Medicare and Mediscare, medicare, ryan, plan

Posted by:  :  Category: Medicare

"Associate yourself with men of good quality if you esteem your own reputation, for 'tis better to be alone than in bad company." ~ George Washington. by eyewashWhat was the biggest political lie of 2011? Lots of competition there. But recently Politifact, the St. Petersburg Times’ fact-checking website, declared its winner: the claim by Democrats that House Budget Committee Chairman Paul Ryan’s budget plan would “end Medicare.” Ryan’s innovative proposal kept Medicare intact for people 55 or older, Politifact noted, “but dramatically changed the program for everyone else by privatizing it and providing government subsidies.” The big Mediscare lie worked; Ryan’s plan didn’t clear the Congress. Recently, Ryan and Democratic Sen. Ron Wyden, of Oregon, introduced a new plan — think of it as Ryan’s now-familiar philosophy, Version 2.0 — to tame Medicare costs while maintaining quality health care for seniors. There’s much in this for lawmakers of both parties, if only they’ll give it a chance. The congressional duo is telling Americans the truth: Medicare’s current fiscal trajectory is unsustainable. Too many baby boomer seniors. Too much limitless fee-for-service spending. Too little cost control. Some Democratic pols have greeted anything from Ryan with the usual Mediscare fear-mongering: That the plan will bounce Granny out of Medicare as she knows it. That it will cut benefits and raise premiums. Credit Wyden and Ryan for braving decades of Mediscare attacks to produce a thoughtful and dramatic overhaul of system. Here’s how it would work: • The feds would create a “premium support” plan, which means the government would give seniors a certain amount of money to buy health coverage, either from traditional Medicare or from private insurers who would compete with it. Poorer seniors would get more money; richer seniors less. No one would be denied coverage. • Competition would make consumers more cost-conscious and restrain prices. There is evidence that this would work. Check out what happened with the Medicare drug benefit that started in 2006. Private drug plans compete for seniors’ business, and that keeps prices — and government outlays — much lower than projected. • And what if it didn’t work? The Ryan-Wyden plan would cap Medicare spending, based on inflation and the rise in the gross domestic product. If Medicare exceeded that cap, the law would target that overspending: It might trigger cuts in payments to providers, such as doctors or drug companies, or possibly boost premiums for affluent beneficiaries. We’re skeptical about how — and if — the cap would work, in part because the plan is sketchy on that point. Then there’s political reality: Congress never will be eager to cut Medicare payments. Note how lawmakers have tried and failed for almost a decade to enforce a Medicare physician fee cut. Ryan and Wyden promise more details on how their plan would work. Bring them on. In the meantime, let’s credit these lawmakers for thinking big. They’ve demonstrated that bipartisan agreement is possible on a Medicare overhaul. We’d say it is essential. The longer some politicians resort to Mediscare, the harder it will be to rescue Medicare.
Source: limaohio.com

Video: Ohio Medicare Advantage Vs Ohio Medicare Supplement Plans

Ohio Medicare Beneficiaries In Coverage Gap Saving $64,954,039 This Year As Time To Select 2012 Plans Draws To A Close

And, as of the end of November, more than 24.2 million people with Medicare have taken advantage of at least one free preventive benefit – including the new Annual Wellness Visit – made possible by the Affordable Care Act.  In Ohio, 864,243 people with Medicare have taken advantage of the free preventive coverage. Building on savings in 2011, Medicare also recently announced that the Part B deductible will be $22 lower in 2012 and average Medicare Advantage premiums are projected to drop four percent in 2012.  Part B premiums, which cover outpatient services including doctor visits, are estimated to increase by only $3.50 per month for most beneficiaries in 2012, and some will see a decrease.  These changes will be more than offset by the average Social Security cost of living increase ($43 per month for retired workers). People with Medicare can now review their drug and health plan coverage options for 2012 as part of the annual Medicare Open Enrollment Period.  CMS is highlighting plans that have achieved an overall quality rating of five stars with a high performer or “gold star” icon on Medicare’s Plan Finder – www.medicare.gov/find-a-plan. For more information about how the Affordable Care Act closes the donut hole over time, go to http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf
Source: progressohio.org

Ohio Health Policy Review: HPIO releases primer on final Medicare Shared Savings Program rules

