When a severe weather event happens (such as a hurricane, typhoon, earthquake or wildfire), the last thing you or your healthcare provider are thinking about is Medicare. Concerns are about staying alive and what kind of home and property damage you will have. Your situation may be the most-stressful event in your life. When a disaster like the California wildfires or Hurricane Dorian hits, your survival is most important.
Medicare understands this.
For some disasters, like a hurricane or wildfires, the Secretary of Health and Human Services may declare a Public Health Emergency (PHE), which provides waivers for 90 days. In Hurricane Dorian, Medicare made accommodations in the states of Florida, Georgia, North Carolina, South Carolina, and the Commonwealth of Puerto Rico. In those states, providers have an extension on the time allowed to enroll providers or request appeals.
As a patient, you may wonder if Medicare will pay if you see another doctor outside of the disaster area or another sate to receive the care you need. Medicare/Railroad Medicare beneficiaries can receive services anywhere in the United States. The services must be medically necessary and a covered Medicare benefit.
Another concern when a disaster hits is what happens if you lose your Medicare card. If you’ve lost your card (and can’t remember the number) but need to see a doctor or other healthcare provider in an affected area before you receive a replacement card, Medicare advises providers to hold their claims until you receive your new card. It is your responsibility to inform the provider of your new Medicare number. If you need emergency care and do not have your Medicare card or know the number, providers should try to obtain your Medicare number from you or your family. If that fails to be successful, your provider can call Railroad Medicare to request the Medicare number. This should be a rare incidence.
If you have questions or need to obtain a replacement 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.
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.
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.
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.
Whether a person is receiving Medicare through Social Security or through the Railroad Retirement Board (RRB), the patient may be vulnerable to identity theft due to the SSN/RRB Claim number being present on their Medicare card.
Soon, you won’t need to worry about someone obtaining your personal information from your Medicare card. Starting in April 2018, the Centers for Medicare & Medicaid Services (CMS), in conjunction with the RRB, will begin issuing new cards with a ‘Medicare Beneficiary Identifier’ or MBI. These cards will be sent in phases to existing Medicare beneficiaries, and by April 2019, all Medicare/Railroad Medicare cards will be free of personally identifiable information. This includes the removal of the gender and signature line.
Here is what an MBI will look like:
It will have 11 characters
The numbers will be generated randomly. Medicare considers them ‘non-intelligent’ numbers that don’t have any hidden or special meaning
It will be unique to each patient
It will contain capital letters (all letters with the exception of S, L, O, I, B and Z) and numbers (0-9)
The 2nd, 5th, 8th, and 9th characters will always be a letter, while
Characters 1, 4, 7, 10, and 11 will always be a number, and
The 3rd and 6th characters will be a letter or a number
There will be no dashes in the numbers on the card
As you may have experienced, providers can’t always tell the difference between an SSN patient and a RRB patient. They may submit your claims to regular Medicare, instead of Railroad Medicare. To help providers know what patient they have, the new cards will have the RRB logo on them when applicable, so your doctor’s office will know where to submit claims.
This October, you will receive your 2018 Medicare & You handbook, which will contain additional information about the MBI change.
If you have a question about a claim, 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. You’re also encouraged to visit Palmetto’s website at www.PalmettoGBA.com/RR/Me.
It’s been on the news, and you may have heard about it: the Medicare appeals process is taking longer, specifically, at the Administrative Law Judge (ALJ) level. This article explains the five levels of appeals and provides information about the wait times for an ALJ hearing.
To begin, let’s look at the Medicare appeals process. The five levels are:
Redetermination (first-level, performed at Railroad Medicare or your local Medicare Administrative Contractor for part A or durable medical products claims)
Reconsideration (second-level, performed by a Qualified Independent Contractor/QIC)
Hearing before an Administrative Law Judge or ALJ (which are independent from Medicare and are governed by the US Department of Health & Human Services (HHS))
Review by the Medicare Appeals Council
Judicial review in the U.S. District Court
Each level of appeal has certain timeliness standards. For a redetermination and reconsideration, contractors have 60 days to process an appeal request. For a third-level appeal, the guideline is the ALJ will generally conduct a hearing and render a decision within 90 days of the receipt of the hearing request. However, backlogs at the ALJ level are causing appeals to be processed, on average, in 819.4 days for Fiscal Year 2016 (from October 2015 to the present).
This problem with the untimely processing of appeals at the ALJ level is not new; however, the growing wait time has risen greatly since Fiscal Year (FY) 2012. The following trends show the average wait times by day at the ALJ level:
If you have questions about your Medicare coverage, you may call Palmetto’s toll-free Beneficiary Customer Service Center at 800-833-4455, Monday through Friday, from 8:30 a.m. until 7 p.m. ET. For the hearing impaired, call TTY/TDD at 877-566-3572. You are also encouraged to visit the Palmetto GBA Railroad Medicare website at www.PalmettoGBA.com/RR/ME and their beneficiary Facebook page at www.Facebook.com/MyRRMedicare.
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.
