In this recent Forbes article:
the Centers for Medicare & Medicaid Services (CMS) is finally acknowledging the crucial role that family members play in caring for frail older adults and younger people with disabilities. The agency is taking important steps to help them by paying doctors and other providers to deliver critical support to the families of people with certain medical conditions.
The agency plans to pay Medicare providers, including physicians, some nurses, and therapists, to train family caregivers. They will also pay for a social needs assessment and care navigation for people with certain conditions and create an integrated care model for people with dementia and their families.
The new payment model should allow doctors to outsource caregiver training to community-based organizations, such as adult day and senior centers. However, these organizations are generally not Medicare providers. Hopefully, CMS will find a way to make this work.
The second initiative would allow Medicare to pay for a health-related social needs assessment and assistance with care navigation. This new payment rule would allow physicians to partner with non-medical providers, including community-based social service organizations and community health workers.
Comprehensive Dementia Care The third proposed reform focuses on providing dedicated support to families caring for individuals with dementia. Named the "Guiding an Enhanced Dementia Experience" (GUIDE) initiative, this eight-year program is designed to offer a comprehensive range of services. It includes care coordination and management, caregiver education and assistance, as well as respite services.
Scheduled to commence in a year's time, this program represents an ideal model of fully coordinated care for individuals dealing with chronic conditions. As I previously mentioned, innovative integrated care programs for individuals with dementia have faced challenges due to Medicare (and Medicaid) not covering them. However, this initiative has the potential to change that situation.
While the dementia care model appears promising, it raises the question: why is CMS restricting its scope to individuals with dementia alone? Medicare should contemplate implementing a similar model for all individuals dealing with severe chronic conditions.
Overall, these proposals represent a significant step forward in recognizing the vital role that family caregivers play in our healthcare system. While some proposals will provide valuable support, others may be less effective. However, the key takeaway is that traditional Medicare will finally pay to support family caregivers.
The Significant Role of Family Caregivers
There are still many unanswered questions, such as how much Medicare will pay for these services, how often they can be provided, who qualifies as a family caregiver, and whether medical practices will be willing to participate. Despite these uncertainties, the Biden administration’s initiatives represent a significant step forward. They aim to remove some of the biggest obstacles to effective family caregiving and may help individuals with chronic conditions to age at home for longer. Most importantly, they demonstrate that family caregivers are valued and essential members of our healthcare system.
The Medicare Extra Help Program is set to expand in 2024. Seniors and disabled citizens will receive more access to the Medicare Extra Help Program as of the beginning of 2024. This expansion of benefits could enable up to 3 million people to reduce their prescription drug costs. The program was expanded through the Inflation Reduction Act, which President Biden signed in August 2022, by increasing the income limit to 150 percent of the poverty level ($21,870 for an individual and $45,000 for a family of four). When the program expands at the beginning of 2024, 300,000 participants will go from partial to full benefits. That means they will not have to pay a premium or deductible, and they will have lower, fixed co-payments on certain medications. Those who participate in the Medicare Extra Help Program could save nearly $300 per year.
Source - Elder Law Answers:
Extra Help Program Summary
“Extra Help” is a Medicare program that helps people with limited income and resources pay Medicare drug coverage (Part D) premiums, deductibles, coinsurance, and other costs1. A premium is the amount you pay for your health insurance every month. A deductible is the amount you pay for health care services before your health insurance begins to pay2. Coinsurance is the percentage of the cost of a covered health care service you pay (20%, for example) after you’ve paid your deductible2. A copayment is a fixed amount you pay for a covered health care service2.
If you qualify for Extra Help, you won’t have to pay a Part D late enrollment penalty while you get Extra Help. The Part D penalty is an amount added to your Medicare Part D premium if you don’t join when you’re first eligible.
You’ll get Extra Help automatically if you get full Medicaid coverage, help from your state paying your Part B premiums (from a Medicare Savings Program), or Supplemental Security Income (SSI) benefits from Social Security. You’ll get a letter about your Extra Help. It tells you things like how much you’ll pay and your new Medicare drug plan if you don’t have one already.
