Disability Law Blog

SSA to Conduct Phone Survey re Medicare Prescription Drug Benefit Applications

SSA has requested "expedited emergency clearance" from the Office of Management and Budget (OMB) regarding the "Medicare Modernization Act Subsidy Application Mailing Follow-Up Survey." (Unfortunately, SSA left out the "telephonic" before the "survey" so it's not quite as descriptive as it could be.) Here's the plan:

Approximately 19 million Medicare recipients will receive form SSA-1020, which includes a cover letter encouraging them to complete and return the application form to the Social Security Administration (SSA) immediately. However, there are many applicants who may not immediately return their completed applications. The earlier SSA receives subsidy applications, the more time it has to confirm information on the applications, process them, and make a subsidy determination in anticipation of the January 2006 subsidy program's beginning. For this reason, SSA plans to conduct a phone survey of individuals who received the subsidy application but did not return it to SSA. The purpose of the survey is to encourage these individuals to return the completed application to SSA. Respondents are Medicare recipients who have been mailed form SSA-1020 but have not yet returned the form.

Comments should be submitted by August 8, 2005.

Available in text and PDF

70 FR 43208-43209 (July 26, 2005)

Medicare Montly Premium To Go Up More Than 14% in 2006

Medicare premiums continue to rise at an alarming rate. The 2006 premium will be $89.20 per month::

Monthly premiums for Medicare Part B, which covers outpatient services, were $66.60 last year and rose to $78.20 for 2005. In its March 23 report, the Medicare Board of Trustees projected an increase of $9.50 a month, but it now will be $11.

With increased demand and scheduled reductions in the fees Medicare pays physicians, the American Medical Association warned yesterday that doctors may think twice before taking Medicare patients.

"These cuts pose a serious threat to access to care for seniors," said AMA board Chairman J. James Rohack. "No senior citizen should have to worry whether their physician can afford to accept Medicare patients."

Source: The Washington Post

Centers for Medicare & Medicaid Services Issues Interim Final Rule re Medicare Claims Appeal Procedure

The Centers for Medicare & Medicaid Services has (have?) issued an 80-page interim final rule relating to changes in the Medicare claims appeal procedure:

Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services, can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

The rules are effective May 1, 2005.

The comment period ends May 7, 2005.

Available in text and PDF

70 FR 11419-11499 (March 8, 2005)

GAO Says Incomplete Plan to Transfer Medicare Appeals Workload from SSA to HHS Threatens Service to Appellants

The Government Accountability Office (GAO) has issued a report that concludes that a plan to transfer responsibility for the Medicare appeals process from the Social Security Administration (SSA) to the Department of Health & Human Services (HHS) is incomplete and threatens services to those who appeal Medicare denials. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires SSA to transfer its responsibility for adjudicating Medicare appeals to HHS between July 1, 2005, and October 1, 2005.

The full report and a summary report are available in PDF format.

SSA Solicits Comments on Two New Forms Regarding the Medicare Prescription Drug Plan

The Social Security Administration (SSA) is soliciting comments on two new forms that are designed to help low-income people (1) apply for premium, deductible and cost-sharing subsidies related to Medicare Part D (voluntary prescription drug coverage) provided by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173) and (2) appeal denial of those subsidies. The two forms are:

• Application for Help with Medicare Prescription Drug Plan Costs (Forms SSA-1020)
• Appeal of Determination for Help with Medicare Prescription Drug Plan Costs (Form SSA-1021)

You can call or write for copies of the forms (no e-mail available?). SSA requests that comments be submitted to both the Office of Management and Budget (OMB) and SSA within 30 days.

Available in text and PDF

69 FR 58578 (September 30, 2004)

CMS Issues Final Rule Extending Medicare Coverage for People Whose Disability Benefits End Due to SGA

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule to conform existing Medicare regulations to a change in coverage made by the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999. Effective October 1, 2000, the change provides disabled beneficiaries who continued to engage in substantial gainful activity (SGA) after completing a trial work period with continued Medicare coverage for an additional 54 months beyond the previous limit of 24 months following the 15th month of the reentitlement period. The rationale for extended coverage:

The extension of Medicare coverage allows these beneficiaries to return to work without fear of being unable to qualify for health insurance because of pre-existing medical conditions and being faced with the prospect of either no health insurance or health insurance at a high premium, or significant medical expenses. In addition, the law ensures that individuals already entitled to Medicare can continue to receive health care services from the same providers without incurring a break in coverage. This extended coverage also gives individuals with disabilities the ability to continue working and therefore lead productive lives. Together with the other provisions of the TWWIIA (for example, rehabilitation and job training), the extension of Medicare coverage will improve the overall quality of life for these beneficiaries.

