We want to notify you about an issue affecting all Medicare members who elected to pay plan premiums from their Social Security Administration (SSA) or Railroad Retirement Board (RRB) check.
Normally, when members select this premium payment option, the SSA/RRB withholds funds from members’ SSA/RRB checks to cover their plan premiums.
Unfortunately, due to a system issue, this did not occur for two or more months starting February 1, 2019. This issue affected all carriers, not just Aetna. Although the system issue is now fixed, the SSA/RRB cannot retroactively deduct premium payments from members’ checks.
What do members need to do?
Because these members now have past-due accounts, their premium payment method has changed to direct billing, effective February 1, 2019. This means they now need to pay any past-due premium amounts to Aetna directly.
Members will receive a letter explaining what happened and what they need to do later this month. Letters are being mailed in waves, between May 10-24, so members will receive them over several weeks. View the member letter.
What happens next?
Encourage members to call us with any questions
Although this issue was out of our control, we realize it will be an inconvenience for our members. If they have any questions, please encourage them to call Member Services by dialing the number on their member ID card. The Member Services team is available 7 days a week, from 8 a.m. to 8 p.m.
As always, thank you for your dedication to our members and for your help educating them on this matter. If you have any questions, please contact the Aetna Medicare Broker Services Department at 1-866-714-9301 or firstname.lastname@example.org.
Medicare Blog | Medicare News | Medicare Information
How Large is Medicare Part D?
In less than two decades, Part D has become an industry behemoth
Medicare is second only to private insurance as a major payer for retail prescription drugs. The program’s share of the nation’s retail prescription drug spending increased from 18% in 2006 to 30% in 2018.
Percent of Retail Drug Spending, By Payer
Drugs Covered by Part D and Part B Accounted for 19% of all Medicare Spending in 2016
Part D Spending is Poised to Escalate
Mutual of Omaha: Submitting and Tracking Your PDP Enrollments
Scope of Appointment
All paper enrollment forms MUST be received by Mutual of Omaha Rx’s enrollment processor within 48 hours after the signed enrollment date.
Mutual of Omaha Rx (PDP) is a prescription drug plan with a Medicare contract. Enrollment in the Mutual of Omaha RX plan depends on the contract renewal.
Mutual of Omaha: Submitting and Tracking Your Medicare Advantage Enrollments
Humana Adds "Grandkids-on-Demand" as Benefit
Papa is a peer-to-peer service platform — like ride-hailing or short-term-rental services — that connects seniors to vetted college-aged young adults to help them with anything outside of medical or assisted-living needs. Think of things that young adult grandchildren might do for their grandparents, such as light housework, going on walks, running errands or just socializing.
Papa vets and hires young adults through interviews; criminal, background and driving-history checks; and a personality test to ensure the contractors, called Papa Pals, are engaging and sensitive to seniors' needs.
The deal, announced Tuesday, the is another example of Humana's holistic, value-based approach to caring for the seniors it insures. Specifically, the deal is intended to help seniors reduce loneliness and social isolation.
Humana executives said the company's better-than-projected earnings for the third quarter and the year so far were a result of its success in addressing clinical and non-clinical needs of its insurance plans.
“At Humana, we know if we truly want to impact the health of our Medicare Advantage members, we need to look at the whole person, and that includes the social determinants of health, like loneliness and social isolation,” Deb Galloway, president of Humana's Medicare program for Central and North Florida, said in a news release.
Reducing loneliness and social isolation in its members is a big deal for Humana. The Louisville-based health care and health insurance company said in a recently published report that socially isolated seniors are at a much greater risk of developing dementia and Alzheimer's disease; are four times more likely to be hospitalized with in a year of discharge; and are two to five times more likely to die prematurely than seniors with strong social ties.
Papa is headquartered in Miami, Fla., and its services to Humana Medicare Advantage members are currently limited to Tampa region, according to the release. The service is offered for free or at a nominal fee to qualifying Humana members.
In late October, Papa closed a $2.4 million seed funding round that included a lead investment from San Francisco-based Initialized Capital and an investment from Los Angeles-based Sound Ventures, a venture capital firm co-founded by actor and activist Ashton Kutcher, as the South Florida Business Journal reports.
Papa launched its services in late 2017. Seniors can access Papa's services and over 600 contractors by phone, Papa's mobile app or on the company's website.
