Telehealth is a Medicare-approved healthcare service between a provider and a patient via a telecommunication system (such as by phone or video chat). It’s been a covered service for more than a decade, focusing on rural areas where appropriate care may be hard to come by. Patients would be “seen” via a communications medium at a Medicare-approved location (not their homes), and the provider and the facility they were “seen” at would receive payment for the service.
Let’s fast forward to today. The model has changed. As of March 6, 2020, providers can perform “office” visits and other expanded services via telecommunications to a beneficiary at their home. Regulations require that the provider (your doctor, a physician assistant, nurse practitioner, etc.) have an interactive audio and video communications system for use in this service. An “office visit” is another term for a “doctor’s visit;” however, visits completed through telehealth can also include emergency department visits, initial hospital and nursing facility visits and hospice visits. Telehealth services also include psychotherapy, services for substance use disorders, certain physical, occupational and speech-language pathology services and many others.
The expansion to allow for telehealth services in a patient’s home are part of Medicare’s response to the COVID-19 Public Health Emergency (PHE) starting on March 6, 2020. Many Medicare patients are more vulnerable to this disease, based on their medical conditions and age. As such, the expansion of telehealth services makes sense for both the provider and the patient. This has been especially important as many provider offices were closed or were not accepting in-person visits with beneficiaries. Providers are still required to perform the service in a Medicare-approved location, such as a physician’s office, skilled nursing facility or hospital.
Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS) and a member of the White House Coronavirus Task Force, said that this expansion of services “represents a seismic shift, initiating a new era of healthcare delivery in America,” per CMS. (To learn more about Administrator Verma’s comments, please visit the CMS website at www.CMS.gov/Newsroom).
If you have a telehealth service, Part B coinsurance and deductible apply. You pay 20% of the Medicare allowed amount after your Part B deductible has been met. These costs are the same as if you had an in-person visit. If you have a preventive or screening service, for which the Part B coinsurance and deductible do not apply, you will pay nothing.
Be sure to watch your quarterly Medicare Summary Notice (MSN) to be sure the charges are correct as many providers are learning how to bill for these services in real-time. If you notice any discrepancies, or you are asked to pay more than you would for an in-person visit, be sure to call Palmetto GBA’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET when customer service representatives are available or visit Palmetto GBA’s website at www.PalmettoGBA.com/RR/Me.
Last July, the Railroad Retirement Board (RRB) mailed approximately 450,000 new Railroad Medicare cards with new Medicare Numbers. The new Medicare Numbers, which are unique to each person with Railroad Medicare and do not contain Social Security Number (SSNs), replace the former Health Insurance Claim Numbers (HICNs). Providers can bill claims to Medicare with either a HICN or a new Medicare Number through December 31, 2019.
At this time, approximately 70% of the Railroad Medicare claims received are submitted with Medicare Numbers. Beginning January 1, 2020, all providers will be required to file claims with Medicare Numbers only.
When it’s time for a doctor’s appointment or other Medicare service, be sure to take your new card with you. Your provider’s office knows everyone should have a new Medicare Number, and they will need to keep a record of your Medicare Number so they can bill Railroad Medicare correctly.
If your provider does not have a copy of your card, they may be able to look up your information with their local Medicare Administrative Contractor (MAC) or with Palmetto GBA Railroad Medicare through our online provider portals. These portals give authorized providers access to claims history, eligibility and more. The portals also contain a tool that allows providers to look up a Medicare Number with the following patient information:
Date of Birth
Social Security Number
Please note that in order to use the tool to look up your Medicare Number, a provider must have your Social Security Number. If you do not want to give a provider your SSN, allow them to have a copy of your card or verbally give them your Medicare Number. If you have not used your card yet, you are making it much more difficult for your providers to file claims timely. One of the reasons for having the new cards was to give protection from identity theft. One way to do that is to be very selective when giving your personal information to a trusted entity (your doctor, insurers, etc.).
When verbally giving your Medicare Number to a provider, or to a Customer Service Advocate when you call Railroad Medicare, make sure to read it correctly. Medicare Numbers have 11 characters and contain numbers and uppercase letters only. They do not contain the letters S, L, O, I, B or Z. Characters one, four, seven, 10 and 11 will always be a number. The second, fifth, eighth and ninth characters will always be a letter. The third and sixth characters will be a letter or a number.
