The Centers for Medicare & Medicaid Services (CMS) announced this week that it will cover seat elevation technology in Medicare-covered power wheelchairs as durable medical equipment (DME). Effective immediately, both Original Medicare and Medicare Advantage will cover seat elevation for those who need it to perform activities of daily living in the home. This landmark decision meaningfully expands Medicare coverage and appropriately prioritizes enrollee independence and quality of life.

Despite the clear need many power wheelchair users have for technology that helps them safely transfer to and from the wheelchair and to better reach items and surfaces without joint or muscle strain, Medicare generally considered seat elevation in power wheelchairs to be a “mere accessory.” This categorization prevented coverage and downplayed the importance of features that help people maintain well-being, physical health, and community living.

Last year, CMS announced that it was considering updating this policy. The agency proposed allowing Medicare to cover seat elevation for some power wheelchair users as DME. This began a series of comment opportunities where beneficiaries and advocates, including Medicare Rights, applauded this proposal, explained the need for seat elevation, and urged CMS to cover seat elevation for all power wheelchair users, not just the proposed subset.

In the final policy, CMS agreed to expand coverage to additional groups, citing the thousands of public comments from wheelchair users, advocates, and other stakeholders. The new coverage will apply when the individual has a specialty evaluation confirming they can use the equipment safely and when they need it for one of three conditions: (1) to perform weight-bearing transfers with or without caregiver assistance and/or the use of assistive equipment; (2) to perform the non-weight bearing transfer to or from the power wheelchair in the home; or (3) to complete one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home.

Other individuals, including those who do not use complex rehabilitative power-driven wheelchairs, may be able to gain coverage on a case-by-case basis. Future reforms could further improve access—CMS has indicated that it is also considering covering power wheelchair standing systems as DME.

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After getting a kidney transplant, a kidney recipient will need to take immunosuppressant drugs for the rest of their life to prevent their body from rejecting the donor organ. Medicare covers these drugs differently depending on the circumstances:

 Time-limited Part B coverage

If someone receives a kidney transplant in a Medicare-approved facility, Medicare Part B will cover their immunosuppressant drugs for 36 months after their hospital departure if:

• They had Part A at the time of the transplant
• They have Part B when getting their prescription filled
• And, they are only eligible for ESRD Medicare
• If the kidney transplant was successful, Medicare coverage will end 36 months after the month of the transplant

Note: If someone did not have Medicare at the time of their transplant, they can enroll retroactively in Part A within a year of their transplant.

Part B coverage for the rest of one’s life

If someone receives a kidney transplant in a Medicare-approved facility, Part B will cover their immunosuppressants for the rest of their life if:

• They had Part A at the time of the transplant
• They had Part B when getting their prescription filled
• And, they qualify for Medicare based on age or disability

 Part B-ID coverage

If someone’s ESRD Medicare benefits end 36 months after their transplant, they may qualify for Medicare’s new Part B-ID coverage of immunosuppressants if they:

• Qualify for Part B coverage of immunosuppressants prior to losing ESRD Medicare
• Do not have Medicaid or other public or private health insurance that covers immunosuppressants

 Part B-ID coverage may not be the best choice if any other insurance is available. Part B-ID only covers immunosuppressant drugs and does not include coverage for any other Part B benefits or services. It also does not allow someone access to Part A.

Part D coverage

If someone does not have Part A when they receive a transplant, their immunosuppressants will be covered by Part D when they are enrolled in Medicare. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to specific in-network pharmacies for drugs, as compared to coverage under Part B.

All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once someone is stabilized on their immunosuppressant drug. However, prior authorization can apply. This might mean a Part D plan will verify that, for example, Part B will not cover the drugs before providing coverage. It’s good to look for plans that have the fewest coverage restrictions and where one’s pharmacy is in-network and has preferred cost-sharing available to minimize costs and disruptions.

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Published by: medicareresources.org

What is Medicare Part B?

Medicare Part B picks up – to a large extent – where Medicare Part A leaves off.  Part B coverage pays for a broad range of medically necessary services that aren’t picked up by inpatient coverage – even though they might be received while a person is hospitalized – including ambulance services, certain surgical procedures, dialysis, mental health care, physical therapy, transplants, chemotherapy and radiation, urgently needed care and more.

