Make Medicare Work Coalition (MMW)

Bulletin Newsletter

September 16, 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
Medicare coverage of the Flu Vaccine
Flu season is around the corner, and many Medicare beneficiaries will be obtaining their annual flu shot this fall season. As a result, it is helpful for professionals who counsel Medicare beneficiaries to understand how Medicare covers this vaccination.
The influenza vaccine is covered under Medicare Part B for individuals enrolled in original Medicare. Medicare will cover one influenza vaccine (and the cost of the administration of the vaccine) once per flu season (in the fall or winter) at no cost to the beneficiary as long as the provider accepts Medicare assignment. Medicare Part B coinsurance and the Medicare Part B deductible do not apply to the flu shot, meaning that the shot is covered even if beneficiaries have yet to meet their Part B annual deductible. Note: if other medical services are provided to the beneficiary during the same visit, a co-pay or co-insurance amount may apply to the visit/those services.
Medicare Advantage (MA) plans also cover the flu vaccine at no cost to the beneficiary as long as the beneficiary receives the vaccine from an in-network provider that works with the plan. MA plans are not allowed to require beneficiaries to obtain prior authorization or a referral for the flu shot if they receive it in-network. If an individual in an MA plan receives a flu shot out of network, the vaccine may not be covered or they may be responsible for paying a co-pay for the vaccine (depending on the type of MA plan they are enrolled in). For more information about Medicare coverage of the flu shot, visit this Q&A Guide created by CMS To learn how Medicare covers other vaccines visit You can easily find out if vaccines and other services are covered by using the search tool displayed on their home page.
If an individual is a dual-eligible and in a Medicare-Medicaid Alignment Initiative (MMAI) plan, the flu shot will be covered by their MMAI plan without any cost sharing as long as they obtain the vaccine from an in-network provider. 
Updated CMS Guide of Mailings to Medicare Beneficiaries 
The Centers for Medicare and Medicaid Services (CMS) have released an updated Guide to Consumer Mailings for 2016-2017. The guide provides a list of important mailings Medicare beneficiaries may receive from CMS, the Social Security Administration, and Medicare Advantage and Part D plans. These notices include information about Extra Help benefits, Medicare plan benefit changes, plan marketing materials, prescription co-payment changes, etc. The guide also includes the mailing date, sender of the letter, the letter color, what action the beneficiary needs to take, and a link to a copy of the letter.
The guide is a useful resource for professionals to use when counseling Medicare beneficiaries and helping them navigate the different letters they receive in the mail (it is an especially useful tool to use with beneficiaries who receive Extra Help, as it explains the different letters they receive during the year about changes to their subsidy).  
September is Prostate Cancer Awareness Month - Find Out How Medicare Covers Prostate Cancer Screening  
September is Prostate Cancer Awareness month and a great time to remind male Medicare beneficiaries the importance of being screened for prostate cancer. American Cancer Society statistics reveal that prostate cancer is the second leading cause of cancer death in men and that one in seven men will be diagnosed with prostate cancer in his lifetime.
Prostate cancer screening is covered under Medicare Part B for all male Medicare beneficiaries age 50 and older once every twelve months.  Medicare provides coverage for the following two types of prostate cancer screening:
  •  A PSA (Prostate Specific Antigen) blood test - The beneficiary does not pay anything for this blood test (the coinsurance and deductible are waived) if they visit a provider that accepts Medicare assignment. If the test is done by a doctor who does not accept assignment, the beneficiary may be charged a fee for the doctor's visit, but not for the test itself.
  • Digital Rectal Screening - The beneficiary is responsible for paying 20% of the Medicare approved amount for the digital rectal screening test and doctor's visit. The Part B annual deductible does apply to this screening. If the test is conducted in a hospital outpatient setting, the beneficiary also pays the hospital a co-pay.

To learn more about Medicare coverage of prostate cancer screenings visit:

CMS Announces Part D IRMAA Amounts for 2017
CMS recently announced the 2017 Part D Income Related Monthly Adjustment Amounts (IRMAAs). Medicare beneficiaries with annual incomes greater than $85,000 ($170,000 if married and filing a joint tax return) to pay an extra amount each month (an IRMAA) in addition to their monthly Part D plan premium. The Social Security Administration (SSA) will contact beneficiaries if they are required to pay an IRMAA amount. Part D IRMAAs began in 2010 and were a provision of the Affordable Care Act.
IRMAA amounts are based on a sliding scale, using income reported to SSA from the IRS and from a beneficiary's most recent tax return. For many beneficiaries, their IRMAA amount for 2017 will be based on income reported on their 2015 federal tax returns. The IRMAA amount is paid to the federal government, not to the Part D plan. It is usually deducted from a beneficiary's Social Security check if the individual receives Social Security benefits, or billed by Medicare if they are not yet receiving benefits. Beneficiaries must pay the IRMAA amount to maintain their Part D coverage. If they do not, they may be disenrolled from their Part D plan. Refer to the chart below for 2017 IRMAA amounts.
Beneficiaries who file an individual tax return
Beneficiaries who are married and filing a joint tax return
2017 Part D IRMAA Amounts
(in addition to the Part D plan monthly premium)
$85,000 or less
$170,000 or less
$85,001 -$107,000
$170,001 - $214,000
$107,001 - $160,000
$214,001 - $320,000
$160,001- $214,000
$320,001 - $428,000
Greater than $214,00
Greater than $428,00
Note: IRMAA amounts for beneficiaries who are married but file separate tax returns can be found in the CMS announcement mentioned above. 
CMS Extends Home Health Moratorium for Additional Six Months
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 also announced the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) which allows CMS to lift the suspension and enroll new home health agencies on a case-by-case basis to address access to care issues. These type of enrollments would only take place if home health agencies pass "heightened screening requirements".
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 Medicare and Medicaid enrollment applications submitted by home health companies. The moratorium does not affect home health agencies that are already enrolled in the Medicare program.  