The Health Policy Institute of Ohio has released a new policy primer — Final rules for the Medicare Shared Savings Program (4 pages, pdf). On Nov. 2, 2011, the Centers for Medicare and Medicaid Services (CMS) published the Final Rules for the Medicare Shared Savings Program (MSSP). These Final Rules establish the framework for health care providers to join together to form Accountable Care Organizations (ACO) to provide coordinated, high quality, cost effective care to Medicare fee-for-service beneficiaries. The Final Rules include financial incentives for health care providers to join ACOs by allowing providers to share in savings achieved in Medicare expenditures resulting from improved, coordinated care. In May of 2011, HPIO published a Health Policy Brief entitled “Understanding the Medicare ACO and its Potential Impact on Ohio and the Nation: Considerations of the CMS Draft Rules,” (24 pages, pdf) that outlined the Proposed MSSP Rules and reactions from Ohio-based health systems implementing the accountable care model. This policy brief is an update to that original and outlines some of the significant changes included in the Final Rules and impact they may have on participation in the program.
Source: healthpolicyreview.org

Big rally against Social Security/Medicare/Medicaid cuts tomorrow in Cleveland

Sponsors and endorsers of the Rally and March include: United Pastors in Mission; North Shore AFL-CIO Federation of Labor; Occupy Cleveland; American Federation of Government Employees; Cleveland Jobs with Justice; Southern Christian Leadership Conference, Cleveland Chapter; United Church of Christ Justice and Witness Ministries; Progressive Democrats of America – Ohio; Universal Health Care Action Network (UHCAN National); U.S. Labor Against the War; National Lawyers Guild; Single-Payer Acton Network Ohio (SPAN Ohio); Cleveland Peace Action; Chicago & Midwest Regional Joint Board affiliated with Workers United; Service Employees International Union Local 1; Veterans for Peace; Wayne County Progressive Network; Women Speak Out for Peace and Justice; Greater Abyssinia Baptist Church; Lutheran Metropolitan Ministry; Ministers In Action for Environmental Justice; Northeast Ohio American Friends Service Committee; New National Assembly to Bring the Troops Home Now; Coalition for A Better Life, (dba Peace in the Hood, Inc.); The Task Force for Community Mobilization; International Council for Urban Peace, Justice and Empowerment; Greater Cleveland Shurah Council; Black on Black Crime; Emergency Labor Network; United Auto Workers, Local 1005; First Grace United Church of Christ; Social Action Committee, Unitarian Universalist Fellowship of Wayne County.
Source: ohiodailyblog.com

New Medicare Shared Savings Program & ACOs

In October of 2011, CMS released the much-anticipated final rule for the Medicare Shared Savings program. In this rule, Medicare defines an  accountable care organization (ACO) as a legal entity recognized under state law made up of certified Medicare providers or suppliers.  These providers work together to manage and coordinate care for a specific population of Medicare fee-for-service beneficiaries.  ACOs must meet specific performance standards as well as reduce spending below a target amount to be able to receive shared savings.
Source: himss.org

Motivated In Ohio: VIDEO: New Iowa Frontrunner Thinks Medicare, Paper Money And Nearly Everything Else Is Unconstitutional

VIDEO: New Iowa Frontrunner Thinks Medicare, Paper Money And Nearly Everything Else Is Unconstitutional: Yesterday, two new polls showed Rep. Ron Paul (R-TX) emerging as the latest frontrunner in the Iowa GOP presidential caucus. Should the GOP primary electorate ultimately choose Paul as their nominee, however, it would be the clearest possible sign that they want to remake this country into a much meaner and more cruelly indifferent nation […]/  Read More Here
Source: motivatedinohio.com

Ohio 15th District: End to Medicare???? Republicans Want It

Boehner is full of it.  I don’t trust Boehner because his goals include protecting the wealthy and staying in power. As long as Boehner is the Speaker of the House, nothing will get done.  The so-called “jobs” bills passed by the House of Representatives are nothing more than tax cuts for the wealthy, and ending environmental and banking regulations. Ending regulations, especially in the area of banking, will bring us back to the autumn of 2008 when Lehman Brothers and Wall Street collapsed. 
Source: blogspot.com

