement. And while most health care providers are willing to take beneficiaries who are insured with Original Medicare with a Medigap policy, you should always check with your providers to see if they do so before you make a change.

And, of course, don’t forget the deadlines of May 1, 2011 in Georgia and June 30, 2011 in Tennessee.

Wednesday, January 12, 2011

Part D Transition Process

There is an important protection for Medicare beneficiaries called the “transition process” which applies for the first 90 days you are in a Medicare Part D drug plan. During this period it generally allows a beneficiary to continue to receive any prescription drug they were taking (1) whether or not the drug is on their plan’s formulary, and (2) even if it is on the formulary, if it has restrictions due to prior authorization or step therapy. Under this process, a beneficiary new to a plan can always get up to a 30-day supply of a drug; this will give them time to seek an alternate drug with their prescriber, or get a formulary exception from their plan, or attempt to find another way to pay for their drug. However, this process does not apply to drugs not covered by Part D. (This list is on page 95 of Managing Your Medicare.)

In these cases, a plan must supply a beneficiary with up to a 30-day supply of their prescription, and it must also notify the beneficiary, within three business days and by first class mail, that it is only a “temporary fill.” (These are also sometimes called “transition supplies” or “emergency supplies.”) The plan must also make a reasonable attempt to notify the prescriber of this. If the prescription is for multiple fills of less than 30 days, for example, four 7-day fills, the plan still must refill it up to a 30 days supply. (Note that for beneficiaries in long term care the plan must fill up to a 93-day supply in 31 day increments.)

Note that you are not expected to ask for this process to occur; it is supposed to be automatic. For example, if during your first 90 days in a drug plan you go to the pharmacy to get a prescription filled, and it so happens that your drug is not on your plan’s formulary, you plan is supposed to fill your prescription (up to a 30-day supply) without any intervention on your part. And that is why the notification part of this process is so important – you otherwise would probably assume that your drug is always going to be covered – and so it is critical that your plan notify you (and your prescriber) that this is NOT the case. However, if for some reason they do not automatically fill your prescrition, you can always call them and ask for a transitional fill.

And this process applies at other times than when you change or join a plan on January 1. The transition process applies to any beneficiary who joins a Part D plan whether or not they were previously in a plan (for example, they may change plans in the middle of a year because they changed residence; or perhaps they involuntarily lost their creditable drug coverage and they now first join a plan).

And, importantly, it applies to those who are in a plan when the plan changes its formulary so their drug is no longer covered by their plan, or when their plan now imposes prior authorization or step therapy on their drug. Because formulary changes often take place on January 1 of a calendar year, beneficiaries who stay in the same plan are also covered by this process when the formulary changes at that time. And in these cases where the formulary changes, the-90 day window starts when the formulary changes.

So be sure to act promptly if you get a notice that your drug is not ordinarily covered, or that your plan will begin prior authorization or step therapy.

And remember, you always have your appeal rights to try to get your plan to cover a drug you need. You are certainly free to use them when you find out your drug is not on the formulary or will be subject to prior authorization or step therapy. The notice you get from your plan will tell you how to make an exception request and of your appeal rights; all these Part D appeals rights are also fully spelled out beginning on page 206 of Managing Your Medicare.

Change of Care Transitions

Note that there is another transition which Centers for Medicare & Medicaid Services has instructions on. This is called a “change of care transition.” This is when a beneficiary who is enrolled in Part D goes from one institution to another (especially from one that provides all their medicines, such as an inpatient hospital or Skilled Nursing Facility) to one that does not, such as a long term care facility), or from an institution to home, or even beneficiaries who opt to end their hospice care and go back to regular care. (Hospices supply some medications under the Part A benefit, but a when a beneficiary is discharged from a hospice, not only will the beneficiary become responsible for their medications, but their medications may well change on discharge.) In these cases the Centers for Medicare & Medicaid Services has asked that drug plans consider using the transition process, but they are not required to do so. So you can at least review your plan’s literature to see what their policy is, or ask them. And if they do not have a transition policy for these cases, you will have to use the expedited appeals process to try to get a medicine that is not on your plan’s formulary or which requires prior authorization or step therapy.

Tuesday, January 11, 2011

Part D Late Enrollment Penalty Appeals

For those of you who have just joined a drug plan, or for those of you who have switched drug plans, you may need some guidance on how to deal with a few issues that may come up. And remember, this advice is good if your Medicare drug plan is a stand-alone prescription drug plan (sometimes “PDP” is used to describe these), or whether your drug plan is part of your Medicare Advantage Plan (sometimes these drug plans are called an MA-PD”).

For one thing, you may get a notice that you are subject to a “late enrollment penalty.” (Medicare has a tendency to abbreviate everything; sometimes these are called “LEPs.”) That is, you may be told that, because you did not sign up for Part D at your first or earliest opportunity, you may owe a penalty which is added to your monthly Part D premium. But you may believe that this is incorrect. For example, you may have had “creditable” drug coverage with another insurance plan and you have now signed up for Part D as that plan ended or you want to augment its coverage. Or perhaps you were not properly notified that your drug coverage was not creditable. (By “creditable,” we mean drug coverage that is as good as Medicare’s; if you have drug coverage, your insurance plan is supposed to tell you every year whether or not it is “creditable.” If you have creditable coverage and then sign up for Part D, you are not supposed to be penalized for any month you had creditable coverage.) Or perhaps you have qualified for “extra help,” that is, the low income subsidy, in which case you do not owe any penalty.

You can appeal your late enrollment penalty if you believe it is incorrect. You do this by asking for a reconsideration of the decision. While you are not required to use it, a “Part D Late Enrollment Penalty Reconsideration Request Form” is very helpful to filing your request. You are supposed to get on with the notice of you late enrollment penalty, but if you didn’t, you can go to the Centers for Medicare & Medicaid Services website www.cms.hhs,gov and click on “Medicare,” then on “Prescription Drug Grievances and Appeals,” then on “Forms.” Go to the very bottom of that page; the form is “Appendix 15.” Follow the instructions it gives and send your appeal to Maximus – a company that Medicare has hired to make appeals at the address below, NOT the addresses on the form. Be sure to write your Medicare number on everything that you send, and make copies of everything. That company can be reached by calling toll free 1-877-456-5302 to discuss your late enrollment penalty appeal.

Maximus Federal Services
Medicare Part D QIC
P.O. Box 991
Victor NY 14564-0991

Tomorrow I'll blog about getting your new drug plan to pay for medicines it doesn't cover, etc.