Latest news with #MedicareBeneficiaries
Health Line
02-06-2025
- General
- Health Line
What Is the Medicare Beneficiary Ombudsman?
The Medicare beneficiary ombudsman (MBO) is a representative who works on behalf of Medicare enrollees to resolve Medicare-related complaints, ensure access to information, and improve the program. An ombudsman is a person who reviews how an organization operates, investigates complaints, and helps resolve those complaints. They typically work as a client advocate within an organization or business. The MBO serves this function within the Medicare program. Learn more about the services the MBO provides and how to connect. What is the role of a Medicare beneficiary ombudsman? Congress formed the MBO role in 2003. The person in this role assists Medicare enrollees in various areas, including handling complaints, appeals, and requests for information. The general duties of the MBO, as outlined in section 1808 of the Social Security Act, are to: receive and help resolve complaints and inquiries that Medicare beneficiaries and other stakeholders make work with representatives of health insurance counseling programs to provide information and resources to beneficiaries report to Congress on ways to improve the administration of Medicare In addition to addressing complaints, some of the specific issues enrollees may have to address with an MBO include: Appeals: If you disagree with a Medicare payment or coverage determination, you can file an appeal. The MBO can assist you with this process. Enrollment concerns: If you have issues when leaving a Medicare Advantage (Part C) plan or joining a new plan, the MBO can assist you. Claims: If you need to file a Medicare claim, the MBO can help you through the process or troubleshoot issues that arise. What are a beneficiary's rights under Medicare? As a Medicare beneficiary, you have various clearly outlined rights and protections. The MBO exists to help preserve those rights and ensure fair treatment of all Medicare beneficiaries. It can be helpful for Medicare enrollees to periodically review their rights to understand what types of treatment and services they can expect. A Medicare beneficiary's rights include: fair and courteous treatment privacy of personal and health information access to appropriate healthcare professionals for medically necessary services clear, understandable information access regarding coverage, plan options, costs, and more Medicare designs its protections to keep beneficiaries up to date on coverage status and prevent unexpected costs. They come into play when Medicare may not cover a service, or you reach the end of Medicare coverage. A beneficiary's protections include: receiving an Advance Beneficiary Notice (ABN) of Noncoverage for any services that Medicare doesn't cover getting a Notice of Medicare Noncoverage at least 2 days before covered home health services end acquiring a Hospital-Issued Notice of Noncoverage (HINN) for inpatient services that Medicare Part A doesn't cover If you've experienced violations of your rights or protections or have an issue with Medicare noncoverage, you can contact the MBO for assistance. How to contact a Medicare beneficiary ombudsman Not all Medicare-related questions should go directly to the MBO. Other contact points may be more suitable based on your coverage and the nature of your question or concern. If you're a Medicare Advantage or Part D enrollee, contact your insurance carrier with any questions or complaints about your plan. You can generally find contact information for the plan on the back of your insurance card. If you have questions about Original Medicare or need help with issues that a private insurance carrier can't address, you can contact Medicare by phone at 800-633-4227. If you have general questions or would like free, unbiased Medicare counseling, you can contact your local State Health Insurance Assistance Program (SHIP). Finally, if you have questions that the channels above can't resolve, you can direct your query to the MBO. You can do so by contacting Medicare by phone at 800-633-4227 and requesting your case's submission to the MBO. Summary The MBO has a role within the Medicare program to provide customer service and advocacy. The MBO can assist Medicare beneficiaries with resolving complaints and accessing important information. They also work to improve Medicare's administration by submitting an annual report to Congress on its operation. If you have a concern requiring the MBO's attention, you can contact Medicare by phone and explain the situation.
Health Line
19-05-2025
- Health
- Health Line
Qualifying Individuals (QI) Medicare Savings Program
The QI program is a Medicare savings program (MSP) that helps pay your Part B premiums. Your individual or joint income and resources must meet certain criteria to qualify. The Medicare Qualifying Individuals (QI) program helps Medicare beneficiaries cover their Part B premium. Your premium is the monthly fee you pay for your Part B outpatient medical coverage. The QI program is one of four Medicare savings programs. These programs help individuals with limited incomes cover their healthcare costs. To qualify, you need to meet the QI program's income requirements. You must reapply every year to keep your coverage. What is the QI Medicare savings program? The Medicare QI program is one of several Medicare savings programs to help people with limited income and resources pay their Medicare costs. Assistance comes from each state and is based on your income and resources. In 2025, the four Medicare savings programs are: The QI program is for people who have Medicare Part A (inpatient hospital insurance) and Part B (outpatient medical insurance), which together make up Original Medicare. The program covers the cost of the Part B premium for people who qualify. How does QI work with Medicare? The QI program is for Medicare enrollees with Part A and Part B, and it's intended to cover your Part B premiums. In 2025, the standard Part B monthly premium is $185. The QI program will pay this cost if you qualify. The QI program won't change your Part A costs — and most people don't pay a premium for Part A. So, if you have Original Medicare with premium-free Part A and you qualify for the QI program, your total monthly premium would be $0. The QI program applies only to Original Medicare. That means it won't affect any Medicare Advantage (Part C) or Medicare supplement (Medigap) plan you choose to buy. Enrollees who qualify for the QI program will, however, automatically qualify for help with Medicare Part D prescription coverage) through the Medicare Extra Help program. QI eligibility Your eligibility for the Medicare QI program is based on your income. In 2025, the income limits for the QI program are $1,715 per month for individuals or $2,320 for married couples. The income limits are slightly higher in Alaska and Hawaii: Alaska: Individual: $2,220 Married couples: $2,994 Hawaii: Individual: $1,819 