Fong Law Group

Medicare Advantage Plans Often Wrongly Deny Necessary Care, Study Finds

In an alarming number of instances, private Medicare Advantage plans are denying coverage for medical services that would be covered under original Medicare, according to a federal investigation.  These denials are likely preventing or delaying medically necessary care for tens of thousands of Medicare Advantage beneficiaries each year.

The investigation by the Department of Health and Human Services’ Office of Inspector General found that 13 percent of Medicare Advantage plan denials should have been covered under Medicare.  The findings were based on a review by doctors and coding experts of service denials by 15 of the largest Medicare Advantage plans during the first week of June 2019.   Extrapolating from their findings, investigators estimate that nearly 85,000 beneficiary requests for medical care -- everything from MRIs to skilled nursing facility care -- could have been wrongly denied in 2019.

In an even higher proportion of cases, plans are incorrectly refusing to pay claims. Nearly one-fifth of claims that Medicare Advantage plans initially declined to pay were for services that met Medicare coverage and plan billing rules.  This translates to an estimated 1.5 million refused payments for all of 2019, delaying or blocking payments for services that providers had already delivered.

Hidden Barriers to Care

Some 26 million Medicare beneficiaries were in Medicare Advantage plans as of 2021, more than double the figure a decade ago.  The Congressional Budget Office projects that by 2030 more than half of Medicare beneficiaries will be in a private Medicare plan. Unlike original Medicare, where the federal government is the insurer, Medicare Advantage plans are run by private insurance companies. The government pays the plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. The less money the plans spend on patient care, the more they and their investors make. In this way, plans have an incentive to keep costs down.

For many beneficiaries, Medicare Advantage plans’ most disagreeable cost-cutting strategy is “preauthorization” -- the common requirement that doctors and other medical providers obtain the plan's approval before a beneficiary can receive certain medical services. If the plan administrators disagree that a procedure is medically necessary, the plan may refuse to pay for it.

Medicare Advantage plans often look attractive because they offer the same basic coverage as original Medicare at a seemingly lower cost, plus some additional benefits and services like vision and dental care that traditional Medicare doesn't offer. (One reason Medicare Advantage plans can offer such enhanced services is because the federal government gives them additional payments compared to original Medicare.) The inspector general’s report highlights one of Medicare Advantage’s downsides.

“Beneficiaries enrolled in Medicare Advantage may not be aware that there may be greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare,” the report states.

One example highlighted in the report tells of a Medicare Advantage plan that refused to approve a follow-up MRI to find out whether an adrenal lesion was malignant because the lesion was allegedly too small. In fact, Medicare’s rules do not restrict the use of follow-up MRIs based on the size of a lesion. (The plan reversed its initial denial on appeal.)

Denial Appeals Can Work

The report identified two common causes of service denials. First, even though Medicare Advantage plans’ clinical criteria cannot be “more restrictive” than Medicare’s coverage rules, plans often used tighter clinical criteria, such as requiring an x-ray before approving more advanced imaging. Second, plans often claimed that the request for services lacked sufficient documentation, even though investigators who reviewed the denied claims found that the existing medical records were sufficient to support the request.

When a Medicare Advantage plan denies a preauthorization or payment request, the beneficiary can file an appeal with the plan.  The inspector general found that when a beneficiary or provider appealed or disputed the denial of a service that met Medicare’s coverage rules, plans sometimes reversed the denial.  And in certain cases, Medicare Advantage plans corrected their own errors.

The inspector general’s report offers several recommendations for the Centers for Medicare and Medicare Services, which oversees Medicare Advantage plans, including better auditing of plans.   

To read the inspector general’s report, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” click here.  

Medicare Enrollment Period Extended for Those Who’ve Been Getting a Busy Signal

Medicare is part of the Social Security Administration (SSA), so if you need to enroll in Medicare, that’s whom you contact. But in recent months, phone lines at the SSA were experiencing major technical issues, preventing some individuals from being able to reach the SSA via telephone in a timely manner. These issues affected the SSA’s national 800 number as well as its field office general inquiry phone lines. At the same time, because of the pandemic, SSA offices had not been permitting in-person appointments until early April.

Certain beneficiaries — particularly those without Internet access — were therefore unable to reach the SSA before the end of Medicare’s annual general enrollment period, which typically closes March 31.