HHS Proposes to Link Medicare Part B Payment for Prescription Drugs to International Price
Commonwealth Fund research shows that such bold payment models are needed to tackle high prescription drug prices in the U.S., and that paying international prices might move Medicare and beneficiaries’ drug spending in the right direction. If the proposal moves forward, a number of questions about how it will work need to be resolved, and it’s important to note that Part B spending accounts for just a small slice — 5 percent — of the total national drug bill.
Spending in Medicare Part B
Under Medicare Part B, physicians administer drugs in their offices, often to treat patients with cancer, immunological disorders such as rheumatoid arthritis, and age-related eye conditions like macular degeneration. Medicare’s current payment to physicians, which is based on the average U.S. sales price for these drugs and biologics, is 47 percent higher on average than prices paid by 16 industrialized countries for the same products, according to the administration’s analysis.
Beneficiaries’ cost-sharing is also high for Part B drugs; they pay 20 percent of the Medicare price for each dose. Commonwealth Fund research finds drug costs exacerbate struggles of Americans with serious illnesses, who can face financial ruin even if they have health coverage.
The outline of HHS’s proposed Part B rule, which would be released next spring, reflects an innovative attempt to lower drug spending:
Several unaddressed details of the Part B model will determine whether it will save Medicare money and lower what beneficiaries pay for their prescription drugs.
Certain features of Medicare and the pharmaceutical market may present stumbling blocks to achieving the model’s goals. For example, how will a target price enable vendors to negotiate with sole-source manufacturers who retain monopoly pricing power? What levers will vendors have in these circumstances? Could global pricing dynamics spur manufacturers to raise prices in other countries in order to raise the Medicare reference price? Answers to these and other questions raised by HHS could reveal limits of the model design.
Total U.S. Spending
Of course, Part B spending is a small portion of total Medicare drug spending, and the bulk of national drug spending falls outside of Medicare. Medicare Part D, for example, which covers drugs dispensed by retail pharmacies, accounts for a much larger share of total U.S. drug spending (27%). Medicare spending for the highest-cost drugs paid under Part D’s catastrophic benefit has grown at an average annual rate of 18 percent since 2007. That is faster than the 9.8 percent drug spending growth under Part B. Leaving Part D out of the proposal therefore leaves a lot of potential savings on the table.
Moreover, prescription drug costs paid by U.S. workers and employers would not be captured under the Part B model. These costs account for a large share of U.S. drug spending. Insurers estimate that prescription drugs now account for 33 percent of employer-paid health insurance premiums, mainly because of high and increasing prices for the same drugs covered by Part B. The Food and Drug Administration (FDA) has announced a series of steps to encourage more price competition from lower-priced products, such as generics and biosimilars. However, FDA actions will need to be coupled with bolder reforms to patent and exclusivity protections that impede U.S. payers from negotiating prices that approximate those achieved by peer countries.
A Broader Strategy
Rather than linking to prices abroad for a slice of U.S. consumers, HHS could pursue a broader strategy that adapts core elements of the international approach to drug pricing. Other developed countries aggregate purchasing power to gain leverage with drug companies, systematically assess the value of individual drugs to inform their purchasing decisions, and enter into a negotiation process with manufacturers that they can stand behind. Adapting these elements to the U.S. would take bold action, but if we did so we could create our own system — one that could achieve the lower drug costs that other countries are able to provide for their residents.
Scope of Appointment Documentation
What is the Purpose of a Scope of Appointment?
The scope of appointment form is a CMS requirement used to document an in person appointment witch a beneficiary to ensure that no other types of products are discussed outside of what the beneficiary originally requested.
Below is some information regarding Scope of Appointments ("SOAs") to help keep you compliant during this AEP season.
A Scope of Appointment must be completed prior to conducting a sales presentation for Medicare Advantage (MA) and Prescription Drug Plans (PDP). Also, sales presentations are required to be by appointment only and should not be made by marketing through unsolicited direct contact.
When completing an SOA:
CROSS SELLING - Under no circumstances can you discuss and/or complete an application for a non-health product; e.g., life insurance or annuity at the time of a Medicare Advantage or Part D enrollment. Returning a minimum of 48 hours later allows the consumer to have a "fresh mind" and gives way to a better understanding of the new product you are discussing.
Medicare Advantage / AEP Updates:
Feds loosen telehealth rules for
A telehealth consultation. Photo: BSIP/UIG via Getty Images
New proposed regulations, authorized by President Trump's budget deal from earlier this year, would open the door for Medicare Advantage companies to cover telehealth services for all enrollees starting in 2020.
The bottom line: This rule would give a leg up to the MA program, which is managed by the health insurance industry, since traditional Medicare strictly limits coverage of telehealth. The Congressional Budget Office has worried that telehealth visits will serve as add-on services to in-person clinic visits instead of acting as replacements, thus driving up Medicare spending.