Mental health conditions, such as depression or anxiety, can come at any age and can happen to anyone. They are nothing to be ashamed of. While they can occur at any time, stressful holidays and the let-down after the holidays often make these conditions worse.
With that in mind, it’s important to know that Railroad Medicare covers many mental health services (Medicare pays 80 percent while the patient pays 20 percent) after your annual deductible is met and when the service is provided by: a psychiatrist or other doctor, a physician assistant, a nurse practitioner, a clinical psychologist, a clinical social worker or a clinical nurse specialist.
Some of the covered services are
Annual screening for depression;
Individual and group psychotherapy with doctors, or certain other licensed professionals who are allowed by the state to offer these services;
Family counseling (if the main purpose is to help with your treatment);
Testing to find determine if you’re getting the services you need and/or if your current treatment is helping you;
Occupational therapy that’s part of your mental health treatment;
Individual patient training and education about your condition;
Talk to your doctor or health care provider if you feel you may be depressed or have any of these following symptoms (this is not an all-inclusive list):
Sad, empty, or hopeless feelings;
A lack of energy;
Difficulty sleeping or sleeping too much;
Little interest in things you used to enjoy;
If you have questions about your Railroad Medicare coverage, you can call their toll-free Customer Service Line 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.
The standard Medicare Part B monthly premium will be $104.90 in 2015, the same amount as in 2014.
Some beneficiaries will continue to pay higher premiums based on their modified adjusted gross income, but these amounts are also remaining the same as in 2014. The monthly premiums that include income-related adjustments for 2015 will be $146.90, $209.80, $272.70, or $335.70, depending on the extent to which an individual beneficiary’s modified adjusted gross income exceeds $85,000 (or $170,000 for a married couple). The highest premium rate applies to beneficiaries whose incomes exceed $214,000 (or $428,000 for a married couple). The Centers for Medicare and Medicaid Services estimates that less than five percent of Medicare beneficiaries pay the larger income-adjusted premiums.
Beneficiaries in Medicare Part D prescription drug coverage plans pay premiums that vary from plan to plan. Beginning in 2011, the Affordable Care Act required Part D beneficiaries whose modified adjusted gross income exceeds the same income thresholds that apply to Part B premiums to also pay a monthly adjustment amount. In 2015, the adjustment amount ranges from $12.30 to $70.80.
The Railroad Retirement Board withholds Part B premiums from benefit payments it processes. The agency can also withhold Part C and D premiums from benefit payments if an individual submits a request to his or her Part C or D insurance plan. The RRB will also begin withholding Part D income-related adjustment amounts from benefit payments in January 2015.
The following tables (click here) show the income-related Part B premium adjustments for 2015. The Social Security Administration is responsible for all income-related monthly adjustment amount determinations. To make the determinations, SSA uses the most recent tax return information available from the Internal Revenue Service. For 2015, that will usually be the beneficiary’s 2013 tax return information. If that information is not available, SSA will use information from the 2012 tax return.
Those railroad retirement and social security Medicare beneficiaries affected by the 2015 Part B and D income-related premiums will receive a notice from SSA by December 2014. The notice will include an explanation of the circumstances where a beneficiary may request a new determination. Persons who have questions or would like to request a new determination should contact SSA after receiving their notice.
Additional information about Medicare coverage, including specific benefits and deductibles, can be found at www.medicare.gov.
Palmetto GBA is reminding railroad retirees that Railroad Medicare Part B provides coverage for services such as doctors’ visits, ambulance transports, lab tests and some supplies. Benefits are the same for eligible individuals, whether eligibility is through Railroad Retirement or Social Security.
Railroad Medicare is funded by a portion of Railroad Retirement Tier I and Social Security payroll taxes paid by employees and employers. Monthly premiums are also applied to the program.
There are times when Medicare-participating providers and suppliers don’t understand that if they accept Medicare Part B, this includes Railroad Medicare too.
The Centers for Medicare and Medicaid (CMS) has incorporated information about Railroad Medicare in its online manual publications pertaining to Medicare Policy and Regulation. The CMS manual states:
“Carrier jurisdiction claims for individuals who are QRRBs (Qualified Railroad Retirement Beneficiaries), including those who are entitled to both Social Security and Railroad Retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) L.L.C., a subsidiary of Blue Cross and Blue Shield of South Carolina.”
The CMS also includes information about Railroad Medicare in its annual Medicare & You booklet mailed to Medicare patients every year.
When Palmetto GBA conducts educational events or speaks one-on-one with providers and suppliers, they always explain what Railroad Medicare is and confirm that Medicare Part B benefits are standard nationwide.
If a provider or supplier you want to work with participates in Medicare, but states “not Railroad Medicare,” Palmetto GBA recommends that they call Palmetto’s Provider Contact Center at (888) 355-9165. Palmetto’s staff is trained to discuss these matters with all Part B providers and suppliers. They also recommend providers or suppliers visit Palmetto’s website at www.PalmettoGBA.com/RR.
If you have questions about your Part B coverage, call Palmetto’s Beneficiary Contact Center at (800) 833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET.
