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“In Original Medicare, according to an example provided by Kaiser, a $100 doctor’s bill involving a participating provider would cost you a 20 percent copayment, or $20, after Medicare’s 80 percent payment under Part B insurance rules. If you were, instead, seeing a nonparticipating provider, Medicare would first reduce its allowable fee for the service by 5 percent, from $100 to $95. If your doctor agreed to assignment here, Medicare would cover $76 of the $95 bill (its 80 percent payment) and you would pay the remaining $19. But if the doctor did not accept assignment, he or she would be able to charge you up to 115 percent of the reduced charge. In our example, this would total up to $109.25 (115 percent of $95). Medicare would still pay $76. But now you would pay not $19 but as much as $33.25. In the real world, of course, especially if the doctor involved was performing surgery, you would be multiplying this $100 many, many times over. And balance billing could definitely unbalance your budget.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“ProPublica, a foundation-supported investigative journalism site, has a Surgeon Scorecard.9 It’s been criticized by doctors’ groups, among others, and has generated lots of those learned papers mentioned earlier. I wouldn’t rely solely on this rating tool, or any other, but would use them collectively to get a better sense of surgical and hospital quality. It’s also important to note that we are still at an early stage of health care provider ratings, and that the tools will become better over time.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“There is an IRMAA appeals process designed to help people whose current incomes are substantially less than their two-year-old MAGI figure. There are eight specific “change of life” factors that might qualify someone for reconsideration of their IRMAA: • Death of spouse • Marriage • Divorce or annulment • Work reduction • Work stoppage • Loss of income from income-producing property • Loss or reduction of certain kinds of pension income • Employer settlement payout Work”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“By way of background, the measure of income used in the IRMAA rules is called modified adjusted gross income, or MAGI. It consists of adjusted gross income (AGI), which taxpayers are used to seeing on their tax returns. Adding tax-exempt interest income (from, say, municipal bonds) to AGI produces MAGI. The other key thing about IRMAA is that any IRMAA charges this year will be based on your tax returns of two years ago. So, for 2016 IRMAA obligations, use your 2014 tax returns. This lag, by the way, reflects how long it takes Social Security to get and process IRS tax-return records.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“For interested consumers, there are many health pricing tools. For starters, I recommend The Wall Street Journal’s “Medicare Unmasked” tools,2 although they may be behind a paywall. The Health Care Cost Institute3 is a health-insurer funded effort to compare the cost of various procedures around the country.4 ProPublica, a non-profit news site, is one of several consumer sites that has used the CMS databases to build tools that are not exactly beloved by health care providers, including Dollars for Docs5 and Surgeon Scorecard.6”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“If you are a wealthier taxpayer, you get a double Medicare hit. You pay more in Medicare payroll taxes because you earn more (recall that, unlike Social Security, there is no wage ceiling on Medicare taxes). But you also pay more in Medicare Part B and Part D premiums, and this enforced tithing will get worse, beginning in 2018.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Medicare has large financial assistance programs. The main program for drugs is called Extra Help.21 There is a broader set of Medicare Savings Programs22 that help cover other Medicare expenses. These important supports are explained in depth in the next chapter, which deals with the enormous, and enormously complex, maze of Medicare supports, income-based benefits, and premium surcharges. As always, please join me and read on.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Just so you know, drug discounts are viewed by Medicare as kickbacks and are therefore illegal. The logic is that such a discount could encourage a Medicare beneficiary to use a drug that costs more than a perfectly acceptable alternative. If Medicare thinks consumers or their prescribing health care providers will be improperly swayed by drug discounts, you’d think it could come up with other ways to deal with this problem.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“The company says it “weighs dozens of factors—ranging from a patient’s age, geography, and marital status, to prior prescription records and physician’s profile—to determine with 94 percent accuracy whether that patient will take his medication as prescribed. By comparison when asked, patients themselves correctly predict their own future nonadherence just 10 percent of the time.”3 It also analyzes speech patterns in its call-center traffic to identify follow-up needs. Other PBMs have similar “predictive analytics” capabilities.4”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Express Scripts, based in St. Louis, is the nation’s largest independent PBM, and fills prescriptions for more than 85 million health plan customers in and out of Medicare. Express Scripts knows what drugs these people are being prescribed and, over time, knows which drugs they take and which they don’t. It has assembled individual profiles of each of these 85 million consumers, and tracks 400 variables that not only reveal what people have done with their prescription meds but also, the company believes, predict what people will and won’t do, and their future health outcomes.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“The insurers who run Part D plans don’t like high drug prices, either. Even though their cost exposure is only 15 percent—remember, you pay 5 percent at most and Uncle Sam pays 80 percent—they would like it to be 15 percent of the smallest number possible. And it’s not Big Pharma that takes the calls and emails from unhappy Part D customers.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Now, Part D plans often market themselves based on their annual out-of-pocket limits on your drug expenses. Ceilings differ by plan and can be a major factor in choosing a plan in the first place. But these ceilings do not protect you from those 5 percent charges.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“It’s also true that today’s state of affairs is far, far better than it was before passage of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which created Medicare’s Part D drug plans. Prior to that law, many seniors could not afford drugs and either skimped on prescriptions or simply went without medications.