Proposed rule would strengthen the popular system for private health insurance plans to provide Medicare coverage, increase plan flexibility to offer telehealth benefits, and improve coordination for dual-eligible beneficiaries
In a proposed rule issued today, the Centers for Medicare & Medicaid Services (CMS) took action to build upon the Administration’s ongoing efforts to modernize the Medicare Advantage and Part D programs, which provide seniors with Medicare health and prescription drug coverage through private plans. The changes proposed today would allow plans to cover additional telehealth benefits and would make other much-needed updates, including for individuals who are eligible for Medicare Advantage special needs plans.
Medicare Open Enrollment for 2019 is currently underway and runs through December 7, 2018, so seniors can review their coverage options and decide how they would like to receive their Medicare benefits in 2019. CMS offered new flexibilities to Medicare Advantage plans starting in the 2019 plan year, and plans are making additional benefits available including adult day care services, in-home support services, and benefits tailored for patients with chronic diseases like diabetes. The average Medicare Advantage premium will decline by 6.1 percent, enrollment is projected to grow by 11.5 percent, and there will be approximately 600 more plans available across the country next year.
Today’s proposed changes for plan year 2020 would leverage new authorities provided to CMS in the Bipartisan Budget Act of 2018, which President Trump signed into law earlier this year. With respect to telehealth, the proposed changes would remove barriers and allow Medicare Advantage plans to offer “additional telehealth benefits” not otherwise available in Medicare to enrollees, starting in plan year 2020 as part of the government-funded “basic benefits.”
This proposal will allow Medicare Advantage plans broader flexibility in how coverage of telehealth benefits is paid to meet the needs of their enrollees. As Medicare beneficiaries become more tech savvy, CMS is working across the agency to promote beneficiary access to telehealth, but the Medicare fee-for-service program telehealth benefit is narrowly defined and includes restrictions on where beneficiaries receiving care via telehealth can be located. The proposed rule would give MA plans more flexibility to offer government-funded telehealth benefits to all their enrollees, whether they live in rural or urban areas. It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places like their homes, rather than requiring them to go to a health care facility to receive telehealth services. Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.
Today’s proposed changes are a major step towards expanding access to telehealth services because the rule would eliminate barriers for private Medicare Advantage plans to cover such additional telehealth benefits under the MA plan. While MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that MA plans will offer them and that more enrollees will be able to use the benefits.
Additional changes proposed today would improve the quality of care for dually-enrolled beneficiaries in Medicare and Medicaid who participate in “Dual Eligible Special Needs Plans” or D-SNPs. These beneficiaries generally have complex health needs. Today’s proposed changes would unify appeals processes across Medicare and Medicaid to make it easier for enrollees in certain D-SNPs to navigate the system. The proposed rule would also require plans to more seamlessly integrate benefits across the two programs to promote coordination.
Today’s proposed rule also improves accountability and bolsters program integrity within the Medicare Advantage and Part D programs. The proposed changes would update the methodology for calculating Star Ratings, which provide information to consumers on plan quality. The new methodology would improve stability and predictability for plans, and would adjust how the ratings are set in the event of extreme and uncontrollable events such as hurricanes.
The proposed rule also includes critical updates with respect to program integrity. First, CMS is making revisions to an earlier regulation that made available to Part D sponsors and Medicare Advantage plans a list of precluded providers and prescribers that have engaged in behavior that bars their enrollment in Medicare. Under the earlier regulation, plans would be required to deny payment for any prescription, service, or item that is prescribed or furnished by an individual or entity on the Preclusion List.
Second, the proposed rule would take steps to help CMS recover improper payments made to Medicare Advantage organizations. CMS conducts Risk Adjustment Data Validation audits to confirm that diagnoses submitted by Medicare Advantage Organizations for risk adjusted payments are supported by medical record documentation. CMS recovers improper payments based on these audits. The proposed rule would strengthen CMS’s ability to return dollars to the Medicare Trust Funds as a result of these audits. If finalized, the proposed changes would result in an estimated $4.5 billion in savings to the Medicare Trust Funds over a ten year period, largely from the recovery of improper payments to Medicare Advantage plans through contract- level Risk Adjustment Data Validation audits. In addition, CMS released an analysis on the application of a Fee-For-Service adjuster in determining the Medicare Advantage payment recoveries. The analysis can be accessed at: https://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation- Program/Resources.html (the Fee-For-Service Adjuster executive summary and technical appendix are available in the “Downloads” section of the webpage).
