The New Medicare and You

The New Medicare and You



“It ain’t your father’s or grandfather’s Medicare.” After 48 years Medicare is changing its health care focus from treatment of acute diseases to caring for Medicare beneficiaries with chronic diseases. Why?Simple! Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions. About 65 percent of Medicare beneficiaries have two or more chronic diseases, and 43 percent have three or more. Reducing chronic expenses is the fastest way to bring the exploding Medicare costs under control.


Chronic diseases are often caused by unhealthy behaviors that increase the risk of disease—poor nutrition, inadequate physical activity, overuse of alcohol or smoking. Social, emotional, environmental and genetic factors also play a role. As people age, they are more likely to develop one or more chronic disease.

How ill is America’s health? The picture isn’t pretty:
• During 2011–2014, more than one-third of adults (36 percent), were obese.
• 36.5 million adults in the United States (15.1 percent) said they currently smoked cigarettes in 2015.
Cigarette smoking accounts for more than 480,000 deaths each year.
• 90 percent of Americans aged two years or older consume too much sodium, which can increase their risk of high blood pressure. Of course, obesity, smoking-related disease and high blood pressure are key chronic diseases. Chronic diseases are painful diseases; example quotes of chronic patients taken from an online site:
• “Sitting down in the shower to shave because it’s easier on my joints. I sometimes forget that many
people stand to shave.”
• “I have a habit of collecting my hospital bracelets after I get out of the hospital as it reminds me that I won yet another battle. It seems odd, but for some reason, I hold onto the bracelet feeling empowered that I walked away from what tried to defeat me again.”


You better get to know how to present C-SNP plans as ‘chronic’ is the new buzzword with Medicare. The Center for Medicare and Medicaid Services (CMS) has opened the door for health plans to add Value-Based Insurance Design (VBID) benefits such as air conditioners for asthma patients, home health benefits, healthy groceries, home-delivered meals and installing safety items like grab bars.

As an example of a health plan’s preparation for the expansion of VBID, Humana recently purchased Kindred Healthcare. Kindred Healthcare owns an array of businesses including home health, hospice, long term care hospitals and inpatient rehabilitation facilities. Humana has a significant business administering Medicare health benefits for the elderly, and the Kindred deal helps Humana form closer ties with a provider of home care and related services predominantly used by the elderly.

Starting in 2019, health plans in California and other targeted states can expand their benefits to include more Medicare beneficiaries with chronic conditions than previously identified by CMS, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories. The new chronic list will include beneficiaries with lower back pain, chronic kidney disease, obesity/pre-diabetes, asthma, and tobacco use. Beginning in 2018, CMS also allowed benefits for enrollees with dementia and rheumatoid arthritis. Medicare Advantage plans can cover adult day care services, and in-home help with activities such as dressing, bathing and managing medications. Seema Verma, the administrator CMS, told insurance company executives at a recent conference that “CMS hopes its new ‘reinterpretation’ of the Medicare Advantage program benefits rules will help unleash private-sector innovation and creativity.”

CMS further states, “Plans adding benefits based on the supplemental benefits interpretation must make sure the benefits are ‘primarily health related,’ and not primarily for a patient’s comfort. The services covered must be recommended by a physician or other licensed medical professional as part of a care plan.

The new benefits must not include items or services used to induce enrollment. “The primary contributor to the shift in focus to chronic diseases is Congress passing “The Chronic Care Act of 2018,” February 9, 2018, which opened the doors to the inevitable expansion of C-SNP or “Look-Alike” C-SNP Medicare Advantage Plans that provide VBID benefits. Two of the main sections of the bill that impacts health plans and the brokers that sell them are:

1. Allows MA plans to offer an expanded set of supplemental benefits to the chronically ill enrollee. Enables MA plans to experiment with different types of benefit packages to meet the needs of chronically
ill beneficiaries.
2. Permanently authorizes three types of SNPs: D-SNP (dual eligibles), C-SNP (those with severe disabling chronic conditions), and I-SNP (those in institutions). C-SNPs must meet additional care management requirements starting in 2020. By 2022, and every five years after that, the Health and Human Services (HHS) Secretary must update the list of chronic conditions eligible for participation. The list must include HIV/AIDS, end-stage renal disease and chronic/disabling mental illness.


The Centers for Disease Control and Prevention (CDC) established a comprehensive chronic disease program.The four major components are:

1. Implemented systems that track chronic diseases and their risk factors.
2. Promotes health and support healthy behaviors across the nation, in states and communities, and in settings such as schools, child care programs, work sites and businesses.
3. Developed programs and policies that allow doctors to diagnose chronic diseases earlier and manage them better.
4. Established community programs linked to clinical services to help patients prevent and manage their chronic diseases, with guidance from their doctor. The State of California Chronic Programs,, includes services for health self-management, fall prevention and physical activity, and caregiver and memory programs. The VBID benefits cannot cure chronic diseases but can aid in reducing the hospitalizations due to chronic illnesses. CDC recommends six healthy aging suggestions (as seen by the graph on this page).


The New Medicare and You has a chronic condition focus. You can count on the majority of your Medicare
clients having one or more chronic diseases and they would probably like to to hear about the VBID benefits
of a C-SNP or an MA plan with VBID benefits. Already, there are MA and C-SNP health plans with added benefits, such as:

• Health Coach
• Care Management
• Acupuncture
• Telehealth
• Chiropractic
• OTC Supplies
• International
• Lower Cost Travel Tiered Copays
• Gym Membership
• Transportation
• Quit Smoking Programs
• Nutritional Programs

The emphasis on chronic and CSNP plans also creates a yearlong enrollment opportunity for brokers. Eligible Medicare beneficiaries can enroll anytime during the year into a C-SNP plan with their PCP’s confirmation of their chronic illness. ‘Lockin’–where you can only enroll new to Medicare beneficiaries – is becoming antiquated given C-SNPs. With the new OEP now January 1 to March 31 and AEP October 15 to December 7 and C-SNP’s and New-to-Medicare, enrollments are now a full-time enrollment opportunity. Oh, not forgetting D-SNPs for Dual Eligibles and I-SNPs for Institutional members, brokers have unlimited enrollment opportunities.