MedPAC Failure to Recognize Obvious Medicare

Posted by:  :  Category: Medicare

ILGWU senior female members and retirees holding placards urging "fair play for the aged", "hands off social security", "don't mess with medicare", "keep your promises Mr. President", and more. by Kheel Center, Cornell UniversityAcquisition Amex Amp Annual Meeting Appointment Asia Board Of Directors Breast Cancer Ceo Chief Executive Officer Conference Call Diabetes Fda Firstcall Food And Drug Food And Drug Administration Food And Drug Administration Fda Health Hospitals Insurance Launch Llc Market Research Report Marketwire Medicare Medicine Nasdaq New York Ny Nyse Nyse Amex Otcbb Partnership People Pharmaceuticals Inc Photos Physicians Pinksheets Prnewswire San Diego Subsidiary Today Announced That Toronto Ontario Tsx United States Usnewswire
Source: allhealthnewswire.org

Video: A Short History on Medicare

A Short History on Medicare

About Advantage affordable article Benefits best Business Care Companies compare comparison costs Coverage dental drug financial find from Good great Guide Health Healthcare home Insurance Joint Life Medicaid Medical Medicare News Nursing online Part Plan Plans Private Quotes Reform Report Security Small Social Student Supplemental
Source: healthinsuranceandmedicareupdate.com

The History of Medicare and Its Influence on American Health Care

With the recent plans to change Medicare, we thought it was only necessary to take a look back on memory lane and see how it has enhanced the American healthcare system. The program that provides insurance for more than 43 million elderly and disabled Americans is considered a huge success that has improved the lives of so many. According to the Obama administration the Medicare fund that pays hospitals for treating Medicare patients will deplete in 2017. How will future generations be affected? To discover the history of Medicare, where it’s going in the future, and how you can utilize this program to the fullest read the article below.
Source: villamariatucson.com

New Hampshire Results CoveritLive!

My rules of the road for primary season. Rule #1: Vote for YOUR first choice in the primaries Rule #2: Vote for the R in the general. Rule #3: Don’t let anyone convince you to violate Rule #1 or Rule #2 Rule #4: When in a center-right argument, reaffirm Rules #1-#3–it will help us all to get along better. Rule #5: If you are using the language of the left, you probably aren’t furthering conservativism Rule #6: The priority is issues first, candidates second, and supporters third. Nobody is bigger than the issues. Conversely, if you spend your time focusing on supporters, you are wasting everyone’s time. STOP THE MADNESS! A reduction in the rate of spending increases is NOT a cut! In-state tuition for illegals is NOT amnesty! Requiring someone to pay their medical bills is NOT an individual mandate! Reducing tax rates is NOT a tax increase!
Source: redstate.com

Daily Kos: Republicans trying to rewrite history on Medicare vote

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Source: dailykos.com

The Medicare Gordian Knot

In May 2011, Rep. Tom Price, MD (R), GA, introduced HR-1700, the “Medicare Patient Empowerment Act” (MPEA), and Sen. Lisa Murkosky (R), AK, introduced a companion bill in the Senate, SB-1042. This legislation would change the physician participation restrictions, allowing docs to independently and privately contract with any Medicare patient for a mutually agreed to fee, specifically for non-emergent services, which might differ from the fixed-fee allowed by Medicare. The reason this bill is called the Medicare Patient Empowerment Act is quite simple. Should the system be allowed to go on as is, Medicare patients will soon find themselves unable to find a physician willing to work for what Medicare pays. Then, if the patient decides to go to an ‘opted-out” physician they will lose the benefits they have paid into for many years. This is quite simply unfair. This bill would solve the problem by “empowering” each patient to use their Medicare benefits however they see fit when seeking the care they need and desire.
Source: spiritofhealthcare.com

Historical Context: The Intersection Of Politics And Medicare Policy

California Healthline: Politics Have Always Been Part Of Policy — But Have We Hit A New Low? The 1920s-era charge that national health insurance was socialist eventually begat Ronald Reagan’s 1961 anti-Medicare record album. A 1972 carve-out won special Medicare treatment for patients with end-stage renal disease. A 2009 deal would have given Sen. Ben Nelson’s (D) home state of Nebraska extra Medicaid funding to help win his support for the Affordable Care Act. But outside of sweeping legislative battles, it’s tough to recall another moment when politics felt so present in the day-to-day of our health system (Diamond, 12/14).
Source: kaiserhealthnews.org

