August 6

Medicare Advantage Plans Overbill Taxpayers By Billions Annually, Records Show

Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion over the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.

Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed or backed off efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat more than 22 million seniors — more than 1 in 3 people on Medicare.

Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.

At the same time, the Department of Health and Human Services Inspector General’s Office has launched a separate nationwide round of Medicare Advantage audits.

As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.

America’s Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it “fatally flawed.”

For the article from NPR, click here.

August 2

Research shines light on why women more likely to develop Alzheimer’s

The reason women appear to be at greater risk of developing Alzheimer’s disease than men might be due to a number of genetic, anatomical and even social influences, researchers have suggested.

Recent figures show about 65% of those with living with dementia in the UK are women, with a similar statistic seen in the US for Alzheimer’s disease, while dementia is the leading cause of death for women in England. Alzheimer’s disease is only one of the types of dementia, but the most common form.

While one explanation is that dementia risk increases with age, and women have longer life expectancies than men, new research suggests there might be more to the matter, including that protein tangles found within neurons and linked to Alzheimer’s disease might spread differently in women’s brains than men’s.

The study, presented at the Alzheimer’s Association International Conference in Los Angeles by researchers from Vanderbilt University and which has not yet been peer-reviewed, used scans from a method called positron emission tomography. That allowed them to look at the way clumps of a protein called tau were spread in the brains of 123 men and 178 women without cognitive problems, as well as 101 men and 60 women with mild cognitive problems – although not yet diagnosed with Alzheimer’s disease. Cognitively normal older people often have small amounts of tau in certain areas of their brain.

From the data the team could build maps showing which areas of the brain show similar signals relating to tau in the scans, suggesting they are somehow connected. “Based on that we kind of try to reconstruct the pattern of spread,” Dr Sepideh Shokouhi, who is presenting the research, told the Guardian. “It is kind of like reconstructing a crime scene.”

For the article from The Guardian, click here.

July 30

From baby boomers to Gen X: America’s retirement crisis by the numbers

These days, overwhelming student loan debt and the uncertain future of Social Security’s solvency garner most of the attention, but there’s another equally severe financial crisis looming on the horizon for millions of Americans. Thousands of people retire every day, and many don’t have the savings they need to last the rest of their lives.

When that well runs dry, they’ll need to lean on their family members to support them or seek government assistance to cover their basic living expenses. It’s a fate thousands of Americans are already experiencing, and based on data from the latest Northwestern Mutual Planning & Progress survey, tens of thousands more are set to join them in the coming decades.

While respondents in Northwestern Mutual’s 2019 survey reported better money management skills than those surveyed 10 years ago, the outlook for many of their futures remains grim. The survey found:

  • 22% of Americans have less than $5,000 saved for retirement.
  • 15% have no retirement savings at all.
  • 56% don’t know how much money they need to retire comfortably.
  • 41% are taking no steps to prevent themselves from running out of retirement savings, though many see this as a possibility.

The percentage of Americans with less than $5,000 in retirement savings actually decreased compared to last year, but 22% is still an alarming number of people without adequate savings.

The study focused on baby boomers and Generation X – the two generations next in line for retirement – and the results showed both groups have work to do. Of the 10,000 baby boomers turning 65 every day, 17% have less than $5,000 in retirement savings, and 20% have less than $5,000 in personal savings outside of a retirement account.

These numbers are even higher for Generation X, with 21% having less than $5,000 in retirement savings and 22% having less than $5,000 in personal savings. They have more time left before retirement, so it’s possible they could still increase their savings before then, but if they have less than $5,000 today, it’s unlikely they can save an adequate amount by the time they’re ready to retire.

For the article from USA Today, click here.

October 5

VA Establishes Asset Limits and Transfer Penalties for Needs-Based Benefits

The Department of Veterans Affairs (VA) has finalized new rules that establish an asset limit, a look-back period, and asset transfer penalties for claimants applying for VA needs-based benefits. This is a change from current regulations, which do not contain a prohibition on transferring assets prior to applying for benefits such as Aid and Attendance.