Married couples: $2,452 You'll also need to be at or below the resource limit. In 2025, that meant you'd need less than $9,660 in resources as an individual or $14,470 as a married couple. Resources include bank accounts and stocks. Medicare doesn't consider high value items like your car or home to be resources. Additionally, some income and resources specific to American Indian and Alaska Native communities do not count toward Medicare limits. The income limits can change each year and are based on the federal poverty level (FPL). The FPL is calculated using data like the cost of living and the average salary in each state. Various programs use the FPL as a benchmark to qualify for programs like Medicare QI. You aren't eligible for QI benefits if you also qualify for Medicaid. However, you can still apply for the program through your state Medicaid office. The office will determine which programs, if any, you qualify for. Tips for finding help paying for Medicare Medicare was created to offer healthcare services for people ages 65 years and over as well as individuals with certain health conditions. But out-of-pocket costs like premiums, copayments, and deductibles can add up. If you're having trouble paying for your share of Medicare costs, you can take several actions or look into programs that can help: Dual eligibility: If you have a significant need or disability, you may qualify for both Medicare and Medicaid. This is called dual eligibility, and it could offer you additional health coverage and services. Extra Help: This program offers savings on prescription medication costs, but you have to be enrolled in a Medicare Part D prescription plan to participate. If you qualify for the QI program, you'll also qualify for the Extra Help program. Medicare Advantage (Part C) plans: Medicare parts A and B cover inpatient and outpatient care, respectively. Medicare Part D is an optional program that covers prescription medications. Medicare Part C, also called Medicare Advantage, allows you to tailor a Medicare plan that best suits your healthcare and financial needs. Bundling Medicare services through an Advantage plan may help you save money. Medicare savings programs: These programs — including the QI program — help cover a share of your Medicare costs. Participation is limited to particular needs and income limits. Sign up on time and plan ahead: A variety of penalties may be applied to your share of Medicare costs. Sign up for initial coverage on time. Add additional services you think you might need within designated time frames to avoid late fees and penalties. Update your income: A number of Medicare programs use income to determine eligibility. If your income drops, be sure to update Medicare. How to enroll in Medicare QI programs Ensure eligibility: Make sure you're eligible for Medicare and enrolled in Part A. Contact your local office: Contact your state Medicare savings program office. They will have the application you need and can also provide instructions and assistance. Apply: Medicare encourages anyone who thinks they might be eligible for the QI program to apply. Medicare beneficiaries whose income is close to the qualifying line — and even if it goes slightly over — should apply, as there is no application cost. Reenroll each year: You'll need to reenroll in the QI program each year. Applications for the QI program are approved on a first-come, first-served basis, so you'll want to apply as early as possible. Priority is given to people who were enrolled in the QI program the previous year. The takeaway The Medicare QI program is one of four Medicare savings programs. It helps Medicare beneficiaries with limited incomes pay their Part B premiums. You'll need to apply through your state and meet the income requirements to qualify. If you qualify for the QI program, you'll also qualify for Part D Extra Help.
Medscape
08-05-2025
- Health
- Medscape
Frail Medicare Patients Face Primary Care Follow-Up Gaps
Vulnerable Medicare beneficiaries with frailty and those needing short-term skilled nursing facility care post-hospitalization were less likely to receive timely primary care follow-up after returning home. METHODOLOGY: Researchers conducted a retrospective cohort study using claims data from Medicare beneficiaries, including 94,248,326 hospital discharges (80.1% aged ≥ 65 years; 55.1% women) between January 2010 and December 2022. Patients were discharged from hospitals either directly home (78.5%) or to skilled nursing facilities before returning home (21.5%). The primary outcome was the receipt of a primary care follow-up visit within 30 days of returning home. Secondary outcomes assessed at 30 days included receipt of a transitional care management (TCM) visit and ambulatory visits with any clinicians, whether primary care clinicians or specialists. Researchers also assessed differences in primary care follow-up on the basis of frailty status, which was determined using a claims-based frailty index, and categorized patients into nonfrail (8.9%), prefrail (54.4%), or frail (36.7%) groups according to their scores. TAKEAWAY: From 2010 to 2022, primary care follow-up rates after returning home increased from 51.5% to 57.5% for home discharges and from 24.3% to 28.4% for skilled nursing facility discharges. By 2022, TCM visits were received by only 5% of patients discharged to skilled nursing facilities vs 14.3% of those discharged home. In 2022, discharge to skilled nursing facilities was associated with an 8.2-percentage-point lower predicted probability of primary care follow-up after returning home than discharge directly to home. By 2022, patients with frailty who were discharged to skilled nursing facilities had a 6.1-percentage-point lower predicted probability of primary care follow-up and a 0.9-percentage-point lower predicted probability of receiving TCM services than those without frailty. IN PRACTICE: 'These findings suggest a need to better target high-risk populations for postdischarge care coordination and policy efforts to support safe transitions from postacute SNF [skilled nursing facility] stays to home,' the authors wrote. SOURCE: This study was led by Timothy S. Anderson, of the Division of General Internal Medicine, Department of Medicine, at the University of Pittsburgh, Pittsburgh. It was published online on May 02, 2025, in Journal of the American Geriatrics Society . LIMITATIONS: Unbilled care coordination via phone or electronic messaging was not captured in claims data. The increase in the Medicare Advantage enrollment over time may have affected follow-up trends. Follow-up for patients in long-term care nursing homes or those discharged to long-term care hospitals was not examined. DISCLOSURES: This study was supported by grants from the National Institute on Aging and the American Heart Association. Few authors disclosed receiving grants from the funding sources and other organizations, and one author reported receiving payments unrelated to this work.