Sample RRB Medicare Card:
If you are enrolled in a Medicare Advantage Plan, your new Medicare card does not replace your plan’s identification card. You will continue to use your plan’s ID card to receive your Medicare benefits.
If you did not receive your new Medicare Card with your new Medicare Number, you can call Palmetto’s Beneficiary Contact Center at 800-833-4455 or the Railroad Retirement Board at 877-772-5772.
If you have questions about new Medicare cards or Medicare Numbers, please call Palmetto GBA’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. You are encouraged to sign up for email updates. To do so, click ‘Listservs’ on the top banner on the Palmetto website at www.PalmettoGBA.com/RR/Me. You are also encouraged to use the beneficiary portal, MyRRMed, which is located at www.PalmettoGBA.com/MyRRMed.
The federal Medicare program provides hospital and medical insurance protection for Railroad Retirement annuitants and their families, just as it does for Social Security beneficiaries. Medicare has the following parts:
Medicare Part A (hospital insurance) helps pay for inpatient care in hospitals and skilled nursing facilities (following a hospital stay), some home health care services and hospice care. Part A is financed through payroll taxes paid by employees and employers.
Medicare Part B (medical insurance) helps pay for medically-necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services. Part B is financed by premiums paid by participants and by federal general revenue funds.
Medicare Part C (Medicare Advantage Plans) is another way to get Medicare benefits. It combines Part A, Part B, and sometimes, Part D (prescription drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare.
Medicare Part D (Medicare prescription drug coverage) offers voluntary insurance coverage for prescription drugs through Medicare prescription drug plans and other health plan options.
The following questions and answers provide basic information on Medicare eligibility and coverage, as well as other information on the Medicare program.
1. Who is eligible for Medicare?
All Railroad Retirement beneficiaries age 65 or over and other persons who are directly or potentially eligible for Railroad Retirement benefits are covered by the program. Although the age requirements for some unreduced Railroad Retirement benefits have risen just like the Social Security requirements, beneficiaries are still eligible for Medicare at age 65.
Coverage before age 65 is available for disabled employee annuitants who have been entitled to monthly benefits based on total disability for at least 24 months and have a disability insured status under Social Security law. There is no 24-month waiting period for those who have ALS (Amyotrophic Lateral Sclerosis), also known as Lou Gehrig’s disease.
If entitled to monthly benefits based on an occupational disability, and the individual has been granted a disability freeze, he or she is eligible for Medicare starting with the 30th month after the freeze date or, if later, the 25th month after he or she became entitled to monthly benefits. If receiving benefits due to occupational disability and the person has not been granted a disability freeze, he or she is generally eligible for Medicare at age 65. (The standards for a disability freeze determination follow Social Security law and are comparable to the medical criteria a person must meet to be granted a total disability.)
Under certain conditions, spouses, divorced spouses, surviving divorced spouses, widow(er)s, or a dependent parent may be eligible for Medicare hospital insurance based on an employee’s work record when the spouse, etc., turns 65. Also, disabled widow(er)s under 65, disabled surviving divorced spouses under 65, and disabled children may be eligible for Medicare, usually after a 24-month waiting period.
Medicare coverage at any age on the basis of permanent kidney failure requiring hemodialysis or receipt of a kidney transplant is also available to employee annuitants, employees who have not retired but meet certain minimum service requirements, spouses and dependent children. The Social Security Administration has jurisdiction over Medicare in these cases. Therefore, a Social Security office should be contacted for information on coverage for kidney disease.
2. How do persons enroll in Medicare?
If a retired employee or a family member is receiving a Railroad Retirement annuity, enrollment for both Medicare Part A and Part B is generally automatic and coverage begins when the person reaches age 65. For beneficiaries who are totally disabled, both Medicare Part A and Part B start automatically with the 30th month after the beneficiary became disabled or, if later, the 25th month after the beneficiary became entitled to monthly benefits. Even though enrollment is automatic, an individual may decline Part B; this does not prevent him or her from applying for Part B at a later date. However, premiums may be higher if enrollment is delayed. (See question five for more information on delayed enrollment.)