As a result, the Centers for Medicare and Medicaid Services (CMS) has announced it will provide what is known as equitable relief to anyone who, due to these challenges, was unable to submit their Medicare enrollment or disenrollment requests after January 1, 2022. These individuals will now have extra time — through Friday, December 30, 2022 — to submit Medicare Part A or Part B enrollment or disenrollment requests without penalty. This relief from penalties also applies to the 2022 Initial Enrollment Period and Special Enrollment Periods.

Individuals who were eligible to be on Medicare and incurred medical care costs during this time period can request retroactive Medicare coverage going back to January 1, 2022. Note, however, that premiums must be paid as a lump sum or else can be deducted from any Social Security benefits the individual currently receives.

Contact the SSA’s national 800 number at 1-800-772-1213 for more information, or find an SSA office near you via the SSA’s online office locator.

Medicare Now Covers the Cost of COVID At-Home Tests

If you have Medicare, you can now receive up to eight free rapid at-home Covid-19 tests a month at participating pharmacies. 

The free tests are available without a prescription to all Medicare beneficiaries with Part B, including those enrolled in a Medicare Advantage plan. If you only have Medicare Part A, Medicare won’t cover the cost. 

To get the tests, you can visit one of the pharmacies participating in the program.  (For a partial list of participating pharmacies, click here.) You do not have to be a current customer of the pharmacy in order to receive the tests, and Medicare Advantage plan enrollees may use an out-of-network pharmacy. You should bring your red, white, and blue Medicare card (even if you have a Medicare Advantage or Medicare Part D plan), but the pharmacy may be able to get the information it needs to bill Medicare without the card. 

Unlike with private insurance, there is no upfront cost for the tests. As long as you do not order more than eight tests in a calendar month, you will not pay anything. Note that tests are often packaged with two in each box, so eight tests may not mean eight boxes. If you pay for a test yourself, Medicare will not reimburse you. Medicare enrollees who order tests from covidtests.gov do not need to count those tests against Medicare's eight-test-per-month limit.

When the Biden administration originally announced it was requiring private insurers to reimburse the cost of up to eight rapid at-home Covid tests a month purchased at retail stores and pharmacies, this news left out the nation’s 62 million Medicare beneficiaries – seniors and people with disabilities who are at the highest risk of death from Covid-19. If paid for out-of-pocket, tests typically cost more than $20 for a package of two, which can discourage many Americans from getting tested. 

The problem in the case of tests for Medicare beneficiaries was that the federal program’s rules did not permit coverage of over-the-counter tests. Amid pressure from Congress and advocacy groups, officials scrambled to find a regulatory workaround.  

For more information about the free COVID tests from the Centers for Medicare & Medicaid Services, click here.

Claiming Social Security Benefits at Age 70

If you are about to turn 70, congratulations on reaching a big milestone.  And if you also have delayed claiming Social Security retirement benefits up till now, you are joining a select group -- only 6.5 percent of Social Security recipients put off collecting their benefits until they reach three score and ten, the age at which they can collect the maximum benefit. If you are about to join this elite group of septuagenarian claimers, it’s important to know when and how to claim.

The decision of how long to wait to claim Social Security benefits depends on a number of factors, including other income sources in retirement and projected longevity.  But Social Security experts advise waiting as long as possible to start collecting benefits, up to age 70.  This is because if you delay taking retirement beyond your full retirement age (66 for those born from 1943 to 1954), you amass “delayed retirement credits” that increase your benefit by 8 percent for every year that you wait, over and above annual inflation adjustments.  Your checks will be about 76 percent more than had you claimed at age 62, the earliest you can file. It’s tough to find a better and more reliable investment than that. (However, keep in mind that if you are collecting benefits based on the work record of a current or ex-spouse, there is no point in waiting until 70 -- you won't accrue delayed retirement credits beyond your full retirement age.)

Don’t Wait Any Longer

Delayed retirement credits stop at age 70, so there is no advantage to putting off starting benefits any longer.  Not only won’t your credits increase by claiming after age 70, but if you wait longer than half a year, you’ll start losing monthly benefits you would have otherwise received.  The Social Security Administration (SSA) will pay you retroactively for benefits accrued up to six months after your 70th birthday, but that’s it.  If you wait any longer, benefits you would have received are permanently forfeited.

The next thing to know is that the SSA won’t automatically start sending you checks once you turn 70. You need to apply for benefits. You can do this starting four months before the date that you want your benefits to begin.  To get the maximum amount, you’ll want the benefits to start the month you turn 70.  There is, however, one scenario where benefits will automatically kick in at 70: those who took benefits after reaching their full retirement age and then suspended their benefits to earn delayed credits until age 70.  For them, the SSA should automatically restart benefits at 70.

You can apply online -- click here.  If you can’t submit your application online, you can call 1-800-772-1213 (TTY 1-800-325-0778). In normal times, another alternative is to visit your local Social Security office, but during the pandemic visits are by appointment only and only for a limited number of reasons. However, SSA offices should be reopening soon; check the SSA’s Coronavirus Disease page for updates. The SSA will want certain information and documents when you apply. For a checklist of what may be required, click here.

When will you get your first check?  The SSA issues checks a month behind, so your benefits should start arriving the month after the month you turned 70.  For example, if you were born July 17, you should ask that your benefits start in July and your first check will come in August.  However, those born on the first day of the month get a small bonus: the SSA treats them as if they were born the previous month and starts paying benefits in their birth month.  So, for example, if you were born July 1, you’d request benefits to start in June and the payments would begin in July.

What If You’re Still Working?

Working past age 70 (or any time past your full retirement age, in fact) won’t affect your benefits.  And while you won’t increase your monthly benefit by waiting past age 70 to claim, you could boost it by working in addition to collecting Social Security. This is because the SSA recalculates your benefits each December based on your 35 highest-earning years of work. If your earnings plus your Social Security benefits allow you to replace a lower-earning year, your overall benefit could increase in the annual calculation. But Social Security benefits are taxable, so if you’re earning more money your tax rate may be higher.

In most cases, your Medicare premiums will be deducted from your Social Security check. If you happen to be retiring at age 70 and you’ve been paying Medicare’s high-earner surcharges, keep in mind that you can reverse these surcharges if your income drops far enough. The Social Security Administration uses income reported two years ago to determine a beneficiary's premiums. If your income decreases significantly due to certain circumstances, including retirement, you can request that the SSA recalculate your benefits and your premium surcharges could be eliminated or reduced. 

For an article in The New York Times on determining the optimal time to claim Social Security benefits and ways to maximize benefits, click here.

For the SSA's Retirement Benefits page, click here.

Biden Proposes Major Nursing Home Reforms, Most Extensive "In Decades"

The Biden administration has announced far-reaching nursing home reforms, targeting staffing and accountability at facilities with deficient care. Advocates are calling the proposals, which include the first-ever federal minimum staffing levels, the most significant reforms in decades. 

Nursing homes have been plagued by chronic understaffing and high turnover rates for years, a problem only exacerbated by the COVID-19 pandemic. Studies have revealed that nursing home staffing levels are often inadequate and inaccurately reported and recent research found that increasing staffing by just 20 minutes a day led to fewer COVID cases and deaths. Meanwhile, there is evidence that most nursing homes have inadequate infection control measures in place. 

Currently there are no minimum staffing levels for nurse's aides, who provide most of the day-to-day care. Instead, nursing homes are required "to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident."

Recognizing these issues, President Biden announced new measures aimed at improving the safety and quality of care in nursing homes. The Biden administration’s proposals include taking the following actions: 

• The Centers for Medicare and Medicaid Services (CMS), which regulates nursing homes, will study the level and type of staffing needed to ensure safe and quality care and propose minimum staffing levels within a year. 
• CMS will explore ways to phase out multi-occupancy rooms and promote single-occupancy rooms. 
• The administration will call on Congress to provide $500 million for health and safety inspections, a 25 percent increase. 
• CMS will increase enforcement actions against poor-performing facilities. After reversing a Trump era change that imposed a one-time fine for nursing home deficiencies, CMS will explore making per-day penalties the default penalty. 
• In an effort to increase transparency of nursing home ownership, CMS will create a database to track nursing home owners and operators across states. In addition, the government will investigate the role private equity firms play in buying and selling nursing homes. 

The Consumer Voice,  an advocacy group for long-term care issues, calls the proposals the “most significant reforms in nursing homes in decades.” Terry Fulmer,  president of the nonprofit John A. Hartford Foundation, which works to improve long-term care, calls the plan “a major step forward for quality and safety in our nation’s nursing homes.” 

CMS had previously announced that it will add data on staff turnover rates and weekend staffing levels to its Care Compare website, giving consumers another tool when choosing a nursing home. 

To read the announcement from the administration, click here.

For more information about the reforms from Kaiser Health News, click here.

Court Rules Medicare Beneficiaries Can Appeal Switch to Hospital Observation Status

A federal court has ruled that hospitalized Medicare beneficiaries who were switched from inpatient to observation status can appeal the decision, making it easier for them to receive coverage for subsequent nursing home care. The ruling appears to bring to an end more than a decade of litigation on behalf of Medicare recipients.

Medicare covers nursing home stays entirely for the first 20 days, but only if the patient was first admitted to a hospital as an inpatient for at least three days. In part due to pressure from Medicare to reduce costly inpatient stays, hospitals often do not admit patients but rather place them on observation to determine whether they should be admitted. Even if a hospital originally admits a patient, a hospital review board can switch the patient from inpatient to observation status, before or after the patient’s stay. If the patient does not have a full three days as an inpatient, Medicare will not cover a subsequent nursing home stay – potentially costing the Medicare recipient thousands of dollars. 

There are other consequences to being considered under observation. Instead of billing you under Medicare Part A, which covers inpatient services, the hospital will bill you under Medicare Part B. This means that you will owe a co-payment for every service offered. Your total co-payment could be much larger than the one-time deductible you have to pay under Part A.

In 2011, a group of Medicare beneficiaries sued the federal government in a class action lawsuit, arguing that they should have the right to appeal when their status is switched from inpatient to observation status. After the case wended its way through the courts for 11 years, in January the U.S. Court of Appeals for the Second Circuit affirmed a lower court’s ruling in favor of the beneficiaries, noting that Medicare allows appeals of other decisions. According to the court, “the decision to reclassify a hospital patient from an inpatient to one receiving observation services may have significant and detrimental impacts on plaintiffs’ financial, psychological, and physical well-being.” The court ordered Medicare to set up a process to appeal for coverage as hospital inpatients and to notify people of their appeal rights. The class was represented by advocacy groups the Center for Medicare Advocacy and Justice in Aging and the law firm Wilson, Sonsini, Goodrich, and Rosati.  

Observation status has been controversial for years. Originally, hospitals didn’t have to give patients notice that they were in observation status rather than inpatients. That changed in 2017, when a federal law required hospitals to notify patients who are under observation for more than 24 hours of their outpatient status within 36 hours, or upon discharge if that occurs sooner. 

What Patients Can Do Now

If you are in the hospital and told you that you are under observation status, you can ask the hospital doctor to be admitted as an inpatient. You should also contact your primary care physician to ask if he or she can call the hospital and explain the medical reasons that you need to be admitted.

If you are kept in observation status and transferred to a nursing home and denied coverage by Medicare, you can appeal. In order to appeal, you must wait for your Medicare Summary Notice (MSN) to arrive. Copy the notice and highlight the disputed charges. The notice should provide information on where to send the notice to request an appeal. You can appeal both the hospital's denials of hospital admission as well as subsequent nursing home charges. The appeal process can be very complicated and you may need the help of an attorney to navigate it. For more information about the Medicare appeals process, click here.

For more analysis of the decision by Kaiser Health News, click here.

Things to Remember at Tax Time

Tax day, which is Tuesday, April 19 in 2022, is approaching and it is time to begin crossing T's and dotting I's in preparation for paying taxes. As tax time draws near, you want to make sure you file all the proper forms and take all deductions you're entitled to.

Following are some things to keep in mind as you prepare your tax form.

