October 17

Medicare Guide 2017: Check for providers in ‘narrow networks’

Fewer than half of all doctors in Multnomah County and other U.S. metropolitan areas are covered by privately run Medicare Advantage plans, a new study has found.

The Kaiser Family Foundation, an independent health policy research center, found that more than 1 in 3 enrollees in private Medicare Advantage plans had access to “narrow networks” comprising less than 30 percent of the physicians and specialists in their areas.

The findings underscore how important it is that seniors ensure their doctors and care centers are included in their plan’s preferred network. Enrollees who go to out-of-network providers either pay more for their care or get no help from their plan.

Yet that task isn’t simple. Network sizes are not prominently advertised by insurers or the government, and provider directors can change at any time, experts say.

“Most of the provider directories are hundreds of pages, and some are organized differently,” said study co-author Gretchen Jacobson, associate health policy director at the foundation in Washington, D.C. “Even some broad network plans had relatively few physicians in specialties.”

Insurance broker Drew Shavere, president of Columbia Benefits Group in Wilsonville, recommends clients use online provider directories, which are more up-to-date than printed directories.

“It can be a little cumbersome,” he said. “The more doctors someone has, the more legwork there is. Not all carriers publish a printed directory. The insurance carriers will tell you themselves those are outdated almost as soon as they’re printed.”

Medicare Advantage plans offer beneficiaries the chance to get their coverage from private insurers and health organizations. Nationwide, 19 million — or 1 in 3 — seniors do, but in Multnomah County, nearly 60 percent enroll in such plans, one of the highest rates in the country.

The study examined nearly 400 plans in 20 U.S. counties, including 30 plans in Multnomah County. On average, the plans covered 46 percent of the providers in a county. In Multnomah County, they covered 42 percent.

None of Multnomah County’s plans offered a “broad network” covering at least 70 percent of the medical providers in the county, while 1 in 5 plans had narrow networks.

Plans most severely limited access to psychiatrists, cardiothoracic surgeons, neurosurgeons, plastic surgeons and radiation oncologists, the study found. In Multnomah County, plans covered only 29 percent of geriatricians, 34 percent of cancer doctors and surgeons, and 31 percent of physiatrists, who specialize in rehabilitation.

Those results were surprising, Jacobson said, because geriatricians specialize in caring for older people, and physiatrists often help seniors rehabilitate from surgeries, arthritis or broken bones.

The study’s authors suggested that insurers limit access to providers to control costs and quality of care.

The foundation, which isn’t affiliated with Kaiser Permanente, believes the study to be the first of its kind to assess the size and makeup of physician networks in Medicare Advantage plans. Experts say networks have been contracting in recent years, but the study only looked at network sizes in 2015.

Article Courtesy of Brent Hunsberger of The Oregonian

October 16

Social Security Announces 2.0 Percent Benefit Increase for 2018

Monthly Social Security and Supplemental Security Income (SSI) benefits for more than 66 million Americans will increase 2.0 percent in 2018, the Social Security Administration announced today.

The 2.0 percent cost-of-living adjustment (COLA) will begin with benefits payable to more than 61 million Social Security beneficiaries in January 2018. Increased payments to more than 8 million SSI beneficiaries will begin on December 29, 2017. (Note: some people receive both Social Security and SSI benefits) The Social Security Act ties the annual COLA to the increase in the Consumer Price Index as determined by the Department of Labor’s Bureau of Labor Statistics.

Some other adjustments that take effect in January of each year are based on the increase in average wages. Based on that increase, the maximum amount of earnings subject to the Social Security tax (taxable maximum) will increase to $128,700 from $127,200. Of the estimated 175 million workers who will pay Social Security taxes in 2018, about 12 million will pay more because of the increase in the taxable maximum.

Information about Medicare changes for 2018, when announced, will be available at www.medicare.gov.

The Social Security Act provides for how the COLA is calculated. To read more, please visit www.socialsecurity.gov/cola.