If an individual is eligible for, but not receiving an annuity, he or she should contact the nearest Railroad Retirement Board (RRB) office before attaining age 65 and apply for both Part A and Part B. (This does not mean that the individual must retire, if working.) The best time to apply is during the three months before the month in which the individual reaches age 65. He or she will then have both Part A and Part B protection beginning with the month age 65 is reached. If the individual does not enroll for Part B in the three months before attaining age 65, he or she can enroll in the month age 65 is reached, or during the three months that follow, but there will be a delay of 1 to 3 months before Part B is effective. Individuals who do not enroll during this “initial enrollment period” may sign up in any “general enrollment period” (January 1 – March 31 each year). Coverage for such individuals begins July 1 of the year of enrollment.
3. Are there costs associated with Medicare Part A (hospital insurance)?
Yes. While individuals don’t have to pay a premium to receive Medicare Part A, recipients of Part A benefits are billed by the hospital for a deductible amount ($1,364 in 2019), as well as any coinsurance amount due and any noncovered services. The remainder of the bill from the hospital, as well as bills for services in skilled nursing facilities or home health visits, is sent to Medicare to pay its share.
4. What are the costs associated with Medicare Part B (medical insurance)?
Anyone eligible for Medicare hospital insurance (Part A) can enroll in Medicare medical insurance (Part B) by paying a monthly premium. The standard premium is $135.50 in 2019. However, some Medicare beneficiaries will not pay this amount because of a provision in the law that states Part B premiums for current enrollees cannot increase by more than the amount of the cost-of-living increase for Social Security (Railroad Retirement Tier I) benefits. Since that adjustment was 2.8 percent for 2019, about 2 million Medicare beneficiaries saw an increase in their Part B premiums, but still pay less than $135.50. The standard premium amount applies to new enrollees in the program, and certain beneficiaries who pay higher premiums based on their modified adjusted gross income.
Monthly premiums for some beneficiaries are greater, depending on a beneficiary’s or married couple’s modified adjusted gross income. The income-related Part B premiums for 2019 are $189.60, $270.90, $352.20, $433.40, or $460.50, depending on how much a beneficiary’s modified adjusted gross income exceeds $85,000 ($170,000 for a married couple), with the highest premium rates only paid by beneficiaries whose modified adjusted gross incomes are over $500,000 ($750,000 for a married couple).
There is also an annual deductible ($185 in 2019) for Part B services.
Palmetto GBA, a subsidiary of Blue Cross and Blue Shield, generally processes claims for Part B benefits filed on behalf of Railroad Retirement beneficiaries in the Original Medicare Plan (the traditional fee-for-service Medicare plan). An individual in the Original Medicare Plan should have his or her hospital, doctor, or other health care provider submit Part B claims directly to:
Persons with questions about Part B claims under the Original Medicare Plan can contact Palmetto GBA as noted above.
5. Can Medicare Part B premiums increase for delayed enrollment?
Yes. Premiums for Part B are increased 10% for each 12-month period the individual could have been, but was not, enrolled. However, individuals age 65 or older who wait to enroll in Part B because they have group health plan coverage based on their own or their spouse’s current employment may not have to pay higher premiums because they may be eligible for “special enrollment periods.” The same special enrollment period rules apply to disabled individuals, except that the group health insurance may be based on the current employment of the individual, his or her spouse or a family member.
Individuals deciding when to enroll in Medicare Part B must consider how this will affect eligibility for health insurance policies which supplement Medicare coverage. These include “Medigap” insurance and prescription drug coverage and are explained in the answers to questions six through eight.
6. What is Medigap insurance?
Many private insurance companies sell insurance, known as “Medigap,” that helps pay for services not covered by the Original Medicare Plan. Policies may cover deductibles, coinsurance, copayments, health care outside the United States and more. Generally, individuals need Medicare Part A and Part B to enroll, and a monthly premium is charged. When someone first enrolls in Medicare Part B at age 65 or older, he or she has a one-time 6-month “Medigap open enrollment period.” During this period, an insurance company cannot deny coverage, place conditions on a policy, or charge more for a policy because of past or present health problems.