New Medicare Pre-Claim Review for Home Health Services
Illinois has been identified by CMS as one of five states in the U.S. in which fraud and abuse within Medicare's home health benefit is extensive. To address this issue, CMS has suspended the enrollment of new home health agencies into the Medicare program (as previously mentioned in this bulletin) and created a new three-year demonstration program that began in Illinois on August 3, 2016. The program creates a new process in how Medicare-certified home health agencies submit claims to Medicare.
The new process, called Pre-Claim Review of Home Health Services, now requires home health agencies to submit documentation to Medicare earlier, while beneficiaries are receiving services, in order to receive payment from Medicare. The new pre-claim review process does not change the types of documentation home health agencies must submit to Medicare, nor does it impact the services a beneficiary receives. Instead, it requires home health agencies to submit documentation to Medicare so the claim can be reviewed before the home health agency submits a final claim for payment. The pre-claim review process is not prior authorization, and a beneficiary should not experience a delay in receiving home health services because of this new process. If a home health agency does not submit a pre-claim review before they submit their final claim for payment, the agency may receive a reduced payment rate for that claim. If this occurs, the home health agency cannot bill the beneficiary for the difference.  
It is important to note that the new pre-claim review process does not change the home health care requirements beneficiaries are required to meet in order to receive Medicare covered home health care. The requirements to qualify for Medicare covered home health benefit remain the same and include being:
  • enrolled in Medicare
  • certified by a doctor as being homebound
  • in need of skilled nursing care, physical, speech or occupational therapy and
  • under the care of a doctor and receive services under a plan of care that is that is created and reviewed by a doctor regularly
  • in need of intermittent and part time care (not long-term care)
  It is important to note that if a home health agency's claim is ultimately denied, they cannot charge the beneficiary for the cost of services that took place during pre-claim review process. The only circumstance in which beneficiaries may be financially liable for the cost of services is if the home health agency issues an Advanced Beneficiary Notice (ABN) . ABNs are issued to a beneficiary if a provider anticipates that Medicare will not cover a service. It provides the beneficiary with the option of proceeding with the service but being financially liable if the claim is denied by Medicare. For example, an ABN may be issued by a home health agency if a beneficiary is not homebound or home health services to that beneficiary may not considered medically necessary, and as a result, the provider expects that claims for services to that beneficiary may be denied by Medicare. If the home health agency expects Medicare to approve a claim for a service, then an ABN should not be issued. In addition, CMS prohibits providers from routinely or extensively issuing ABNs. Beneficiaries who believe they are inappropriately being asked to sign an ABN may contact 1-800-Medicare.
For additional information about the pre-claim review process for home health services, visit the CMS website.  

Affordable Care Act Updates
Marketplace Special Enrollment Period Chart
The Center for Budget and Policy Priorities has updated their Health Insurance Marketplace chart of special enrollment periods (SEPs) that allow individuals and their families enroll into a Marketplace health plan and apply for premium tax credits outside of the open enrollment period. The Marketplace open enrollment period for 2017 begins November 1, 2016 and ends January 31, 2017. During this time, individuals and their families can apply for coverage or change their Marketplace plans for coverage in 2017. Individuals who would like to apply for coverage before or after the open enrollment period can only do so if they qualify for a special enrollment period.
The SEP chart lists the kinds of events that trigger a SEP and the eligibility criteria an individual must meet to be able to use it. The chart lists how long the SEP lasts for, when the change in coverage will begin or end, and how to access the SEP (through an application on the Marketplace's website or by contacting the Marketplace call center). This chart is especially useful to use with individuals who experience common situations that may require them to change Marketplace plans, such as a permanent move, losing other qualifying health insurance, a change in eligibility for premium tax credits or cost sharing assistance, or enrollment or plan errors. To access the chart click here

Training Opportunities and More!

MMW Coalition Meeting on September 26, 2016 - There's Still Time to Register!
There is still time to register for our upcoming Make Medicare Work (MMW) Coalition meeting that will take place on Monday, September 26 from 9:30 a.m. - 4:00 p.m. The meeting will feature presentations on Medicare, Medicaid, and Health Insurance Marketplace updates, MMW advocacy issues, and a panel of experts providing tips on working with a variety of client populations. The meeting will be held at the Michael A. Bilandic Building in Chicago and registration is required. To register for this meeting, please visit:
Information about Emergency Alert System Test and Opportunity to Comment
Do you or your organization serve limited English speakers, people who are deaf, hard-of-hearing, blind or have low-vision? If so, please share the following important information with them.  The Federal Communication Commission (FCC) will be performing a test of the Emergency Alert System that will broadcasted on television, cable and radio. The Emergency Alert System (EAS) is a warning system used to alert the public of any local or national emergencies The test will take place on September 28, 2016 at 1:20 p.m. Central Time and will be broadcasted in English and Spanish. It will also include audio and text of the alert for people with disabilities.
The FCC would like the public to circulate information about this upcoming test to determine if there are any accessibility issues or for comments on how the test can be improved. Any feedback can be submitted to the FCC through their Public Safety Support Center at This is a great opportunity to let the FCC know of any needed improvements to the test to assure it is accessible and understood by all individuals. For more information, visit

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