The Office of Inspector General within Health and Human Services (HHS) recently released a report outlining an audit of service denials from Medicare Advantage Organizations. The full report can be found using this link.
Some of the key highlights from the report can be found below (and summarized in the video above).
The Top 3 impacted areas for these denials were:
There were three recommendations that the Inspector General is requesting of CMS (Center for Medicare and Medicaid Services).
CMS has acknowledged and agreed to implement these recommendations.
Hopefully, this improves the overall experience for Medicare Advantage Plans going forward.
This short articles (and video above) covers two Press Releases came out this week from the government. One from the Social Security Administration (SSA) and one from CMS (Center for Medicare and Medicaid Services).
(1) SSA Re-opening offices on Thursday, April 7, 2022
(2) OTC Covid Test Kits available with Medicare Part B
SSA Offices Re-opening on April 7, 2022
Social Security offices were essentially shut down during the beginning of the Public Health Emergency (PHE). They re-opened about a year ago, but were still not taking walk-ins. There were very limited appointment time slots, which sometimes resulted in waiting 6-8 weeks to meet with someone. This press release is positive news because the offices will be re-opening for walk-ins starting on Thursday, April 7, 2022. SSA is still strongly encouraging individuals to use the online tools when possible to find answers and/or to book an appointment with Social Security. The SSA press release also mentions the migration to a new phone system which has resulted in some technical issues for phone calls with SSA. Hopefully, these issues get resolved soon!
Over-the-counter COVID test kits available with Medicare Part B
CMS announced Medicare enrollees (in Medicare Part B) can get up to eight (8) COVID test kits per month as long as the Public Health Emergency continues. You must be enrolled in Medicare Part B to qualify. (Even if you are enrolled in a Medicare Advantage Plan, you can still get the free test kits and the pharmacy will bill Medicare directly.) You just have to go to a participating pharmacy and show them your red, white, and blue Medicare card. You can find participating pharmacies using this link:
We hope you found this information helpful.
Secure Act 2.0 (HR-2954) passed the House of Representatives on March 29, 2022 by an overwhelming majority 414 to 5.
This bill is intended to provide additional opportunities for Americans to save for retirement.
The short video above some of the key highlights of this bill:
Expand Catch-Up Contributions
Delay Required Minimum Distributions (RMDs)
Mandatory/Automatic Enrollment in Retirement Plans for Employees
Authorize Student Loan Matching for Employers
Secure Act 2.0 provides some interesting incentives to improve retirement savings for individuals.
The Senate still needs to pass a companion bill and then it will need to be signed by the President to become law.
We still have some concerns with the lack of focus in Washington on the two large looming financial issues with Medicare (Hospital Trust Fund running out of money to cover expenses by 2026) and Social Security (not able to pay out full benefits by 2034). Hopefully, these important issues are addressed soon in Washington.
Some people are in for a bit of sticker shock when they enroll in Medicare benefits. Specifically, those in a higher income bracket who are responsible for IRMAAs (Income Related Monthly Adjustment Amounts) for Part B and Part D of Medicare. For the top earners, the Part B Premium and IRMAAs can cost over $600/month (per person) to the government, and this is before adding the premium for a Supplement and Part D Prescription plan.
For 2022, the base Part B premium amount is $170.10/month (if your single income is below $91k/year, or joint income is below $182k/year). However, if your income is above the base income amount, you have to pay additional amounts to the government called IRMAAs for both Part B and Part D of Medicare per the tables below.
Table 1. Part B Premiums and Part B IRMAAs
This table outlines the Part B premium and Part B IRMAA amounts each of the six different income tiers.
Table 2. Part D IRMAAs
This table outlines the Part D IRMAA amounts each of the six different income tiers. The Part D IRMAA is an additional amount due to the government on top of the Part D premium you have to pay the insurance company for the Part D Prescription coverage.
Table 3. Total Part B Premium + Part B IRMAAs + Part D IRMAAs
Most of our clients want to know what the total amount they will owe the government will be; so in Table 3 we have just summed the IRMAAs from Table 1 and Table 2 for each of the six income tiers.
FAQ: What income is being used to determine the IRMAA?
