First Health Part D – Changes For 2012

Posted by:  :  Category: Medicare

HHS-DSC_0104 by USDAgovMedicare Part D plan providers are scrambling to make their 2012 prescription drug plans stand out. Coventry Health Care is the insurance company behind the First Health Part D brand. Coventry’s First Health Part D plans will see minor changes for 2012 but the big change is the addition of a new prescription drug plan to the line up. This article will address some of the changes for 2012 and give a sneak peak to the new First Health Part D plan. Part D plan benefits and formularies can vary by State so you should check benefits relative to the State where you live.
Source: wordpress.com

Video: Rep. Anthony Weiner (D-NYC) Leaves Joe Scarborough “Speechless” Part 1

Coventry First Health Part D Plan Preview

Coventry First Health Part D has released to us a preview of their 2012 PDP  products.  These product plans will offer broad formularies, a large national pharmacy network, and strong benefits all at a competitive price that leaves additional money for other product sales.   Coventry First Health PDP product plans are widely available – Premier (PDP) and Premier Plus (PDP) are available in all 50 states and the District of Columbia as well as Value Plus (PDP) is available in 48 states and the District of Columbia, not in Hawaii or Alaska.  New for 2012:
Source: neishloss.com

Coventry Announces First Health Value Plus Medicare Part D Plan

who is selling only a PDP to someone 80 years old. Think about it by the time they are 80 they have 4 kids 10 grand kids and 18 greats, they also have 30 neighbors and 40 people at church and 400 people in their circle of influence. Now you have 400 leads that all need medical, dental, life and disability insurance along with home auto and business coverage. What happened to the $30 comission that you complained about? I think many Agents just need to get out of the business anyway because they are smart enough to know what their doing in the first place.
Source: ritterim.com

Medicare Prescription Drug Plans Will Drop In Price By 4 Percent

“We believe our pricing in 2012 for Medicare Part D plans will provide beneficiaries with affordable options that will enable them to access many of the prescription drugs they need,” Aetna spokeswoman Susan Millerick said, “and will also make us more competitive in the Part D market. In 2012, Aetna will offer Part D plans with premiums lower than the Low-Income-Subsidy Benchmark in 40 states and the District of Columbia. This is historically an indicator of a Part D product that is well positioned to meet the needs of Medicare beneficiaries.”
Source: courant.com

IPBiz: Ranbaxy’s Lipitor copy goes on sale, but…

Ranbaxy’s Lipitor-copy goes on sale 1 Dec 2011, but the impact on consumers is a bit more complicated than one might think. For example, Watson Pharmaceuticals is selling a Lipitor copy under an agreement made with patentee Pfizer (thus, an authorized generic). And Pfizer has made deals with insurance companies. Bloomberg reports: UnitedHealth Group Inc., the biggest U.S. health insurer by sales, said Nov. 19 it will charge a lower co-pay for Pfizer’s pill than it does for generics for the next six months, taking advantage of a price reduction from the drugmaker. Looking at this a different way, the out-of-pocket expense for generic Lipitor can be different for someone without health insurance (who will likely buy generic) than with certain health insurance (who will keep buying Pfizer-made). Bloomberg also reported: Pfizer has struck deals with companies including Catalyst Health Solutions Inc. and Coventry Health Care Inc. to prevent generic Lipitor from reaching some patients until the end of May 2012. As one can see, the big price break for this statin is 6 months from today. Ranbaxy is 64 percent-owned by Daiichi Sankyo Co. Ranbaxy’s Lipitor-copy will be made in “Princeton,” NJ. See also What happened to the guy who developed Lipitor? Yes, Virginia, Ranbaxy Will Sell A Generic Lipitor Ranbaxy to Share Part of Lipitor Profits With Teva **UPDATE. Concerning other drugs, doctors frequently express “surprise” that a certain drug is NOT covered by a certain health insurance. From Consumer Reports on how Lipitor is being covered: For example, Cigna RX1 is reducing its co-pay from $31 in 2011 to $3 in 2012, CVS Caremark Value is going from $42 to $8, and WellCare Classic from $41 to $6. On the other hand, First Health Part D Premier appears to be dropping Lipitor from its formulary entirely. And Consumer Reports gets into generic substitutes for Lipitor (atorvastatin ), such as lovastatin or simvastatin. But note that the cleverly worded phrasing — if you need to need to lower your LDL by less than 30 percent — includes reducing LDL by 0 %. At least Consumer Reports acknowledges differences among the statins. [Some insurance companies will assert losartan is a reasonable substitute for Diovan (valsartan), and won’t pay for the latter. A study put out by Novartis (the patent holder for Diovan) asserted: The weighted average reduction in mean SBP and DBP for valsartan 160 mg was -15.32 mmHg (95% CI: -17.09, -13.63) and -11.3 mmHg (95% CI: -12.15, -10.52) and for 320 mg was -15.85 mmHg (95% CI: -17.60, -14.12) and -11.97 mmHg (95% CI: -12.81, -11.16); these are statistically significantly greater reductions compared with losartan 100 mg, which was -12.01 mmHg (95% CI: -13.78, -10.25) and -9.37 mmHg (95% CI: -10.18, -8.54) for SBP and DBP respectively. [See Int J Clin Pract. 2009 May;63(5):766-75. ] BUT, there is an interesting difference among the two as to uric acid: serum uric acid levels, which decreased from 6.0 to 5.7 mg/dL in the losartan group and increased from 5.9 to 6.0 mg/dL in the valsartan group (P = 0.001 for between-treatment difference, from Clin Ther. 2001 Aug;23(8):1166-79.] See also New generic version of Lipitor like an early Christmas present which includes: A month’s supply of Lipitor costs about $120. The first shipment of the generic version, atorvastatin, costs about 15 percent less, said Mike Koelzer, owner of Kay Pharmacy at 2178 Plainfield Ave. NE. But in about six months, the price for generic versions of Lipitor likely will drop to about $10 a month, he said. AND Still, Decker said he has been prescribing the other generics to many patients to keep costs down or because the insurance company requires they first try a lower-cost drug. The article omits the observation that even if one tries the lower cost drug first, and it comes up lacking, the insurance company may not provide any payment for the higher cost drug. One is “allowed” by the insurance company to pay full price for the higher cost drug.
Source: blogspot.com

Does Colonial Penn Offer The Best Medicare Supplemental Insurance?