In addition, Part B covers diagnostic tests (such as MRIs, CT scans, EKGs, and x-rays) and a host of preventive medical services, such as pap tests, HIV screening, glaucoma tests, hearing tests, diabetes screening, and colorectal cancer screenings. Part B also pays the costs of durable medical equipment such as wheelchairs, hospital beds, and oxygen equipment, and for drugs that are taken by infusion (most drugs are covered under Medicare Part D, but drugs administered via infusion are covered under Part B instead).

Is there a premium for Part B?

Yes. The premium tends to increase from year to year, but for 2023, it’s declining for the first time in more than a decade. For most enrollees, the 2023 Part B premium will be $164.90/month.

The reduction in Part B premiums for 2023 stems from lower-than-anticipated Part B spending in 2022, leaving the government with a surplus that could be used to reduce Part B premiums for 2023. This was partly due to lower-than-expected spending on Aduhelm, the new Alzheimer’s drug that’s given by infusion in a doctor’s office.

Medicare Part B premiums can be covered by Medicaid if the beneficiary is eligible for both programs. And high-income enrollees pay more than the standard premiums for Part B.

How do I enroll in Part B?

If you are already receiving Social Security or Railroad Retirement benefits, you will be notified three months prior to your 65th birthday that you are about to become a Part A Medicare enrollee, and that Part B is an option. You’ll receive the Part B card at the same time as the Part A card.

If you choose not to enroll in Part B, you must return the card (which means you’re rejecting Part B coverage; more on that below) or the premium will automatically start to be deducted from your Social Security checks. If you keep the card, Part B coverage kicks in the month you turn 65.

If you’re not already receiving Social Security or Railroad Retirement benefits, you’ll have an opportunity to enroll in Medicare B (along with Medicare A) during a seven-month window that includes the three months before the month you turn 65, the month you turn 65, and the following three months.  If you enroll in the three months prior to the month you turn 65, your coverage will be effective the month you turn 65.

It’s important to note that if you fail to enroll in Part B during your seven-month enrollment period, the program will offer you another opportunity to enroll each succeeding year (January 1 – March 31), with coverage effective the month after you enroll (note that the effective date used to be July 1, but this changed as of 2023, under the BENES Act). The catch? If and when you do eventually enroll in Medicare B, for each year that you were eligible for Part B but turned it down, your monthly premium will be increased by 10%, and the higher rate will be in place for as long as you have Part B.

So if you wait three full years to enroll after your initial enrollment period, you’ll pay premiums that are 30% higher than the normal price, for as long as you have Part B coverage (generally, for life). The penalty does not apply, however, if you delay your Part B enrollment because you have other coverage in place from a current employer or your spouse’s current employer.

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Fall Open Enrollment begins October 15 and ends December 7 each year. (You also might hear it be called Medicare’s Open Enrollment Period or Annual Election Period.) You can make changes to your health insurance coverage during this time, including adding, dropping, or changing your Medicare Advantage and Part D coverage for next year. Even if you are happy with your current health and drug coverage, Fall Open Enrollment is the time to review what you have, compare it with other options, and ensure that your current coverage meets your needs for the coming year.

You can make as many changes as you need to your Medicare coverage during Fall Open Enrollment. The changes you can make include:

1. Joining a new Medicare Advantage Plan
2. Joining a new Part D prescription drug plan
3. Switching from Original Medicare to a Medicare Advantage Plan
4. Switching from a Medicare Advantage Plan to Original Medicare (with or without a Part D plan)

You should consider:

• Your access to health care providers you want to see
• Your access to preferred pharmacies
• Your access to benefits and services you need
• The total costs for insurance premiums, deductibles, and cost-sharing amounts

If you have Original Medicare, visit www.medicare.gov or read the 2023 Medicare & You handbook to learn about Medicare’s benefits for the upcoming year. You should review any increases to Original Medicare premiums, deductibles, and coinsurance charges.