Palmetto also encourages beneficiaries to visit their website at www.PalmettoGBA.com/RR/Me and sign up for email updates. To do so, select “Email Updates” on the lower left-hand side of the web page under “Stay Connected.”
Would you accept a job paying $1 million to count out $2 billion in $1 bills?
Think again, because working a 40-hour week and counting out $1 per second, you would require 266 years to count out the $2 billion total.
Now that you have an idea how much $2 billion is, consider that in the 12 months ending Sept. 30, 2010, the federal government, through the Department of Justice, recovered $2.6 billion in Medicare health care fraud judgments and settlements from 726 separate defendants.
This $2.6 billion total has exploded from $490 million in 1999, meaning that Medicare health care fraud is on the rise, according to PalmettoGBA, which administers Railroad Medicare.
As we struggle to preserve Medicare – and keep a lid on what we, as current and future retirees must pay for its coverage — it is necessary to do all we can to keep a lid on Medicare inflation.
We can help keep those costs down and help preserve Medicare by recognizing, reacting to and reporting Medicare health care fraud.
Here is what you can do:
Examine carefully your Medicare Summary Notices (MSNs).
Be alert for charges for services you didn’t receive, double billings for the same service, and procedures or services not ordered by your physician.
Keep your Medicare card in a safe place. If it becomes lost or stolen, notify your Medicare provider immediately.
If you see a charge or a date of service that is incorrect, first call your provider and ask about it. If the billing is not corrected, or if you suspect a pattern of improper billing, call the Department of Health and Human Services Medicare fraud hotline at (800) 447-8477, which will initiate an investigation and keep your identity confidential.
Many physicians and medical practitioners are choosing to withdraw from participation in Medicare. This has a direct financial impact on all UTU members who are retired or intend to retire in the near future.
If you are eligible for Medicare, and your physician or medical practitioner withdraws from participation in Medicare, you are faced with a choice of signing a binding contract for continued medical services or choosing a physician who does participate with Medicare.
While Palmetto GBA, which administers Railroad Medicare, provided the following information, this alert also affects airline and bus members covered by Medicare.
If you are covered by Medicare, and your physician or medical practitioner has withdrawn or withdraws from participation in Medicare, the physician or medical practitioner will ask you to sign a contract for future services that would have been covered by Medicare prior to the physician or medical practitioner withdrawing from Medicare participation.
Once you sign the contract, Medicare will not pay for any services provided by that physician or medical practitioner. Additionally, no Medicare payment may be made to you for items or services provided directly by a physician or practitioner who has opted out of Medicare.
The contract you will be asked to sign is a binding agreement that you give up Medicare payment for services furnished by the physician or medical practitioner and that you agree to pay from your own pocket the physician or medical practitioner without regard to any limits that would otherwise apply to what they charge.
The only exception is in an emergency or urgent care situation.
Even if you sign such a contract with your physician, you may still receive services from other physicians and practitioners who are participating with Medicare.
“Physician” means doctors of medicine, doctors of osteopathy, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine and doctors of optometry.
“Medical practitioner” means physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, registered dietitian and nutrition professional.
Not affected are chiropractors, physical therapists and occupational therapists. They are not permitted to withdraw from Medicare participation.
If you are asked to sign a contract with a physician or medical practitioner who withdraws from Medicare participation, the contract must:
Be in writing and in print large enough so you can read it.
State whether the physician or medical practitioner is excluded from Medicare.
State that you or your legal representative accept full responsibility for payment of charges for all services provided by the physician/practitioner.
State that the you or your legal representative understand that Medicare limits do not apply to what the physician/practitioner may charge for items or services provided by the physician/practitioner.
State that you or your legal representative agree not to submit a claim to Medicare or to ask the physician or medical practitioner to submit a claim to Medicare.
State that you or your legal representative understand that Medicare payments will not be made for any items or services furnished by the physician or medical practitioner that would have otherwise been covered by Medicare if there was no contract and a proper Medicare claim had been submitted.
State that you or your legal representative are entering into the contract with the knowledge that you have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare.
State that you are not compelled to enter into contracts that apply to other Medicare-covered services provided by other physicians or practitioners who have not withdrawn from Medicare participation.
State the expected or known effective date and expected or known expiration date of the withdrawal period.
State that you or your legal representative understand that Medigap plans do not — and that other supplemental plans may elect not — to make payments for items and services not paid for by Medicare.
Be signed by you or your legal representative and by the physician or medical practitioner.
Not be entered into by you or your legal representative during a time when you require emergency care services or urgent care services.
Be provided to you (photo copy is acceptable) or to your legal representative before items or services are furnished to you under the terms of the contract; and be made available to the Centers for Medicare and Medicaid upon request.
Staying with, or going to, a physician who does not participate in Medicare is a difficult choice.
Retirees covered by Railroad Medicare may call the Railroad Beneficiary Contact Center at (800) 833-4455 or TTY at (877) 566-3572 to obtain names of physicians and medical practitioners in their area who participate in Medicare.
Those not covered by Railroad Medicare should contact their Medicare provider.
For more information on Railroad Medicare, sign up for email updates at :