For pre-Medicare health insurance policyowners, pre-authorizations by an insurance carrier, prior to many healthcare services, is a standard practice. In many cases, pre-authorizations can be difficult to obtain, and/or policyholders can experience delays in receiving services.
Generally speaking, this does not occur to Medicare beneficiaries, with notable exception of home healthcare service recipients in certain states, under a Review Choice Demonstration (RCD) for Home Health Services. For the overwhelming majority of healthcare services under original Medicare, pre-authorizations are not required. Pre-authorizations can be used to deter fraud with respect to durable medical equipment
Pre-authorizations have recently been introduced to certain hospital procedures conducted on an outpatient basis, under a new program that took effect on July 1, 2020. This applies to a limited number of hospital outpatient department (OPD) services. The following hospital OPD services will require prior authorization, when provided on or after July 1, 2020:
- Botulinum toxin injections
- Vein ablation
For Medigap policyholders, this would be a new development. And as long as the service is deemed to be reasonable and medically-necessary, Medigap carriers will pay for the 20% of the Part B approved charge amount.
Medicare Advantage policyholder may have encountered a pre-authorization requirement, a process that is used in the large majority of Medicare Advantage plans, according to the Kaiser Family Foundation (“Prior Authorization in Medicare Advantage Plans: How Often Is It Used?,” October 18, 2018).
If a pre-authorization is denied, there is a formal appeals process at Medicare. For those covered by Medigap, the process begins by filing for a reconsideration with Medicare. For Medicare Advantage policyholders, the appeal process begins with the Medicare Advantage insurance company.
The complete list of procedures that require Pre-Authorization is here: https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf
For more information about Medicare, the website for Mr. Oh’s book, Maximize Your Medicare: Qualify for Benefits, Protect Your Health, and Minimize Your Costs: https://www.maximizeyourmedicare.com
The BENES Act (S. 1280/H.R. 2477) has been in the works since 2018. It is meant to address problems with enrolling in Medicare Part B. 760,000 pay a late enrollment penalty for Part B, according to estimates.
The BENES Act would:
- Send notices to beneficiaries about their upcoming 65th birthday, so that people are aware of Medicare enrollment dates.
- Change the General Election Period, the period to enroll in Part B, to be the same as the Annual Election Period (October 15 – December 7.
- Change the delay in coverage date of Part B when you enroll after the month of your birth date.. Currently, if you enroll in the month after your birth month, then there are delays in your Part B coverage date.
- The BENES Act would solve some other delays as well, such as the Special Enrollment Period vs IEP conflict. Currently, when both occur at the same time, the delay in coverage takes priority, and the result is that the Part B coverage date is not the one intended by the beneficiary. If this seems complicated and convoluted: it is.
- Introduce a Special Enrollment Period for those on COBRA, who want to enroll in Medicare Part B, but cannot, due to a misunderstanding about COBRA. Note: currently COBRA does not count as “health insurance” for Medicare purposes, and people unknowingly are subject to Part B Late Enrollment Penalties. In addition, those applicants currently are required to wait until the Open Enrollment Period, which runs from January 1st – March 31st of each year. Even from that point, Medicare Part B coverage would not begin until July 1.
This, and more, on the Maximize Your Medicare Weekly Video: https://youtu.be/YV8UY-SNYw8
Find out more about Medicare: https://www.maximizeyourmedicare.com
The BENEs Act is slowly making its way through Congress, with bipartisan support (oy vey!)
I am interviewed by Art Lewis, Medicare beneficiary. I have appeared on his shows almost 20 times over the years
An Early Look at the Potential Implications of the COVID-19 Pandemic for Health Insurance Coverage (click here to read).
Commonwealth Fund = top of the class thinktank. The stunning takeaway is the huge number of people that have lost health insurance coverage due to unemployment.
What is unknown and unreported here:
How many then enrolled in private health insurance?
How many are now newly uninsured after all is said and done? Update: we have estimates now: at least 5,000,000 (link).