HAP's Troubleshooting Medicare project identifies and assesses the persistent and systemic access to care and quality of care issues negatively affecting Medicare beneficiaries. Together with the SHIP network, HAP is working to spot issues in four categories. As we identify issues, we will work with you to raise awareness around each issue and develop recommendations for policymakers, including members of Congress and the Centers for Medicare & Medicaid Services (CMS), to improve the Medicare program as a whole.

HAP has developed informational tools to help SHIPs counsel and assist their clients in the interim. See below for more information on each issue category and for links to available resources.

Access to Care

QMB and Medicare Cost-Sharing

This category encompasses those situations that prevent a beneficiary from getting the care they need, such as out-of-pocket costs for health plan deductibles and copayments. For example, a member of a Medicare Advantage (MA) plan who has to pay $50 for each outpatient physical therapy visit may forgo a number of prescribed visits as the bills begin to mount. The result may be an incomplete recovery from joint replacement surgery, an injury, or stroke. This is an access to care issue.

Informed Decision-Making

Moving & Extending the AEP

Complete and accurate information is essential to making informed decisions and choices about health care options. For example, Medicare rules state that medical providers should only issue Advance Beneficiary Notices (ABNs) in cases where a patient's condition makes Medicare coverage for a specific test or procedure unclear. Yet some providers, including clinics and labs, wrongly give ABNs to all of their patients, informing them that they will be liable for the bill if Medicare denies coverage. The indiscriminate use of ABNs prevents beneficiaries from making informed decisions about their health care. This category reflects those situations in which your client’s decision-making has been compromised.

Health Care Inequities and Disparities

Low-income and limited resources create barriers to care for some Medicare beneficiaries. For example, Medicare rules prevent physicians and other providers from billing Qualified Medicare Beneficiaries (QMBs) for Medicare cost-sharing amounts. Yet some providers, who say they do not participate in the state Medicaid program, do so. The result is that many QMBs face bills that they cannot afford to pay. This issue category reflects any beneficiary situation in which one’s demographics lead to compromised coverage or receipt of benefits.

Plan Design and Benefits

This category includes issues related to plan design and benefits. For example, coinsurance charges for Part B drugs are common in Medicare Health Maintenance Organizations (HMOs) and Private-Fee-for-Service (PFFS) plans. However, beneficiaries who do not understand that they are liable for 20 percent of the cost of expensive chemotherapy drugs may be overwhelmed by unexpected bills that amount to tens of thousands of dollars. The result is that misunderstandings like this example can be disastrous to a beneficiary.

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