For a fact sheet on the CY 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P), please visit: https://www.cms.gov/newsroom/fact-sheets/contract-year-cy-2020- medicare-advantage-and-part-d-flexibility-proposed-rule-cms-4185-p.
Medicare Advantage Insurer Anthem Wants to ‘Push Innovation Buttons’ with Senior Living
As senior living providers assess how they can seize new opportunities in Medicare Advantage (MA), they should consider one of the nation’s largest insurance companies an interested potential partner.
Indianapolis-based Anthem Inc. is the largest for-profit managed health company under the Blue Cross and Blue Shield umbrella. It is also the most prominent insurer to announce benefits packages created under newly relaxed Medicare Advantage rules, which allow for coverage of non-skilled in-home care and other services.
The Centers for Medicare & Medicaid Services (CMS) first announced this MA policy change last April. In the months since, senior living operators have been contemplating what the change could mean for them, because the newly allowed benefits cover the sorts of services typically provided in settings like assisted living.
However, it’s been unclear how insurance companies that offer MA plans might structure these benefits and when — and if — these insurers will start to offer this type of coverage.
Anthem has been one of the first insurance companies out the gate, announcing its new benefits packages in early October. These benefits, which take effect in 2019, could be tapped by plan members residing in senior living communities. And Anthem’s speed in bringing these new offerings to market should be a signal to senior living providers that the insurance company wants to be on the leading edge of innovation. As part of that effort, Anthem is open to developing future benefits and business arrangements that are more tailored specifically to the senior housing sector.
“It’s an open question for me, how do we work with these facilities in the future?” Martin Esquivel, vice president of Medicare product management at Anthem, told Senior Housing News. “Going forward, we want to push the innovation buttons and see what we can do together.”
The new benefits offered by Anthem-affiliated health plans are branded “Essential Extras” in Georgia, Indiana, Kentucky, Missouri, Ohio, Virginia and Wisconsin;
“Everyday Extras” in Tennessee, Texas, and New Jersey; and the new benefits are not branded in Anthem’s health plan affiliates in California or Arizona. They cover services such as food delivery, transportation, adult day center visits, installation of assistive devices in the home, and up to 124 hours of in-home non-skilled care. Individuals enrolled in plans with access to “Essential Extras” or “Everyday Extras” will need to choose one of the services offered in the package.
“The reason we could jump so quickly [and offer these benefits] is Anthem and its affiliated health plans are committed to offering plans that offer high-quality medical care and other social and support needs,” Esquivel said. “We had a list we were already contemplating, and when the language came through, we were able to add to that list, pressure-test it all, and identify the items we knew we could deliver. Culturally, we were already there.”
MA insurers have multiple incentives for offering these sorts of benefits. For one, they might build enrollment by differentiating themselves from competing plans, and give consumers access to services that they want. Insurers also could see bottom-line benefits through better cost control. For example, by covering transportation and in-home assistance with daily activities, Anthem might help prevent a beneficiary from missing doctors’ appointments or experiencing a fall - and this in turn should cut down on costly hospital stays.
While the new benefits are most obviously tailored to people who are not living in institutional settings, there are certainly some MA beneficiaries who reside in independent living and assisted living communities, Esquivel acknowledged. Anthem does not track the exact number of its beneficiaries in senior living.
There might need to be some discussion among senior living residents, Anthem representatives and leaders at the senior living community about how to coordinate these newly covered services. For example, an assisted living apartment probably already has grab-bars and similar features installed, but a resident might tap the new MA benefit to get a particular type of toilet seat, Esquivel said. Similarly, a senior living community probably already provides some form of transportation, but a resident might want to supplement that through the new MA coverage. And if there are discussions to be had about residents using MA to pay for some services already being offered in senior living settings, Anthem is also open to those conversations.
“How do we innovate and leverage what [senior living communities are] offering their consumers today?” Esquivel said. “It could be as simple as a contracting arrangement where they bill [the insurer], or something much more innovative that we haven’t thought of yet.”
Anthem may need to ‘get in line’
In light of expanding Medicare Advantage benefits, it’s plausible that residents will be approaching senior living providers and saying, “I’m getting this [service covered] through my MA plan, so I shouldn’t have to pay for it out of pocket,” according to Anne Tumlinson, founder and CEO of Washington, D.C.-based health care consultancy Anne Tumlinson Innovations.
However, assisted living companies do not have to quickly reassess their fee structures in response to this move by Anthem.