The ‘New Medicare and You’ is BetaBenefits’ title for our Medicare educational classes in which we discuss Medicare’s milestones (see chart) and the benefits each milestone provides Medicare beneficiaries. With CMS’ emphasis on chronic diseases and VBID benefits, shouldn’t you rethink how you present Medicare to your clients?

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

Senior Surprise: Getting Switched With Little Warning Into Medicare Advantage

Senior Surprise: Getting Switched With Little Warning Into Medicare Advantage

Only days after Judy Hanttula came home from the hospital after surgery last November, her doctor’s office called with bad news: Records showed that instead of traditional Medicare, she had a private Medicare Advantage plan, and her doctor and hospital were not in its network. Neither the plan nor Medicare now would cover her medical costs. She owed $16,622.

“I was panicking”, said Hanttula, who lived in Carlsbad, N.M., at the time. After more than five hours making phone calls, she learned that because she’d had individual coverage through Blue Cross Blue Shield when she became eligible for Medicare, the company automatically signed her up for its own Medicare Advantage plan after notifying her in a letter. Hanttula said she ignored all mail from insurers because she had chosen traditional Medicare. “I felt like I had insured myself properly with Medicare, she said. So I quit paying attention to the mail.”

With Medicare’s specific approval, a health insurance company can enroll a member of its marketplace or other commercial plan into its Medicare Advantage coverage when that individual becomes eligible for Medicare. Called a seamless conversion, the process requires the insurer to send a letter explaining the new coverage, which takes effect unless the member opts out within 60 days.

Medicare officials refused recently to name the companies that have sought or received such approval or even to say how long the Centers for Medicare and Medicaid Services has allowed the practice. Numerous insurers, including Cigna, Anthem and other Blue Cross Blue Shield subsidiaries, also declined to discuss whether they are automatically enrolling beneficiaries as they turn 65.

But others say they’re moving ahead. Aetna will begin the process soon for its marketplace members in 17 Florida counties. The effort will kick off with individuals who qualify for Medicare in November, Aetna spokesman Matthew Clyburn said. They’ll receive 90 days advance notice instead of the required 60 and a postcard they can mail back, he said, and the company will follow up by phone to make sure they understand the change.

In November, UnitedHealthcare will start to automatically enroll members of its Medicaid plans in Tennessee and Arizona into its Medicare Advantage plans, a spokeswoman said. And Humana, the nation’s second largest Medicare Advantage provider, has asked for federal permission to also do auto-enrollment. The process will benefit people who want to stay with the same insurance company, said Mark Mathis, director of Humana’s corporate communications. It would simplify administration, eliminating a step in the process and help maintain continuity with the same company.

Medicare officials are developing a procedure for reviewing seamless conversion requests as well as a system to monitor implementation, agency spokesman Raymond Thorn said. A company given approval must automatically enroll all Medicare-eligible beneficiaries. But because federal law prohibits marketplace insurers from dropping a member who qualifies for Medicare, both marketplace and Medicare Advantage coverage continue until the person cancels the marketplace plan, Thorn said.

Sally Thomphsen, who lives outside Chicago and had an individual health policy from Blue Cross Blue Shield last year, was more than surprised when she received her member card for a Medicare Advantage plan shortly before turning 65. Printed on the card was the name of her new primary care physician, someone she didn’t know.

“I almost hit the ceiling”, said Thomphsen, who had already enrolled in traditional Medicare. She demanded that Blue Cross cancel her enrollment and reported the situation to Erin Weir, health-care access manager at the local advocacy group AgeOptions. Weir heard a similar story from another local woman, who had received a letter from her insurer saying a Medicare Advantage plan was selected for you because it is similar to your current plan. Unless you contact us, you will be automatically enrolled.


After learning about the problem both from constituents and health-care advocates, Rep. Jan Schakowsky (D-Ill.) wants stronger consumer protections. “I am exploring the option of requiring an opt-in so that Medicare beneficiaries are adequately informed and able to make the choices that work best for them”, said Schakowsky, whose district includes the Chicago area.

The Lovelace Medicare Advantage plan in which Hanttula found herself is run by Health Care Service Corporation, which administers Blue Cross Blue Shield plans covering 15 million beneficiaries in Illinois, Montana, New Mexico, Oklahoma and Texas. An HCSC spokeswoman said it offers seamless conversion enrollment on a limited basis. She would not provide details.

Hanttula finally solved her problem with help from a Medicare counselor at New Mexico’s Aging and Disability Resource Center, who contacted David Lipschutz, a policy lawyer at the Center for Medicare Advocacy in Washington. He advised the counselor to tell Medicare officials that the retiree was enrolled in Medicare Advantage without her knowledge even though enrollment must be voluntary.

Eventually, officials un-enrolled Hanttula from her unwanted plan, restored her traditional Medicare coverage and agreed to cover her medical bills. Lipschutz said giving beneficiaries the chance to opt out doesn’t adequately safeguard consumers. An insurer’s notification letter can easily be mistaken or overlooked in the deluge of marketing materials seniors receive.

“The right to opt out doesn’t exist if they didn’t get the notice or if they did get the notice but didn’t understand it”, he said.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

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