October 13

Congress Approves NOTICE Act (Observation Status)

The U.S. Senate unanimously approved legislation Monday night requiring hospitals across the nation to tell Medicare patients when they receive observation care, but have not been admitted to the hospital. It’s a distinction that’s easy to miss until patients are hit with big medical bills after a short stay. The vote follows overwhelming approval in the U. S. House of Representatives in March. The legislation is expected to be signed into law by President Barack Obama, said its House sponsor, Texas Democratic Rep. Lloyd Doggett. It’s called the NOTICE Act, short for “Notice of Observation Treatment and Implication for Care Eligibility.” The law would require hospitals to provide written notification to patients 24 hours after receiving observation care, explaining that they have not been admitted to the hospital, the reasons why, and the potential financial implications. Meanwhile, the number of claims hospitals submitted for observation care continues to skyrocket. According to the most recently available data from CMS, total claims increased 91 percent since 2006, to 1.9 million in 2013. Long observation stays, lasting 48 hours or more, rose by 450 percent to 170,219 during the same period, according to a Kaiser Health News analysis. In 2013, Medicare officials attempted to control the use of observation care by issuing the so-called “two-midnight rule,” which would require hospitals to admit patients who doctors expect to stay at least two midnights. But Congress delayed its enforcement after hospitals said the rule was confusing and arbitrary.

For the complete story Click Here

October 12

Centers for Medicare and Medicaid Services (CMS) Proposes New Regulation to Govern Nursing Home Arbitration Agreements

On July 16, 2015, CMS published in the Federal Register an exhaustive proposed rule on requirements for long-term care facilities. One of the proposed provisions concerns dispute resolution — specifically, binding arbitration agreements — at Sec. 483.70(n). The posted background on this topic provides, “We considered not proposing any requirements concerning binding arbitration agreements. We share stakeholders’ concern that some nursing homes may be requiring residents to sign agreements for binding arbitration as a requirement for admission into the facility. In addition, if the nursing home is not requiring the agreement as a condition of admission, some facilities may be requesting the resident to sign the agreement without fully explaining the rights the resident is waiving and the consequences of that waiver. We have proposed specific requirements if a nursing home chooses to request that a resident sign an agreement for binding arbitration. These requirements include, among other things, that the nursing home must explain the agreement to the resident in a form and manner that he or she understands, and that the resident acknowledge that they understand the agreement. We have also proposed specific requirements for the agreement, including that admission to the facility cannot be contingent upon the resident signing the agreement, the agreement must be entered into voluntarily, and the arbitration must be conducted by a neutral arbitrator in a venue convenient to both parties.

For full text of the proposed legislation Click Here

October 11

U.S. Court Rules That Assets Transferred to Testamentary Trust Are Subject to Penalty Period

A federal court rules that Colorado’s Medicaid agency acted properly when it imposed a penalty period on a nursing home resident’s benefits after she transferred her share from the sale of a residence to her late husband’s fully discretionary testamentary trust. Kadingo v. Johnson et al (U.S. Dist. Ct., D. Col., No. 15-cv-02835-NYW, Aug. 14, 2007).

In 2011, nursing home resident Lilafern Kadingo applied for Medicaid benefits. At the time, Mrs. Kadingo was the sole beneficiary of a fully discretionary testamentary trust established by her late husband’s will after his death months earlier. Mrs. Kadingo also owned a residence, which she sold in 2013, placing the proceeds into the trust.

In 2014, the Colorado Department of Health Care Policy and Financing, the state’s Medicaid agency, determined that Mrs. Kadingo had received an overpayment of $98,703.52 in Medicaid benefits. Mrs. Kadingo appealed and an administrative law judge (ALJ) determined that there had been a transfer without fair consideration that warranted a 14-month penalty period. The agency upheld the decision.

Mrs. Kadingo appealed, but before a final agency decision was issued she filed a lawsuit against the agency. Mrs. Kadingo argued that the agency’s policy, which presumed that the failure of a surviving spouse to elect a share of a spouse’s estate is a transfer without consideration, violated her rights insofar as federal Medicaid law excludes testamentary trusts established by the individual or the individual’s spouse from the rules governing the treatment of trusts in eligibility determinations. The agency countered that the rules do not wholly exempt assets contained in testamentary trusts and that because Mrs. Kadingo placed the proceeds from the sale of the residence into the trust and failed to take an elective share of her husband’s estate, it amounted to a transfer without fair consideration. Mrs. Kadingo and the agency filed competing motions for summary judgment.

The United States District Court, D. Colorado, grants the agency’s motion for summary judgment, finding that “…nothing in the [law] suggests that once a testamentary trust is excluded as an exempt trust for the purposes of Medicaid eligibility, later-acquired assets placed in that Trust cannot be considered as some other type of asset for eligibility purposes at all simply because of where they are deposited.” [emphasis in original] The court explains that, if followed, Mrs. Kadingo’s interpretation would undermine the law and allow a recipient to “transfer assets she is legally entitled to under the auspices of the testamentary trust exception while concomitantly avoiding any transfer penalty and enjoying both continued Medicaid benefits as well as the use of the transferred assets.”