Category Archives: Educational Material

Not too late for certain Medicare beneficiaries to make changes

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Although Medicare’s annual Open Enrollment period has ended, it’s not too late for certain Medicare beneficiaries to make changes for 2014.

Between Jan. 1 and Feb. 14 each year, people currently enrolled in a Medicare Advantage plan who wish to return to Original Medicare can disenroll from their Medicare Advantage plan, return to Original Medicare, and join a Part D drug plan. (In western Nevada County, the only Medicare Advantage Plan in 2014 is the AARP MedicareComplete SecureHorizons HMO.)

If beneficiaries who qualify for the Medicare Advantage Disenrollment Period decide to make this change, their new plan becomes effective the first day of the month following their enrollment request.

Anyone in need of assistance choosing a new plan for 2014 is welcome to make a free HICAP counseling appointment by calling the HelpLine office at 530-273-2273.

HICAP is a nonprofit organization that provides free, unbiased, one-on-one counseling to Medicare beneficiaries, including people who are new to Medicare.

Karin Hofland, Nevada County regional coordinator

HICAP Services of Northern California

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Not too late for certain Medicare beneficiaries to make changes

Minnesota attorney general asks U.S. to investigate Humana

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Karen MerrickMinnesota Attorney General Lori Swanson said patients and doctors are having “significant problems” with Humana.

Minnesota Attorney General Lori Swanson is asking the federal government to investigate Humana’s Medicare Advantage policies after uncovering what she said were “significant problems” reported by Minnesota patients and medical providers.

Affidavits gathered from 25 Minnesotans showed a pattern where Humana denied claims for medical services required by law, overcharged for co-payments and coinsurance, and failed to disclose the providers that are in the network, she said. Swanson’s office also found that Humana didn’t follow procedures laid out by federal regulations for patients to appeal their cases.

“They were stringing people along, taking months to get back to people,” she said. “Oftentimes, it took the intervention of our office — and oftentimes we had to write multiple times.”

Humana, based in Louisville, Ky., is one of the nation’s largest health care insurers in Medicare Advantage, a private policy that covers seniors and those with disabilities. Humana has been doing business in Minnesota for more than 10 years, and provides insurance coverage to more than 100,000 residents through various types of Humana Medicare Advantage plans, including a plan for prescription drugs, according to a company official.

Humana spokeswoman Kate Marx said in an e-mail that the insurer has not been notified of the complaint by the Minnesota attorney general’s office or by federal regulators.

“We take this very seriously and are working to identify the facts,” Marx said.

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Minnesota attorney general asks U.S. to investigate Humana

MN Attorney General Asks Feds To Investigate Humana

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ST. PAUL, Minn. (WCCO) – Minnesota Attorney General Lori Swanson says a federal investigation is needed to look into business practices at one of the nation’s largest private Medicare insurers.

On Friday, Swanson sent a massive file of complaints against Humana to the federal agency charged with overseeing that part of Medicare.

She’s asking the Centers for Medicare & Medicaid Services (CMS) to look into more than 27 complaints on file.

For the past couple of years, Humana policy holders in Minnesota have complained of improper denial of coverage, overcharges for co-payments and failure to follow the required appeals process.

Kentucky-based Humana provides private Medicare insurance coverage to more than 100,000 Minnesota seniors.

This investigation into Humana’s alleged wrongdoing has been going on for a couple of years, Swanson asserts. It stems from both consumer and medical provider complaints from across the state.

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MN Attorney General Asks Feds To Investigate Humana

ATTORNEY GENERAL SWANSON ASKS FEDERAL AGENCY TO INVESTIGATE COMPLAINTS AGAINST HUMANA BY MEDICARE PATIENTS

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Minnesota Attorney General Lori Swanson today asked the federal agency responsible for regulating private Medicare insurance policies to investigate and remedy complaints by Minnesota senior citizens about improper claims handling by Humana, which sells private Medicare policies in Minnesota.

In a letter containing over 25 sworn affidavits from Minnesota patients and medical providers, Attorney General Swanson called on the federal Centers for Medicare & Medicaid Services (“CMS”), which regulates private Medicare plans, to investigate and remedy any violations of federal regulations arising from Humana’s improper claims handling in Minnesota. The United States Congress has determined that states are preempted from regulating benefit determinations of private Medicare Advantage plans and has vested jurisdiction to regulate such plans with CMS.

“Medical bills that aren’t covered or processed properly can hit senior citizens hard in the pocketbook. We are asking the federal agency that has authority over these plans to fully investigate and remedy the problems experienced by Minnesota patients,” said Swanson.

Medicare Advantage plans are private health plans approved by CMS, but sold and administered by private insurance companies as an alternative to traditional Medicare fee-for-service coverage. Medicare Advantage plans may provide prescription drug coverage and include mandatory or optional supplemental benefits such as vision and dental benefits. Minnesota has the highest number of enrollees in Medicare Advantage plans in the nation on a per capita basis, according to a June 2013 report by Kaiser Family Foundation.