7. Do Medicare beneficiaries have choices available for receiving health care services?
Yes. Under the Original Medicare Plan, the fee-for-service Medicare plan that is available nationwide, a beneficiary can see any doctor or provider who accepts Medicare from qualified Railroad Retirement beneficiaries and is accepting new Medicare patients. Those enrolled in the Original Medicare Plan who want prescription drug coverage must join a Medicare prescription drug plan as described in question eight.
However, a beneficiary may opt to choose a Medicare Advantage Plan (Part C) instead. These plans are managed by Medicare-approved private insurance companies. Medicare Advantage Plans combine Medicare Part A and Part B coverage, and are available in most areas of the country. An individual must have Medicare Part A and Part B to join a Medicare Advantage Plan, and must live in the plan’s service area. Medicare Advantage Plan choices include regional preferred provider organizations (PPOs), health maintenance organizations (HMOs), private fee-for-service plans and others. A PPO is a plan under which a beneficiary uses doctors, hospitals and providers belonging to a network; beneficiaries can use doctors, hospitals and providers outside the network for an additional cost. Under a Medicare Advantage Plan, a beneficiary may pay lower copayments and receive extra benefits. Most plans also include Medicare prescription drug coverage (Part D).
8. How does Medicare Part D (Medicare prescription drug coverage) work?
Medicare contracts with private companies to offer beneficiaries voluntary prescription drug coverage through a variety of options, with different covered prescriptions and different costs. Beneficiaries pay a monthly premium (averaging about $33 in 2019), a yearly deductible (up to $415 in 2019) and part of the cost of prescriptions. Those with limited income and resources may qualify for help in paying some prescription drug costs.
The Affordable Care Act requires some Part D beneficiaries to also pay a monthly adjustment amount, depending on a beneficiary’s or married couple’s modified adjusted gross income. The Part D income-related monthly adjustment amounts in 2019 are $12.40, $31.90, $51.40, $70.90, or $77.40, depending on the extent to which an individual beneficiary’s modified adjusted gross income exceeds $85,000 ($170,000 for a married couple), with the highest amounts only paid by beneficiaries whose incomes are over $500,000 ($750,000 for a married couple).
To enroll, individuals must have Medicare Part A and live in the prescription drug benefit plan’s service area. Beneficiaries can join during the period that starts three months before the month their Medicare coverage starts and ends three months after that month. There may be a higher premium if an individual does not join a Medicare drug plan when first eligible. A beneficiary can generally join or change plans once each year during an enrollment period from October 15 through December 7. Drug coverage would then begin January 1 of the following year. In most cases, there is no automatic enrollment to get a Medicare prescription drug plan. Individuals enrolled in Medicare Advantage Plans will generally get their prescription drug coverage through their plan.
9. Where can I get more information about the Medicare program?
General information on Medicare coverage for Railroad Retirement beneficiaries is available on the RRB’s website, RRB.gov, under the Benefits tab (Medicare) or by contacting an RRB field office toll-free at 1-877-772-5772.
More detailed information on Medicare’s benefits, costs, and health care options are available from the Center for Medicare & Medicaid Services (CMS) publication Medicare & You, which is mailed to Medicare beneficiary households each fall and to new Medicare beneficiaries when they become eligible for coverage. Medicare & You and other publications are also available by visiting Medicare’s website, Medicare.gov, or by calling the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227).
When a natural disaster, extreme weather or other emergency occurs that affects providers and the Medicare beneficiaries that they serve, special emergency-related policies and procedures may be implemented.
The process begins when a governor of an affected state requests assistance. This is done if the event is beyond the combined response abilities of the state and local governments. From this request, the President of the United States can declare a Public Health Emergency (PHE), using the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
Under Section 1135 or 1812(f) of the Social Security Act, the Centers for Medicare & Medicaid Services (CMS) can issue ‘blanket waivers’ for providers and suppliers when it comes to services that are provided by skilled nursing facilities, home health agencies and critical access hospitals. Measures are in place to assist with durable medical equipment and supplies, as well as quality reporting, extending the appeals time limit, and getting replacement prescription refills.
