Medicare Updates for PHers

Goodbye SGR, Hello New Medicare Cards

On April 16, 2015, the Medicare Access and CHIP Reauthorization Act (H.R. 2) was signed into effect by President Barack Obama after a bipartisan effort in both the House and Senate. Here are some notable results:

1. SGR Repeal
   The Medicare Sustainable Growth Rate, or SGR, is an outdated payment formula that has been in place since the '90s. Historically, it has reduced payments to Medicare physicians and threatened patients' access to treatment. H.R. 2 will replace this flawed formula with modest annual increases to Medicare funding.
    
2. Upgraded Medicare Cards
   Medicare will finally upgrade its Medicare cards to remove beneficiaries’ Social Security numbers from their cards. Many, including the Social Security Administration, have long protested this practice, noting the potential for identify theft. In this bill, Congress allocates $320 million over four years to fund the transition.
    
3. Higher Quality Care
   The bill includes a provision that incentivizes a transition from volume-based payments to value-based payments. This will encourage physicians to provide PH patients on Medicare with more consistent quality care at reasonable costs.

PHA has long lobbied for Medicare reform to address these needs and ensure treatment access for PH patients. Moving forward, PHA hopes to target the high out-of-pocket costs of specialty PH medications with the Patients' Access to Treatments Act (H.R. 1600).

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Advocacy Success - National PH Call-In Day

April 16, 2015, was also PHA’s National Call-In Day, a day-long event where PH community members called their Members of Congress and asked them to co-sponsor the Patients’ Access to Treatments Act. Constituents from 17 reported states made the calls and, within a week, eight legislators co-sponsored the bill, bringing the total to 66 co-sponsors.

To help PHA move this legislation through Congress and reduce the excessive out-of-pocket costs of PH medications, please visit PHA's Advocacy Action Center.

Insurance Updates and Cost-Saving Legislation

Insurance Updates and Cost-Saving Legislation

Take Action! If you or someone you know suffers from pulmonary hypertension (PH), then you have a powerful story to tell. Share yours on April 16, PHA's National Call-In Day. Tell your Members of Congress about the need for better access to treatment and urge them to co-sponsor the Patients' Access to Treatments Act (PATA).

With the ever-changing landscape of healthcare policies, it's important to stay up to date. Here are some recent insurance and healthcare updates:

1. Patient's Access to Treatments Act (PATA)
   A bipartisan bill that will limit costs for medications placed in a specialty tier, was introduced on March 25, 2015. The legislation seeks to make life-saving medications more accessible by reducing excessive out-of-pocket costs.
   
   PHA is one of 32 members of the Coalition for Accessible Treatments, which encourages patients, caregivers and physicians to ask lawmakers to support and co-sponsor the bill. See the sidebar to learn how you can take action to advance this important legislation.
2. ACA Enrollment ChangesThe Obama administration announced a change to the 2016 Affordable Care Act open enrollment period late last month. The open enrollment period for 2016 health insurance Marketplace plans will run from Nov. 1, 2015 to Jan. 31, 2016. This is a change from the 2015 open enrollment period, which ran from Nov. 15, 2014, to Feb. 15, 2015.
    
3. Medicare Network DirectoriesThe Center for Medicare & Medicaid Services (CMS) now requires Medicare Part C (Medicare Advantage) and Part D (prescription drug plan) providers to update their network directories four times a year.
   
   Previously, out-of-date directories were resulting in higher out-of-pocket costs and, in some cases, outright denials of coverage. Updated directories will also prevent situations where beneficiaries make plan selections based on a plan's network directory, only to find out that their preferred choice is not accepting new patients. If plans are found to have inadequate or outdated lists, the insurance providers can be fined or subject to sanctions that prohibit them from enrolling new members.

Know Your Oxygen Access Rights

Over the past few years, Medicare has been changing the way it pays for oxygen. Some oxygen providers have been taking advantage of patients' confusion to bend, and even break, the rules governing what they must provide. PHA can help you advocate for your oxygen rights.

What is supplemental oxygen or oxygen therapy?
Supplemental oxygen is prescribed by a physician and administered through a cannula or a face mask.

What are my rights?
Medicare recipients have the following rights. Those with private insurance should review their health benefits and contact their insurance provider with questions.

You have the right to continuous service. Oxygen suppliers:

• Cannot drop you, change your equipment or delivery system without approval from both you and your doctor
• Cannot change the terms of your contract regarding either your equipment or the number of tanks you receive
• Must continue to provide you services if you move to a new area - either directly or by contracting with another supplier for the remainder of your contract

You have the right to effective equipment and treatment. Oxygen suppliers:

• Must provide you with the necessary oxygen equipment accessories for the entire duration of your contract, including regulators, filters, masks and tubing
• Must provide you with working equipment and repair any broken equipment
• Must honor changes in medical necessity if your physician decides your oxygen equipment can no longer provide what you need (Note: your physician must provide a new letter of medical necessity)

Will my insurance provider pay for a portable oxygen concentrator (POC)?
Medicare and most insurance providers only cover the costs of your main source of oxygen. If you claim a POC as your main oxygen supply at the beginning of your contract, your insurance provider may pay for it. You would then have to pay for any additional equipment you need, such as a home concentrator. Please research the costs of all oxygen modalities prior to submitting an insurance claim.

What should I do if my oxygen provider is breaking the rules?

• Refuse any change of equipment or coverage. Provide your supplier with a written notice, refusing any unfair changes.
• Contact your oxygen supplier and insist that they provide you with written documentation of their proposed changes and intentions. This will be needed to file a Medicare complaint.
• Contact your physician and inform him/her of the situation.
• Ensure that your oxygen supplier is in communication with your physician and has the most recent letter of medical necessity.
• File a Medicare complaint with your written refusal notice, the oxygen supplier's documentation of changes and any medical documents regarding your oxygen needs (e.g., letter of medical necessity).
• Get the local media involved if your provider continues to break the rules.
• File an Americans with Disabilities Act complaint.

PHA can help you through this process. Contact Tim at Insurance@PHAssociation.org or 301-565-3004 x773 for assistance and additional information.