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“MA quality ratings are based on a large set of medical care indicators, measuring such things as whether patients in the plan are using Medicare wellness tests and staying healthy, how well the plans help manage patients with ongoing or chronic health issues, how patients feel about the care they’ve received, and how Medicare assesses plan performance. These variables are contested by many professional groups and practitioners. That’s hardly a surprise. But in the interest of being consumer friendly myself, let me give you a few tips:”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Once you have an idea about the type of MA plan you want, it’s time to check out the CMS “star” ratings that measure the quality of MA plans. Plans receive from 1 to 5 stars, with some half stars in between. These ratings are being cleverly used by CMS. First, they give quick and easily understood guidance to consumers. Beyond this, however, they also represent powerful carrots and sticks for insurers.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Annual out-of-pocket maximums. One of the strongest selling points of MA plans is that they put a cap on your maximum annual health expenses. The ceiling, as noted earlier, was set at $6,700 several years ago by CMS. Most plans set lower ceilings.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“There are lots of ways that MA plans make money, but none is more important than their ability to build efficient provider networks. These networks certainly may promote your health, and there is impressive evidence that coordinated care provided in a network can be good for you. But it is unquestionably good for the health of the plans’ bottom lines.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Beyond these supports, which are comparable to the subsidies provided to Original Medicare users, Medicare began several years ago to pay bonuses to MA plans with high-quality ratings of 4 or 5 stars. These ratings will be explained in a bit. The takeaway here is that MA plans with high ratings are receiving several billion dollars each year in additional payments from Washington.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“MA insurers get roughly $10,000 from Uncle Sam for each and every beneficiary who buys a policy.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“When he trains people who provide Medicare counseling to consumers, here are his six “go-to” websites: • Medicare.gov, the Medicare website • CMS.gov, the CMS website • Regulations.gov, the federal regulations website • eCFR.gov, the electronic Code of Federal Regulations website • SSA.gov, the Social Security Administration’s website, and • HealthCare.gov, the federally facilitated medical marketplace website”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Part B charges a monthly premium that in 2016 is $104.90 for most beneficiaries. However, about 5 percent of Part B subscribers earned enough money to push them into higher premium brackets. This set of surcharges is known as the income-related monthly adjustment amount, or IRMAA.16 Social Security makes this call and bases premiums on federal tax returns two years prior to the program year in question. So, the agency used 2014 returns to determine any 2016 Part B premium surcharges. For the detail-minded, the agency uses a measure of taxable income called “modified adjusted gross income.”17 Chapter 9 includes details of Part B premiums and surcharges.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“versus admissions. By the way, this is true even if the actual care a person receives in both situations is identical—same doctors, same procedures, same medications, same supplies, same everything.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“For reasons I’ll get to shortly, hospitals have compelling reasons to “observe” people as outpatients instead of admitting them as inpatients. The distinction is important because Medicare may pay different amounts for observational hospital stays”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“During each benefit period, you pay $0 coinsurance for the first 60 days you’re hospitalized, $322 a day for days 61 through 90, and $644 a day for days 91–150, assuming you have not used any of what Medicare calls your “lifetime reserve days.” You get 60 of these your entire life. After 150 days, or after 90 days if you’ve already used up your lifetime reserve days, you’re responsible for all hospital costs.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“I also am a fan of the Medicare Rights Center (MRC), a nonprofit providing free consumer Medicare information and counseling. Its Medicare Interactive online service4 lets you pose specific questions or subject areas that will lead you to helpful information. And you can always pick up the phone and call its national helpline at 800-333-4114 if you have questions.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“The linkage between Medicare and Social Security is hardly accidental. The SSA is legally responsible for a lot of Medicare work, including alerting people when they’re eligible, signing them up, sending out their Medicare cards, and withholding Medicare premiums from monthly Social Security payments.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Part D plans are voluntary per Medicare rules, which strikes me as a really bad idea. Who except the 1 percenters can afford to pay for their own meds? Yet while Medicare is telling people they are not legally required to have Part D plans, it will sock them with potentially enormous penalties should they fail to enroll in the plans when they first take Medicare.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“The freedom of choice provided by fee-for-service Original Medicare to beneficiaries comes at a financial cost. The reason is as obvious as the phrase. Fee-for-service means that health care providers get paid for the surgeries, care, and other health care services they provide. It says nothing about whether all this health care is needed or even in the best interest of the patient. Medicare Advantage health networks, by contrast, can be cheaper providers of care than can fee-for-service Medicare. Insurers can control costs more effectively by assembling their own groups of doctors, hospitals, and other service providers. Cheaper health care, not surprisingly, has its own downsides. Provider networks are so important to the present and future prospects of Medicare beneficiaries that they merit their own chapter (12) later in this book.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Original Medicare is a fee-for-service program that allows people to choose whatever caregivers they wish (provided the caregiver accepts Medicare, which not all caregivers do). However, even if MA plans can be cheaper and cover more health needs than Original Medicare, there is no free lunch here, meaning there can be some big downsides to MA plans.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs

“Among all Original Medicare beneficiaries, fewer than 25 percent get Medigap policies.”
― Philip Moeller, Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs