UNEXPECTED MEDICARE PENALTIES AND INCOME-RELATED ADJUSTMENTS: CAN YOU APPEAL? HOW?

Medicare can be confusing and lead to unexpected costs. This is especially true if you’re not informed on the front end when you first become eligible for Medicare; or, if you delay enrollment, when you enroll that first time. The three most common surprise-cost culprits sprung on those new to Medicare include:

1.)   Medicare Income-Related Monthly Adjustment Amount (IRMAA)

• IRMAA is an amount you may pay in addition to your Part B and/or Part D premium if your income is above a certain level.  We wrote about IRMAA in this recent post 2020 Medicare Part B Monthly Premium and Income-Related Monthly Adjustment Amounts

2.)  Part B late enrollment penalty (LEP)

• For each 12-month period you delay enrollment in Medicare Part B, you may have to pay a 10% Part B premium penalty, UNLESS you have other credible coverage that is compliant with Medicare rules (such as insurance based on your or your spouse’s job-based insurance).

3.)  Part D late enrollment penalty (LEP)

• For each month you delay enrollment in Medicare Part D (Prescription Drug Plan), you may to pay a Part D late enrollment penalty unless you have creditable coverage that is as good or better than the basic Part D benefit or get “extra help” (Low Income Subsidy).

The good news, if you want to call it that, is if you get dinged for income adjustments or penalties – Yes, you can appeal.

In cases of IRMAA adjustments you can request a new initial determination right out of the chute if you have experienced a life-changing event that caused an income decrease, or if you think the income information Social Security used in making the initial determination is incorrect. If you don’t agree, you can also file for reconsideration or file an appeal.

You can also appeal your Part B and/or your Part D Late Enrollment Penalties (LEP) though the processes for doing so are different for Part B and Part D.

For Part B LEP, just follow the instructions on the notice that you received informing you of the penalty. You will need to prove that you were enrolled either in Part B or in coverage through current employment during the period of time for which you are being penalized.

For Part D LEP, you can appeal the penalty if you think you were continuously covered or if you think the amount of the penalty was calculated incorrectly. This appeal must be filed with Medicare’s contractor (MAXIMUS Federal Services) for handling appeals.

For more information on adjustments, penalties and how to file an appeal refer to this month’s Medicare Minute Newsletter courtesy of The Medicare Rights Center.

And go to:

Medicare Part B Premium Appeals | HHS.gov

Medicare IRMAA Life Changing Event Form

Late Enrollment Penalty (LEP) Appeals

If you have questions, we are happy to help:
Email: 65Plus@bbginc.net
Phone: 866-845-8600; Ext 130

Medicare Basics: 5 Things to Know About Medicare Part A

There are four basic parts of Medicare: A, B, C, and D. Each part helps pay for certain medical services. Here are 5 things to know about Part A:

#1  Part A is one of two parts of what is considered “Original Medicare”. (Part B is the other).

#2  Most people don’t have to pay a premium for Part A. They’ve already paid into the system in the form of the Medicare tax deductions in their paycheck if they (or their spouse) worked at least 40 calendar quarters (10 years) in the U.S.

#3  Medicare Part A helps cover the costs of inpatient care in the hospital, short-term skilled nursing facilities, home health care, and hospice care.

#4  Benefit periods apply. These benefit periods measure the use of inpatient hospital and skilled nursing facility services. Medicare will stop paying for your inpatient-related hospital or skilled nursing facility costs (such as room and board) if you run out of days during your benefit period.

#5  Most people either add a Medicare Supplement (Medigap) Plan or they opt to enroll in a Medicare Advantage Plan.  Both of these options in different ways can serve to limit liability, extend benefit periods, and cover some out of pocket costs (like deductible and coinsurance) associated with Medicare Part A.

You can read more about Medicare Part A covered services in this Medicare Minute Newsletter courtesy of the Medicare Rights Center.

Cost of Employer-Provided Health Coverage Passes $20,000 a Year

An ‘Annual poll of employers by Kaiser Family Foundation finds premiums rose 5% for family plans; ‘It’s the cost of buying an economy car.’

Let us show you how we help our employees operate at substantially below this scary number through SharedFunding.

Click here for The Wall Street Journal article for more insights into the survey results.

Are Groupons For Healthcare Good or Bad? Yes

Groupons have been in the medical news lately (for example “Groupons For Medical Treatment? Welcome To Today’s U.S. Health Care” and “Groupons for medical care are helping patients save money“) with stories of deeply discounted rates for some medical tests in several local markets across the country.

Here’s the net of the good and bad from a smattering of the news reports.

Good because the lower rates may make the tests affordable for some who need them and who may otherwise pass because they simply can’t afford.  In other words, if you have to have a test and don’t have coverage or if you have coverage but your plan’s deductible coupled with your network’s contracted rate for the test are out of reach, the Groupon rate may make it affordable.

Bad because the discounted rates sometimes prompt people to undergo testing unnecessarily and often without their doctor’s input or supervision.  In some respects, it could be a cousin to a practice known as “predatory testing” (offering free initial tests designed to encourage more not so free tests and/or costly treatments…….when they may not be necessary or advisable in the first place.)

And, bad because the quality is sometimes not up to par leading to a retest which usually ends up being performed somewhere else at an additional cost.  Essentially, patients end up having to pay multiple times to have the test done right.

According to one of the reports “Groupon dictates the price for its deals based on the competition in the area — and then takes a substantial cut”…

‘They take about half. It’s kind of brutal. It’s a tough place to market,’ said a provider that signed on with Groupon to market for his testing facility.”

Makes me think we could do just as well or even better fending for ourselves with a qualified provider of our choosing without Groupon as the middleman.  If a test is needed, first talk to your doc and ask for a list of multiple qualified providers.  And/or, check your insurance carrier’s online provider network directory for participating providers. Most insurance carriers now have online cost comparison tools that you can access by logging into your account. They are simple to use and allow you to shop for where you receive your healthcare. Once you have your lists of providers, check for quality ratings and pricing information.

After you do a little homework, select a few qualified providers.  Ask each of the providers for their best rates; and, what kind of break they’ll give you for pre-payment or paying in cash.