People excused from paying Medicare cost-sharing being tricked into paying it anyway

[eridani]

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/Access_to_Care_Issues_Among_Qualified_Medicare_Beneficiaries.pdf

People with QMB are excused, by law, from paying Medicare cost-sharing. Providers are prohibited from charging them. All cost-sharing (premiums, deductibles, co-insurance and copayments) related to Parts A and B is excused, meaning that the individual has no liability. The state has responsibility for these payments for QMBs regardless of whether the particular service is also a Medicaid-covered service.

Despite this prohibition, the CMS study found that providers illegally balance-billed participants for Medicare cost-sharing on a regular basis. Due to a lack of information, confusion regarding the system, or concern over outstanding bills, most QMB enrollees participating in the study paid these bills. Additionally, participants reported that unpaid bills were submitted to collection agencies. Another finding in the study was that participants experienced challenges with the appeals process. The study also found that beneficiaries were dissatisfied with service coverage, particularly for Durable Medical Equipment (DME).

The CMS report shows an alarming trend that low-income beneficiaries enrolled in the QMB program are frequently being illegally balance-billed, and that though they are not liable for the charges, many of the bills were sent on to collections if unpaid, and most beneficiaries actually paid. In addition, the CMS report found that QMB enrollees were less likely to use office visits and hospital outpatient services compared to Medicare-only enrollees in states that employed the “lesser-of” policy for reimbursement, thereby limiting access to essential routine and preventive care for beneficiaries. The report provides troubling information regarding access to care for low-income beneficiaries that underscores the need for continued advocacy efforts for this vulnerable population.

[Katashi_itto]

1. K&R!

[bemildred]

2. This is why I avoid "health care" whenever I can. nt

[eridani]

3. Actually, that is very easy to do. In every demographic slice, 5% of that slice accounts for--

--50% of all health care costs, and 15% for 25% of costs. The vast 85% majority is pretty healthy.

[pnwmom]

5. The older you are, however, the less likely that is true. The elderly tend to have

a lot more chronic illnesses.

[eridani]

6. That means that total expenses for the 60ish demographic are higher than those for the--

--20ish demographic. The percentages still hold.

[pnwmom]

7. Okay. But it isn't generally "easy" to stay healthy when you're 80,

even if it is easier for some people than others.

[eridani]

8. Slowly things start breaking down, but the whole point of Medicare Advantage--

--is avoiding policies for that sickest 5%.

[pnwmom]

4. Thank you! My mother has been getting some bills I don't understand

since she has even has a Medigap policy. My mother in law had the same policy and she never had to pay anything.

[1939]

9. Some try to get the bills out quick

My insurance works so that Medicare gets the bill and determines how much they will pay. then they throw the bill "over a fence" to my secondary insurer who pays the deductibles and copays. Some of the time, the provider bills me for the deductible as soon as they get the Medicare check. I then have to call them (actually a third party biller) and explain that they have to wait for the second check. Big waste of time because everyone is defended from having to answer the phone by an automated system with several layers of brainless menus.