As an example in an impacted area, when a waiver is granted for submitting appeal requests (which normally would need to be filed 120 days from the date of the claim denial notification), an appeal may be filed after the 120 days based on CMS guidance.
The following are the most recent hurricane-related PHE’s for which HHS has authorized waivers:
Hurricane Michael – Florida (at the time of writing this article)
Hurricane Florence – North Carolina, South Carolina and Virginia
Hurricane Maria – Puerto Rico and the U.S. Virgin Islands
Hurricane Nate – Louisiana and Mississippi
Hurricane Irma – Florida, Georgia and South Carolina
Hurricane Harvey – Texas and Louisiana
Medicare has a toll-free helpline you can use if you are in an impacted area. This Disaster Distress Helpline is available 24/7. The toll-free, multilingual and confidential crisis support service can be reached by calling 1-800-985-5990. You can also text TalkWithUs to 66746 (for Spanish, press 2 or text Hablanos to 66746) to connect with a trained crisis counselor.
Hurricanes don’t discriminate in terms of destruction, and there are times when a person only has the clothes on their back – but no wallet or Medicare card to get assistance. If you lose your Medicare card, you can call our Beneficiary Customer Service Center at 800-833-4455, Monday through Friday, 8:30 a.m. until 7 p.m. ET to order a new one. For the hearing impaired, call TTY/TDD at 877-566-3572. You may also call the Railroad Retirement Board at 877-772-5772.
The Centers for Medicare & Medicaid Services (CMS) is reviewing regulations that mandate how doctors and other practitioners document the services they provide. The focus is on the following:
Reducing unnecessary burden
Increasing process efficiencies
Improving the patient’s experience with their provider
CMS is beginning this process with evaluation and management services (office or outpatient visits). The goal is to increase the time providers spend with their patients and decrease the time spent documenting services. At the same time, CMS consistently seeks to reduce provider errors and unnecessary appeals.
CMS Administrator Seema Verma explained: “…we are moving the agency to focus on patients first. To do this, one of our top priorities is to ease the regulatory burden that is destroying the doctor-patient relationship. We want doctors to be able to deliver the best quality care to their patients.”
If you have questions about your Railroad Medicare coverage, you may call Palmetto GBA’s Beneficiary Contact Center at 800-833-4455, or for the hearing-impaired, call TTY/TDD at 877-566-3572. Customer service representatives are available Monday through Friday, from 8:30 a.m. until 7 p.m. ET. Visit Palmetto’s Facebook page at https://www.facebook.com/myrrmedicare/.
Visit Palmetto GBA’s free online beneficiary portal at www.PalmettoGBA.com/MyRRMed. This tool offers you the ability to access Railroad Medicare Part B claims data, historical Part B Medicare Summary Notices (MSN), and a listing of individuals you have authorized to have access to your personal health information.
Medicare is always working to fight fraud and abuse. With that, a new type of claim review has recently begun: a process called Targeted Probe and Educate, or ‘TPE’ for short.
How TPE works:
Palmetto GBA/Railroad Medicare will conduct data analysis and find providers whose billing may be very different from their peers. Palmetto will also look at providers who have been identified as having a high error rate (having filed claims that should not be paid, due to medical necessity issues, billing or coding errors, or ones that do not have sufficient documentation to support the service was rendered as billed).
Once a provider is identified, Palmetto will request records for 20 to 40 services, depending on how much the provider has billed to Railroad Medicare.
After the claims are reviewed, one of Palmetto’s clinical staff members will contact the provider by letter and by phone to go over their results and offer education on how to bill and document their services correctly. If the provider has a high error rate in the review, then Palmetto will ask for records for an additional 20-40 claims submitted for payment and follow the process outlined above. If the provider fails to improve again, then a last round of TPE is conducted. If the provider’s error rate is still unacceptable, they will be referred to Palmetto’s Benefit Integrity Unit for investigation. The same is true for providers who refuse to respond to the records requests.
However, if the provider makes an appropriate improvement, they can be removed from the TPE process for a period of time, and then rechecked later to be sure they are still in compliance.
