Tag: Aetna Medicare

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Part C Medicare Advantage

About Those Nursing Home Denials and Appeals

Earlier this month, Wall Street Journal published an article about a federal investigation(i) update into Medicare Advantage insurers’ rejection rates for patients seeking nursing home stays.  

The OIG review found that only 13% of prior authorization denials issued by Medicare Advantage organizations actually met federal Medicare coverage rules. Stays in post-acute facilities were highlighted as one of the most prominent service types improperly denied, meaning these vital nursing home and rehab stays likely would have been approved under traditional, government-run Medicare. (Medicare typically covers a nursing-home stay if patients need skilled care after a hospital admission of three days or more.)

The investigation noted that most people don’t appeal when the Medicare Advantage insurer denied their doctor’s request for access to a skilled nursing facility.  There is likely a number of reasons why that is the case; people give up, arrange for alternative care, pay out of pocket or simply don’t realize the initial denial is not the final word. 

However, of the 18% of patients who did appeal, nearly all of them were able to overturn the initial denial. 

Prior Authorization and Appeals

Medicare Advantage plans are when a private company, not the federal government, is managing and coordinating your Medicare Parts A and B benefits. Since these plans were introduced in 1999, and modified in 2003 to include drug coverage, the presumption has been these private companies can do a better job at improving health outcomes while saving the taxpayers money. 

In doing so, the private insurance company managing your benefits has the right to request “prior authorization” of a service provided by a Medicare participating provider or facility. The insurance company must post a list of services that require prior authorization and make a decision within seven days. Beginning in 2027 the companies must publish the percentage of PA requests approved vs. denied as well as the average and median time it took to make the decision.

An individual enrolled in a Medicare Advantage plan, or the physician requesting the service, can appeal; the formal way to ask the company to change the coverage decision. 

In Short..

Medicare Advantage plan insurance companies are under intense pressure from the federal government (and in some cases, corporate shareholders) to reduce cost while improving health outcomes. That means more scrutiny (another term for managed care) and prior authorization requirements. Physician groups now employ an army of people whose only job is to appeal the Medicare Advantage insurance company authorization denials. If individuals, too, join the appeal the reporting shows the denials can be overturned.   

(i)Health and Human Services Office of Inspector General (OIG)

Categories
Medicare A & B

Your 2026 Medicare Part B and D Premiums

May Be Increased. Or Eliminated.

The 2026 standard monthly premium for Medicare Part B beneficiaries is $202.90.

However, your 2026 Medicare Parts B and D premiums could be higher or lower – based on your prior or current income.

  • Higher? Yes. If the Modified Adjusted Gross Income (MAGI) on your 2024 tax filing exceeded $109,000 ($218,000 joint) your 2026 Medicare Parts B and D premiums are increased. This will be withheld from your 2026 Social Security benefit. Here is more information about the Income Related Monthly Adjustment Amount (IRMAA) for Parts B and D
  • Lower? Yes. If your current annual income is below 186% of the Federal Poverty Level you will be eligible for the Medicare Savings QI Program, regardless of assets, and will not be paying any Part B premium.

 

  • If you are being charged IRMAA and had a life-changing event that resulted in a reduction in your income, you may be eligible for a reduction in IRMAA. Call Social Security at 1-800-772-1213 for instructions on how to file an appeal via the SSA-44 form.
  • Plan ahead. Assuming the law is not changed, check with your financial planner or tax preparer to confirm whether your 2025 tax filing will trigger a 2027 IRMAA.
  • Or, if your current monthly income is below $2,426 individual / $3,279 couple one of our agents listed below and we can review whether you are eligible for the Medicare Savings QI Program.

 

Questions?

Our licensed, independent and certified agents are available to answer your questions about Parts A, B, IRMAA and other Medicare topics. Send us a note below to request an individual consultation.

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Categories
Medicare Part C Medicare Advantage Part D Prescription Drug

Medicare Annual Notice of Change

“The ANOCs are in the mail.”
Each year, by September 30, individuals enrolled in a Medicare Advantage (Part C) or Medicare Part D Prescription Drug plan receive by mail a document called Annual Notice of Change (ANOC.)
The ANOC document spells out upcoming changes to the plan you are currently enrolled in and compares those changes to the current year.
Points to Remember:
Your ANOC document is only for the plan you are enrolled in and not any other plan that may be available to you.
The document will confirm that if you take no action during the Annual Enrollment Period, your plan will be renewed January 1 with the new terms.