The government uses the MAGI (Modified Adjusted Gross Income) from the last tax return they have processed to determine the initial IRMAA. For most people, MAGI will be the same as AGI (Adjusted Gross Income), but it is possible the MAGI is higher than AGI.
For example, for someone enrolling in Medicare for the first time effective June 1, 2022, the government will check the MAGI from the 2020 Tax return (they haven’t fully processed the 2021 tax returns yet) to determine the IRMAAs (if any) for 2022.
Additionally, the government will review tax returns at the end of each year to determine IRMAAs for the following year. For example, in December 2022, the government will send out 2023 IRMAA letters to higher earners based on the MAGI from their 2021 tax returns.
FAQ: What if my income dropped because I retired? Do I still have to pay the IRMAA?
The government is using the best income information they have to determine the IRMAA, but they understand the system is flawed due to the delay in reporting and processing returns. For this reason, the government allows you to appeal IRMAAs if you had a life changing event (e.g. Work Reduction, Work Stoppage, etc.). If you have a life changing event that will result in your income dropping to a lower income tier (see Table 1), you can complete and submit the form SSA-44 to Social Security to request the IRMAAs be reduced / removed.
It is possible you may need to appeal the IRMAA twice (once when you initial enroll and again in December for the following year) due to the delay in tax return timing and processing. In the example mentioned earlier, if you first enroll in Medicare for June 1, 2022 you may need to appeal once for 2022 IRMAAs, and again in December for 2023 IRMAAs (since they will be using the 2021 tax return for 2023 IRMAAs).
FAQ: I received my bills from Medicare and they are very confusing. Can you help clarify?
For people that are receiving a monthly Social Security check, the Part B premiums and IRMAAs are deducted from the monthly Social Security payment.
For those not yet taking Social Security, the government will send quarterly bills for the Part B premiums and IRMAAs. The initial billing for these IRMAAs is incredibly misleading & confusing. Generally, the first quarterly bill only includes the base Part B premium (e.g. $170.10/month in 2022). The second bill is a huge bill because it includes the IRMAAs for the first billing period and the IRMAAs for the second billing period. This second bill sometimes results in confusion and sticker shock. Also the line item detail is not very clear on the bills which creates more confusion.
In this situation, the billed amount is generally correct but you have to do some math to back into the numbers. You can take the total amount of the first two bills and divide it by the number of months for the bill periods. This monthly average should align with the monthly amount the person is responsible for based on their income.
For example, if someone is in the second income Tier in 2022 ($91k-$114k single income), the correct amount they should be billed is $250.50/month ($170.10/month for Part B, $68/month for Part B IRMAA, and $12.40/month for Part D IRMAA). The first bill this person receives will likely be for three months of just the base Part B premium which is $510.30. The second bill this person receives will likely be for $992.70 (base Part B premiums for the second 3 months + IRMAAs for the first bill and IRMAAs for the second bill).
People tend to panic when they see that second bill. In this case, you can add up the total of the two bills ($510.30 + $992.70) = $1,503. Then divide by the number of months billed (in this case 6 months)… to get $250.50/month which matches the correct amount this person should be paying.
By the third bill, the amounts should be billed correctly as $751.50 ($250.50 x 3 months).
We hope you found this information helpful.
If you prefer to watch videos, here is a link to a short video that explains these IRMAAs.
Earlier this week, the Secretary of Health and Human Services (HHS), Xavier Becerra directed the Centers for Medicare and Medicaid Services (CMS) to reassess the recommendation for the 14.5% Part B Premium increase for 2022.
One of the main reasons given for the large Part B premium increase in 2022 was based on the cost of a new drug to treat Alzeimer's (Aduhelm) which recently cut the price by 50%.
A Part B premium change in the middle of the year has never really been done before, so we shall see what comes of this...
CMS just announced the updated Part B premiums for 2022.
This is the largest premium and deductible increase we have seen in years.
According to CMS, the main reasons for the increases are to...
"prepare for expenses, such as spending trends driven by COVID-19, and prior Congressional action in the Continuing Appropriations Act, 2021 that limited the 2021 Medicare Part B monthly premium increase during the COVID-19 pandemic. It also reflects the need to maintain a contingency reserve for unanticipated increases in health care spending, particularly certain drug costs. There is significant uncertainty regarding the potential for future coverage of clinician-administered Alzheimer’s drugs (i.e., Aduhelm™), requiring additional contingency reserves. Potential Medicare drug coverage is currently the subject of a Medicare National Coverage Determination (NCD) analysis, which, if covered, could increase Medicare spending. The proposed NCD on Aduhelm (as well as any drugs in this category) is still to be determined.