Medicare Supplemental Insurance will cover costs which are not covered by medicare, these include by are not limited to ambulance transportation, extended hospital visits, and co-pays. The most important aspect of your health and well being is excellent medical care. Making decisions on what medical care to receive should not be determined by an apprehension of the overall costs. With Medicare Supplemental Insurance, you will be able to get the care you deserve without worrying about the costs.
Source: seniorcorps.org

Medicare Part D Insurance Made Easy!

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Source: designforum-gfx.com

Canadian Pharmacy Brings Outside Perspective to Medicare Part D

The Government is enforcing Medicare Part D. Proof of this is evident if considering the penalties individuals will incur by not joining Medicare Part D by May15th. The accumulative 1% penalty (per month) can become expensive over time and looks counter productive. It seems more likely the Government agenda is geared towards herding the public into a central plan and closing the doors for international prescription imports.
Source: danmuk.com

OIG Identifies Part D Oversight Gaps : Health Industry Washington Watch

“Audits of Medicare Prescription Drug Plan Sponsors,” examined the extent to which CMS conducted seven types of audits developed to identify problems and correct deficiencies in the Part D program: auto-enrollment readiness audits; benefit integrity audits; bid audits; compliance plan audits; long-term-care pharmacy contract audits; pharmacy access audits; and program audits.  Note that there is no legal requirement for CMS to conduct these audits; mandatory financial audits of PDP sponsors are being examined by the OIG for a separate report. The OIG found that CMS did not conduct any of the seven types of audits for 50 of the 125 stand-alone PDP sponsors in 2006 through 2009. For the audits that were conducted, 79% identified problems (the majority of which involved beneficiaries’ coverage status or payment issues). The OIG recommends that CMS establish a comprehensive Part D auditing strategy that ensures that each plan sponsor is audited within a certain timeframe. While CMS plans to complete a bid audit of every PDP parent organization, CMS believes a comprehensive oversight/performance monitoring strategy is more effective than an auditing strategy. CMS concurred with a second recommendation that it ensure that evidence is available to show that corrective actions have been implemented.
Source: healthindustrywashingtonwatch.com

Medicare disenrollment allowed until Feb. 14

The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[11] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[12] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[10] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[13] Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[14] Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.”[15] There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.”[16] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[17] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[18][19] In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[20] Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[21] Others have reported that minority enrollment is not particularly above average.[22] Another study has raised questions about the quality of care received by minorities in MA plans.[23] The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[24] [edit] Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Source: medicare-health.com

Low Cost Health Insurance Plans and Companies: Medicare Part D Newsletter from Q1Medicare.com

For instance, people who use only low-cost generic medications, and choose a Medicare Part D plan with a low monthly premium and standard initial deductible, may find that they never get any cost-sharing benefits — because they must first satisfy the initial $320 deductible before their low-cost generics are covered by their plan.
Source: blogspot.com

Secure Horizons Medicare Advantage – Medicare Full Or Medicare …

Posted by:  :  Category: Medicare

New Online Rx System Makes UM Student 'Top Entrepreneur' Finalist by University of Maryland Press ReleasesThe original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[11] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[12] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[10] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[13] Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[14] Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.”[15] There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.”[16] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[17] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[18][19] In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[20] Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[21] Others have reported that minority enrollment is not particularly above average.[22] Another study has raised questions about the quality of care received by minorities in MA plans.[23] The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[24] [edit] Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Source: medicare-health.com

Video: Eligibility for Medicare Part D – Beers Mallers Backs & Salin LLP

What Was the Biggest Political Lie of 2011?

Two years ago, the scribes who put together PolitiFact selected Sarah Palin’s comment about “death panels” as the biggest lie of 2009. In 2010, they once again sprang to the defense of Obamacare, pooh-poohing claims that it represented a “government takeover of health care” as the year’s biggest falsehood.
Source: patriotupdate.com

Continuing To Understand Differences Within Medicare

For many this territory is uncharted and confusing. Terms are used interchangeably which can only add to the confusion. It is best to get a handle on the terms and there meanings. For instance a premium is the amount that an individual pays for their coverage. It will be the amount paid for Medicare Part B plus the additional for the Medigap supplemental insurance policies. Depending on the coverage that is chosen the premium will vary for each individual. Deductibles are the amount that is paid out of an individual’s pocket before any covered medical expenses are paid for by Medicare. Co-pays, copayments, are a fixed dollar amount that is paid for medical visits. Finally coinsurance which is the amount that is required to be paid by an individual after Medicare has paid their agreed upon portion.
Source: articlesaffair.com

Silver Sneakers Fitness Program

Unlock the door to greater independence and a healthier life with SilverSneakers. Health plans around the country offer our award-winning program to people who are eligible for Medicare or to group retirees. SilverSneakers provides a fitness center membership to any participating location across the country.
Source: reallifedeals.com

Am i eligible for medicare

Hi all, I am a Pome living in New Zealand, been here about 9 years and I have been a N.Z. citizen for 4 years. My wife and I plan on crossing the ditch to Oz. My question is: Am I eligible for Medicare as soon as I arrive and apply or is there a period I have to be in Oz before I can apply. Anyone ??? (that knows,of course)
Source: pomsinoz.com

Daily Kos: Gaming Medicare

A Medicare patient initially has a max of 150 consecutive days in the hospital. Then they either would be discharged to their homes with Part B home health services for at least 60 days to reset the benefit period to zero or is sent onto hospice where they need to be periodically recertified as terminal. If the patient is sent home, they can still receive intraventive care. If the patient is sent to hospice, they can only receive palliative (comfort) care. A lot of times, a patient will stop the intraventive care and go to hospice because of the discomfort of treatment only to change their mind some weeks or months later after they feel better which justifies the “ooops, I’m sorry” discharges. A Medicare patient who has a reset benefit period under Medicare Part A, but has expended their lifetime reserve days now has a maximum stay of 90 consecutive days in the hospital/SNF or Part A home health. The game continues until someone at the MAC (Medicare Administrative Contractor, which used to be called a fiscal intermediary – the private companies that actually run the Medicare programs) decided that the statistics are well under the tails of the bell curve. The Mac takes too long to investigate and sics a RAC auditor on it The MAC brings in the DOJ Seven years or so later…..
Source: dailykos.com

What is Supplemental Medicare and Who offers it in California?

