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.

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.

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.)