Most people with Medicare will see a significant net increase in Social Security benefits. For example, a retired worker who currently receives $1,565 per month from Social Security can expect to receive a net increase of $70.40 more per month after the Medicare Part B premium is deducted."
The Income Related Monthly Adjustment Amounts (IRMAAs) were also updated for 2022. You can find the tables below for individuals with income greater than $91,000 (or joint filers with income greater than $182,000). This income is based on your MAGI (Modified Adjusted Gross Income) from your 2020 Tax Return. These IRMAAs only affect about 7% of people with Medicare Part B.
If you are in one of the higher income brackets for the Part B IRMAAs, there is an additional IRMAA for the Part D Drug Coverage. The updated table for 2022 can be found below.
The table below shows the sum of the Part B Premium, Part B IRMAA, and Part D IRMAA for the higher income brackets.
The other changes for 2022 that were included in the announcement are below.
If you have a Medicare Supplement Plan F, Plan G, or Plan N, the Part A cost-sharing is fully covered by the Supplement so these changes below will not impact you.
Every year, the non-partisan Medicare Trustees Group in Washington D.C. issues a report regarding the Financial state of the Medicare Program.
Below are some links to prior years articles we wrote on this topic:
The report is normally released in the Springtime. This year, we anxiously awaited the report to see the impacts of the recent Pandemic.
A few days ago the 2021 Report was released. You can find the full report here.
Some of the key highlights of the report:
This is the same message from the Medicare Trustees from the last several years, and the Medicare Program is essentially a ticking time-bomb that requires significant financial changes ASAP to minimize the impact of this impending issue.
Legislation must be passed to add funding and/or reduce expenditures to sustain the Medicare Program for the long-term.
Unfortunately, our lawmakers continue to be focused on adding expenditures which will only accelerate the financial solvency issues.
Adding Dental, Vision & Hearing?
One of the big focuses in Washington is to add additional benefits to Medicare, specifically Dental, Vision & Hearing benefits. The early indication is that this benefit will likely be passed by end of 2021. We should hear more in the next few weeks about how this would be funded and how the coverage might work.
To be perfectly clear, I think it would be wonderful to have Dental, Vision, Hearing and (also Long-Term Care) included with Medicare.
However, there is a significant cost to add these services to Medicare. Adding additional expenditures to a program that is already faltering financially is like giving a mortgage to someone for a brand new house while they are not able to make payments on their current mortgage. There is a good reason banks wouldn't approve a new mortgage in this case because it wouldn't be good for the individual requesting the loan or the bank providing it.
Reducing Medicare eligibility age to 60?
The other top Medicare priority in Washington is to reduce the Medicare eligibility age from 65 to 60. Here again, is another proposal that would significantly increase expenditures on an already faltering program.
Will Medicare Really Go Under?
There are over 60 million Americans on Medicare. The large majority of Medicare Beneficiaries are voters. It is highly unlikely the program will ever go under. But changes do need to made to sustain the program for the long-term and I really hope Washington starts to shift their focus ASAP on the correct long-term priorities to sustain this important Program.
Each year, there are changes to the Part D Prescription Drug Coverage of Medicare. We won't have visibility to the actual Part D Plans until October 1, but there are some structural changes that occur each year with Part D. Key updates for 2022 are below.
The government sets a maximum deductible amount for the Part D Plans. In 2021, the maximum deductible was $445. In 2021, this is increasing $35 to $480. On most of the Part D Plans, the deductible only applies to higher tiered drugs (e.g. Tiers 3, 4, 5). Also, some Part D Plans have a $0 deductible, or other amounts lower than the maximum deductible.