To be eligible for supplemental Medicare policy, it is required for you to enroll in part A and B of original health insurance policy. Either you can opt for these plans during open enrolling period or you can undergo medical screening and buy the policy individually. The supplemental Medicare plans in California are sold by private insurance companies which are allowed to offer 12 such standard plans. Each plan comes with different benefits though all the benefits cover under part A and B are also found in all these insurance plans (because they are part of basic health insurance plan). Those planning to enroll for supplemental Medicare policies in California should be aware there are some terms and conditions to participate in the same. If you have enrolled in Standalone Part D, you cannot continue to avail drug coverage. Whichever company in California you buy the supplemental Medicare plan from; the plans offer the same benefits though the premium may vary.
Source: projektgenerika.org

Federal justice officials accuse hospice provider of Medicare fraud

“We believe that the allegations are without merit or are not violations of the law, and we intend to vigorously defend ourselves against all claims,” Blair Jackson, Golden Living’s vice president of corporate communications, said in an e-mail. “AseraCare operates in full compliance with the law. We believe this case is all about access to appropriate hospice care for Medicare beneficiaries. We are on the side of protecting the rights of our patients to receive the care they need and the hospice benefit they are entitled to. The action of the government in this case is especially troubling because it has the potential to deny Medicare beneficiaries the hospice benefit they are entitled to.”
Source: californiawatch.org

HIPP Program Benefits Medicare Recipients, Saves Money for the State

To bolster the Agency’s efforts, Alabama Medicaid contracted with Health Management Systems (HMS) to help identify and enroll additional Medicaid recipients who would benefit from enrollment in the HIPP program. During the planning stage, officials from the Agency and HMS met to discuss strategies on how to connect with ideal HIPP candidates. Promotional strategies include direct mail campaigns targeted toward individuals that fall within specific segments of the state’s Medicaid eligibility file, online resources such as a membership application, and partnerships with Medicaid caseworkers and others that can refer Medicaid recipients through their daily interaction with this group.
Source: heraldnewsmedia.com

New Guide Helps Boomers Transition to Medicare — Palos Hills news, photos and events — TribLocal.com

“The guide will be especially helpful for professionals such as employment benefits counselors, social service agencies, health care providers and human resources staff who serve people who have or are becoming eligible for Medicare,” said Terri Gendel, director of benefits and advocacy at AgeOptions, the Area Agency on Aging of suburban Cook County. “They can use the different documents to learn the rules, refresh their understanding, create presentations for consumers and share specific handouts with the people they counsel.”
Source: triblocal.com

What is Supplemental Medicare and Who offers it in California?

Posted by:  :  Category: Medicare

MORE DIRTY TRICKS FROM YOUR SOCIALIST/MARXIST   PRESIDENT AND HIS NASTY LITTLE ADMINISTRATION HACKS by SS&SSTo be eligible for supplemental Medicare policy, it is required for you to enroll in part A and B of original health insurance policy. Either you can opt for these plans during open enrolling period or you can undergo medical screening and buy the policy individually. The supplemental Medicare plans in California are sold by private insurance companies which are allowed to offer 12 such standard plans. Each plan comes with different benefits though all the benefits cover under part A and B are also found in all these insurance plans (because they are part of basic health insurance plan). Those planning to enroll for supplemental Medicare policies in California should be aware there are some terms and conditions to participate in the same. If you have enrolled in Standalone Part D, you cannot continue to avail drug coverage. Whichever company in California you buy the supplemental Medicare plan from; the plans offer the same benefits though the premium may vary.
Source: projektgenerika.org

Video: What are Medicare Supplement Plans?

Medicare insurance Supplement Insurance policy, Or Medicare supplemental health insurance Policies

Probably the most common misunderstandings with Medicare health insurance supplement insurance coverage is the fact that newer, less highly-priced coverage come each time during offered enrollment with November 15th to be able to December 31st. This is false. The once-a-year open application period ideal for changing treatment plan Part N plans, dis-enrolling in a Medicare Convenience plan, or changing to some new Medicare health insurance Advantage system. It is absolutely not however an occasion when you can finally purchase an innovative supplement with no medical underwriting on a yearly basis.
Source: jstreetjive.com

Travel Health Insurance For Over 65′s What Senior Travelers Should Know

Travel health insurance covers unexpected medical expenses when you are outside of your home country. If you are covered under Medicare, these plans become your primary insurance while abroad. Travel health insurance also fills critical gaps with most Medicare supplemental plans while you are overseas. For example, Medicare supplements typically cover emergencies up to $50,000 and are subject to a $250 deductible and 20% co-insurance. In this case, the coverage gap on a $60,000 hospitalization followed by a medical evaluation of $35,000 will cost the unfortunate traveler $85,000 $20,000 on the hospital bill and $35,000 for the evacuation charge.
Source: g00gledog.com

Medicare supplement Plans

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Source: pacas.info

Medicare supplement information

Medicare supplement plans can be found by a number of private health insurance companies. To find the detail specifics of the various Medicare insurance supplemental plans you have to sign in for their websites to know the plans precisely. The most crucial factor is the fact that in the beginning you need to determine the precise necessity of yours and you must talk to the insurance experts to avail the needed plans. The non-public health insurance policies companies offer different cost rates for same plan. When you buy Medicare insurance Supplement you have to concentrate on the prices as the budget is a vital factor too. Health is easily the most concerned affair for seniors as maladies can certainly encounter them. Under this circumstance costly remedies and incredibly frequently visits to hospital cost vast amounts. Senior citizens above 65 years old get efficient kinds of medical health insurance under Medicare insurance Supplement Plans. Plans are very useful to avail where investment is less and benefits are great.
Source: gamechangersdnabonus.com

Continuing To Understand Differences Within Medicare

For many this territory is uncharted and confusing. Terms are used interchangeably which can only add to the confusion. It is best to get a handle on the terms and there meanings. For instance a premium is the amount that an individual pays for their coverage. It will be the amount paid for Medicare Part B plus the additional for the Medigap supplemental insurance policies. Depending on the coverage that is chosen the premium will vary for each individual. Deductibles are the amount that is paid out of an individual’s pocket before any covered medical expenses are paid for by Medicare. Co-pays, copayments, are a fixed dollar amount that is paid for medical visits. Finally coinsurance which is the amount that is required to be paid by an individual after Medicare has paid their agreed upon portion.
Source: articlesaffair.com

HIPP Program Benefits Medicare Recipients, Saves Money for the State

Posted by:  :  Category: Medicare

Dr. Donald Berwick by TalkMediaNewsTo bolster the Agency’s efforts, Alabama Medicaid contracted with Health Management Systems (HMS) to help identify and enroll additional Medicaid recipients who would benefit from enrollment in the HIPP program. During the planning stage, officials from the Agency and HMS met to discuss strategies on how to connect with ideal HIPP candidates. Promotional strategies include direct mail campaigns targeted toward individuals that fall within specific segments of the state’s Medicaid eligibility file, online resources such as a membership application, and partnerships with Medicaid caseworkers and others that can refer Medicaid recipients through their daily interaction with this group.
Source: heraldnewsmedia.com

Video: Fox News: Cut Medicare to Fund Wars!

