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12 Medicare facts you need to know for the current open enrollment period

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Every 12-year-old that can create a Web page seems to want to create a private Medicare exchange these days.

Every drug store seems to have a table of staffed Medicare plan sales reps.

See also: Medicare annual enrollment period starts

What can you do to stand out, especially given the tight marketing restrictions on agents who want to sell Medicare Advantage plans and Medicare Part D prescription drug plans?

You can smile a lot more brightly than a website, and you are much less likely to freeze up because software has decided that it ought to update itself.

You can weave your Medicare advice into a comprehensive plan that includes disability insurance, long-term care insurance and more.

You can also know more. You might feel as if others have a huge head start, and they may, but the Centers for Medicare & Medicaid Services (CMS) website complex is complicated enough that even professionals may miss documents of keen interest, and newcomers may click on the right link at the right time and discover major, embarrassing changes buried in footnotes.  

See also: 3 top Medigap sales tips

For a look at 12 interesting facts we’ve gleaned from CMS websites, read on. 


1. Who runs Medicare?

The Center for Medicare is part of CMS, which is, in turn, part of the U.S. Department of Health and Human Services (HHS).

Sylvia Mathews Burwell is the HHS secretary.

Andy Slavitt is the acting administrator for CMS.

Sean Cavanaugh is the director of the Center for Medicare.

Before Cavanaugh took over as head of Medicare, he was the head of the programs and policy operation at the Center for Medicare and Medicaid Innovation. He also has been director of health care finance at the United Hospital Fund in New York and an official in the New York City Mayor’s Office of Health Insurance Access.

See also: CMS: Average drug plan base premium rises

Cavanaugh succeeded Jonathan Blum, who left in 2014. Blum is now executive vice president of medical affairs at CareFirst BlueCross BlueShield in Baltimore and a member of the board of the Medicare Rights Center.

Manager chair

2. Who runs Medicare’s private plan programs?

CMS relies heavily on private health insurers to run the traditional fee-for-service Medicare program.

But the agents and brokers who sell Medicare plans typically offer Medicare supplement (Medigap) insurance products, which fill in the gaps left by Medicare Part A hospitalization coverage and Medicare B physician services coverage; Medicare Advantage plans, which are also known as Medicare Part C plans; and Medicare drug plans.

Elizabeth Richter is the Center for Medicare deputy director in charge of the traditional fee-for-service Medicare program. She has been working for CMS since 1990.

In Medigap announcements for 2016, CMS has identified Derrick Claggett as a Medigap policy specialist. 

Cynthia Tudor is the acting deputy director in charge of the Center for Medicare’s Medicare Advantage and Medicare Part D prescription drug plan programs. Earlier, she helped run the Medicare Advantage risk-adjustment program. She has a doctorate in sociology from Johns Hopkins University and received post-doctoral training in epidemiology at the University of Maryland.

CMS lists Arrah Tabe-Bedward as director of the Medicare Enrollment and Appeals Group, and Maria Ramirez as director of the group’s Division of Appeals Operations. Tabe-Bedward has a master’s degree in public service management from DePaul University and a law degree from the University of Maryland.

See also: Big Medicare Changes Ahead

CMS regional map

3. Who in the CMS private plans operation might, possibly, actually read a plea for help from an agent?

One sign that some of the highest-level Center for Medicare officials may be unexcited about seeing your emails about enrollment or administration problems is that they seem to have worked hard to keep themselves off Google.

If they have any LinkedIn entry at all, they may have one connection, or no connections at all.

James Kerr, the administrator at the CMS Consortium for Medicare Health Plans Operations, seems to be more open to the possibility of communicating with members of the public. His LinkedIn entry shows that he has a bachelor’s degree from Renssalaer Polytechnic Institute and a master’s degree from the City University of New York’s Baruch College.

Before he got involved with CMS, he was the deputy executive director at a health plan owned by New York Life and vice president for government health at a unit of UnitedHealth Group (NYSE:UNH). He manages about 400 field staff members in 10 CMS regional offices.

On the CMS regional offices website, CMS provides PDFs that give the name, e-mail address and telephone number of the associate regional administrator in charge of the Medicare Advantage and Medicare drug plan programs in each region. The associate regional administrators’ functions include “managing beneficiary and provider casework.”

  • Atlanta: Jabel Chase (acting).

  • Boston: Douglas Edwards.

  • Chicago: Heather Lang.

  • Dallas: Julie Kennedy.

  • Denver: Tod Anderson.

  • Kansas City: Judith Flynn.

  • New York: Reginald Slaten.

