October 24

How the Social Security Cost of Living Increase will Affect the Part B Premium

Last week, the Social Security Administration announced that there will be a 2% cost-of-living adjustment (COLA) to Social Security benefits in 2018. However, some people with Medicare will not see the full two percent increase in their monthly benefits. Those who paid less than the standard $134 Part B premium in 2017 had lower costs because they were protected by the hold harmless provision.

This provision prevents an individual’s Social Security benefit from going down from one year to the next as a result of Medicare premium increases. Many people were held harmless in 2016 and 2017 because the COLAs for those years (0% and 0.3%) were not large enough to cover the full amount of the increased Part B premium ($134). For these individuals, the Part B premium increased the same amount as the increase in their Social Security benefit. The average premium for individuals protected by hold harmless in 2017 is $109.

In 2018, the two percent COLA is likely to be enough to cover the difference between a person’s previous premium and the standard Part B premium, which is expected to stay at around $134 per month. In this case, the hold harmless provision will not affect premiums and most people will pay the standard premium. If a person’s benefit does not increase enough for them to pay the $134 without their Social Security benefit decreasing, the hold harmless provision will limit the Part B premium increase to the amount their Social Security benefit increased.

Here is an example of how this will work for someone whose Social Security award in 2017 is $1,300 a month. If someone with Medicare pays the average $109 Part B premium in 2017, their check is $1,191 after the premium is deducted. In 2018, their benefit will increase by $26 to $1,326, and their premium will increase by $25 to $134. Their Social Security check, after the premium deduction, will be $1,192.

People who paid $134 for Part B in 2017 (including people who were new to Medicare in 2017) will have the same 2% increase to their Social Security benefits, but no increase in Part B premiums if the 2018 premium stays the same. These individuals will see an increase to their Social Security check after the premium is deducted.

Everyone should look at their Social Security statement for personalized information about their benefit and premium amounts.

Once the Part B premium for 2018 is announced, we will update the hold harmless page on Medicare Interactive with more details about how the COLA and the Part B premium affect Social Security benefits for people with Medicare in 2018.

Written By: Emily Whicheloe

October 23

Yahoo Is Not Prohibited From Disclosing Contents of Email Account to Estate Representatives

Massachusetts’ highest court rules that the Stored Communications Act does not prohibit an email provider from disclosing the contents of a decedent’s email account to the decedent’s personal representatives. Ajemian v. Yahoo!, Inc., (Mass., No. SJC-12237, Oct. 16, 2017).

John Ajemian had a Yahoo email account that he used as his primary email. After he died, his personal representatives sought access to the email account. Yahoo declined to provide access without a court order.

Mr. Ajemian’s estate sued Yahoo, seeking a declaratory judgment that it was entitled to access the emails in the account. Yahoo filed a motion for summary judgment, arguing that the federal Stored Communications Act (SCA), which prohibits unauthorized third parties from accessing communications stored by service providers, prevented it from disclosing the emails. The trial court judge agreed, and the estate appealed.

The Massachusetts Supreme Judicial Court reverses, holding that the SCA does not prohibit the estate from accessing Mr. Ajemian’s emails. According to the court, the SCA “permits Yahoo to divulge the contents of the e-mail account where, as here, the personal representatives lawfully consent to disclosure on the decedent’s behalf.”

For the full text of this decision, go to: https://www.mass.gov/files/documents/2017/10/16/12237.pdf

October 20

Leading Medicare Advocates Voice Opposition to the Graham-Cassidy Bill

Washington, DC – The Medicare Rights Center and the Center for Medicare Advocacy sent a letter to Senate leadership today in opposition to the recently unveiled “Graham-Cassidy” bill. The letter voices both organizations’ deep concerns that the Graham-Cassidy bill, like its predecessors, would take away access to affordable health care for millions of Americans, especially older adults and people with disabilities. The bill is particularly destructive to the Medicaid program and puts long-term care and services, including nursing home care and the ability for people to stay in their homes, at risk through damaging per-capita caps. The letter urges the Senate to instead pursue bipartisan solutions to strengthen the Affordable Care Act (ACA), Medicaid, and Medicare through an open and transparent process.

“This plan, like those before it, makes no attempt to enhance health care access or affordability for American families,” said Joe Baker, president of the Medicare Rights Center. “Instead, it creates chaos, permanently damages Medicaid, eliminates protections for people with pre-existing conditions, and strips coverage from millions of Americans. This is not the path forward.”

“It’s awful to have to fight for health care—yet again,” said Judith Stein, executive director of the Center for Medicare Advocacy, “but we’re ready. We are appalled the Senate is trying to take away coverage, without public input or a complete Congressional Budget Office score. Americans want to know what the Graham-Cassidy bill would do to their families’ health care coverage. We won’t give up the fight for continued access to the ACA, Medicaid, Medicare, and quality health care.”

