Medicare Watch

CMS Releases Draft Guidance for Medicare Private Health and Prescription Drug Plans

Last Friday, the Centers for Medicare & Medicaid Services (CMS) released the 2013 Advanced Notice and draft Call Letter. The draft Call Letter provides payment, coverage and other policy guidance for Medicare private health plans, also known as Medicare Advantage (MA) plans, and prescription drug plans (PDPs) for the plan year beginning January 1, 2013. The draft guidance further implements the changes to the Medicare Advantage (MA) and prescription drug coverage programs that were included in the Affordable Care Act (ACA). In 2013, beneficiaries who reach the prescription drug coverage gap will pay 47.5 percent of the cost of brand name medications and 79 percent of the cost of generic medications, an increased discount from this year’s rates. The draft guidance also further establishes a rebalancing of payments to MA plans so they are more comparable with costs under Original Medicare. As part of this rebalancing, CMS will continue to implement the bonus payment demonstration that allows plans with quality ratings of three stars or more to receive additional reimbursements.

The draft Call Letter also clarifies several Medicare policies, including what constitutes supplemental benefits provided by plans, and how new and existing policies that affect Special Needs Plans (SNPs) will be implemented. For example, the proposed guidance includes a definition of “Enhanced Disease Management” that requires such benefits to be more comprehensive than care coordination services that all MA plans are required to provide. In addition, the guidance provides additional details on a SNP initiative included in a proposed rule released in October 2011, which allows for greater flexibility in benefit design for those SNPs that meet specified qualifying criteria.

As is the case every year, the draft Call Letter contains updates to annual benefit parameters, such as the 2013 voluntary and mandatory out-of-pocket limits and related cost-sharing requirements for MA plans, as well as the deductibles, initial coverage limits, out-of-pocket limits and cost-sharing requirements for Medicare prescription drug plans. CMS will accept comments on the draft guidance through March 2.

Read the 2013 Advance Notice and draft Call Letter.

Read CMS’ press release on the 2013 Advance Notice and draft Call Letter.

Explaining the Medicare Doctor Payment Debate

Do you have questions about the debate over Medicare payments to doctors? The Medicare Rights Center has released a new video featuring Joe Baker, the organization’s president, which explains the action taken by Congress last week to prevent a 27.4 percent cut to Medicare doctor reimbursement rates as a result of the Sustainable Growth Rate (SGR) formula. Under the agreement, current Medicare reimbursement rates will remain the same through the end of 2012. At that time, Congress will need to take further action to prevent a reduction in Medicare doctor payments from taking place at the beginning of 2013.

The video also explains the history of the issue, the meaning of the SGR formula, which was passed by Congress in 1997, and the actual effect of the SGR on the number of physicians who accept patients with Medicare. At present, doctor participation rates in Medicare are generally high, and in most cases, the program does not suffer from a shortage of physicians. However, some people worry that doctors would no longer see patients with Medicare if the cuts required by the SGR formula were enacted. To preserve access to physicians for Medicare beneficiaries, Congress—as they did this month—usually temporarily prevents cuts as a result of the SGR from taking place. However, each time Congress passes a temporary fix, the size of the cut grows when the fix expires. So too does the cost of paying for both subsequent temporary fixes and a permanent repeal of the formula.

Watch the new video on Medicare and physician reimbursements, featuring Medicare Rights Center President Joe Baker. To stay up-to-date on Medicare and learn more about Medicare benefits and options, press “Like” at the top of our page.

Medicare Reminder

If you are enrolled in Original Medicare, Medicare will pay for you to see a doctor to get a second opinion if a doctor has recommended that you have surgery or a “major diagnostic or therapeutic procedure.”

Medicare will pay for a third opinion if the first and second opinions you received were different. Even if the surgery or other procedure is determined not to be covered, Medicare will cover the second and third opinions. If you want a third opinion but the first and second opinions were the same, Medicare may cover a “confirmatory consultation” with a third doctor, as long as that doctor submits a claim using the right code and writes in your medical record that the services provided were reasonable and medically necessary.

If you are enrolled in a Medicare private health plan, otherwise known as a Medicare Advantage plan, different rules about second and third opinions may apply. Your private plan may only cover second and third opinions if you see in-network doctors and have a referral from your primary care physician. Call your plan to find out the exact rules for getting second and third opinions.

Learn more about Medicare coverage of second and third opinions at www.medicareinteractive.org.

Spotlight

As part of its coverage of the Supreme Court’s review of the Affordable Care Act (ACA), HealthReformGPS is posting highlights of the briefs filed in relation to the case. Included is the friend of the court brief that Medicare Rights and five other aging advocacy groups filed. The brief argues that the numerous provisions in the ACA that greatly benefit people over the age of 65 should be implemented regardless of the Supreme Court’s decision on other parts of the law.

Read HealthReformGPS’ “Challenges to the Affordable Care Act: Highlights from the Supreme Court Briefs.”