Make Medicare Work Coalition (MMW)

Bulletin Newsletter

April 27, 2016
To view other MMW materials and resources, including past MMW Bulletin newsletters, fact sheets, and recorded webinars, visit our MMW Coalition webpage at

Medicare Updates
Resources on Balance Billing Beneficiaries with QMB
The Centers for Medicare and Medicaid Services (CMS) recently released guidance to Medicare providers reminding them that federal law prohibits them from balance billing beneficiaries enrolled the Qualified Medicare Beneficiary (QMB) program. This law applies to QMB beneficiaries in original Medicare and Medicare Advantage (MA) health plans.
Balance billing is when medical providers bill beneficiaries for Medicare cost sharing, such as Part A and Part B deductibles and co-payments. Some Medicare beneficiaries have insurance, like Medigap or group health plans, that help pay some of these costs not covered by Medicare. Other beneficiaries with only original Medicare Part A and Part B pay for these costs out-of-pocket. However, beneficiaries with limited incomes enrolled in the QMB program have their Part A and Part B cost sharing amounts covered by QMB and as a result, do not have to pay these costs. QMB is a Medicare Savings Program that helps beneficiaries with limited incomes pay for Medicare's out-of-pocket costs. Eligibility is determined and benefits are administrated through Medicaid.
The law applies to all Medicare and MA providers regardless of whether they accept Medicaid or not. Original Medicare and MA plan providers must accept Medicare and Medicaid's payment as payment in full for Medicare covered services provided to a beneficiary with QMB. Providers and plans cannot bill the QMB beneficiary any Medicare cost sharing since QMB covers these costs. This includes providers who try to bill QMB beneficiaries in MA plans for the MA plan's co-pay.  According to CMS, providers who fail to comply with this law "are violating their Medicare Provider Agreement and may be subject to sanctions".
Some providers may be unaware of this law and continue to bill Medicare QMB beneficiaries co-pays and deductibles. Beneficiaries with QMB who experience balance billing issues can share this CMS notice with the provider that explains the rule prohibiting charging these beneficiaries co-pays. CMS also recently addressed this issue for QMB individuals in MA plans and released guidance that encourages MA plans to educate providers in their networks about the illegal practice of balance billing Medicare beneficiaries who are enrolled in QMB.
If a provider continues to bill the QMB beneficiary after receiving the notice, the beneficiary can take specific steps that are listed in a useful presentation (see slide 27) created by Justice in Aging.  These steps include first educating the provider about the QMB beneficiary's rights, working with a local legal services organization and contacting the local CMS regional office. Justice in Aging has also released a two-page document that shares the portion of the CMS letter to MA plans that addresses QMB balance billing. For more information and materials on balance billing QMBs, please see Justice in Aging's website.

MMW Resources for Individuals Turning 65
MMW Coalition staff at AgeOptions have created multiple tip sheets for consumers who are turning 65 to help explain their health coverage options and what they need to know if they already have health insurance when they become eligible for Medicare. The tip sheets are currently available in English and are in the process of being translated into Spanish. All of the following  consumer tip sheets are available on our website here
Turning 65 - What You Need to Know
This tip sheet reviews health coverage options for people who are turning 65 and what they need to know once they become eligible for Medicare.
How to Enroll in Medicare and Pay Your Premiums
This tip sheet explains how to enroll in Medicare, when a beneficiary's coverage will begin, and how to pay for Medicare premiums if they do not receive Social Security, Railroad Retirement Board, or Civil Service benefit payments.
Turning 65 with Employer Insurance
This tip sheet provides an overview of what individuals with health coverage through a current employer need to know once they turn 65 and become eligible for Medicare.
Coverage options for People Age 65 and Older Flow Chart
This chart can be used to assist consumers to determine what type of health coverage they are eligible for - Medicare, Medicaid or coverage through the Health Insurance Marketplace. Please note this flow chart is currently available in English, Arabic, Chinese, Hindi, Korean, Polish, Russian, and Spanish. 

 CMS Extends Moratorium on the Enrollment of New Home Health Agencies
Effective January 29, 2016, CMS announced an additional six month temporary suspension on the enrollment of new home health agencies. This means that CMS will not enroll new home health agencies into Medicare, Medicaid or Children's Health Insurance Program (CHIP) in the metropolitan Chicago area (includes Cook, DuPage, Kane, Lake, McHenry, and Will counties). CMS introduced the moratorium in 2013 (under authority of the Affordable Care Act) in the Chicago area and other selected geographic areas nationwide. The goal of this moratorium is to combat fraud, waste and abuse and is also a result of an increase in the number of enrollment applications submitted by home health companies to become Medicare and Medicaid providers. The moratorium does not affect home health agencies that are already enrolled in the Medicare program.

CMS Expands Quality Data on Physician and Hospital Comparison Tools on
In December, CMS added new quality data to the Physician and Hospital Comparison tools available on The comparison tools allow consumers and professionals who serve them, to locate and compare providers near them. The Physician Compare tool includes provider contact information, geographic location, and whether they accept Medicare assignment. It also includes newly added quality measures for some individual physicians, group practices and Accountable Care Organizations if the data was reported to Medicare by the provider. The quality measures include performance scores on measures such preventive care, diabetes, cardiovascular care and patient safety, as well as patients' experiences with some group practices. CMS has created a video tutorial on how to use the physician compare tool that you can view here. For more information on the Physician Compare Tool and to view all the quality measures providers are scored on, click here.
The Hospital Compare Tool was updated to include specific quality measures that list whether hospitals utilize safe surgery practices and data about infections that occurred while a patient was in a hospital. In addition to these two comparison tools, the website also provides comparison tools for home health services, dialysis facilities, nursing homes, Medicare Part D and Medicare Advantage plans, and Durable Medical Equipment providers.