• Gifts. Did you give away any money this year? The gift tax can be very confusing. If you gave away more than $15,000 in 2021, you will have to file a Form 709, the gift tax return. This does not necessarily mean you will owe taxes on the money, however. 
• Medical Expenses. Many types of medical expenses are tax deductible, from hospital stays to hearing aids. To claim the deduction, your medical expenses have to be more than 7.5 percent of your adjusted gross income. This includes all out-of-pocket costs for prescriptions (including deductibles and co-pays) and Medicare Part B and Part C and Part D premiums. (Medicare Part B premiums are usually deducted out of your Social Security benefits, so be sure to check your 1099 for the amount.) You can only deduct medical expenses you paid during the year, regardless of when the services were provided, and medical expenses are not deductible if they are reimbursable by insurance.  
• Parental Deduction. If you are caring for your mother or father, you may be able to claim your parent as a dependent on your income taxes. This would allow you to claim the $500 tax credit for any non-child depedents. 
• Long-Term Care Insurance Premiums. Premiums for "qualified" long-term care policies are treated as an unreimbursed medical expense. Long-term care insurance premiums are deductible for the taxpayer, his or her spouse and other dependents. 
• Social Security Benefits. Although Social Security benefits are generally not taxable, people with substantial income in addition to their Social Security may pay taxes on their benefits. If you file a federal tax return as an individual and your "combined income," including one half of your Social Security benefits and nontaxable interest income is between $25,000 and $34,000, 50 percent of your Social Security benefits will be considered taxable. If your combined income is above $34,000, 85 percent of your Social Security benefits is subject to income tax. 
• Home Sale Exclusion. Married couples can exclude from income up to $500,000 in profit on the sale of a home ($250,000 for single individuals). If a surviving spouse sells the home, he or she can still claim the exclusion as long as the house was sold no more than two years after the spouse's death. 
• Elderly or Disabled Tax Credit. Some low-income elderly or disabled individuals are entitled to a special tax credit. To be eligible, you must meet income limits. For more information, click here.
• Earned Income Tax Credit. Previously primarily available to people with young children, for 2021 working seniors without dependents may qualify for this important credit.  For more, click here.  
• Tax Refunds. Getting a federal tax refund should not affect your Medicaid or Social Security benefits. For a year after recieving a tax refund from the federal government, the refund will not be considered income or resources for SSI or Medicaid purposes. You can also transfer the refund within a year without incurring a penalty. 

The IRS's Tax Counseling for the Elderly (TCE) Program offers free tax help to taxpayers who are 60 and older. For more information, click here. The IRS also publishes a Tax Guide For Seniors.

Advocates Sound Alarm About Pilot Program They Say Could Privatize All of Medicare

The Biden administration is moving forward with a Trump-era pilot program that would hand over the care of millions of Medicare beneficiaries to private, mostly for-profit, groups. 

Health care advocates warn that that the little-known plan will limit patients’ choice of providers and effectively privatize Medicare for beneficiaries who specifically chose traditional, public Medicare because they wanted to be able to select their own doctors. The program was created without congressional oversight and can expand without Congress’s approval.

“It could potentially complete the privatization of our public precious good called Medicare,” says Ed Weisbart, MD, who chairs the Missouri chapter of Physicians for a National Health Program (PNHP). “It violates the spirit of a public health program, which Medicare is, by driving larger corporate profits as a priority over improving our health, which Medicare is remarkably successful at.”

Already, some 42 percent of Medicare beneficiaries are in private Medicare Advantage plans, to which the federal government gives a fixed monthly fee for each Medicare beneficiary under the plan’s care. The less money the plans spend on patient care, the more money they and their investors make.

The new pilot program, called Direct Contracting, would extend key aspects of this model to other Medicare beneficiaries in 38 states, Washington, D.C., and Puerto Rico, potentially covering 30 million of the 36 million beneficiaries in traditional Medicare.  Fifty-three Direct Contracting Entities (DCEs), most of which are investor-owned with ties to Medicare Advantage commercial insurers, have already signed contracts to be fiscal intermediaries between patients and their providers.

Beneficiaries Automatically Enrolled

Under the program, these DCEs will form their own networks of providers, which beneficiaries will be strongly encouraged, although not required, to use.  Traditional Medicare beneficiaries will be enrolled in these networks, often without their knowledge or consent.  The DCEs will be paid a set amount per patient, called a capitation payment, which will vary depending on a patient’s “risk score.”  If the patient care costs less than the per-patient amount, the DCE keeps some or all of the difference.  If it costs more, the DCE loses money.

Beneficiaries will not be able to opt out of being “aligned” with a DCE.  Medicare will assist the DCEs by searching the claims history of beneficiaries – again without patients’ knowledge or consent -- to see if they have visited a participating DCE provider with which they could be aligned.

All this will likely be confusing for Medicare beneficiaries, many of whom will have three different entities processing their claims: the DCE, Medicare, and the beneficiary’s Medicare supplemental insurance (Medigap) plan.

“Rather than allowing patients to go to providers directly under traditional Medicare, DCEs invite insurers and investors to step in and interfere with the care that Americans get,” said Rep. Katie Porter (D-CA) at a recent PHNP webinar on Direct Contracting. The DCEs, Porter charged, will “drive up costs for patients in order to maximize profits . . . Wall Street wins, patients and taxpayers lose.” 