If you need help navigating your way through the ins and outs of Medicare or Medicaid coverage selection, connect with Ted Czabanowski for assistance now.
A recent article published on 2/16/2023 at www.medicareresources.org addresses whether individuals who have retiree coverage through the Federal Employees Health Benefits (FEHB) program need to enroll in Medicare. Per the article which was titled: If I have retiree coverage through the FEHB, do I need to enroll in Medicare?, the short answer is no, they are not required to enroll in Medicare, but they may choose to do so.
FEHB coverage provides comprehensive health insurance for federal retirees and their eligible family members, but it does not cover all medical expenses. Medicare can help cover some of the gaps in FEHB coverage, such as deductibles, coinsurance, and some prescription drug costs. However, individuals who choose to enroll in Medicare may need to pay monthly premiums for Medicare Part B, and they may also face higher deductibles and coinsurance amounts for their FEHB coverage.
The article recommends that individuals review their current health care needs and compare the costs and benefits of Medicare and FEHB coverage before making a decision about enrollment. It is also important to note that individuals who delay enrolling in Medicare may face penalties and restrictions on when they can enroll in the future.
What is the FHEB Program?
The Federal Employee Health Benefits Program (FEHB) is a health insurance program offered to federal employees, retirees, and their dependents. It provides comprehensive health insurance coverage, including medical, dental, and vision benefits, and offers a wide range of plan options from various private insurance carriers. The program is administered by the Office of Personnel Management (OPM) and is the largest employer-sponsored health insurance program in the United States, covering over 8 million people.?
Insurance Agent in RI offering assistance with Medicare plans
If you are a Rhode Island resident and are enrolled in FEHB, connect with Ted Czabanowski for a complimentary consultation if you have questions about your health care coverage options.
According to this article:
www.kiplinger.com/retirement/medicare/602937/you-can-appeal-a-medicare-premium-surcharge, there is a good chance that you can get your Medicare premium surcharge reduced or eliminated if your income has fallen in the last two years.
Here is the body of the Kiplinger article which contains all important details as follows:
Your modified adjusted gross income for the past two years is what determines your Medicare surcharge. The surcharge for 2022 is calculated based on your MAGI from 2020. MAGI is your adjusted gross income minus interest on tax-exempt municipal bonds. This can add up to a significant amount for many retirees. The less common items that are added back include income earned overseas that is not included in AGI or nontaxable income from the U.S. territories.)
However, a lot can happen within two years. If you can show Social Security that your income has changed, your premiums will be reduced or waived. Retirement is the most common life event that can lead to a reconsideration or reduction in the surcharge, according to Jim Blankenship, founder and author of A Medicare Operator's Manual: Your Guide To Medicare Benefits. If you were employed full-time in 2020, and had not yet retired, you may be eligible based on your income decline since you retired. If you work fewer hours than in 2020, or your spouse has retired, you may be eligible for a reduction in your premiums. You may also be eligible for a reduction of your premiums if you die or divorce your spouse.
However, if your surcharge was triggered due to a one-time income spike, you are probably out of luck. Blankenship states that one of the most common reasons that retirees are hit with a Medicare high income surcharge is a conversion to a Roth IRA. This will increase your MAGI. A large withdrawal from your traditional IRA can also lead to a surcharge.
You may also be subject to a surcharge if you have large capital gains or home sales that exceed the exclusion for capital gains. If a couple files jointly, they can exempt up to $500,000 from their taxes for the sale of their primary residence. For a single homeowner, it is $250,000. However, homeowners are seeing huge increases in their housing values and are now able to rake in more than the exclusion . (See How To Cut Your 2021 Tax Bill ). A business sale could also result in the surcharge.
It is good to know that Social Security recalculates income each year. However, this has a two-year delay. This means that a sudden increase in income won't be a problem forever. A large Roth conversion can lead to an increase of premiums in the future, but future withdrawals from Roth IRA will not affect the formula used for calculating the surcharges.
How to appeal
You should have received an initial notice from Social Security if you are subject to the surcharge. Complete Form SSA-4 and attach supporting documents to request a review. If you have lost income as a result of retirement, please include a copy the tax return from the year that your income decreased, and a letter from your former employer. Include a copy the death certificate if your income has declined due to your spouse's death. The form can be mailed to your local Social Security office, or you can bring it in person (though many offices are closed due to the pandemic).