If your provider has questions:
Your provider may have questions about this review process. If they do, please ask them to call our Provider Contact Center at 888-355-9165 and select Option 5. Customer Service Representatives can assist them in understanding the TPE process. All Medicare contractors are using the TPE process to review claims.
If you have any questions about your Railroad Medicare coverage, please call Palmetto’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at 877-566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available.
Palmetto also invites you to join their listserv/email updates. Just select the ‘Listservs’ link at the top of their main webpage at www.PalmettoGBA.com/RR/Me.
Palmetto GBA has introduced a new beneficiary portal, MyRRMed, where users will have access to claims data, historical Medicare Summary Notices and data on who they have authorized to have access to their private health information.
At this time, you can use the portal to access:
Status and details of your last 22 Railroad Medicare claims on file
Historical Medicare Summary Notices (MSNs)
You also can view a list of individuals with whom you have authorized Railroad Medicare to grant access to your healthcare information.
Creating an Account:
Accessing MyRRMed information is easy. Just click here to follow the link and enter the following information:
Your Medicare number (as printed on your Medicare card)
Your last name
Your first name
Your date of birth
The effective date for Part B (as printed on your Medicare card)
Once you have entered this information and it is verified within our files, you will create a user name and password.
Logging Into the Portal:
To enhance the security of Medicare data, the Centers for Medicare & Medicaid services (CMS) requires Palmetto GBA to adhere to several security requirements. Some of these security features require the user to verify their identity using their email address.
This is done through what’s called ‘Multi-Factor Authentication’, or ‘MFA’. MFA has the user log partially in, and then the system sends a ‘passcode’ (a unique and random set of numbers) to either your telephone by text or your email for you to enter on the portal access page. Upon each log in, users are required to enter an MFA code in addition to their password to access MyRRMed. CMS requires that Medicare contractors use MFA as a secondary level of security to protect beneficiary data.
When is the Portal Available?
MyRRMed is generally available 24 hours a day, seven days a week. However, certain functions are only available from 8 a.m. to 7 p.m. Eastern Time (ET). These include accessing claims data and MSNs.
If you have questions about using the tool, please call Palmetto’s Beneficiary Contact Center at 800-833-4455, or for the hearing-impaired, call TTY/TDD at 877-566-3572. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. until 7 p.m. EST.
Beginning Oct. 15 and running through Dec. 7, 2017, the open enrollment period allows Medicare-eligible patients the option of changing their coverage for 2018. Your 2018 Medicare & You Handbook should have arrived via the postal mail, and it’s important that you read this guide as you are making your decision. Every year, open enrollment is the chance to decide if you want to keep your current plan, or change to a Medicare Advantage Plan, or other health plans. If you were eligible for but not enrolled in Medicare Part B last year, you can sign up for coverage with Original Medicare or a Medicare Advantage Plan. Open enrollment is also the time to sign up for or change your prescription drug coverage, if you need to.
While the Part B premium and deductible have not yet been published, Part B (which includes Railroad Medicare) works as the following:
You pay a Part B premium each month (most people will pay a standard amount).
You may pay more if your adjusted gross income on your income tax return from two years ago is above a certain level.
For most services, you have a 20 percent copay.
If you need help determining the best plan for you, we encourage you to contact your State Health Insurance Program, also called ‘SHIP’. SHIP is available in all 50 states and U.S. territories. It may be called something slightly different in your state (California’s SHIP is called the ‘California Health Insurance Counseling & Advocacy Program’ (HICAP)). However, they function the same way. You can find the contact information for the SHIP in your state by visiting Palmetto GBA’s website at www.PalmettoGBA.com/RR/Me/SHIP.
If you have questions about SHIP, you can call Palmetto’s toll-free Beneficiary Customer Service Line at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. EST. For the hearing impaired, call TTY/TDD at 877-566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available.
Palmetto GBA invites you to join their listserv/email updates. Just select the ‘listservs’ link at the top of their main webpage at www.PalmettoGBA.com/RR/Me.
The Centers for Medicare & Medicaid Services (CMS) has released the 2016 Part B premium and deductible costs for 2016. Railroad Medicare processes claims for Part B services.