Hospice Company Accused Of Medicare Fraud

California Watch/San Francisco Chronicle: AseraCare Hospice Accused Of Medicare Fraud A national for-profit hospice care company that is partially owned by a San Francisco private equity firm has allegedly bilked Medicare of millions of dollars, according to a legal complaint filed this week by the U.S. Department of Justice. In court documents, the U.S. government alleges that since at least 2007, AseraCare Hospice of Texas has fraudulently certified patients as terminally ill to illegally collect Medicare payments. “AseraCare, through its reckless business practices, admitted and retained individuals who were not eligible to receive Medicare hospice benefits, because it was financially lucrative — and did so even after AseraCare’s auditor alerted AseraCare to troubling problems,” court documents state (Yeung, 1/6).
Source: kaiserhealthnews.org

As Predicted, Obama Administration Backs Off Medicare Anti

ACH19-ValueforMoney AHC13-PovertyandHealth Entitlement Reform NN11-Personal-News NN12-Job-Listings NN13-FellowshipsInternships NN18-Conferences-Meetings NN19-Books NN20-Articles-Papers NN21-Grey-Literature NN22-Organization-News NN25-Videocasts NN27-Blogs PPACA-Constutionality PPACA-Impact-Access PPACA-Impact-Consumers PPACA-Impact-Costs PPACA-Impact-Employers PPACA-Impact-HealthInsurers PPACA-Impact-HealthProfessionals PPACA-Impact-Hospitals PPACA-Impact-Outcomes PPACA-Impact-States PPACA-Medicaid PPACA-Medicare PPACA-PublicOpinion PPACA-Repeal Regulation-FDA Regulation-HealthFacilities Regulation-HealthProfessionals
Source: wordpress.com

Medicare beneficiaries with PEIA not affected by Humana decision 

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Source: wvgazette.com

What You Need to Know About Medicare in 2012

January 2012 December 2011 November 2011 October 2011 September 2011 August 2011 July 2011 June 2011 May 2011 April 2011 March 2011 February 2011 January 2011 December 2010 November 2010 October 2010 September 2010 August 2010 July 2010 June 2010 May 2010 April 2010 March 2010 February 2010 January 2010 December 2009 November 2009 October 2009 September 2009 August 2009
Source: beebenews.com

New Guide Helps Boomers Transition to Medicare — Palos Hills news, photos and events — TribLocal.com

“The guide will be especially helpful for professionals such as employment benefits counselors, social service agencies, health care providers and human resources staff who serve people who have or are becoming eligible for Medicare,” said Terri Gendel, director of benefits and advocacy at AgeOptions, the Area Agency on Aging of suburban Cook County. “They can use the different documents to learn the rules, refresh their understanding, create presentations for consumers and share specific handouts with the people they counsel.”
Source: triblocal.com

63 percent of health insurance exchange

We publish live insurance news daily so you can keep informed whether it be insurance industry news or consumer related – we’ve got a full array and it’s all based on one subject, Insurance! Consumers often look for insurance product information so we highlight everything from cancer insurance to cell phone insurance so you can be informed! Insurance professionals will find daily property and casualty insurance news too – we have dedicated a complete section to insurance news today for agents! Thank you for visiting and let us know your thoughts!
Source: liveinsurancenews.com

Humana dropping Thomas, Saint Francis for Medicare plans 

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Source: wvgazette.com

2012 Medicare debate is all about the baby boomers

With more than 1.5 million baby boomers a year signing up for Medicare, the program’s future is one of the most important economic issues for anyone now 50 or older. Health care costs are the most unpredictable part of retirement, and Medicare remains an exceptional deal for retirees, who can reap benefits worth far more than the payroll taxes they paid in during their careers.
Source: news-sentinel.com

Canadian Pharmacy Brings Outside Perspective to Medicare Part D

Posted by:  :  Category: Medicare

DC Voting Rights by dbkingThe Government is enforcing Medicare Part D. Proof of this is evident if considering the penalties individuals will incur by not joining Medicare Part D by May15th. The accumulative 1% penalty (per month) can become expensive over time and looks counter productive. It seems more likely the Government agenda is geared towards herding the public into a central plan and closing the doors for international prescription imports.
Source: danmuk.com

Video: 5 minutes to lower Medicare Part D spending on MedicareSaver.com

New Medicare Part D Pharmacy Notice Rule In Effect; Stay Tuned for Final Model Notice 

[1] See, generally, Medicare Prescription Drug Benefit Manual, Ch. 18, at: https://www.cms.gov/MedPrescriptDrugApplGriev/Downloads/PartDManualChapter18.pdf [2]As referenced in previous Alerts, Health Care Reform consists of two separate laws, the Patient Protection and Affordability Care Act of 2010 (PPACA), Pub.L. 111-148 (March 23, 2010), and the Health Care and Education Reconciliation Act of 2010 (HCERA), Pub. L. 111-152 (March 30, 2010). The laws often are collectively referred to as the Affordable Care Act (ACA). [3] 76 Fed Reg 21471 (April 15, 2011). [4] 42 CFR §423.562(a)(3). [5]42 CFR §423.128(b)(7)(iii). [6]See 10/14/11 CMS Memo re: Revised Standardized Pharmacy Notice (CMS-10147), available at: htt ://mcoaonline.com/content/pdf/20111014-RevStdPharmNotice.pdf. [7] The new 2012 Revised Standardized Pharmacy Notice (
Source: medicareadvocacy.org

Viewpoints: Protecting Home Health Workers; Minn. Plans Cuts In Health Safety Net

The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[11] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[12] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[10] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[13] Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[14] Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.”[15] There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.”[16] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[17] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[18][19] In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[20] Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[21] Others have reported that minority enrollment is not particularly above average.[22] Another study has raised questions about the quality of care received by minorities in MA plans.[23] The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[24] [edit] Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Source: medicare-health.com

Memo to Social Security: How about a Buy

Posted by:  :  Category: Medicare

wtf by moppet65535Naturally,  not everyone receiving Social Security benefits can or should opt for a buy-out.  But millions of other retired Americans could.  Many have worked hard, lived below their means, saved, invested, and planned carefully for retirement.  They might use their one-time payment to purchase an annuity from an insurance carrier, and/or invest in bonds, stocks, or other income-producing vehicles.   Frankly, after Obama threatened to withhold Social Security checks this past year, and with the downgrading of US debt, these other investments are looking a lot more secure.
Source: westernfreepress.com