If you are denied a redetermination, you have three options: the Office of Medicare Hearings and Appeals (or the Medicare Appeals Council), or the federal district court in your home. These appeals are mainly used by beneficiaries to appeal coverage decisions. If your claim is not based on one of these life-changing events, you can lose an IRMAA appeal. It's much harder to get approved if it's not on the list," Danielle Roberts, cofounder and CEO of Boomer Benefits insurance agency, which assists baby boomers with Medicare. Then, it's a difficult battle.
Barbara Hughes, a retired lawyer, successfully appealed two Medicare IRMAAs after she cut her hours in 2015, and again after she retired in June 2020. Hughes was required to submit a letter from her employer, a completed form SSA-44, and income tax information for both occasions.
If you need help with a Medicare issue, connect with Ted of Elder Care Insurance Solutions Inc. for assistance now.
On Friday August 5 2022, The U.S. House of Representatives passed a comprehensive climate, tax, and healthcare bill. It includes significant measures to lower prescription drug prices within Medicare. This allows the government to negotiate drug prices and caps seniors' out-of pocket drug costs at up to $2,000 per year. President Biden will sign the Inflation Reduction Act of 20,22 which was passed by party lines in a 220-207 vote.
The Senate passed the package which also extends premium subsidies under the enhanced Affordable Care Act and expands and adds clean energy tax credits.
The bill will allow for the government to negotiate prices on certain medications, limit seniors' out of pocket spending on drugs at $2,000 per year, penalize drug manufacturers that raise their prices more than the Medicare inflation rate, and cap the Medicare beneficiary's out-of–pocket insulin cost at $35 per month.
The 2003 Part D drug program was established by legislation that was heavily influenced from the pharmaceutical industry. It prohibits the government from directly negotiating with pharmaceutical companies. Part D insurance companies can negotiate with each other, but not with the same bargaining power as the federal government. According to estimates by the Congressional Budget Office, allowing the government to negotiate directly will save approximately $100 billion over 2031.
Juliette Cubanski (deputy director, Program on Medicare Policy, Kaiser Family Foundation) stated that "the pharmaceutical industry has largely avoided this level of legislation"
Although the bill is a major policy change, its negotiating clauses will be gradually implemented over several years and will only affect a few medications. Experts say that the bill's greatest impact will be felt immediately by seniors with high prescription drug prices.
According to the Senior Citizens League, about one quarter of current Part D beneficiaries (or more than 16,000,000 people in 2022) are at risk of spending $2,000 per year on prescription drugs. Mary Johnson, the Senior Citizens League's Medicare and Social Security policy analyst, said that there are "some really expensive drugs." She helped a neighbor to research Part D plans several years ago before she became eligible for Medicare. The neighbor found that her co-pay for Humira (a drug used in rheumatoid joint pain) was about $1,000 per month. To afford treatment, the neighbor researched alternative therapies and pharmacy assistance programs.
Part D currently does not cap out-of-pocket drug costs. In 2022 beneficiaries will have to spend $7,050 on medications. Once they reach this point, they will be responsible for 5%.
Even these small payments can add up for patients who need expensive prescriptions such as those that treat multiple sclerosis, rheumatoid and cancer. A beneficiary might reach catastrophic coverage in August if they have a $1,000 monthly co-pay. The remaining five months of the year will be covered by $50, which is a total of $250. It's only a rough example, because Part D rules are more complex and older adults often take multiple medications.
In 2025, the $2,000 annual cap will take effect. It will be indexed to inflation. Anyone enrolled in Part D drug plans, including stand-alone or Medicare Advantage plans that cover drugs, is subject to the cap. This includes co-pays as well as deductibles and coinsurance, but does not include the monthly premium cost. In 2024, the beneficiary responsibility for catastrophic coverage will be reduced to zero.