The 2016 monthly premiums will remain unchanged for approximately 70 percent of Medicare beneficiaries. However, the remaining 30 percent will pay a different amount based on the following criteria:
those enrolling for the first time in 2016
individuals not receiving Railroad Retirement/Social Security benefits
those who are directly billed for their Part B premiums
those who have Medicare and Medicaid and Medicaid pays the premiums, or
individuals whose modified gross incomes from two years ago is above a certain threshold
For beneficiaries who meet one of those criteria, Part B premiums for 2016 will be based on their annual income in 2014.
Those filing individual tax returns with annual incomes (in 2014) noted here will pay the following in 2016:
less than or equal to $85,000 will pay $121.80 in 2016
greater than $85,000 and less than or equal to $107,000 will pay $170.50
greater than $107,000 and less than or equal to $160,000 will pay $243.60
greater than $160,000 and less than or equal to $214,000 will pay $316.70
greater than $214,000 will pay $389.80
Those filing joint tax returns with annual incomes (in 2014) noted here will pay the following in 2016:
less than or equal to $170,000 will pay $121.80
greater $170,000 and less than or equal to $214,000 will pay $170.50
greater than $214,000 and less than or equal to $320,000 will pay $243.60
greater than $320,000 and less than or equal to $428,000 will pay $316.70
greater than $428,000 will pay $389.80
The rates are slightly different for married beneficiaries who lived with their spouse (at any time during the year) and file separate tax returns. Those filing separate tax returns with annual incomes (in 2014) noted here will pay the following in 2016:
Less than or equal to $85,000 will pay $121.80
Greater than $85,000 and less than or equal to $129,000 will pay $316.70
Greater than $129,000 will pay $389.80.
The Medicare Part B deductible will be increasing from $147 per year in 2015 to $166 per year in 2016.
If you have questions about your Part B Premium, you can call the Railroad Retirement Board toll free at 877-772-5772 or for the hearing impaired (TTY) call 312-751-4701. General information can also be found at the RRB’s website at www.rrb.gov.
If you have questions about your Railroad Medicare coverage, you can call the Beneficiary Contact Center at 800-833-4455, or for the hearing impaired, call TTY/TDD at 877-566-3572. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. until 7 p.m. ET.
We all know the joke: if you have poor penmanship, you should become a doctor.
Unfortunately, poor penmanship on patient notes and records can lead to claim denials, because if Medicare can’t read what the doctor wrote, we can’t know if the services were reasonable and necessary and meet all guidelines for coverage.
Medicare requires that the patient’s medical record be complete and legible, and it should include the readable identity of the provider and the date of service. With the inception of electronic records (the likely reason your doctor is now toting around a laptop computer), issues such as this are declining. However, they still present a problem when a claim is subjected to medical review.
What a doctor can do about this issue (if they have illegible handwriting):
Have notes transcribed and then electronically signed by the doctor, when necessary
Add amendments/corrections and delayed entries (only when needed) into medical documentation in the following way:
Clearly and permanently identify the changes or corrections
Clearly indicate the date and author of these changes or corrections
Do not delete the original content in the record
Provide an acceptable handwritten signature that meets Medicare guidelines. These guidelines allow Medicare to look at the records and consider a ‘signature log’ or ‘attestation statement’ that identifies the author of the record, and there are specific ways a doctor who signs their name in a ‘scribble’ can meet the signature requirements. These specific ways are identified on the CMS website, as well as the Palmetto GBA website for providers. If your doctor needs to know more about these methods, we encourage them to call our Provider Contact Center at 888-355-9165.
What you can do about the issue:
If a claim denies due to illegible records, and your Medicare Summary Notice (MSN) indicates that you owe $0.00, do not pay your doctor for the service. If your doctor insists that you pay for a service in this situation (when the MSN says you don’t owe anything), call our Beneficiary Contact Center at 800-833-4455.
If a claim denies and your MSN shows that you owe $0.00, it is not necessary to file an appeal. You can still file an appeal because it is your right to do so; however, you are not required when you are not liable.
If you have any questions about your Railroad Medicare coverage, please call our Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. We encourage you to sign up for email updates. To do so, click ‘E-Mail Updates’ on the top of our beneficiary website at www.PalmettoGBA.com/rr/me to start the process.