Lowering Costs Is the Stated Aim . . .

The idea behind the pilot is that these care networks will lower costs and spur innovation by managing care.  The model, according to the federal Centers for Medicare and Medicaid Services (CMS), “is expected to increase beneficiaries’ access to innovative, affordable care while maintaining all original Medicare benefits.”

Not all medical providers oppose Direct Contracting, particularly those already affiliated with provider groups.

“Models of care that are focused on systems of reimbursement such as capitation and holding physicians accountable for cost, coordination, and quality are integral to moving away from the fee-for-service model and toward more transformative models of care that reward value,” said Don Crane, president and CEO, of America’s Physician Groups said in December 2020.

. . . But Financial Incentives Worry Critics

Critics of the program have raised a number of concerns.  They note that many beneficiaries will be unaware that they can opt out of a DCE’s provider network, and say that DCEs will seek to contain costs by discouraging or denying needed care. (It is unclear how CMS will monitor beneficiaries’ access to care.)

Advocates also note that, as with Medicare Advantage, DCEs will have a strong financial incentive to “upcode” patients – that is, to tell the government that patients in their care are sicker than they really are so the DCE can receive a higher reimbursement.  Finally, critics are convinced that DCEs affiliated with Medicare Advantage plans will use the opportunity to steer beneficiaries away from traditional Medicare and into these highly lucrative plans.

No one knows whether the DCEs will actually be profitable, but Wall Street is betting that they will be.

“Wall Street considers Direct Contracting Entities to be eight times more valuable per patient than Medicare Advantage firms,” wrote Chris Tomlinson, a business columnist for the Houston Chronicle. 

Even if DCEs don’t make money initially, patient advocates say that many investors are betting on selling the DCE for a profit down the road, a favored model of private equity investment.  “The real strategy is to make rapid growth and then leave and go on to the next investment,” said PNHP’s Weisbart.

Two nationally known physicians who once led CMS are warning against the pilot program. Writing in the blog of the journal Health Affairs, Dr. Donald M. Berwick, a former CMS Administrator, and Dr. Richard Gilfillan, a former director of CMS’s Center for Medicare and Medicaid Innovation, call Direct Contracting a new addition to the “Medicare Money Machine” and characterize its name as “Orwellian.”  “‘Indirect Contracting’ would have been a far more accurate name,” they write, “since the cornerstone of the program was CMS’s opening the door to non-provider-controlled [DCEs] to become the fiscal intermediaries between patients and providers.”

Blanket Authority to Experiment

Experimental health delivery models like Direct Contracting were made possible by the Affordable Care Act.  The landmark 2008 law established the Center for Medicare and Medicaid Innovation and gave it almost blanket authority to test ways to improve health care quality and reduce costs without congressional approval or oversight.  The Trump administration seized on this authority to craft the Direct Contracting model. 

Its most extreme version is called Geographic Direct Contracting, which would auto-assign every traditional Medicare beneficiary living in a number of large geographic regions into a Medicare Advantage-like “Geo DCE” without the right to opt out. Advocates persuaded the Biden administration to pause this program in March, although it is still “under review” and could resurface. 

But the Biden administration has continued the rollout of a less extreme version, the Global and Professional Direct Contracting (GPDC), which CMS calls a “voluntary risk-sharing payment model.”

Rep. Porter is among lawmakers who are calling on the administration to immediately freeze this version as well, contending that while it is intended to make Medicare more efficient, it actually will do the opposite, noting that between 2008 and 2020 the federal government has overpaid Medicare Advantage plans -- which were designed to contain costs in similar ways – by $143 billion.

In late November a group of physicians from around the nation traveled to Washington, D.C., to educate lawmakers about the Direct Contracting threat, call for a congressional hearing and present U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra a petition signed by more than 13,000 people, including 1,500 physicians.  The petition warns that moving the DCE program forward threatens “the future of Medicare as we know it.”

“[Direct Contracting] is very complex and it is extremely hard to explain,” said PNHP board member Dr. Judy Albert at the HHS press event.  “There has been very little coverage in the mainstream media, allowing the program to fly under the radar. . . . Together, we will continue to raise the alarm until we stop this threat to Medicare.”