Negotiations will begin in 2026 with a maximum of 10 drugs, rising to 15 drugs in 2027, 2028 and 2029, and then to 20 drugs in 2029. Negotiated drugs include Part D and Part A medications. This includes drugs that are administered in the doctor's office (e.g., infusions) and not taken at home.
The drugs subject to negotiation are still unknown. Drugs with generic equivalents would also be exempted from consideration. Eylea, which is a drug for macular damage from Regeneron Pharmas is one possible candidate, as well as Keytruda from Merck. According to Karen Andersen (Healthcare strategist at Morningstar), there are many other candidates.
Beginning in 2023, any drug maker who raises their prices at a higher rate than inflation will be subject to a Medicare program fine. In addition, Medicare beneficiaries will have a $35 per month limit on insulin, and will receive free vaccines under Part D.
The Inflation Reduction Act also lowers the premiums on health insurance for millions of Affordable Care Act participants through 2025. The Affordable Care Act's income caps were temporarily lifted by the American Rescue Plan of 2021, which capped silver-tier insurance's cost at 8.5% of the enrollees' annual income. Consumers who earned more than 400% of federal poverty, or $54,360 per person in 2022, were not eligible for government assistance to pay their premiums. The bill extends the premium subsidies to 2025.
View the original version of this article by Elizabeth O'Brien of Barron's here:
For assistance with any questions related to how these Medicare changes will affect your coverage, contact Ted Czabanowski now at: 401-885-7467.
Medicare beneficiaries will see a reduction in their premiums, but not until next year
This recent article at abcnews.go.com explains how Medicare beneficiaries will receive a reduction in their premiums, but not before next year. This is due to what Health and Human Services Secretary Xavier Becerra recently stated as an overestimate of the cost of coverage for an expensive and controversial new Alzheimer's medication.
Becerra explained that the premium for 2022 should be reduced, but officials were prevented by legal and operational obstacles from making this happen in the middle of the calendar year. The amount of the reduction is unclear at this point. Medicare Part B premiums rose by $22 per month to $170.10 for 2022. This was partly due to the high cost of the controversial prescription drug Aduhelm, which showed only limited evidence that it can slow the progression of Alzheimer’s. Aduhelm is only covered by the Centers for Medicare (CMS) and Medicaid Services for use in approved clinical trials. Under pressure from Congress and consumers, CMS began to reevaluate the premium rise. Biogen, a Cambridge, Massachusetts-based drug manufacturer, has reduced the price of the drug by half to $28,000 per year.
CMS pointed out the dramatic reduction in drug prices and limitations on coverage to conclude that Medicare beneficiaries could result in cost savings to the program. According to a report by Becerra, CMS stated that the premium recommendation for 2022 would be $160.40 per month if the coverage determination and price reduction had been in place at the time officials calculated the figure. In the fall, the agency will announce the premium for 2023 Medicare's 56 million beneficiaries.
Becerra also stated that while they had hoped to get there sooner, CMS was not able to deliver the premium reduction in 2022. "CMS, HHS are committed lowering health care cost -- so we look forward seeing this Medicare premium adjustment through the finish line to ensure seniors receive their cost-savings by 2023."
The following Q & A was written by:
Karin Price Mueller | NJMoneyHelp.com for NJ.com
It's an excellent synopsis of what you need to know about what happens to your SSDI benefits when you reach full retirement age.
Q. I was placed on permanent SSDI due to medical concerns. I was paid retroactively to the date of my medical disability and have been collecting monthly SSDI for years. I am now 65. Do I have to sign up for Medicare or will it be adjusted to SSI at 66 years and seven months of age?
— Almost there
A. There’s plenty to know about how your benefits will change over time.
Before we start, remember that it’s always a smart choice to contact Social Security so it can advise based on your specific situation. Its number is (800) 772-1213.
Because you’re currently receiving Social Security disability benefits (SSDI), your disability benefits automatically convert to Social Security retirement benefits at your full retirement age, said Jeanne Kane, a certified financial planner with JFL Total Wealth Management in Boonton.
She said full retirement age (FRA) ranges between age 66 and 67, depending on your age. As you noted, yours is 66 years and seven months.
“In most cases, the benefit amount will remain the same,” she said. “You don’t need to do anything.”