To Read the Letter Click Here


Center for Medicare Advocacy – Matthew Shepard: 860-456-7790, mshepard@MedicareAdvocacy.org
Medicare Rights Center – Mitchell Clark: 212-204-6286, mclark@medicarerights.org

October 19

To Waive or Not To Waive: The Trump Administration’s Legal Dilemma

If the Trump administration’s sabotage of the Affordable Care Act (e.g., threatening to cut-off cost sharing reduction payments, reducing outreach funding by 90 percent, cutting navigator grants by more than 40 percent) is any guide, Medicaid faces a rocky road in the coming months and years.

After Congress failed in its legislative attempts to dismantle Medicaid by capping its funding, the immediate threats to Medicaid lie with the administration as it considers approving waivers submitted by states pursuant to Section 1115 of the Social Security Act. While some of the waivers coming from the states are indeed proposing innovative approaches to improve Medicaid, some states are seeking waivers to impose harmful cuts and restrictions.

Medicaid operates as a federal-state partnership; the federal government provides states with generous funding, but states must adhere to the provisions of the federal Medicaid statute and regulations. Section 1115 of the Social Security Act, however, allows the Secretary of HHS to waive some requirements of the Medicaid Act so that states can test novel approaches to improving medical assistance for low-income people. To be approved, a waiver must:

implement an “experimental, pilot, or demonstration” project;
be limited to the subset of Medicaid provisions in one specific section (42 U.S.C. Sec. 1396a);
be likely to promote Medicaid’s objectives; and
be limited to the extent and period needed to carry out the experiment.

Over the years, courts have enforced these legal limits to the scope of Section 1115 waivers. For example, courts have noted that Section 1115 was not enacted to enable states to save money or to evade federal requirements but rather to test out new ideas and ways of addressing the problems of public benefit recipients.

The administration’s initial HHS Secretary Tom Price signaled a willingness to allow states to dramatically reshape and limit their Medicaid programs using section 1115. We expect his successor will continue on this path. Indeed, the Administration seems on the brink of approving waivers whose main outcomes will be to reduce Medicaid enrollment (thus increasing the numbers of the uninsured) and to unwind the achievement – 30 years in the making – of tying Medicaid coverage to income rather than paternalistic notions of who are the “worthy poor.” The current crop of waiver requests would roll back this progress by conditioning Medicaid (i.e., access to medically necessary health care) on such things as work requirements, drug testing, unaffordable premiums, and high copayments for even emergency use of an emergency department. Several states’ waiver applications (including Ark., Ind., Ky., Maine, Texas, Utah, Wis.) contain some or all of these harmful cutbacks yet the Administration is likely to approve them in whole or in part as early as this month.

These approvals will be problematic. None of them is designed to improve the Medicaid program. Those states that even bother to state a hypothesis focus on saving money rather than improving access.

All this raises some potential legal problems. As noted, section 1115 waivers must be experimental projects that are consistent with the objectives of the Medicaid Act. The stated purpose of Medicaid is to furnish medical assistance and long-term care (such as nursing home care) to low-income individuals.

Instead, the proposals now under consideration are harmful. Take work requirements: In the 50-plus years of Medicaid’s existence and through both Republican and Democratic administrations, HHS has never approved a waiver permitting a mandatory work requirement for Medicaid applicants or enrollees. HHS has always denied these requests, recognizing they reduce access to care. For example, HHS denied work requirement requests from Ariz., Ark., Ind., and N.H. concluding that such requirements are not consistent with Medicaid’s purposes. Lessons from work requirements in TANF reinforce this conclusion. The purpose of Medicaid has not changed, only the administration has changed. Given the limits imposed by section 1115, serious legal questions arise as to whether the HHS secretary has authority to allow a state to impose work requirements.

Mandatory drug testing is also impermissible. Receipt of Medicaid can assist an individual with a substance-use disorder get the treatment needed to stop using drugs and, of course, also provides access to other medically necessary services that the individual needs. Requirements for drug testing that cause people to lose access to care thus conflict Medicaid’s stated purpose.

Notwithstanding this administration’s desire to allow states to restructure their Medicaid programs, Section 1115 does not give the secretary unfettered discretion. The secretary cannot ignore the underlying requirements of the Medicaid Act and has only limited authority to approve Medicaid waivers. If the secretary acts beyond the scope of Section 1115, the approval will be without statutory authorization, and the courts will need to step in.

Courtesy of Mara Youdelman and Jane Perkins on October 12, 2017

October 18

Who Cares for the Care Givers? We All Do.

Nearly 44 million people in the United States, three-quarters of whom are women in their late 40s, spend at least 22 hours a week providing unpaid care to loved ones with a disability, illness, or terminal diagnosis, and one in four spend at least twice that amount. Typically, they assist with the activities of daily living such as bathing, dressing, toileting, and feeding their loved one, as well as taking care of shopping, finances, and transportation to and from medical appointments.

These responsibilities generally last at least three years, with demands increasing as the loved one nears death. Caretaking offers emotional and other personal rewards, but when added to other family and personal responsibilities, it can impact the caregivers’ employment and their own personal well-being. Depression and burnout among caregivers can often lead to poor health choices, including turning to unhealthy use of substances.

How can we support these unpaid millions who are themselves hurting? There are steps that can mitigate, or at least control, some undue stress for the caregiver.

