- It's Health Care Enrollment Season
- NEW! CMS Again Reissues Improved Medicare Home Health Booklet
- THIS Week In ACA Sabotage…
- Happy Anniversary SSI
- Medicare "Homebound" Class Action Settled – Fairness Hearing Set for January 11, 2018
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Social Security Disability Insurance (SSDI) Part 2 – Overview of Benefits for Those Who Qualify, and Best Practices for Applications
November 15, 2017
Open Enrollment for the Affordable Care Act (ACA) Health Insurance Marketplace begins on November 1st and ends on December 15th. Since we are also in the middle of the Medicare Annual Enrollment Period, it is important to note that Medicare is not part of the ACA Marketplace.
- Medicare provides coverage to people who are 65 or older, paid into Social Security or Railroad Retirement, have End-Stage Renal Disease or ALS, or are eligible because of SSDI or a Railroad Retirement Board disability pension.
- The ACA Marketplace offers coverage for people who don’t have other forms of health coverage and are not eligible for Medicare.
- Medicare beneficiaries don’t need to do anything in the ACA Marketplace enrollment period to maintain coverage.
- Please note that it is illegal for someone to knowingly sell a Medicare beneficiary an ACA Marketplace plan.
ACA Marketplace Open Enrollment is the time for people without Medicare to shop around and find a plan that meets their needs. The ACA requires that everyone have a healthcare plan that meets a standard for “minimum essential coverage.” Medicare beneficiaries with Part A satisfy that requirement, while those with only Part B do not.
The Medicare Annual Enrollment Period (October 15 – December 7) is the time for Medicare beneficiaries to enroll, review current coverage and make any changes for the coming year.
Although ACA Marketplace enrollment doesn’t involve Medicare beneficiaries, the ACA did many things to strengthen Medicare. Just like ACA Marketplace plans, Medicare now covers preventive services such as mammograms and colonoscopies. Medicare Beneficiaries also get a free yearly wellness visit and significant drug discounts in the Part D Donut Hole coverage gap, and the Donut Hole will close completely by 2020. ACA also extended the solvency of the Medicare Trust Fund to 2029.
Americans with pre-existing conditions can’t be denied a plan on the ACA Marketplace and traditional Medicare is stronger than ever. The unfortunate rhetoric about the ACA being a “disaster” isn’t true.
In a CMA Alert last month, the Center for Medicare Advocacy (Center) discussed CMS’ updates to the newly revised CMS Home Health Booklet based on suggestions and coverage clarifications made to CMS by the Center. While the Center was encouraged by CMS’ revisions to the Booklet, the Center continued to seek further improvements. In a quick response, CMS incorporated most of the Center’s suggested follow-up edits into the revised Booklet. The re-revised CMS Home Health Booklet is available at https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.
While the current Booklet more accurately describes Medicare’s home health coverage, the example on page 16 of the Booklet, comparing quality measures between home health agencies, provides a chart that favors improvement, not maintenance care. Unfortunately, current quality measures and payment incentives for home health agencies do not meaningfully measure care for people who need maintenance care. As a result, many beneficiaries with chronic conditions who require maintenance care are not able to access the level of home health care described in the Booklet, and authorized by Medicare law.
Please contact the Center if you, or someone you know, experience difficulty obtaining Medicare-covered home health care. Tell us your home health care story at https://www.medicareadvocacy.org/submit-your-home-health-access-story.
Like a villain in a classic Halloween movie, the administration’s sabotage of the Affordable Care Act (ACA) will not stop. Over the weekend, the president tweeted “As usual, the ObamaCare premiums will be up…but we will Repeal & Replace…” What he failed to mention is that premiums are spiking in large part due to the administration’s own refusal to fund the ACA’s Cost Sharing Reductions (CSRs).
In fact, an analysis by the Kaiser Family Foundation found that premiums for Silver plans are increasing anywhere from 7 to 38 percent. Kaiser’s analysis clearly attributes these spikes to the administration’s refusal to pay the CSRs.
We’ve also seen other frightful actions to sabotage the ACA, such as:
- Issuing an Executive Order that would allow the sale of junk plans;
- Cutting the enrollment period in half;
- Slashing funding for both advertising and enrollment assistance;
- Refusing to participate in enrollment events;
- Shutting down healthcare.gov during critical times; and
- Likely auto-enrolling millions of Americans without giving them time to find a better deal.
With all of this cutting, slashing, and sabotage, what could be scarier this Halloween week than Trumpcare?
- Read the Kaiser analysis about premium increases: https://www.kff.org/health-reform/issue-brief/how-the-loss-of-cost-sharing-subsidy-payments-is-affecting-2018-premiums
- Read about how ACA sabotage could impact rural communities: https://khn.org/news/rural-areas-already-short-on-health-resources-face-enrollment-hitches
- Read about how ACA sabotage could hurt Latino enrollment: https://khn.org/news/big-gains-in-latino-coverage-poised-to-slip-during-chaotic-enrollment-season
This week marks the 45th anniversary of Supplemental Security Income or SSI. SSI is a program that provides income supplements to people who are older, blind or disabled and have very little income or assets. Blind or disabled children may also receive benefits from the program. The system that originally supported these populations was a patchwork of federal and state programs with varying rules, eligibility standards and benefits. On October 30, 1972, President Richard Nixon signed the Social Security Amendments, creating SSI and replacing this patchwork system with one centralized federal program.
Decades later, SSI remains a critical lifeline that helps people afford basic life necessities such as food, shelter and medical care. In most states, people with SSI can get Medicaid, which is critical for low-income people with serious medical needs. Medicaid covers many long-term care costs for SSI beneficiaries with severe disabilities or advanced illness. Beneficiaries may also be eligible for other assistance programs such as Supplemental Nutrition Assistance (SNAP) or Temporary Assistance for Needy Families (TANF). Please contact your local social services office to learn more about other programs that offer critical supports for people with SSI.
On October 27, 2017, a federal court preliminarily approved a settlement agreement in Ryan v. Hargan, 5:14-cv-269-gwc (D. Vt.). The case involves the Medicare agency’s failure to apply a policy that was helpful to beneficiaries seeking coverage of home health nursing or therapy services. One requirement for coverage of home health services is that the beneficiary be “confined to the home” (i.e. homebound). The policy in question directed that when a beneficiary had previously been found to be homebound in a Medicare appeal, that conclusion should be given “great weight” in any subsequent appeal for home health services, provided there had not been a significant change in the beneficiary’s condition. This “Prior Favorable Homebound” provision, which was contained in one of the agency’s manuals, was intended to prevent beneficiaries from having to repeatedly prove that they were homebound. Vermont Legal Aid and the Center for Medicare Advocacy brought the lawsuit because the Medicare agency was not following the Prior Favorable Homebound provision, which has since been rescinded.
The proposed settlement applies to Medicare beneficiaries in the northeast United States whose appeals for coverage of home health services were denied between January 1, 2010 and March 5, 2015 on the basis of not being homebound, and who had previously received a favorable appeal decision determining that they were homebound. More details on the class definition can be found in the notice to class members. The agreement will allow class members to have their eligible claims for home health services reviewed under the Prior Favorable Homebound provision.
A Fairness Hearing on the settlement will be held in Rutland, Vermont on January 11, 2018. The proposed settlement agreement and notice to the class, with information on filing objections in advance of the Fairness Hearing, are below.