In her letter, Attorney General Swanson cites numerous problems reported by Minnesota patients and providers about Humana, including:

  1. Denial of claims involving Medicare-covered services. (Other than hospice care, Medicare Advantage plans must cover anything traditional Medicare would cover.)
  2. Overcharges for co-payments and co-insurance.
  3. Failure to adequately disclose what providers are in network and to update its network provider directories.
  4. Failure to follow the appeal procedures required by federal regulations.

Humana is a publicly traded, for-profit insurance company. It is one of the biggest insurers in the Medicare Advantage market nationwide, offering at least one type of Medicare Advantage plan in all 50 states. About 17 percent of all Medicare beneficiaries nationwide are enrolled in a Humana Medicare Advantage plan, according to a June 2013 report by Kaiser Family Foundation.

The Attorney General’s Office provides this advice to Medicare beneficiaries who are thinking about enrolling in an Medicare Advantage plan:

  1. Determine if your health care providers are in-network.
  2. Identify the copays, deductibles, and out-of-pocket maximum costs for the plan. Plans’ costs will vary, especially for in- versus out-of-network care.
  3. Determine if supplemental benefits are offered by the plan.

People may report complaints against Humana to the Minnesota Attorney General’s Office by calling (651) 296 3353 or (800) 657 3787. Individuals may also download a Complaint Form from the Attorney General’s website by clicking here and mail the completed form to the Attorney General’s Office at: 1400 Bremer Tower, 445 Minnesota Street, St. Paul, MN 55101 2131. People should also contact CMS directly about this problem by calling CMS at 1-800-633-4227 or by writing to its Administrator, Marilyn Tavenner, at Centers for Medicare & Medicaid Services, U.S. Department of Health & Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201.

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ATTORNEY GENERAL SWANSON ASKS FEDERAL AGENCY TO INVESTIGATE COMPLAINTS AGAINST HUMANA BY MEDICARE PATIENTS

Judge blocks UnitedHealthcare Medicare Advantage doctor cuts

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A federal judge has temporarily blocked UnitedHealthcare’s move to terminate Connecticut physicians from its Medicare Advantage network.

U.S. District Judge Stefan R. Underhill granted a preliminary injunction requested by the Fairfield County Medical Association and the Hartford County Medical Association. The two medical groups took legal action after UnitedHealthcare notified about 2,200 doctors that they would be dropped from its Medicare Advantage network as of Feb. 1.

UnitedHealthcare said in a statement Friday that it intends to appeal the ruling. The company has about 58,000 Medicare Advantage members in Connecticut and is the largest private Medicare insurer in the state.

The open enrollment period for Medicare beneficiaries to select a Medicare Advantage plan ends Saturday.

UnitedHealthcare’s move to reduce its physician network drew intense criticism from medical groups and from state officials. They argued that the network changes would disrupt longstanding doctor-patient relationships and could make it harder for seniors, particularly those with limited mobility, to get care.

The company said it was focused on offering access to doctors that provide quality, affordable care, and cited “severe government funding cuts” to the Medicare Advantage program.

Underhill’s order prohibits UnitedHealthcare from terminating doctors in the two county medical associations from its Medicare Advantage networks. The company is also barred from notifying Medicare Advantage customers that the providers will be dropped from the network as of Feb. 1, and cannot omit the affected doctors from its 2014 Medicare Advantage directories.

In its statement, UnitedHealthcare said the ruling would “create unnecessary and harmful confusion and disruption to Medicare beneficiaries in Connecticut.”

“We continue to have a broad network of doctors that is designed to encourage higher quality, affordable health care coverage,” the statement said. “We know that these changes can be concerning for some doctors and customers, and supporting our customers is our highest priority.”

Critics of the company’s move praised Underhill’s ruling.

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Judge blocks UnitedHealthcare Medicare Advantage doctor cuts

Medicare Advantage? or DISAdvantage?

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signing 2The following article appeared originally on the healthinsurance.org Blog.

If you’re being courted by a private insurance company to enroll in one of its Medicare Advantage plans, don’t sign on the bottom line until you’ve read a recent report by a researcher at the Center for Medicare and Medicaid Services (CMS). The real bottom line you need to understand is that the insurer might want to keep you enrolled only as long as you’re relatively healthy. When that changes, you just might find that you’re no longer considered a valued member and that the traditional Medicare program is a much better deal for you.

The study, published recently in the Medicare and Medicaid Research Review, confirmed what some who are familiar with the Medicare Advantage program, including me, have suspected: when people enrolled in MA plans become critically ill, many realize that the only way they will get coverage for the care they need – and at a facility of their choice – is to return to the traditional Medicare program.