Video: My Social Security Claim Has Been Denied, What Next? – By MySocialSecurityAttorney

Social Security Lawyer Talks About Work Attempts : Indiana Personal Injury Lawyers

So, the Social Security Administration rules and regulations allow for trial work periods.  If you apply for benefits, you may try to reenter the work force while your application is pending without prejudice to your application if you are unable to continue that work.  The rules are contained in the Code of Federal Regulations, 20 CFR Sec. 1592.  Under this provision, if you are unable to work for nine consecutive months, then this work will not be evidence that you are able to work.  If you work more than 9 consecutive months then the work will be considered in making the disability decision.  It is my experience that Administrative Law Judges look favorably on those with failed work attempts, especially in those cases where the judge’s discretion is key to the case.  What I mean is if your claim is a “close call”, a failed work attempt may serve to increase the claimant’s credibility and give them the benefit of the doubt.
Source: youngandyoungin.com

The Interesting Political Economy of the Social Security Tax Cut, David Henderson

The tax cut extension means that the social security trust fund will receive $159 billion less in 2011, causing it to run a deficit for a second straight year. The Social Security trust fund deficit will be paid from the general fund of the Treasury. “This pretty much ends the claim that Social Security is self-financing or that it doesn’t contribute to the budget deficit,” says Andrew Biggs, a resident scholar at the non-partisan American Enterprise Institute and a former deputy commissioner of the Social Security Administration. Why is this interesting? When I talk about Social Security with people over age 60, many of them believe that there’s a trust fund there, with lots of dollars in it, that they “contributed” to. Some even believe that the government has a special account with their name on it. They believe, in essence, that they have a property right to those benefits. Of course, not only is there no account with their name on it, but also there is no trust fund with actual money in it. I think, though, that the trust-fund belief is one of the main barriers to getting rid of, if only in slow motion, Social Security. As Biggs points out in the quote above, it will be increasingly hard to maintain that Social Security is self-financing. In other words, it will be increasingly clear to everyone that Social Security is a welfare program that takes tax revenue from current taxpayers. That fact will undercut the case for Social Security as a contractual obligation.
Source: econlib.org

STOP NEIGHBORHOOD SOCIAL SECURITY FIELD OFFICE CLOSURES!

Those most vulnerable– including the elderly, immigrants and refugees, people with physical and mental disabilities, very-low or no income, and the homeless– will suffer disproportionately from these service cuts. We need the SSA Regional Commissioner, Stanley Friendship, to reverse his decision and preserve equitable, accessible, community-based service for all.
Source: thenativecircle.org

Social Security Is An Online Leader In Spanish Too — Palos Hills news, photos and events — TribLocal.com

Get an instant, personalized estimate of your future Social Security benefits using the Retirement Estimator. Using the actual wages posted in your Social Security record, the Estimator will give you a good picture of what to expect in benefits. It protects your personal information by providing only retirement benefit estimates — it does not show the earnings information used to calculate the benefit estimate, nor does it reveal other identifying information. You can plug in different scenarios and future wage amounts to get estimates for different situations.
Source: triblocal.com

Social Security Administration Clarifies Rules on Past Relevant Work

In this example, the SSA recommends “…the adjudicator should carefully consider whether the (residual function capacity) limitations resulting from his impairment and the side effects of his medications would preclude his PRW as a truck driver.” The adjudicator would not consider that the truck driver’s licensing department will not issue a driver a license, according to the SSA’s website. In effect, a SSA adjudicator could find a person could drive when in reality another governmental agency, who has the actual authority of issuing the driver’s license, says the driver can not drive. Notably, obtaining a CDL truck driver’s license generally requires a physical exam.
Source: lawfirmnewswire.com

Legal Help With Social Security Disability Application

The first thing that you should be looking out for on the official website of a law firm is the information that is provided there. There will be quite a few out there that provide vague info and you will end up more puzzled than you were at the beginning. However, a good site will tell you exactly what you need to know; nothing less, nothing more.
Source: nwasga.org

Terminally ill die while waiting for Social Security because of backlogs

Services provided to low-income people include employment (getting illegally denied unemployment benefits and back pay and wages due), housing (preserving affordable housing, stopping illegal evictions from public and subsidized housing, advocating for the correction of substandard housing, preventing homelessness), income maintenance (helping those with disabilities avoid institutionalization, preserving or obtaining public benefits, overcoming denial of public benefits), juvenile (representing abused and neglected children), consumer (preventing foreclosure, helping homeowners bilked by foreclosure rescue scams, correcting credit ratings, stopping dept-collection activity, overcoming illegal or unfair sales contracts, avoiding utility terminations), health (helping sick children and the elderly get medical assistance, helping seniors get Medicaid assistance so they can live in their communities), family (making sure custodial parents don’t lose custody of their children, helping abused women obtain custody, divorce and alimony), farmworkers (educating and representing farmworkers regarding their employment rights and educating service providers, government and the public about farmworkers’ rights and needs), and education (helping children get special education services to which they are entitled, avoiding illegal or unfair school suspensions and obtaining correct school records).
Source: wordpress.com

Criminal Lawyer Fort Lauderdale Website

My wife and I need to find an excellent criminal lawyer fort lauderdale to help us in court. We want to make sure that we are represented by the best possible lawyer in our local area. My wife and I do not want to try and represent ourselves because we need quality legal advice to help us through this difficult situation. We are very nervous and hope that our lawyer will be able to ease our worries and walk us through what to expect.
Source: californiasocialsecuritylawyerblog.com

Social Security Resolutions — Homer Glen news, photos and events — TribLocal.com

1. Think about retirement. Whether you’re 26 and beginning a career or 62 and thinking about the best time to stop working, give some thought to what your retirement plan will be. Social Security is the largest source of income for elderly Americans today, but it was never intended to be your only source of income when you retire. You also will need savings, investments, pensions or retirement accounts to make sure you have enough money to live comfortably when you retire. The earlier you begin your financial planning, the better off you will be. For tips to help you save, visit www.mymoney.gov.
Source: triblocal.com

Social Security: What Should You Do at Age 62? 1/6/2012

This material was prepared by Broadridge Investor Communication Solutions, Inc., and does not necessarily represent the views of John Jastremski, Jeremy Keating, Erik J Larsen, Frank Esposito, Patrick Ray, Robert Welsch, Michael Reese, Brent Wolf, Andy Starostecki and The Retirement Group or FSC Financial Corp. This information should not be construed as investment advice. Neither the named Representatives nor Broker/Dealer gives tax or legal advice. All information is believed to be from reliable sources; however, we make no representation as to its completeness or accuracy. The publisher is not engaged in rendering legal, accounting or other professional services. If other expert assistance is needed, the reader is advised to engage the services of a competent professional. Please consult your Financial Advisor for further information or call 800-900-5867.
Source: xxxmthai.com

