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  1. Improve and Expand Medicare: Add an Out-of-Pocket Cap
  2. There's Still Time to Go Back to Traditional Medicare or Change MA Plans
  3. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Updates
  4. Healthcare Sabotage Continues

Improve and Expand Medicare: Add an Out-of-Pocket Cap

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare plans. We previously wrote about other key issues currently limiting choice and coverage for Medicare beneficiaries, including limited access to Medigap plans and oral health care. Another important component missing in traditional Medicare is an out-of-pocket cap on beneficiary expenses.

Since 2011, Medicare Advantage (MA) plans have been required to establish a maximum out-of-pocket (MOOP) amount for all Part A and B services (in 2019, the mandatory maximum amount is $6,700). Many individuals in traditional Medicare have other sources of coverage which may supplement their benefits by covering some or all of Part A and B cost-sharing and, sometimes, some benefits not otherwise covered by Medicare. However, traditional Medicare does not have an out-of-pocket limit.

Further, as noted in a recent issue brief by the Kaiser Family Foundation, a sizeable portion of people with traditional Medicare have no supplemental coverage at all:

In 2016, eight in 10 beneficiaries in traditional Medicare (81%) had some type of supplemental insurance, including employer-sponsored insurance (30%), Medigap (29%), and Medicaid (22%) (Figure 1). But nearly 1 in 5 beneficiaries in traditional Medicare (19%)—6.1 million beneficiaries overall—had no source of supplemental coverage in 2016, which places them at greater risk of incurring high medical expenses or foregoing medical care due to costs. […]

Compared to all traditional Medicare beneficiaries in 2016, a larger share of beneficiaries with no supplemental coverage had modest incomes (between $20,000 and $40,000), were age 85 or older, and male. Beneficiaries in traditional Medicare with no supplemental coverage are fully exposed to Medicare’s cost-sharing requirements, unlike people with [employer-sponsored coverage] and Medigap, and lack the protection of an annual limit on out-of-pocket spending, unlike beneficiaries enrolled in Medicare Advantage. [emphasis added]

It’s time to bring Medicare in line with coverage provided through Medicare Advantage plans, Medigaps and other supplemental coverage, and other types of insurance, such as qualified health plans available through the Affordable Care Act – all of which limit out-of-pocket expenses for individuals. Congress should add an out-of-pocket cap to traditional Medicare.


There's Still Time to Go Back to Traditional Medicare or Change MA Plans

Annual Enrollment has ended, but the Medicare Advantage Open Enrollment Period, allowing plan changes or a return to traditional Medicare continues through March 31 – Make sure you are fully informed about the Medicare that is right for you.


  • January 1–March 31

What Can I Do?

  • If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage).
  • You can disenroll from your Medicare Advantage Plan and return to Original Medicare. If you choose to do so, you’ll be able to join a Medicare Prescription Drug Plan.
  • If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without drug coverage) within the first 3 months you have Medicare.

What Can't I Do?

  • Switch from Original Medicare to a Medicare Advantage Plan.
  • Join a Medicare Prescription Drug Plan if you're in Original Medicare.
  • Switch from one Medicare Prescription Drug Plan to another if you're in Original Medicare.


Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Updates

All Competitive Bid Program Contracts Ended on December 31, 2018.

What Beneficiaries Should Know:

  • Equipment in process under the 13 month capped rental program should continue “business as usual”.
  • While providers who do not accept Medicare assignment cannot charge more than 15% higher than Medicare’s allowed charge. There is no such restriction (no limiting charge) for DME suppliers. (See Resource 7, below.) A Medicare enrolled supplier that does not accept assignment can charge without a prescribed limit. The beneficiary is responsible for the difference between what Medicare will pay and what the supplier will charge. Competitive Bid Program Contractors were required to accept assignment. Now that there are no contracts, fewer suppliers are accepting assignment. Make sure to ask if the supplier accepts assignment. Then get the answer in writing. If the answer is “no”, the beneficiary should confirm in writing what the charges will be.
  • If a supplier accepts assignment, the supplier should not be charging for delivery, set up or training (this cost is included in the Medicare payment). (See Resource 6, below.)
  • Repairs – CMS has “disassociated” the purchase of equipment by Medicare to require repairs and is now allowing for repairs to “stand on their own merit”, despite whether Medicare paid for the equipment originally. Beneficiaries should ensure the continued need for the equipment is updated in the medical record and ensure the need for the repair is also documented. The repair may be performed by any “authorized” repair place (CMS recommends working with the DMACs (Durable Medical Equipment Medicare Administrative Contractors) and suppliers to find an authorized repair place. (See Resource 4, below.)
  • The CBICs (Competitive Bid Implementation Contractors) are no longer available for oversight of suppliers. The DMACs will continue to pay claims based on rules and policies. Generally, the NSC (National Suppliers Clearinghouse) is responsible for oversight of Medicare enrolled suppliers adherence to “supplier standards”.
  • The first point of contact to resolve issues should be 1-800-MEDICARE. If a beneficiary is trying to resolve a problem, the caller should ask for the call to be “escalated”.
  • Second point of contact would be the DMACs. (See Resource 4, below.)
  • Third point of contact The Competitive Bidding Program Ombudsman’s Office is still active to monitor inquiries, to establish a baseline for a complaints process, and to inform CMS of beneficiary access problems. (See Resource 8, below.)
  • Why has CMS abruptly allowed all Competitive Bidding Contracts to expire after building the program for more than a decade, rather than extend the contracts? CMS states that, “this Administration wishes to pursue improvements to the program via rulemaking”. CMS further states they, “anticipate no negative implications for beneficiaries.” It already appears too late for that.

To help the Center for Medicare Advocacy track, report on, and seek resolution to access barriers, please report any problems obtaining DMEPOS to

DMEPOS Resources:

  1. CMS Fact Sheet on the Temporary Gap Period, Effective January 1, 2019 through December 31, 2020.
  2. Final Rule, published November 14, 2018.
  3. Medicare supplier directory, or to locate a supplier, ask a question or file a complaint, call 1-800-MEDICARE (1-800-633-4227).
  4. To locate the correct DMAC for each state, see
  5. Contact a state SHIP to help resolve local/state problems.
  6. The Medicare Claims Processing Manual, for questions about payment for DMEPOS, including delivery and services charges (Section 60 of the Manual)
  7. For questions about assignment (and the lack of a limiting charge on some supplies and on Durable Medical Equipment) see
  8. For further assistance after 1-800-MEDICARE and DMACs, contact the Office of the Competitive Bidding Acquisition Ombudsman at
  9. Watch out for aggressive marketing by suppliers. Report suspected fraud for investigation via online form or phone 1-800-HHS-TIPS (1-800-633-4227)(TTY 1-877-486-2048).


ACA and Health Care Sabotage Continue

We are only a few weeks into 2019 and the Administration is already busy sabotaging the Affordable Care Act (ACA). Last week, the Centers for Medicare & Medicaid Services (CMS) issued the 2020 Notice of Benefit and Payment Parameters rule. In one part of the rule, CMS seeks input on ending an ACA process called “silver loading.” As the name implies, this practice allows insurers to “load,” or increase premiums for silver tier ACA plans to mitigate losses incurred due to the loss of cost-sharing reductions. In turn, insurers can offer lower premiums for certain consumers and add stability to the ACA Marketplace. Ending this process, along with other parts of the rule, have been described by former CMS Administrator Andy Slavitt as “changes to the ACA which would cut coverage for ~ 2 million Americans, significantly increase premiums, and raise out of pocket costs.”

According to Protect Our Care, the CMS rule would: Cut premium tax credits by $1 billion; cause 100,000 people to lose coverage annually starting in 2020; and increase annual premiums and out of pockets costs for individuals and or families.  

Throughout 2018 we highlighted the many ways the Administration sought to undermine the ACA. During the last Open Enrollment period alone we watched as they: once again shortened the amount of time to enroll in a plan; slashed funding for enrollment assistance and outreach; and removed critical consumer assistance information from Unfortunately, it seems like we can expect more of the same in 2019.

Comments to the proposed rule are due on February 19.


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