The VA proposed the new regulations in January 2015. Three years later, after receiving more than 850 comments, the VA has finally published the final regulations, which are similar, with a couple of exceptions, to the proposed regulations.

In order to qualify for benefits under the new VA regulations, which go into effect October 18, 2018, an applicant for needs-based benefits must have a net worth equal to or less than the prevailing maximum community spouse resource allowance (CSRA) for Medicaid ($123,600 in 2018). Net worth includes the applicant's assets and income. For example, if an applicant's assets total $117,000 and annual income is $9,000, the applicant's net worth is $126,000. The net worth limit will be increased every year by the same percentage that Social Security is increased. The veteran's primary residence (even if the veteran lives in a nursing home) and the veteran's personal effects are not considered assets under the new regulations. If the veteran's residence is sold, the proceeds are considered assets unless a new residence is purchased within the same calendar year.

The VA has also established a 36-month look-back period and a penalty period of up to five years for those who transfer assets for less than market value to qualify for a VA pension. The look-back period means the 36-month period immediately before the date on which the VA receives either an original pension claim or a new pension claim after a period of non-entitlement. There is an exception for transfers made as the result of fraud, misrepresentation, or unfair business practices and transfers to a trust for a child who is not able to self-support.

The penalty period will be calculated based on the total assets transferred during the look-back period if those assets would have put the applicant over the net worth limit. For example, assume the net worth limit is $123,600 and an applicant has a net worth of $115,000. The applicant transferred $30,000 to a friend during the look-back period. If the applicant had not transferred the $30,000, his net worth would have been $145,000, which exceeds the net worth limit. The penalty period will be calculated based on $21,400, the amount the applicant transferred that put his assets over the net worth limit (145,000-123,600).

Any penalty period would begin the first day of the month that follows the last asset transfer, and the divisor would be the applicable maximum annual pension rate for a veteran in need of aid and attendance with one dependent that is in effect as of the date of the pension claim. The penalty period cannot exceed five years, a change from the 10-year maximum in the proposed regulations.

The rules also define and clarify what the VA considers to be a deductible medical expense for all of its needs-based benefits. Medical expenses are defined as payments for items or services that are medically necessary; that improve a disabled individual's functioning; or that prevent, slow, or ease an individual's functional decline. Examples of medical expenses include: care by a health care provider, medications and medical equipment, adaptive equipment, transportation expenses, health insurance premiums, products to help quit smoking, and institutional forms of care.

As noted, the rules become effective on October 18,2018. To read the new regulations, click here.

October 2

Medicaid Director Needs to Hold Full Hearing on Facts Before Ruling Against Recipient

A New Jersey appeals court rules that a state Medicaid director could not rule against an assisted living facility resident who wanted to deduct the cost of a full-time aide from her income because the administrative law judge (ALJ) did not hold a full evidentiary hearing on whether the aide was medically necessary. G.F. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-3067-16T3, Sept. 12, 2018).

Assisted living resident G.F. received Medicaid benefits that required her to contribute some of her income to her care. She claimed a full-time aide was medically necessary to keep her from falling, and she asked to deduct the cost of the aide from her income. The state denied the request, and G.F. appealed.

In filings with the ALJ, the state did not dispute that the aide was medically necessary. Instead, the state argued that G.F. needed to be in a nursing home. The ALJ determined that there was no dispute as to facts, so it ruled for G.F. without an evidentiary hearing. The state Medicaid director ruled that because G.F.'s doctor did not testify at the hearing, G.F. did not prove that the aide was medically necessary and reversed the ALJ's decision. G.F. appealed to court.

The New Jersey Superior Court, Appellate Division, remands the state's decision for a full hearing on whether the aide is medically necessary. According to the court, while the director correctly determined that G.F. did not prove the aide was medically necessary, G.F. "did not present live testimony to support her claim because the parties agreed there was no need to do so, and the ALJ determined the matter could be decided on the papers."

For the full text of this decision, go to: https://www.njcourts.gov/attorneys/assets/opinions/appellate/unpublished/a3067-16.pdf?cacheID=Uga2KPl

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