Here’s advice for sorting out Medicare changes

Posted by:  :  Category: Medicare

Cassandra Q. Butts by Center for American ProgressThe good news is that the so-called “donut hole” – the gap in Medicare Part D prescription drug coverage – has been narrowed. If the total you and the plan spend on medications costs more than $2,840 but less than the yearly $4,550 out-of-pocket spending limit, until recently you were hit for the full cost of your prescriptions. But, beginning this year, those who fall in the donut hole get a 50 percent discount on brand-name drugs and declining costs on generic medications. The charge for brand-name drugs will begin to drop starting in 2013 and the donut hole will be closed completely by 2020. (Those who already receive Medicare Extra Help, a program for people with low incomes, are not eligible for these discounts.) The new law also covers many preventive care options under Medicare, such as a yearly wellness exam and screening for a number of conditions.
Source: echopress.com

Video: Barletta Questioned About Medicare Changes In Ryan’s Budget During Town Hall

Doctor Groups Seem Less Wary of Medicare Changes

Although the association didn’t specify in its letter what changes they like or provide further comment, other doctor groups like the AMA said the physician community is happy they will be able to participate without losing money in the first three years and the federal government will allow certain doctor groups access to $170 million in initial Medicare savings to help them form ACOs. In addition, doctors said they were encouraged that the number of quality measures that need to be met was cut in half, but there will still be more than 30 or so benchmarks.
Source: nytimes.com

Health Care 2012: Medicare Faces Big Changes, New State Laws Include Abortion Issues

The Texas Tribune: What Will 2012 Hold for Texas Politics, Policy? The new year will determine how Texas proceeds with two contentious public health matters: family planning and the state’s huge uninsured population. The Obama administration has rejected Republican state lawmakers’ efforts to block Planned Parenthood from participating in the Medicaid Women’s Health Program, but has extended the program into March so the state can reconsider its options. … It’s a game of who will blink first, with cancer screenings and birth control for some 130,000 low-income Texas women hanging in the balance (Ramshaw, 1/1).
Source: kaiserhealthnews.org

Baby Boomers And Medicare: What 2012 Holds

With the Presidential election coming up, many people are wondering whom to pick for the best Medicare changes, but, no matter who is elected, Medicare will definitely see major changes in 2012. With baby boomers now having eligibility for Medicare, the future of the Medicare plan now concerns anyone 50 or older because health care costs are unpredictable, and that is why so many people sign up for Medicare. But one of the changes in 2012 may be raising the age of eligibility, but doing this will cut out the 1.5 million baby boomers who have found Medicare the best deal in retiring.
Source: ewireinformer.com

Medicare headed for big changes regardless

LOS ANGELES, CA (Catholic Online) – Medicare remains an exceptional deal for retirees, who can reap benefits worth far more than the payroll taxes they paid during their working years. “People would like to have what they used to have. What they don’t seem to understand is that it’s already changed,” Gail Wilensky, a former Medicare administrator and adviser to Republican says. “Medicare as we have known it is not part of our future.” Medicare’s giant “trust fund” for inpatient care is projected to run out of money in 2024. At that point, the program will collect only enough payroll taxes to pay 90 percent of benefits. Furthermore, researchers estimate that 20 to 30 percent of the more than $500 billion that Medicare now spends annually is wasted on treatments and procedures of little or no benefit to patients. With these undeniable facts, lawmakers can’t let Medicare keep running on “autopilot” and they’ll look for cuts before any payroll tax increases. Privatization of health care remains the biggest divide between Democrats and Republicans. Currently about 75 percent of Medicare recipients are in the traditional government-run, fee-for-service program and 25 percent are in private insurance plans known as Medicare Advantage. Ryan’s plan would have put 100 percent of future retirees into private insurance. His latest plan, developed with Sen. Ron Wyden of Oregon would keep traditional Medicare as an option, competing with private plans. Older people would get a fixed payment they could use for private health insurance or traditional Medicare. Proponents call it “premium support.” To foes, it’s a voucher. People now 55 or older would not have to make any changes. GOP presidential candidates Mitt Romney and Newt Gingrich praise his latest plan. How would it work? Would it save taxpayers money? Would it shift costs to retirees as Ryan’s earlier plan did? Would Congress later phase out traditional Medicare? Those and other questions must still be answered. “I’m not sure anybody has come up with a formula on this that makes people comfortable,” said health economist Marilyn Moon, who formerly served as a trustee helping to oversee Medicare finances.
Source: catholic.org

Upcoming Changes to the Medicare Program

Beginning January 1, 2012, all Part B withholdings and overpayments shown on the remittance advice with PLB adjustment reason code ‘WO’ and forwarding balances with provider level adjustment (PLB) reason code FB will no longer have the beneficiary’s Health Insurance Claim number (HICN) on the remittance advice alongside the financial control number (FCN). If your office submits claims with the Patient Account Number field completed, this field of the remittance advice will now contain the patient account number instead.
Source: grassicpas.com

First Edition: January 6, 2012

Posted by:  :  Category: Medicare

HEALTHCARE WITH GOVERNMENT OPTIONS PLAN: IS THIS REALLY GOING TO MAKE ALL AMERICANS EQUAL IN THEIR TREATMENT? by roberthuffstutterThe original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[11] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[12] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[10] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[13] Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[14] Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.”[15] There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.”[16] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[17] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[18][19] In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[20] Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[21] Others have reported that minority enrollment is not particularly above average.[22] Another study has raised questions about the quality of care received by minorities in MA plans.[23] The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[24] [edit] Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Source: medicare-health.com

Video: Medicare Locals Video

McKenzie County Memorial Hospital First in State to Receive Medicare Funding for Use of Electronic Health Records

The program was created by the Health Information Technology for Economic and Clinical Health (HITECH) Act to offer healthcare providers financial incentives for implementing and demonstrating meaningful use of an EHR system. McKenzie County Memorial …
Source: blackmereconsulting.com

Ron Paul’s other 1964 (okay 1965) problem

Paul’s apparent bigotry and his crackpot economic views attract scorn when they lead to his principled objections to (say) the Civil Rights Act of 1964 as an undue infringement on individual liberty. They certainly should. Those who admire Paul’s issue positions sometimes regard these unpalatable conclusions as oddly admirable, an example of Paul’s willingness to push basic principles to their logical conclusion. Or these views are treated as a freakish and embarrassing, yet now operationally irrelevant aspect of an otherwise justified way to look at the world. Conor Friedersdorf complains, for example, that “For Critics of Libertarianism, It’s Always 1964.”
Source: tcf.org