You only get one benefit — Social Security retirement benefits — when you reach full retirement age, she said.
“Everyone eligible for Social Security disability insurance benefits is also eligible for Medicare after a 24-month qualifying period,” she said. “At that time, you would have been automatically enrolled in both Medicare Parts A & B at the start of your twenty-fifth month.”
At that time, you would have had the option to decline or delay Medicare Part
B, she said. Some people choose to do that if they want to remain on a spouse’s employer-based plan, she said.
“If you currently have Medicare parts A and B, you don’t need to do anything because you are already participating in Medicare,” she said. “The Medicare Part B premium is paid from your SSDI today and will be paid from your SSI when you reach full retirement age.”
If you declined Medicare Part B at the time you became Medicare-eligible through SSDI, you can continue using the company-based plan until there is a change of circumstances, such as your spouse retiring, she said.
“At change in circumstance, you have an eight-month special enrollment period to sign up for Medicare Part B,” she said. “You’ll need to call the Social Security Administration to obtain the specific forms to complete with your Part B application.”
“If you don’t, you may pay a penalty of up to 10% for each 12-month period you could have had Medicare part B but didn’t sign up,” she said.
For any specific questions, contact Ted Czabanowski for a complimentary review of your current health and long term care insurance plan(s).
Some Medicare beneficiaries will be hit with late-enrollment fees in 2022. These charges would be warned of by Congress before they occur, per this recent CNBC article. Here is a summary of the article:
The latest feedback on how to best navigate the Medicare system if you return to the work force can be found in a recent article from CNBC.
The CNBC article explains that if the company you work for employs fewer than 20 people, and you wish to enroll in the Medicare health plan, you will need to stay on Parts A or B. If you go to work for a larger company, different rules apply, but there are some things to consider before you sign up for an employer health plan.
There will be new rules and deadlines for you to re-enroll in Medicare.
Read the full article here:
When is open enrollment for Medicare Advantage? How does it work?
How long is open enrollment for Medicare?
Every year from January 1 through March 31 current policyholders of Medicare Advantage (MA) plans are eligible to enroll in a different MA plan.
How does open enrollment work?
MA, or Medicare C, plans can be changed once a year. Those who currently have this type of managed-care alternative to Original Medicare can choose to keep the same plan, to opt into a different Advantage plan, or to enroll in Medicare A, or Original Medicare.
If you decide to drop your MA plan in favor of Medicare A you may not be able to buy a supplemental Medigap plan.
Who is eligible for open enrollment?
This open enrollment period is only for people who already have an Advantage plan.
What are Medicare parts A, B, C, and D?
Medicare A is hospital insurance. Premium-free Part A is available to people who meet the criteria.
To qualify for premium-free Part A:
Whether or not you have a monthly premium, the benefits are the same, including deductibles and coinsurance. If you choose Part A, you must also:
Medicare Part B
Part B is optional medical insurance with a monthly premium. After the deductible is met, you’ll typically pay 20% for most doctor services. Included are inpatient hospital stays, outpatient therapies, and durable medical equipment (DME). Enrolling in Part B when you’re eligible for Medicare will save you a late enrollment penalty.
Medicare Part C
Medicare Advantage plans, (MA or Medicare Part C), is Managed Care, very much like most employer-offered insurance. MA plans combine parts A and B, and 90% of MA plans include drug coverage (Part D). Medigap plans insurance can’t be used for MA plans, as they’re unnecessary. Talk about one-stop shopping!
Medicare Part D
Medicare Part D is available as a separate policy for prescriptions only. Choosing a drug plan at the time you enroll in Medicare, even if you don't currently take medications, will avoid a possible late enrollment penalty if you do eventually need drug coverage; late enrollment penalties will increase your monthly premium.
The pros and cons
Medicare Advantage Plans may have rules that are different from Original Medicare. However, in keeping with CMS rules, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in a particular facility or for patients with certain conditions. Some MAs offer more comprehensive plans to fit your needs: many cover over-the-counter medications or gym memberships.
Carefully research your options; compare your needs to each plan’s offerings before enrolling. Very rare circumstances will permit a change before the open enrollment period begin.