Medicaid's Benefits for Assisted Living Facility Residents

Assisted living facilities are a housing option for people who can still live independently but who need some assistance. Costs can range from $2,000 to more than $6,000 a month, depending on location. Medicare won’t pay for this type of care, but Medicaid might. Almost all state Medicaid programs will cover at least some assisted living costs for eligible residents.

Unlike with nursing home stays, there is no requirement that Medicaid pay for assisted living, and no state Medicaid program can pay directly for a Medicaid recipient’s room and board in an assisted living facility. But with assisted living costs roughly half those of a semi-private nursing home room, state officials understand that they can save money by offering financial assistance to elderly individuals who are trying to stay out of nursing homes. 

As of 2019, 44 states and the District of Columbia provided some level of financial assistance to individuals in assisted living, according to the website Paying for Senior Care, which features a “State by State Guide to Medicaid Coverage for Assisted Living Benefits” that gives details on each state’s programs. According to the website, the Medicaid programs of Alabama, Kentucky, Louisiana, Maine, Pennsylvania, and Virginia are the only ones that provide no coverage of assisted living, although non-Medicaid assistance may be available.

Nevertheless, the level and type of support varies widely from state to state. Prevented from paying directly for room and board, some states have devised other strategies to help Medicaid recipients defray the cost of assisted living, including capping the amount Medicaid-certified facilities can charge or offering Medicaid-eligible individuals supplemental assistance for room and board costs paid for out of general state funds. States typically cover other services provided by assisted living facilities. These may include, depending on the state, coverage of nursing care, personal care, case management, medication management, and medical assessments and exams.   

In many states, this coverage is not part of the regular Medicaid program but is delivered under programs that allow the state to waive certain federal rules, such as permitting higher income eligibility thresholds than regular Medicaid does. To qualify for one of these waiver programs, applicants almost always must have care needs equivalent to those of nursing home residents. These waiver programs also often have a limited number of enrollment slots, meaning that waiting lists are common. In some states, the support programs may cover only certain regions of the state. And one state’s definition of “assisted living” may differ from another’s, or other terms may be used, such as “residential care,” “personal care homes,” “adult foster care,” and “supported living.”

If your state does not cover room and board at an assisted living facility, help may be available through state-funded welfare programs or programs run by religious organizations. If the resident is a veteran or the surviving spouse of a veteran, the resident’s long-term care may be covered.  

For Paying for Senior Care's page on assisted living benefits, including its state-by-state guide to Medicaid’s coverage of assisted living facilities, click here.

What Vaccines Does Medicare Cover?

Vaccines can become less effective over time. Even individuals fully vaccinated as children may need to update their immunizations. Medicare Parts B and D offer vaccination coverage.

Medicare Part B covers shots for the flu, hepatitis B, pneumococcal (pneumonia), and COVID-19. Medicare covers 100 percent of the cost of these vaccines if you go to an approved provider, and you do not have to pay a deductible or coinsurance. Medicare Advantage plans are also required to provide these vaccines at no additional costs.

Medicare covers one flu shot per flu season, which runs from November to April, and not the calendar year. For example, if an individual gets a flu shot in January and again in November of the same year, Medicare would pay for both.

Medicare covers two different pneumonia shots. Medicare recipients can get the first shot at any time and it will cover the second shot if it's administered at least one year after the first shot.

Hepatitis B shots are free for anyone considered medium or high risk for contracting the virus. End-stage renal disease and diabetes are two conditions that place individuals into a higher risk category. A medical professional can help determine an individual’s risk level.

Medicare Part D plans (as well as Medicare Advantage plans with built-in Part D) should cover all other commercially available vaccines, including shingles and Tdap (tetanus, diphtheria, and pertussis), when they are reasonable and necessary to prevent illness. Contact your Part D plan to make sure it covers the shot you need. To limit your copay, you should go through an in-network provider that will either handle billing your Part D plan electronically or coordinate this with a pharmacy. 

Ask your vaccine provider if it can bill your Part D plan directly.  If your doctor or pharmacy can’t do this, the provider will have to bill you for the entire cost of the vaccination and you’ll have to request reimbursement from your plan.  And note that the plan will reimburse for only the approved amount, which may be less than what the provider charged you.

Keeping current on your vaccinations is one of the best ways to prevent serious illness and disease. Talk with your doctor to determine what vaccines you need to minimize risks to your health.

For more from the Medicare Rights Center on Medicare’s vaccination coverage, click here.