CMS Approves First Group of Pioneer ACOs

Massachusetts-based organizations selected by CMS in this first round are Atrius Health, the Beth Israel Deaconess Physician Organization, the Mount Auburn Cambridge Independent Practice Association, Partners Healthcare, and the Steward Health Care System.
Source: publicconsultinggroup.com

CMS advises providers to hold 2012 Medicare claims for first 10 days of
January

“Congress must act in a meaningful way to prevent the looming 27.4% cut in Medicare reimbursements,” Berry stated in the release. “Our nation’s elderly and disabled citizens deserve better than the uncertainty that the current system engenders. A stable Medicare physician reimbursement system is essential for establishing a foundation for new payment models and delivery reforms that provides security for patients and the physicians who care for them.”
Source: orthosupersite.com

Medicare Disenrollment Period For 2012

If you are enrolled into a Medicare Advantage Plan, you are allowed to drop your Medicare Advantage Plan and go back to original Medicare.  If you do this, you will also want to enroll into a Medicare Part D Prescription drug plan.  Original Medicare is the Part A and Part B that is on your paper Medicare card that you received when you first joined Medicare.  It does not include drug coverage which is why you would want to enroll into a Part D drug plan.  You have until February 14th to enroll into a Part D drug plan.  The coverage starts the first day of the month after you enroll.  For example, if you enroll into the drug plan on January 20th, your coverage would start on February 1st.  If you wait until February 14th to enroll, then your coverage starts on March 1st.
Source: medicare-plans.net

CMS Approves First Group of Pioneer ACOs

CMS announced on December 19 that it has selected the first 32 health care organizations nationwide to participate in the Pioneer Accountable Care Organization (ACO) program. The Pioneer ACO program is designed to test a rapid transition to outcomes-based contracting and is an accelerated version of ACO model in the Medicare Shared Savings Program under section 3022 of the Affordable Care Act (ACA). The inaugural class of Pioneer ACOs consists of distinguished medical organizations with the ability to show what actually can be achieved through better coordinated, patient-centered care for Medicare fee-for-service beneficiaries.   Massachusetts-based organizations selected by CMS in this first round are Atrius Health, the Beth Israel Deaconess Physician Organization, the Mount Auburn Cambridge Independent Practice Association, Partners Healthcare, and the Steward Health Care System. Other New England organizations selected by CMS in the first round include the Dartmouth-Hitchcock ACO and the Eastern Maine Health Care System. The Medicare ACO contract period of performance for these leading organizations began on January 1.  
Source: publicconsultinggroup.com

Making Sense of Medicare Part D

Posted by:  :  Category: Medicare

319 | Tragedies of Medicine by The DoctrBasically, the insurance policy providers that function online pharmacy review the several options have a Pharmacy & Therapeutics committee that chooses which medications they will go over on their formulary and which medications they will not cover. There is a nationwide formulary coverage regular that the insurance policies companies ought to adhere to when creating their formulary underneath the new Medicare Prescription Drug Plan. They should present a certain regular stage of drug coverage for certain condition/health ailment categories. This indicates that these programs have to go over a specific amount of medicine in most disease groups which influence seniors overall health. The big mystery for Medicare-eligible folks to figure out is, will these ideas cover the medication that they have been approved by their medical doctor and that they have been taking for some time.
Source: wordpress.com

Video: Medicare Part D Formulary

Q1Medicare.com Launches Enhanced Medicare Prescription Drug Plan Formulary Browser

The Formulary Browser also has several searches designed for medical, pharmaceutical, and healthcare professionals who have access to Medicare plan information that is not specific to a geographical area or when they are assisting geographically dispersed Medicare beneficiaries. Professionals or technically savvy seniors can search by the Medicare plan Contract ID and Plan ID to find a specific Medicare plan’s formulary by selecting the “PlanID” search. Alternatively, healthcare professionals can search the Formulary Browser by entering just the eight-digit Formulary ID by selecting the “FormularyID” search. Both the Contract ID/Plan ID and the Formulary ID search results will return the geographical service area for the plan in question along with the Medicare plan’s formulary details and the actual plan features.
Source: bestlongtermcare.org

Medicare Part D, formularies, competition, pricing leverage and getting it all wrong

Medicare Part D has long presented a controversy because the law prevents direct negotiation by the government with drug companies for lower prices and rebates; something common in the private sector via pharmacy benefit managers (PBMs). Rather, each Part D provider must negotiate on its own, but with so many vendors offering Part D benefits their negotiating power is limited. In New Jersey for example there are eighteen different vendors offering Part D plans to 1,336,988 Medicare beneficiaries. That is an average of less than 74,277 individuals per vendor (some beneficiaries have private drug coverage through previous employers). How much more pricing leverage would there be if there were only three or four Part D insurers in NJ (or nationally)? In addition, these vendors are prevented from limiting their formulary drugs.
Source: quinnscommentary.com

Humana Medicare Advantage Plan

humana drug formulary 2012 (18),humana formulary 2012 (15),humana 2012 drug formulary (13),Humana Medicare Advantage Plan (13),humana medicare drug formulary 2012 (5),2012 humana formulary (4),2012 humana gold plus hmo formulary (4),www humana com/providers (3),humana medicare formulary 2012 (2),humana 2012 formulary (2),humana medicare providers directory ohio (2),in network doctors for humana gold south mississippi (2),humanamedicareadvantageplan (2),humanadrug formulary (2),humana gold choice private fee for services plan primary care providers (2),humana medicare drug formulary for 2012 (2),2012 doctor network for humana medicare ppo plan (2),Does Florida hospital inZephyrhills Fl except HumanaChoice(PPO)? (2),www humanamedicare com (2),www Humana medicare directory pf physicians (2)
Source: medicareadvantagesupplementplans.com

Lack of Monitoring and Clinical Efficacy Key Drivers of Prerferred Formulary Placement for Pradaxa

“Pradaxa’s high price was always going to prompt some resistance, but Pradaxa’s unfamiliar safety profile will also be feeding conservatism among cardiologists,” said Decision Resources’ Therapeutic Area Director Nikhil Mehta. “Many cardiologists are taking a wait-and-see approach before prescribing Pradaxa widely, preferring the devil they know, even when that devil is warfarin.” Approved for the U.S. market in October 2010, Pradaxa is the only currently available antithrombotic for atrial fibrillation that combines superior efficacy over warfarin and simple dosing that does not require frequent adjustment or monitoring. Three factor Xa inhibitors, Xarelto (Bayer/Janssen’s rivaroxaban), Eliquis and Lixiana (Daiichi Sankyo’s edoxaban), will likely launch in the next two years for the same indication resulting in direct competition with Pradaxa. “Pradaxa’s first-to-market status may give it an initial advantage over factor Xa inhibitors, but brands that achieve incremental improvements over Pradaxa may ultimately achieve greater success given the serious and costly clinical events associated with atrial fibrillation (stroke and systemic embolic events) and the risk of major bleeding with warfarin,” continued Mr. Mehta. Decision Resources market access analysis on the atrial fibrillation drug market includes key insights from primary and secondary research addressing different aspects of market access for atrial fibrillation. The analysis is informed by:
Source: decisionresources.com

Medicare Q&A: Which drugs are covered by Medicare Part D?