  • Philadelphia: James McCaslin.

  • San Francisco: Ann Duarte.

  • Seattle: Brenda Suiter.

See also: GAO Finds Gaps in Medicaid Rate Oversight 2016

4. Can a Medicare client use the PPACA public exchange system to get dental coverage?

Even if you’ve been advising clients about Medicare since Harry Truman got his Medicare card, you may have trouble answering the many questions clients have about how traditional Medicare coverage, Medigap plans, Medicare Advantage plans and Medicare drug plans do (or don’t) relate to the rules and programs created by the Patient Protection and Affordable Care Act of 2010 (PPACA).

One obvious question is: Why can’t your clients use PPACA exchange coverage to overcome the shortcomings of Medicare and Medicare-related plans?

Example: The traditional Medicare program, typical Medigap plans and typical Medicare Advantage plans do not provide dental benefits.

The PPACA public exchange programs can sell stand-alone dental plans.

Can your Medicare clients get their dental coverage from the PPACA public exchange system?

The fact is that the answer to this question depends on where you live. HHS requires residents of the states that use its enrollment system to buy qualified health plan (QHP) medical coverage through the system before they can sign up for stand-alone dental coverage. Consumers are not supposed to have Medicare coverage and QHP coverage at the same time. Because Medicare enrollees cannot have Medicare coverage together with QHP coverage, and they need QHP coverage to get dental coverage, they cannot get dental coverage.

Because of all of these rules, in the states, the only Medicare-eligible adults who can get dental coverage from the exchange system are those who use exchange QHP medical coverage in place of basic Medicare coverage. 

The QHP-first requirement for dental coverage purchases does not apply to the state-run exchanges.

Several state-based exchanges we checked apply the QHP-first requirement to would-be dental coverage purchasers.

Covered California, for example, says, “Adults with and without children can enroll in family dental plans, but they must purchase a health plan through Covered California in order to be eligible.”

But Connect for Health Colorado does let adults buy dental coverage without QHP coverage. “You can purchase a stand-alone dental plan even if you don’t plan to purchase a health insurance plan through the Marketplace,” that exchange says.

See also: Retirees can’t afford to lose dental coverage

Another important point is that we found this answer in Frequently Asked Questions Regarding Medicare and the Marketplace, a batch of guidance that CMS posted in August 2014 and updated earlier this year. CMS officials answer many other interesting questions in that set of frequently asked questions (FAQ) answers, ranging from, “Is having Medicare Part B coverage all by itself enough to protect a taxpayer from the penalties now imposed on people who fail to have “minimum essential coverage” (MEC)?” (the answer: no) to whether consumers with QHP coverage who become eligible for Medicare have to drop their QHP coverage (the answer: no, but any premium tax credits will go away).

Anyone who’s selling Medicare-related products will want to bookmark that FAQ set, print it out and read it carefully.

IRS headquarters

5. At tax time, how can Medicare clients show that they had MEC?

Individuals and couples now have to show they had MEC for most of the year, or had a good excuse not to have MEC, to avoid paying the penalties to be imposed on the uninsured and underinsured.

CMS is the agency responsible for requiring other coverage providers to send enrollees coverage notices, but it’s decided to give itself more time to come into full compliance with the notice requirements for Medicare enrollees.

For the 2015 tax year, CMS will provide MEC notices only for “Medicare beneficiaries who most need the information for tax filing purposes,” according to a new announcement

The enrollees who will get coverage notices for 2015 include Medicare Part A users under 65, consumers who enrolled in Part A for the first time in 2015, and consumers who had Part A for only part of 2015.

So, how do taxpayers with Medicare show the Internal Revenue Service (IRS) that they had MEC?

The IRS will cope with the lack of formal Medicare Part A MEC notices for all 2015 Medicare Part A users by letting users who are age 65 or older and have had Part A coverage for at least 12 months document that they had MEC by simply checking a box on the tax return form, CMS officials say in an announcement.

CMS will send MEC notices to all Part A users in early 2017 for the 2016 tax year.

CMS says it’s also conducting a tax form outreach campaign aimed at Medicare enrollees.

“CMS is confident that this approach will provide notices to the segment of beneficiaries who most need the information, while raising awareness among all beneficiaries that having Medicare Part A coverage means they are in compliance with the requirement to have health insurance,” officials say.

See also: Meet the 2015 PPACA tax forms

 Purple number fog

6. When your client gets a Medicare Summary Notice (MSN) with message number 14.8 on it, what does that mean, and what’s the Spanish translation of the English version of the message?