With attention focused on the patient, it is easy to overlook the needs of the caretaker. Because of their outsized responsibilities, caregivers report a reduction in the ability to experience positive activities in their own daily lives by almost a third in comparison to non-caregivers. It is estimated that between 40 percent and 70 percent of caregivers have clinically significant symptoms of depression and up to half meet the diagnostic criteria for major depression. As the loved one’s functional status declines, levels of caregiver depression and perceived burden tend to increase. New stresses arise for those who try to locate appropriate end-of-life care for their loved ones. They may also question whether the services their loved one is receiving are of high quality and properly integrated with other health care and social services.

Sensitizing communities to the mental health risks these caregivers face and increasing understanding of the importance of mental health is a good place to start. A terrific resource to accomplish these goals is Mental Health First Aid, an eight-hour course that gives people skills to help someone who is developing a mental health problem or experiencing a mental health crisis. It was created in Australia by Betty Kitchener and Anthony Jorm, and brought to the United States by the National Council for Behavioral Health. Mental Health First Aid teaches individuals how to identify, understand, and respond to signs of mental illness and substance abuse disorders in their community.

With more than a million people trained in mental health first aid across the country by 11,800 instructors, the impact has been invaluable. Mental health first aiders include teachers, first responders, veterans, parents, friends, students, mayors, and first ladies including former First Lady Michelle Obama. First responders who have completed the training report that it has changed the way they do their jobs. They have learned to approach people differently, responding to calls equipped with the “right tools” or questions to ask and ultimately connecting individuals to the help they need. Students completing the youth mental health first aid training report they have learned to be better friends, feel more comfortable knowing what to do in difficult situations, and can now apply principles learned in their lives. This is making a difference in high schools and college campuses.

This program has improved and saved lives by increasing awareness in communities about behavioral health. Mental health first aid for older adults is a special program that addresses the unique risk factors and warning signs of mental health problems in adults older than age 65 and provides the tools to recognize them and respond.

Taking this course can help caregivers and people who know caregivers develop a better understanding of how to help an older adult who is in crisis or experiencing a mental health challenge. It also empowers the caregiver with knowledge about how to select an intervention and provide initial help. More than one million volunteers in the United States have completed the training and many report that just knowing they have the skills to assist someone experiencing a mental health crisis gives them a feeling of confidence and a heightened sense of responsibility to their community.

An essential element of mental health first aid is self-care. Just as mental health first aiders become more aware of their role in mental health within their families and communities, they are reminded that maintaining their health is key to helping others. This “care for the caregiver” aspect of mental health first aid training is critical for the population of caregivers.

In addition to sensitizing communities to be aware of mental health risks for caregivers, it is important to note that caregivers also have a higher risk of losing employment while caring for loved ones with complex care/end-of-life support needs. Helping caregivers stay employed is an important support strategy in decreasing caregiver burden. However, with limited protection under the Family Medical Leave Act, the caregiver may be forced to work fewer hours or drop out of the workforce altogether. Research illustrates that the economic toll on caregivers can be devastating. A 2013 study shows the overall unpaid value of caregiving contributions is around $470 billion—up $20 billion from 2009 and double the impact of paid caregivers and nursing homes combined. For caregivers who remain employed, lost productivity is estimated to average more than $25 billion annually, on top of a rate of about one week of absenteeism annually per caregiver.

Loss of employment can not only create financial hardship, one study found that employment had a protective effect on women caregivers who reported that work provided a buffer from the stress of caregiving. The additional income also provided them with the financial and social resources to maintain a higher level of self-care and embrace a healthier lifestyle with greater access to more fresh fruits and vegetables, medicines, and health care than their unemployed counterparts. Workplace policies that offer employees flexibility around their caregiving also have been shown to help reduce rates of depression in this group. The National Alliance for Caregiving study of Best Practices in Workplace Eldercare identifies current trends and innovations in workplace policies and practices that support employees with eldercare responsibilities including individuals with complex care needs.

Navigating the complex health system is the last thing overburdened caregivers need to deal with; understanding the protections afforded under the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 can help alleviate the burden. The MHPAEA requires group health plans and health insurance issuers to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits.

What this means for the caregiver is that there must be comparable copayments for mental health and substance use disorder care and physical health care. If there are no limits on the number of outpatient visits for physical care, there can be no limits for outpatient mental health or substance use disorder care, and prior authorization requirements for mental health or substance use disorder services must be comparable to those for physical health services.

We can all make a difference by increasing awareness in our own communities and sharing resources with local community organizations, caregivers, and people who may know someone who is struggling. As an example, “Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits” is a consumer-oriented brochure that provides an overview of the MHPAEA and provides resources for additional information about state and federal parity laws. It discusses which health care benefits should be covered under a patient’s health plan or insurance. These include clinical treatment, health care services, and medications.

While policy-driven programs to support the mental health of caregivers are important and should be pursued, there are interventions we can implement immediately, without waiting for legislators to act. The first step is to adopt a caring attitude for our caregivers and to educate ourselves about the simple but effective ways we, as community members, can help.

Article Courtesy of Nicole Cadovius, the director of practice improvement for the National Council for Behavioral Health