If you have a Medicare Advantage Plan or a stand-alone Part D plan, read your plan’s Annual Notice of Change (ANOC) and/or Evidence of Coverage (EOC). If you do not receive these notices by the end of September, contact your plan to request them. Review these notices for any changes in:

• The plan’s costs
• The plan’s benefits and coverage rules
• The plan’s formulary (list of drugs your plan covers)

Additionally, make sure that your drugs will still be covered next year and that your providers and pharmacies are still in the plan’s network. If you are unhappy with any of your plan’s changes, you can enroll in a new plan. Contact your State Health Insurance Assistance Program (SHIP) for unbiased counseling if you want assistance reviewing your options.

Even if you are happy with your current Medicare coverage, consider other Medicare health and drug plan options in your area. For example, even if you do not plan to change your Medicare Advantage or Part D plan, you should check to see if there is another plan in your area that will offer you better health and/or drug coverage at a more affordable price. Research shows that people with Medicare prescription drug coverage could lower their costs by shopping among plans each year; there could be another Part D plan in your area that covers the drugs you take with fewer restrictions and/or lower prices. You can use Medicare’s Plan Finder tool to compare your options and call your SHIP for assistance.

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Published by: AARP

The Inflation Reduction Act of 2022 will help millions of Americans better afford their life-sustaining medications and also help them pay for other out-of-pocket health care costs. Here are the answers to some commonly asked questions about the new law. Go to AARP.org/fiercedefender to learn more about the law’s health care provisions and AARP’s role in fighting for these changes.

Lowering Drug Prices 

When will Medicare drug-price negotiations begin?

The U.S. Department of Health and Human Services (HHS) will begin the negotiation process in 2023. By 2024 the agency will identify which 10 prescription drugs will be the first whose prices will be negotiated. By 2029, up to 60 drugs will be subject to price negotiation.

When can we expect to see a difference in drug prices?

The first prices resulting from the negotiations between HHS and drugmakers will take effect in 2026.

Which drugs will be subject to negotiation?

The drugs selected will be among the 100 medications that Medicare spends the most on. The drugs selected for negotiation can’t have any direct competition from generic or biosimilar (a generic form of a biologic drug) alternatives. And they have to have been on the market for a certain number of years.

What will happen to the money Medicare saves from lower prices?

Lower prices mean the Medicare program will save money while providing the same drugs to beneficiaries. And beneficiaries taking drugs with negotiated prices will have lower out-of-pocket costs. The money Medicare doesn’t need to spend on medicines should help bolster the program’s budget, reduce premiums and improve long-term solvency.

Is there anything else in the new law to help rein in soaring drug prices?

Yes. Starting in 2023 drugmakers who raise their prices more than the rate of general inflation will have to pay Medicare a rebate for the amount of their price increases above the rate of inflation.  

Medicare Part D Changes

When will the $2,000 out-of-pocket cap take effect?

Beginning in 2025 Medicare beneficiaries will not have to spend more than $2,000 a year on their medications. Before that, in 2024, Medicare enrollees who reach the catastrophic phase of the Part D prescription drug program will not have to pay any more out-of-pocket for their drugs during that year.  

Which vaccines will be free?

Starting in 2023 Medicare will cover at no cost to beneficiaries vaccines that have been approved for adults by the Centers for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices. Among the shots to be fully covered is the shingles vaccine, which currently requires cost-sharing for those on Part D.

When will my insulin be capped at $35 a month?

Beginning in 2023, copays for a 30-day supply of any insulin that a Medicare drug plan covers will be capped at $35. 

What will happen to my Part D premium?

Beginning in 2024 and continuing through 2029, Part D premiums cannot increase by more than 6 percent a year. Be aware that premiums for these private insurance drug plans vary widely depending on which plan you pick and where you live.

Do these changes apply to Medicare Advantage plans?

Yes. Almost all Medicare Advantage (MA) plans include prescription drug coverage, and those who belong to the few that do not can enroll in a standalone Part D prescription drug plan. All the Part D changes apply to all Medicare beneficiaries with drug coverage — whether they enroll in original Medicare with a standalone drug plan or an MA plan with prescription drug coverage.

Making Health Care More Affordable

How will the new law help Medicare beneficiaries pay Part D premiums and copays?

The new law expands eligibility for Medicare’s Part D Low-Income Subsidy (LIS) benefit, also known as the Part D Extra Help program. Beginning in 2024, Medicare beneficiaries with annual incomes of up to 150 percent of the federal poverty limit ($20,385 for an individual in 2022) who also meet the program’s resources limit can qualify for full benefits under the Extra Help program. The income threshold for full benefits currently is 135 percent of the federal poverty guidelines ($18,347 for an individual in 2022).