The new regulations are effective November 23, 2004.

Available in text and PDF

69 FR 57224-57225 (September 24, 2004)

Background on the Medicare Premium Increase

The Washington Post gives a more detailed assessment of the Medicare premium increase. (The increase was reported to be 17% at boston.com, but the Post says it's 17.5%.)

Medicare Premiums to Rise 17% in 2005--the Largest Increase Ever

Via boston.com

Medicare premiums for doctor visits will rise 17 percent next year, the largest increase in the program's 40-year history, the Bush administration said Friday.

Monthly payments for Part B of the government health care program doctor visits and most other non-hospital expenses will jump to $78.20 from $66.60.

The premiums are updated annually under a formula set by law. The federal government picks up about 75 percent of the cost of Part B benefits and beneficiaries pay the rest.

The increase reflects rapidly rising health costs and last year's Medicare overhaul, said Dr. Mark McClellan, administrator of the federal Centers for Medicare and Medicaid Services.

A well-timed announcement!

Centers for Medicare & Medicaid Services (CMS) Announces Computer Matching Program with Social Security Administration (SSA) and Internal Revenue Service (IRS)

CMS has announced a new computer matching program with SSA and the IRS:

The purpose of this agreement is to establish the conditions under which: a. The Internal Revenue Service (IRS) agrees to disclose return information relating to taxpayer identity to the Social Security Administration (SSA); and b. The SSA agrees to disclose return information relating to employer identity, commingled with taxpayer identity information disclosed by the IRS, to the Centers for Medicare & Medicaid Services (CMS).

These disclosures will provide CMS with information for use in determining the extent to which any Medicare beneficiary is covered under any Group Health Plan (GHP).

Effective Date: "The Matching Program shall become effective no sooner than 40 days after the report of the Matching Program is sent to OMB and Congress, or 30 days after publication in the Federal Register, which ever is later. The matching program will continue for 18 months from the effective date and may be extended for an additional 12 months thereafter, if certain conditions are met."

Since this matching program involves the Medicare Secondary Payer Program, Medicare will use this information to insure that it doesn't pay for something covered by a group health plan. This also has implications for Worker's Compensation settlements nationwide.

Available in text and PDF

69 FR 53728-53729 (September 2, 2004)

SSA Announces Renewal of Computer Matching Program with Centers for Medicare & Medicaid Services (CMS)

The Social Security Administration (SSA) renews "an existing computer matching program that SSA is currently conducting with CMS."

The purpose of this matching program is to establish the conditions, safeguards and procedures under which CMS agrees to disclose Medicare non-utilization data to SSA. In some instances, if an individual has not used Medicare benefits for an extended period of time, this may indicate that the individual is deceased. SSA will use the selected data as an indicator of cases that should be reviewed to determine continued eligibility to SSA-administered programs.

Available in text and PDF

69 FR 53128 (August 31, 2004)

Medicare Now Considers Obesity to be an Illness

From USAToday: Tommy Thompson, Secretary of Health & Human Services, announced at a Senate hearing yesterday that Medicare will remove barriers to covering anti-obesity treatments after 40 years of saying fat was not an illness and not covered.

Previously, Medicare's Coverage Issues Manual said obesity was not an illness, and by law, only illnesses and injury could be covered. The new HHS language stops short of calling obesity a disease, which would have required Medicare to pay for treatments. But the change removes the reference to obesity not being an illness. That means approval of treatments is possible, but only if scientific research proves them effective and a national Medicare panel agrees. So coverage won't change immediately. HHS officials say they can't predict what this will cost Medicare because they don't know yet what it will be asked to cover.

Problems with the Medicare Drug Law

Via the New York Times:  This article asks two questions about the new Medicare law:   First, what impact will the new Medicare law have on drug company programs that offer free drugs to low-income people, including those on Medicare? The answer--No one knows:

Nancy Pekarek, a spokeswoman for GlaxoSmithKline, said her company had made no decisions yet about its free-drug program. "We have to see what this new Medicare bill is really saying and how it will play out, or be amended," she said.