For many years, the Centers for Medicare & Medicaid (CMS) has funded programs to reduce claims payment errors (either paying too much, paying too little or payments being made when none should be). Some of these programs are handled through systematic checks that look for anomalies and mismatched services, and some are handled through clinical reviews of specific claims.
The program integrity initiatives pertaining to Railroad Medicare include:
Medically Unlikely Edits (MUEs) – These are systematic checks that look for claims that exceed the maximum number of services expected to be reported, in most cases, for a single patient by the same provider on a single day.
National Correct Coding Initiative (NCCI) Edits – These are also systematic checks, and they look for combinations of codes that should not be reported together in all or most situations. Either we would not expect both services to occur in one treatment, or Medicare does not reimburse both services when performed together. This could be two codes that represent different methods of performing the same service, such as a laparoscopic gallbladder removal and an open incision gallbladder removal. It could also be two codes that are components of each other, such as a rhythm electrocardiograph (ECG) and a cardiovascular stress test, which by definition includes an ECG.
Medical Review Program – This initiative involves complex reviews by Medicare (including Railroad Medicare) in which documentation is requested, and then the reviews determine if the claim was correctly billed and properly documented, and that the services meet Medicare coverage criteria.
Comprehensive Error Rate Testing (CERT) Program – This initiative involves complex reviews in the same manner as the Medical Review program. External entities include the CERT Review Contractor, the CERT Documentation Contractor, and the CERT Statistical Contractor, and they work together to review a random sample of claims and determine an error rate for local Medicare, as well as Railroad Medicare. They do this by:
Requesting medical records from providers who submitted claims
Reviewing claims and medical records for compliance with Medicare coverage, coding and billing rules
The CERT program calculates an improper payment rate, and it also develops an improper payment rate by claim type, to measure Medicare (and Railroad Medicare’s) performance processing claims correctly.
Working together, these initiatives reduce the number of claims that are underpaid, overpaid or should never have been paid.
If you have any questions about your Railroad Medicare coverage, please call Palmetto’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. Members can sign up for email updates. To do so, visit Palmetto’s website at www.PalmettoGBA.com/RR/Me and click ‘Email Updates’ on the top of the webpage to start the process.
The start of a new year is the time for resolutions. Railroad retirees covered under Medicare can receive the help they need in making some of their resolutions a reality.
According to USA.gov, the top three New Year’s resolutions are:
The year 2015 can be a year of change with the help of Medicare’s coverage of obesity counseling.
All Medicare patients with body mass indexes (BMI) of 30 or more are eligible for counseling if performed in a primary care setting – such as in a doctor’s office. When conducted in a doctor’s office, it can be coordinated with a personalized prevention plan. The patient will pay nothing for this service as long as the primary care provider accepts Medicare assignment. Patients should also ask questions if their doctor recommends other services to be sure that Medicare covers them.
Some of the covered counseling services include one face-to-face visit each week for the first month, one face-to-face visit every other week for months two through six, and then one face-to-face visit every month for the seventh through 12th months, as long as the patient has lost at least 6.6 pounds during the first six months.
Medicare is now covering counseling in a group setting for two to 10 people when conducted by providers in the following categories:
Certified clinical nurse specialist
Medicare is also tackling number three on the list of most popular New Year’s resolutions: quitting smoking. Smoking and tobacco-use cessation counseling is a benefit which offers up to eight face-to-face visits in a 12-month period for patients who have not been diagnosed with a smoking-related illness.
The counselor must be a qualified doctor or other Medicare-approved practitioner. The following resources are available to those considering quitting smoking:
National Network of Tobacco Cessation Quitline (1-800-Quit-Now or 1-800-784-8669)
If you have questions about Medicare’s coverage of obesity counseling or smoking/tobacco-use cessation, call the Railroad Medicare Beneficiary Contact Center at (800) 833-4455. Representatives are available Monday through Friday from 8:30 a.m. to 7 p.m. ET.
Email updates are available on Medicare’s website at www.PalmettoGBA.com/RR/Me. To register, look for ‘email updates’ under the ‘Stay Connected’ part of the lower left-hand side of the webpage.