They include certain types of anti-anxiety and anti-seizure drugs, Barbiturates, Benzodiazepines, prescription vitamins and minerals, and prescription drugs used for anorexia, weight loss or weight gain, fertility, cosmetic purposes or hair growth, and relief of cold symptoms. 
Source: bernardhealth.com

Federal justice officials accuse hospice provider of Medicare fraud

Posted by:  :  Category: Medicare

“We believe that the allegations are without merit or are not violations of the law, and we intend to vigorously defend ourselves against all claims,” Blair Jackson, Golden Living’s vice president of corporate communications, said in an e-mail. “AseraCare operates in full compliance with the law. We believe this case is all about access to appropriate hospice care for Medicare beneficiaries. We are on the side of protecting the rights of our patients to receive the care they need and the hospice benefit they are entitled to. The action of the government in this case is especially troubling because it has the potential to deny Medicare beneficiaries the hospice benefit they are entitled to.”
Source: californiawatch.org

Video: Health Insurance Information : About Hospice Medicare Benefits

Hospice Company Accused Of Medicare Fraud

The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[11] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[12] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[10] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[13] Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[14] Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.”[15] There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.”[16] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[17] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[18][19] In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[20] Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[21] Others have reported that minority enrollment is not particularly above average.[22] Another study has raised questions about the quality of care received by minorities in MA plans.[23] The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[24] [edit] Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Source: medicare-health.com

Daily Kos: Gaming Medicare

A Medicare patient initially has a max of 150 consecutive days in the hospital. Then they either would be discharged to their homes with Part B home health services for at least 60 days to reset the benefit period to zero or is sent onto hospice where they need to be periodically recertified as terminal. If the patient is sent home, they can still receive intraventive care. If the patient is sent to hospice, they can only receive palliative (comfort) care. A lot of times, a patient will stop the intraventive care and go to hospice because of the discomfort of treatment only to change their mind some weeks or months later after they feel better which justifies the “ooops, I’m sorry” discharges. A Medicare patient who has a reset benefit period under Medicare Part A, but has expended their lifetime reserve days now has a maximum stay of 90 consecutive days in the hospital/SNF or Part A home health. The game continues until someone at the MAC (Medicare Administrative Contractor, which used to be called a fiscal intermediary – the private companies that actually run the Medicare programs) decided that the statistics are well under the tails of the bell curve. The Mac takes too long to investigate and sics a RAC auditor on it The MAC brings in the DOJ Seven years or so later…..
Source: dailykos.com

U.S. sues hospice firm for wrongly billing Medicare

AseraCare, which is owned by Golden Living Communities, was accused of filing Medicare claims for patients who were not terminally ill, even though the program does not allow reimbursements for those who do not have a prognosis of six months or less to live.
Source: empowher.com

AseraCare, a Hospice Company, Owned by Golden Living is the Subject of a Whistleblower Suit : Nursing Home Law Blog

The Federal Government has joined in a Whistleblower suit, which alleges that AseraCare, a national hospice company owned by Golden Living, wrongly took advantage of Medicare’s hospice benefit by pressuring its employees to place people into hospice who weren’t dying. The suit states that AseraCare first recruited patients who are eligible for skilled nursing care for 20 days, for which Medicare pays the entire bill. After 20 days, when Medicare requires patients pick up a part of the tab, AseraCare had the nursing homes send the patients to hospice, according to the lawsuit. In hospice, AseraCare would collect a flat payment from Medicare for each day they are enrolled.
Source: stark-stark.com

ProbateSharks.com: U.S. sues hospice company for wrongly billing Medicare

, even though the program does not allow reimbursements for those who do not have a prognosis of six months or less to live. “The United States alleges that AseraCare, through its reckless business practices, admitted and retained individuals who were not eligible to receive Medicare hospice benefits,” according to the complaint filed in federal court on Tuesday. “AseraCare misspent millions of Medicare dollars intended for Medicare recipients who have a prognosis of six months or less to live and need hospice care,” the government said. The Justice Department lawsuit joins a whistleblower suit filed in 2009 by former employees. The company has about 65 hospice providers in 19 states. The company said the allegations were without merit and noted that the U.S. Department of Health and Human Services has allowed hospice patients to stay under such care without limit as long as they are terminally ill and have a six-month prognosis. “This action is especially troubling because we believe it could constrain certain patients – most notably those who suffer from unpredictable disease – from utilizing the hospice benefit,” said AseraCare general counsel David Beck. The case is United States ex rel. Richardson and Brown v. Golden Gate National Senior Care LLC dba Golden Living et al, No. 2:09-cv-00627, in U.S. District Court for the Northern District of Alabama. For Richardson: Henry Frohsin of Frohsin & Barger. For Golden Gate: Not immediately available. (Reporting by Jeremy Pelofsky) Follow us on Twitter: @ReutersLegal Please read complete article at link below: http://www.chicagotribune.com/health/sns-rt-us-healthcare-hospicetre8021uq-20120103,0,3311310.story
Source: blogspot.com

U.S. Goes After National Hospice Chain for Allegedly Swindling Medicare : Senior Housing News

The original whistleblower suit was filed by Dawn Richardson and Marsha Brown, former AseraCare Hospice employees. The False Claims Act allows private citizens aware of fraud to file whistleblower suits on behalf of the US and to share in any recovery, according to the DOJ; now that the US has intervened, pending its ability to prove the defendant knowingly submitted false claims, it is entitled to recover three times the damage that resulted along with a penalty of $5,500 to $11,000 per claim.
Source: seniorhousingnews.com

U.S. Files Complaint Against National Chain Of Hospice Providers Alleging False Claims On The Medicare Program

WASHINGTON