If your Medicare Advantage or Part D drug plan is being discontinued in 2026, you will receive by October 2 a Notice of Termination instead of the Annual Notice of Change. That plan termination notice must include a list of other plans offered in your county. Our team of licensed and independent agent advisors represent multiple companies and can assist you with selecting a new plan matching your needs.

October 1: This is the first day when we can discuss with you other 2026 plans available in your area. If you have any questions about your ANOC document, our team of licensed, certified and independent agents are available for a complimentary no-obligation review of the announced changes to your Medicare coverage. Click here to locate, call and or send a note to our agent near you.
October 15: This is the day the 2026 Medicare Annual Enrollment Period begins. During this period, which ends on December 7, 2025, you can enroll in or change your Part C Medicare Advantage or Part D Medicare Prescription Drug plan.

Additionally, this is also an important time to protect yourself from fraud and unsolicited behavior.
You may receive phone calls, emails, or mail from individuals offering assistance with your Medicare coverage. Do not allow anyone to pressure you into sharing personal information over the phone, especially your Medicare number, Social Security number, or banking details.
Telemarketing for Medicare Advantage plans without your prior consent is illegal, and Medicare and Social Security will never contact you by phone.

Categories
Part D Prescription Drug Uncategorized

Part D Late Enrollment Penalty

Q: “Dan, I just received a letter stating I will have to pay a Part D late enrollment penalty next year for not having a drug plan during the months of February through December, 2017. What’s this all about?”

A: “Sam, after you turned 65 in October 2016 you had individual coverage with prescription drug benefits through January 2017. Now you’re enrolling in a Medicare Advantage plan with Part D coverage, effective January 2018. For those 11 months, February through December, that you went without drug coverage Medicare will impose a penalty for the late enrollment.”

Again, why do I owe a late enrollment penalty?

If, for any continuous period of 63 days or more after your Initial Enrollment Period is over you go without one of the following, you will have a penalty added to your Medicare Part D premium:

  • A Medicare Prescription Drug Plan (Part D)
  • A Medicare Advantage Plan (Part C) (HMO or PPO) with prescription drug coverage.
  • Creditable prescription drug coverage (a drug plan that pays at least as much as the Medicare standard – most often provided through an employer or the individual insurance exchange.)

 

How does Medicare calculate the late enrollment penalty?

The penalty is based on multiplying two factors.

  1. Medicare calculates 1% of the “national base beneficiary premium” ($35.63 in 2017; $35.02 in 2018) which for 2018 will be $.35
  2. Medicare determines the number of full, uncovered months you didn’t have Part D or creditable coverage. In the above instance, that was 11 months.
  3. The $.35 is then multiplied by the number of months. In our example of 11, that equals $3.85
  4. The monthly penalty is rounded to the nearest $.10 (the example would then be rounded to $3.90) and added to your monthly Part D premium.

Will the late enrollment penalty change?

Yes, annually.  When Medicare determines the national base beneficiary premium has changed, as in $35.63 in 2017 to $35.02 in 2018, the late enrollment penalty amount will be recalculated.

Do I pay the late enrollment penalty through Social Security?

No.  The penalty, rounded to the nearest $.10 is added to your Part D premium and collected by your private insurance company

 

Source: https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html

Categories
Case Studies Part D Prescription Drug

“Having this EPIC plan was a miracle; an absolute miracle.”

Only a fraction of the nearly 3 million New York State residents aged 65 and older are enrolled in the state’s pharmaceutical assistance program known as New York EPIC.

When I meet with New York Medicare Part D clients, I ask if their individual income is below the $75,000 threshold, $100,000 if married. If so, I advise enrolling in EPIC even if they don’t take any or have only inexpensive medication.  Because, as Schenectady County, New York resident Beth says, “You never know.”

Beth shares her story. The $20,000 per dose medication.

In this 16 minute interview Beth shares her story of how she originally enrolled in EPIC and didn’t use it. She explains how her doctor prescribed a specialty medication. And how that medication was not included on her Medicare Part D plan formulary, its list of covered medications. And when she learned the drug would require a special exception approval from her Medicare Part D plan and costs $20,000 per dose, she was relieved to hear that EPIC would help. Listen in as Beth explains how affordable this $20,000 medication became after EPIC’s help.

Beth: “To me, having this EPIC plan was miracle, an absolute miracle. Because I wouldn’t have been able to get that drug and I would still remain very ill.”

If you reside in New York State, are age 65 or above, and have questions about how EPIC and your Medicare Part D plan can work together, please call (518) 346-2115.