Initial Coverage Level
The Initial Coverage Level will increase $300 from $4,130 in 2021 to $4,430 in 2022. This amount is based on the Retail Cost of the Medication for the year (Calendar Year). Most people (about 85%) do not exceed the Initial Coverage Level and thus continue to pay their Copay/Coinsurance amount for the entire year. However, for the people that have very expensive medications that exceed the Initial Coverage Level, they will reach the Part D Coverage Gap, aka Donut Hole where they have to pay 25% the cost of their medications. The increase of $300 to the Initial Coverage level will have a minimal impact on Drug Costs in 2022. Basically, for those 15% of people with expensive medications, there will be a slight delay to reaching the Part D Donut Hole which could save someone ~$20-$40 for the year.
True Out of Pocket Limit (Tro-oP)
The True Out of Pocket limit will increase $500 from $6,550 in 2021 to $7,050 in 2022. The Tro-Op is used to determine when someone exits the Part D Coverage Gap, aka Donut Hole, and moves into Catastrophic Coverage where they only have to pay 5% the cost of their medications. The increase of $500 in the Tro-oP only effects about 5% of people (those that would reach Catastrophic Coverage), and it creates a slight delay for when they will reach Catastrophic coverage. The net impact to this individual is likely about $100 cost increase for the year.
Click the video below for a more detailed explanation of these changes, including a detailed example for someone who reaches the Part D Donut Hole.
When you first enroll in Medicare Part B, Medicare provides an initial "Welcome to "Medicare" visit. This initial "Welcome to "Medicare" visit is different than the Annual "Wellness" visits that Medicare provides. There is some confusion about these two types of visits, so we have provided some highlights of what is included with each of these visits below.
"Welcome to medicare" visit
Per the Medicare website, "This visit includes a review of your medical and social history related to your health and education and counseling about preventive services, including these:
The "Welcome to Medicare" visit must be completed within 12 months of your Medicare Part B effective date. There is no cost to the Medicare Beneficiary for the "Welcome to Medicare" visit, unless the doctor identifies/diagnoses any additional conditions, tests, etc.
Annual "Wellness" Visit
AAfter the first 12 months on Medicare Part B, the Medicare Beneficiary is entitled to an Annual "Wellness" visit.
Per the Medicare website:
"The cognitive impairment assessment is performed to look for signs of Alzheimer's disease or dementia and check for depression and other mood disorders. Your provider may order other tests, if necessary, depending on your general health and medical history.
The personalized prevention plan is designed to help prevent disease and disability based on your current health and risk factors. Your provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your provider develop a personalized prevention plan to help you stay healthy and get the most out of your visit. It can also include:
We hope this provides some clarity about the differences between the "Welcome to Medicare" versus the Annual "Wellness" Visits. It is also important that Provider billing offices understand these differences. We have had some issues with Provider billing offices attempting to bill the Annual "Wellness" visit codes to Medicare when someone was still in their first 12 months of Medicare. This results in declined claims because the Annual Wellness visit is only available once per year starting 12 months after the Part B effective date.
For several years, the Medicare Advisory Group of NAHU has been working on fixing the delayed effective date that occurs for certain Medicare Beneficiaries who enroll during their last three months of their Initial Enrollment Period, or during the General Election Period (January 1 – March 31).
We are excited that our proposed fixes were finally implemented in the Consolidated Appropriations Act of 2021. The changes begin on line 21 of Page 2168 of the bill.
The new rules will begin on January 1, 2023.
Initial Enrollment Period: The Current Rules require a delay of 2-3 months for the Part B effective date when someone enrolls in the three months following their 65th birthday. The New Rules will remove that delay and provide the Part B effective date of the first of the month following enrollment. The table below summarizes the Current rules versus the New rules for the Initial Enrollment Period.
The table below provides an Example for someone who is turning 65 on September 15.
General Election Period: The General Election Period of January 1 through March 31 is for a Beneficiary who missed their Initial Enrollment Period and does not have credible coverage. These individuals must enroll during the General Election Period of January 1 through March 31, and the effective date is July 1. With the New Rules coming in January 2023, the Beneficiary will get an effective date of the first of the month following enrollment. The table below summarizes the Current rules versus the New rules for the General Election Period.
The table below provides an Example for someone who is enrolling during the General Election Period.
We are excited that we have had such a positive impact on Medicare Beneficiaries enrolling during these two time periods and reduced their delays in getting their Medicare Part B coverage!
We will continue to work in Washington to address our other key initiatives: Medicare COBRA Trap, Observation Status, and more.
See bio here