I’m not on Medicare yet. Is there anything in the law to help me afford ACA policies?

Yes. The new law extends until the end of 2025 the expanded Affordable Care Act (ACA) premium subsidies that were instituted under the American Rescue Plan Act of 2021. This means that more people will continue to be eligible for the ACA subsidy and no one will have to pay more than 8.5 percent of their annual income for an ACA health insurance plan premium.

The post The Inflation Reduction Act and Your Health appeared first on C-Medisolutions.

It’s not always easy, but it’s certainly possible

If you enrolled in a Medigap policy during your initial six-month window, your plan is guaranteed renewable every year. And since Medigap policies provide standardized coverage regulated by the government, you don’t need to worry about surprise changes to your plan each year. However, if your healthcare needs or income change, you may want to switch plans at some point.

If you’re interested in changing Medigap plans, keep in mind:

• Unlike with Medicare Advantage plans, you aren’t guaranteed the right to enroll in a Medigap policy outside your initial six-month enrollment window. You can still be denied a new policy, even if you’re already enrolled in a Medigap plan.

• When you switch Medigap plans, your new insurer has the right to make you wait up to six months before providing you any benefits that weren’t covered by your old policy.

• Just because the government discontinues your Medigap plan doesn’t mean you need to find a new one. Generally, your plan is still guaranteed renewable without any changes to your coverage, even if it isn’t available to new enrollees.

• You can attempt to switch Medigap plans at any time—you don’t need to wait for open enrollment.

• When you switch Medigap plans, you can take advantage of a 30-day “free look” period. For the first month, you’ll pay premiums for both your old and new Medigap policies. If you find the new plan isn’t for you, you’ll be able to cancel it and go back to your old plan.

For the most part, you’ll have an easier time downgrading Medigap plans—going from a plan with more benefits to one with fewer—than the other way around. It’s also worth checking your local regulations around Medigap. Some states enforce stricter protections for people trying to switch Medigap plans.

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WHAT TO THINK ABOUT at RENEWAL TIME

What to consider when holiday shopping includes searching for new health coverage

Open enrollment happens every year from October 15 to December 7. And while you may be pleased with your Medicare coverage. It’s still important to take time to review your benefits and consider whether you want to change plans for the coming year. While you may not like the idea of having to compare plans annually (shouldn’t once be enough?), doing so could save money–and more than a few headaches.

As renewal time draws near, focus on the three C’s: coverage, costs, and care. That is, make sure your healthcare needs (including drugs) are covered, at a price you can afford, from providers you trust. Simple, right?

What’s Not Changing

The benefits you receive from Original Medicare won’t generally change from year to year because they’re determined by the government.  Likewise, if you have a Medigap policy, your benefits won’t change, either. Medigap plans themselves are also standardized by the government, even though they’re provided by private insurers. Your premiums for Original Medicare and Medigap won’t go up beyond the rate of inflation unless:

• Your income Goes Up

A higher-income could affect whether you pay an income-related monthly adjustment amount for Part B.

• Your Medigap Policy Premium Is Based on Attained-Age

If so, your premium will go up each year on your birthday—but if you did your homework, this increase shouldn’t come as a surprise.

Original Medicare and Medigap policies can be used anywhere in the country. This means that you’ll still be covered if you move or you’re a winter traveler, no matter where you are. There’s no need to renew your Original Medicare and Medigap plan each year. Your coverage will continue unchanged as long as you pay your premiums.

What Can Change

Part D plans and Medicare Advantage plans make changes reasonably frequently. Any changes for the coming year must be detailed in your plan’s Annual Notice of Change (ANOC), which you’ll receive by the end of September. If you haven’t received it by the beginning of October, call your plan and request one immediately, so you’ll have plenty of time to review it.

There may be changes to:

• Your Part D formulary
• Your Part D pharmacy network
• Your MA plan’s provider network
• Your MA plan’s policies
• Your premiums of deductibles for MA or Part D

Your plan willingness to grant you an exception for specific drug coverage can also change.