She said one possible option was for GlaxoSmithKline to change its requirements and allow free drugs to be offered to low-income people when they encounter gaps in the new benefit. One gap is the so-called doughnut hole, under which coverage stops after a person spends $2,250 in a given year, and does not pick up again until drug expenses reach $5,100. That means an outlay of $2,850, not to mention premiums, deductible and co-payments.

"We've had this program in place for a long time, recognizing there are people who fall between the cracks in the system and need some assistance," Ms. Pekarek added. "My guess is there will still be people falling between the cracks after 2006."

Second:  Why does the law prohibit beneficiaries from buying private insurance to cover the considerable gaps in coverage?

A report accompanying the final Medicare bill when it was passed last year said the insurance prohibition was to keep beneficiaries from becoming "insensitive to costs." Well, if your mother needs a prescription, her "sensitivity" is not going to lessen her need, but the cost may lessen her ability to buy it. And why shouldn't she be allowed to buy private insurance to help if she wants to? By that logic, should we prohibit auto insurance to make people sensitive to high repair costs?

Some administration and Congressional officials argue that older Americans would consume less health care if they had to pay more for it, so the government would save money. Maybe, but what are the health consequences?

Deane Beebe, a spokeswoman for the Medicare Rights Center, said: "The whole concept is based on the idea that people will use too much medication if they have coverage. We're really troubled by that."

Mr. Hayes added, "There is something very unrealistic about politicians who think that people will rush off to take prescription medication they don't need."

The link to this article should be good forever (if I used the anti-link-rot technique described by Howard Bashman here).

Dennis Smith Named Interim Medicare Administrator

Via Reuters:   Dennis Smith, head of the Center for Medicaid and State Operations, was named interim head of the Centers for Medicare & Medicaid Services (CMS) (formerly the Health Care Financing Administration, according to this report from Reuters.

Leslie Norwalk, deputy administrator and chief operating officer at CMS, will take responsibility for implementing the new Medicare changes.

CMS "oversees the huge Medicare and Medicaid programs, which are the state-federal health insurance programs for the poor, disabled and aged. Medicare and Medicaid are the second and third largest federal programs after Social Security, with $495 billion in budget authority. Medicare pays about 1 billion claims per year on behalf of some 40 million elderly and disabled beneficiaries, HHS said. Medicaid pays for medical services for 40 million low-income Americans."

Summary of New Medicare Prescription Drug Plan

The Center for Medicare Advocacy has posted a useful Summary of Major Provisions of the new Medicare prescription drug plan on its website.

Also see the Center's press release which asks the question:   How can a bill designed to reduce costs prohibit price negotiations with pharmaceutical companies? Answer:   Medicare's not just for people; it's for donors, too.

EAJA fees of $325/hour in Connecticut Medicare Case

From law.com: A District Court judge in Connecticut awarded attorney's fees of $325/hour to attorneys for the Center for Medicare Advocacy based on the special expertise exception under EAJA. More of a curiosity for us in the Fourth Circuit:

Federal circuits are split over what constitutes "distinctive knowledge or specialized skill needful of the litigation in question," the phrase used by the U.S Supreme Court in Pierce v. Underwood, construing the EAJA in 1988. The 7th, 9th and 11th circuits broadly construe Pierce to mean expertise in a particular area of the law, such as immigration or Social Security law. The narrower view, held by the D.C., 4th and 5th circuits, "requires technical or other education outside the field of American law," before fees are enhanced.

Revised listing for Lou Gehrig's Disease (ALS)

SSA has revised the listing for Amyotrophic Lateral Sclerosis (ALS) (text and pdf):

"For the reasons we explain below, we are revising listing 11.10, our listing for ALS, in our neurological body system listings. The new listing provides that we will find you disabled if you have medical evidence that shows that you have ALS. Because of this change, we are also making two additional changes:

• We are adding a new section 11.00G to the introductory material to the neurological listings to provide information about ALS and the evidence we need so that we can evaluate ALS under the new listing.
• We are amending Sec. 416.934 of our regulations to include ALS on the list of "specific impairment categories'' our field offices and State agencies use to make findings of presumptive disability under the Supplemental Security Income (SSI) program. This change will allow us to make findings of presumptive disability in claims involving allegations of ALS, without obtaining any medical evidence."

With this change, many claimants will be able to qualify for Medicare sooner, especially in light of the elimination in 2000 of the 24 month waiting period for Medicare eligibility.