Medicare has its own standard version of a claim determination form, the MSN. CMS has posted detailed information about Medicare claims processing, including the Medicare Claims Processing Manual, on the MSN section of the Medicare website.

One download is a guide to the MSN message list. The entries range from 1.1, “Payment for transportation is allowed only to the closest facility that can provide the necessary care,” to 99.xx, which provides a block of message codes solely for use in Florida.

If a Medicare enrollee sees an MSN with message number 14.8, and, for some reason, the actual message is missing, the message list guide will show you that the number corresponds with the message, “Payment denied because the claim did not show if the test was purchased by the physician or if the physician performed the test.”

See also: Official sees Medicare summary notice problems

Justice figurine

7. If your Medicare Advantage plan client objects to a plan determination, how many layers of review could the client eventually pass through?

CMS offers an extensive guide to the Medicare managed care appeals and grievances process, including a Web-based training course.

An appeals process flowchart shows that an enrollee could fight a determination through four levels of appeals, and then, after getting through the fourth level, could try seeking judicial review.

At the first level, for example, reviewers are supposed to decide standard queries about access to medical services within 14 days, and standard queries about payments within 60 days.

See also: 4 PPACA claim fight secrets


8. Does the Medicare program offer a tool your clients can use to compare hospital quality data?

Yes. Try this site: //

See also: SSDI beneficiary says hospital dumped him at bus station

Ben Franklin

9. How many value-based payment programs was Medicare using before this year, and how many other programs is it supposed to add by 2019?

The list of legislation shaping new and coming value-based Medicare purchasing programs includes PPACA; the Medicare Improvements for Patients and Providers Act (MIPPA); the Protecting Access to Medicare Act of 2014 (PAMA); and the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).

Medicare managers added four value-based programs in 2012 and 2014: the End-Stage Renal Disease Quality Incentive Program (ESRD-QIP); the Hospital-Acquired Condition Reduction Program (HACP); the Hospital Readmissions Reduction Program (HRRP); and the Hospital Value-Based Purchasing Program (HVBP).

Medicare is adding the Value Modifier (VM) program this year.

It’s supposed to add the Skilled Nursing Facility Value-Based Purchasing Program (SNF-VBP) in 2019, and the Alternative Payments Models (APMs) and Merit-Based Incentive Payment System (MIPS) in 2019.

What does the start of all of these programs mean for your clients? They may find they have an easier time getting many types of care that factor into the official Medicare value calculations, but a harder time getting or affording types of care that don’t influence the value calculations.

See also: Incentive backer promotes Medicare Advantage changes

 ICD-10 diagnostic codes

10. What if your client’s doctor has a hard time figuring out the new diagnostic code system? 

Physicians are now supposed to be using diagnostic codes from the ICD-10 manual, rather than the ICD-9 manual

The ICD-10 system offers many more codes than the ICD-9 system, and much more precise codes. Defenders say use of the system will give insurers, researchers, public health authorities and others more detailed information about public health.

Critics say the new coding system is too complicated, and that some of the codes, such as a code for swimming pool of a prison as the place of occurrence of the external cause, are absurd.

CMS has responded to the concerns by making Dr. William Rogers, a practicing emergency room physician, the ICD-10 ombudsman. Health care providers can contact him via email.


11. What if your Medicare client’s doctor wants more ICD-10 codes?

The doctor could go before the CMS ICD-10 Coordination and Maintenance Committee to argue, for example, that the world needs more diagnostic codes. Perhaps separate codes for unheated prison swimming pools as the place of occurrence and heated prison swimming pools.

In September, for example, surgeons and others lobbied the committee for a number of new codes, for procedures such as “Branched and fenestrated endograft, repair of aneurysms,” and “Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement.”

For your client, the ICD-10 shift may give physicians even more of a financial incentive to try to increase coding intensity and jack up your clients’ (and their patients’) medical bills.

See also: 70,000 ways to die or get sick (and then bill insurance)

 Sandy damage

12. What if your Medicare clients are in a natural disaster?

Chances are the government will take care of them, but the underlying rules are less flexible than you might think.

Example: Even in a declared disaster, Medicare has no flexibility to reimburse nurses for providing emergency care they would not normally be able to deliver, and it has no flexibility to use traditional Medicare fee-for-service money to pay telehealth providers for providing the kind of screening services that might normally be provided in a hospital emergency room, according to a CMS FAQ set.

See also: Sick, frail struggle in Sandy’s aftermath

Image: Some of the damage in New Jersey caused by Superstorm Sandy. (New Jersey state photo)