CHANGING YOUR COVERAGE

Just because your plan made an exception to cover a drug outside of its formulary this year doesn’t mean it has to do so next year. Call your plan to ask whether or not you’ll need to reapply for the exception. Suppose plan administrators are going to make it difficult to get the drugs you need. In that case, you may be better off switching plans while you have the opportunity.

Back to the Plan Finder

Using Medicare’s Plan Finder (medicare.gov/find-a-plan)—the online tool provided by the government that helps you find a private insurer—can seem tedious at first. However, you’ll likely find that the process gets easier as you get used to it. Even if it doesn’t, using it is still worth the time and effort cause even if your plan’s ANOC doesn’t detail any changes that could affect you. Other plans may have made changes that could make them a better option. For example, a new insurance company could have entered your area, offering a comparable plan to yours but with a much lower premium or deductible. If you don’t bother to check the Plan Finder, you may never hear about new, more attractive options.

Switching from Medigap to Medicare Advantage

Suppose until now you’ve had Original Medicare with a Medigap plan. In that case, you may be considering switching to a Medicare Advantage plan for additional benefits or to limit your out-of-pocket expenses. Be careful if you decide to take this step because you may not be able to get it back once you leave Medigap.

Here is what happens when you drop a Medigap policy:

• Your first 12 months in your new MA plan are considered a “trial period.” You can still switch back to your original Medigap plan with the same benefits and the same government protections that you had previously during this trial period.
• This special protection only applies the first time that you switch from Medigap to Medicare Advantage. And it only applies if you already had a Medigap policy. You can’t take advantage of the trial period if you’re simply going from Original Medicare (with no Medigap) to MA.
• After a 12-month trial period, you no longer have the guaranteed right to a Medigap plan and maybe denied one in the future. However, you’ll still be able to switch between MA plans.

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It’s unlikely, but you should still be prepared

Medicare guarantees you certain rights. As long as you pay your premiums, you should be guaranteed the right to all of Medicare regardless of your age, your health, or where you live. Suppose you abide by Medicare deadlines (and pay your premiums). In that case, you should have access to Part D coverage, Medigap, and Medicare Advantage plans as well. However, there are some situations in which you may lose your coverage. Take care to avoid the following:

Failing to Pay Your Premium

Original Medicare is meant to be accessible. Many people are enrolled automatically and have their premiums automatically deducted from their Social Security payments. However, if for any reason you do stop paying your premiums, you will eventually lose your coverage. You’ll receive multiple notices that your bill is overdue. And finally, in about four months after your initial missed payment, Medicare will be able to drop your coverage.

When this happens, you also lose eligibility for Part D. You can re-enroll. Still, you’ll need to wait until general enrollment (January 1 to March 31) to sign up—and your coverage won’t begin until July. Plus, you’ll probably be stuck with higher premiums as a penalty for late enrollment.

Remember that missing any income-related monthly adjustment amounts you owe on Part B or Part D can also lead to loss of coverage.

Committing Medicare Fraud

Medicare fraud can take many forms, including misrepresenting other coverage you have, such as insurance through an employer. Or frauds like allowing someone else to use your Medicare card to access care. The simplest ways to avoid losing your coverage: Be honest, ask questions, and don’t let others use your card to obtain care.

“Disruptive Behavior”

Though Medicare doesn’t go into specifics, you can lose your MA coverage if you behave in a way that “substantially impairs” the plan’s ability to do its job—namely, providing services to you and/or other beneficiaries. While this possibility may sound scary, MA plans must follow specific steps before they can drop you for this reason. MA plans must also provide reasonable accommodations for beneficiaries with mental illness and developmental disabilities. So this particular clause can’t be used to discriminate based on cognitive conditions. Suppose your MA plan does attempt to disenroll you for disruptive behavior. In that case, it must also inform you of your rights to file a grievance. If your MA plan does ultimately drop you, you’ll be put back onto Original Medicare.

What Happens If Your Plan Closes Up?

If your insurance company goes bankrupt or decides to stop dealing with Medicare, you’ll lose that plan’s coverage. However, you’ll receive notice from your company or from Medicare beforehand. You’ll be entitled to a special enrollment period during which you can select a new plan that will kick in when your old plan ends. Your Medicare Advantage, Part D, and Medigap coverage get the same protection.

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