It may come as a surprise, but one of the reasons the Medicare program costs taxpayers more than it should is that the federal government has for years been overpaying insurance companies to participate in the Medicare Advantage program. (Medicare Advantage plans – typically HMOs and PPOs – are private alternatives to traditional Medicare.) Congress created the program after private insurers insisted that not only could they meet the medical needs of senior citizens and the disabled more cost effectively than the government, they could do so and still make a profit.

Many of the first insurance companies to participate in the program (previously known as Medicare+Choice) found out they couldn’t deliver on that promise. According to Health Affairs, 44 percent of the insurers that tried it between 1987 and 1990 threw in the towel and dropped out of the program. To entice them back, the federal government began paying insurers a bonus every year in the form of overpayments. Those overpayments have been sizable enough to keep most of them in the game and to keep investors of for-profit insurers happy.

You’re helping to keep those investors happy In 2009, the Medicare Payment Advisory Commission (MedPAC), which advises Congress, reported that those bonuses were costing Medicare (read: taxpayers) billions of dollars every year. It estimated that in 2009 alone, Medicare paid private insurers 14 percent more per beneficiary than it would cost the government to cover those beneficiaries in traditional Medicare. Between 2004 and 2008, according to MedPAC, the overpayments totaled nearly $33 billion.

During the debate on health care reform, the Congressional Budget Office estimated those overpayments would cost the government $157 billion over the coming decade. As a consequence of these overpayments, according to CMS, premiums for all Medicare beneficiaries, including those enrolled in traditional Medicare, are higher than they otherwise would be. That’s more than just an annoyance: the Medicare Hospital Insurance Trust Fund will become insolvent 18 months earlier than it would otherwise because of those overpayments, according to Congressional testimony by CMS’ chief actuary. That’s why, despite intense lobbying by the insurance industry, Congress inserted a provision in the Affordable Care Act to eventually phase out those overpayments.

It turns out, though, that those overpayments are not the only reason for MA insurers’ healthy profits. Many MA enrollees are finding that their plans – which offered discounts on gym memberships and hearing aids as an enticement to enroll – are not so willing to cover things like skilled nursing care when they get critically ill.

To see if that might be happening on a large scale, CMS researcher Gerald Riley looked at 240,000 people who dropped out of their MA plans in 2007 and compared them to Medicare beneficiaries who had always been enrolled in traditional Medicare. He found that those who had left their MA plans had used an average of $1,021 a month in medical services during the first six months after returning to traditional Medicare, compared to $710 a month for those who had never been in an MA plan.

Sicker MA enrollees may be less satisfied with program Citing his own findings and previous research that found more problems getting needed care among MA enrollees than beneficiaries in traditional Medicare, Riley wrote that, “Disenrollment of high-cost individuals may be related to persistent lower levels of satisfaction among sicker MA enrollees.”

My own mother will attest to that.

Back when my mother was much younger and healthier – and when I still worked in the insurance industry – I encouraged her to enroll in an MA plan. At the time it was especially appealing because it covered prescriptions medicines. The traditional Medicare program didn’t provide drug coverage until 2006.

Although Mom saw her MA premiums increase significantly over the years, she didn’t have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer “medically necessary.”

Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it “custodial.”

After doing considerable research, I learned that another highly regarded nursing facility nearby would take Mom and provide her with the skilled care she needed, but not if she stayed in the MA plan. That facility had years ago decided not to participate in MA plans like the one my mother was in because what happened to Mom was happening to other patients. Utilization review nurses at MA plans – not the patients’ treating physicians – where making the ultimate decisions as to whether nursing care was medically necessary. They still do.

I’m confident that Mom is alive today – and not completely broke – because she disenrolled from her MA plan and returned to traditional Medicare with a Medicare supplement plan to cover out-of-pocket expenses. And I’m confident after reading Riley’s study that there are hundreds of thousands of other people just like Mom who had similar experiences. And that the traditional Medicare program is paying more than it should because of the practices of many MA plans.

Your chance to leave MA is limited

At the beginning of the MA program, people could disenroll at any time. That’s no longer possible. If you’re in an MA plan and don’t like it, you have a relatively brief window of opportunity each year to go back to traditional Medicare. Keep that in mind as you’re trying to decide whether an MA plan is right for you, either now or later. It very well could be right for you. Some studies have indicated that people in MA plans are less likely to end up in the hospital or emergency room. But you might not know that enrolling in a private plan was not a great idea until you’re critically ill.

Following a 20-year career as a corporate insurance executive, Wendell Potter left his position as head of communications for Cigna in 2008 to advocate for comprehensive health care reform. He is now an analyst at the The Center for Public Integrity and president of Wendell Potter Consulting. He has also served as a consumer representative to the National Association of Insurance Commissioners. His book, Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans, was awarded the Ridenhour Book Prize for “outstanding work of social significance” in 2011. In March, he testified before Congress about the affordability of Obamacare. Potter also provided his perspective on the nation’s broken health care system when he was interviewed for a documentary that aired nationally.

 

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Medicare Advantage? or DISAdvantage?