Extra Help Updates
Medicare Beneficiaries with Retiree Coverage who Qualify for Medicare Extra Help
Medicare beneficiaries who are enrolled in retiree health plans that include prescription drug coverage are allowed to delay enrolling in Medicare Part D if their coverage is considered creditable coverage, meaning that it pays on average as much as a standard Medicare Part D plan pays. Individuals should make sure to ask their retiree plan for a "notice of creditable coverage" if they do not annually receive one and file it away. Individuals with creditable coverage will not have to pay a Part D late enrollment penalty if they lose their retiree health plan or decide to enroll in a Part D plan at a later date, as long as they do not go longer than 63 days without creditable drug coverage. It is important that Medicare beneficiaries with retiree drug coverage do not enroll in a Part D plan without first checking with their plan's benefits administrator. Most Medicare beneficiaries that have retiree health and drug coverage are not allowed to be enrolled in both a retiree drug plan and Part D plan at the same time. In many cases, enrolling in a Part D plan will cause the retiree to lose all their retiree health plan benefits and they may not be able to get them back.
This may be an issue for some Medicare retirees who qualify for public health benefit assistance programs. Medicare beneficiaries who qualify for Medicaid, a Medicare Savings Program, or Supplemental Security Income (SSI) automatically receive Extra Help. If they are not enrolled in Part D plan, CMS will randomly assign them to a stand-alone Part D plan. For most people who qualify for Extra Help, this is an assured way to guarantee the beneficiary is enrolled into a Part D plan and has access to affordable drug coverage. However, this auto-assignment into a Part D plan can negatively impact Medicare beneficiaries with retiree coverage, since facilitation into a Part D plan can cause them to lose all of their retiree health benefits. As a result, it is recommended that beneficiaries who have retiree coverage and qualify for Medicaid, MSP or SSI contact 1-800-Medicare and specifically request to "affirmatively opt out of Part D" if they wish to retain their retiree health and drug benefits. This should only be done if they are certain that they would like to continue using their retiree plan. Consumers should make this call prior to applying for Medicaid/MSP or as soon as they are notified of their Medicaid, MSP or SSI eligibility to guarantee that they are not auto-assigned to a plan by CMS. As a reminder, these beneficiaries will receive a special enrollment period to enroll in a Part D plan without a penalty if they lose their creditable retiree drug coverage in the future.

NCOA Extra Help Eligibility Chart
The National Council on Aging has created a useful chart that explains the different subsidy levels for the Extra Help program (also known as the Low-Income Subsidy or LIS program). The Extra Help program helps people with Medicare pay for their Medicare Part D plan costs, including monthly premiums, the annual deductible, and co-pays for drugs that are on their plan's Part D plan formulary.  The chart provides a breakdown of the different levels of Extra Help (full or partial) a person can qualify for. Which level a beneficiary qualifies for depends on an individual's income and assets, as well as whether they qualify for Medicaid, a Medicare Savings Program, or Supplemental Security Income (SSI); whether they receive home and community based services through one of the Medicaid waiver programs; or whether they are on Medicaid and live in a long term care facility. The chart also explains which beneficiaries automatically receive Extra Help and who needs to complete and submit an application to the Social Security Administration to determine eligibility. 
Free Antibiotics and Select Drugs at Meijer's Pharmacy 
Meijer Pharmacy offers some antibiotics and select commonly prescribed medications for free with a physician's prescriptions regardless of a person's insurance or plan's co-pay. Individuals can obtain up to a 14-day supply of the following antibiotics with a doctor's prescription: amoxicillin, ampicillin, cephalexin, ciprofloxacin (select dosages), penicillin VK, SMZ-TMP.
Meijer also offers the following medications for free with a doctor's prescription:
  • Select prenatal vitamins
  • Metformin immediate release and
  • Atorvastatin calcium (generic LipitorĀ®) in 10, 20, 40, 80 mg strengths and up 30 tablets per fill
  Visit Meijer's website here for more information. 
Training Opportunities / 
CMS Webinar on Medicare and End-Stage Renal Disease
CMS will be hosting a webinar on Thursday, May 12 from 12:00 - 1:30 CT on "Medicare for People with End-Stage Renal Disease". The webinar is free and pre-registration is not required. All you need to do is visit the webinar link below on the day of the webinar. Please note that there will not be a call-in number for this webinar and the audio portion will be delivered via your computer. (Check to make certain your computer has speaker capabilities prior to the webinar.) For more information, visit the CMS website here

Cook County Health and Hospital System Town Hall Meetings
The Cook County Health and Hospital System (CCHHS) will be hosting a series of Town Hall meetings throughout Cook County to gather ideas and feedback on their 2017-2019 strategic plan. CCHHS has released a flyer available in English and Spanish that includes the dates and locations of each meeting. Click here to view the flyer.  Individuals who use CCHHS services, community members and others stakeholders who would like to attend can RSVP to the email listed on the flyer with the date of the meeting they would like to attend. 
 As always, please do not hesitate to contact us with any questions.
Georgia Gerdes, Healthcare Choices Specialist (Mondays, Wednesdays, and Fridays)
1048 Lake Street, Suite 300
Oak Park, Illinois 60301
phone (708)383-0258  fax (708)524-0870

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