FactCheck.org : Ryan Revises History on Medicare Reform

The commission was created by Congress as part of the Balanced Budget Act of 1997. The New York Times reported that Clinton appointed just four of the 17 commission members, and all four of them voted against the report. Clinton himself opposed the final draft report. He issued a statement on the day of the vote that criticized the plan for, among other things, potentially increasing premiums for seniors who remain in the traditional government-run Medicare plan. Why? Clinton and other Democrats feared the subsidies would not keep pace with inflation. 
Source: factcheck.org

Democrats revisit ‘Madoff of Medicare’ as Team Scott touts boss’s hospital history

You may recall that Gov. Rick Scott was forced out of the worldwide hospital chain he founded just before the company paid a record $1.7 billion in fines for Medicare and Medicaid fraud. (His severance was worth about $310 million.) It was one central themes of the 2010 campaign: Democrats spent millions to remind voters, Scott spent millions more to explain it away.
Source: typepad.com

Older Americans With Cirrhosis Suffer High Rates Of Disability

Posted by:  :  Category: Medicare

ROBERT L. HUFFSTUTTER'S HEALTHCARE PLAN FOR AMERICA 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: What Is Medicare Part-C and Part-D?

Annual Enrollment Starts October 15 and Ends December 7 for Medicare Part C & Part D Plans  

Note that there are additional enrollment periods available when someone first becomes eligible for a Medicare Advantage plan and a Part D plan.  These periods are known as the Initial Coverage Election Period (ICEP) for MA plans (see, e.g., §30.2, Chapter 2 of the Medicare Managed Care Manual), and the Initial Enrollment Period (IEP) for Part D (see, e.g., §30.1, Chapter 3 of the Medicare Prescription Drug Manual).  There are also separate enrollment periods relating to enrolling in Part B of Medicare, including the Part B Initial Enrollment Period (IEP), General Enrollment Period (GEP) and Special Enrollment Period (SEP) (see, generally, Chapter 2 of the Medicare General Information, Eligibility and Entitlement Manual (CMS Pub 100-01) at:
Source: medicareadvocacy.org

hCentive Introduces Webinsure Medicare

The hCentive WebInsure Consumer, WebInsure Medicare and WebInsure Group platforms help health insurers cost effectively acquire and manage individual, Medicare and small business customers. The hCentive WebInsure Private Exchange platform allows health plans to offer defined contribution plan marketplace to small business customers. WebInsure State platform helps states create a health benefits exchange to comply with health insurance exchange requirements of the Patient Protection and Affordable Care Act of 2010. The WebInsure Exchange Manager provides a complete connectivity solution for health plans to connect to State Exchanges.
Source: virtual-strategy.com

Learn About Medicare Advantage Plans In Wisconsin

HMO Plans: These plans require members to pick a primary physician, authorized to act as a mediator for your medical services. Primary Care Physicians (PCP) are general practitioners, family doctors or pediatricians. When your primary physician decides you need to visit a specialist her or she will give you a referral. Only specialists that operate in your network are covered by your insurance plan. Their best attribute is that HMOs provide general care at comparatively lower cost. Certain treatment are somewhat less likely to be covered under an HMO because the goal of this type of insurance plan is maintenance.
Source: the-monkey.biz

Tricare Help – I’m about to get Tricare for Life; what else do I need?

15 percent age appeal catastrophic cap child born out of wedlock claims continued care cost share death DEERS dependent disabled divorce doctor doctors FEHBP handbook health care reform hospital ID card limiting charge marriage maternity care Medicare military treatment facilities other health insurance outside the U.S. parents Part A Part B pharmacy pre-existing condition pregnancy reserves secondary insurance social security spouse supplements surgery Tricare For Life Tricare Prime Tricare Standard Tricare Young Adult Program VA widow
Source: militarytimes.com

Older Americans With Cirrhosis Suffer High Rates Of Disability

Posted by:  :  Category: Medicare

Hospital Care B.Y.O.B: Bring Your Own Bed by Grant NeufeldThe 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: Guide to Medicare Part A and Part B

Important Information Surrounding Medicare Plans and Coverage

Many insurance companies offer to explain the different Medigap policies but it is best to find assistance from a company that looks into each situation and explores the options and costs associated through many different insurance agencies. The coverage is completely regulated by the government so the plans consist of the same coverage the differences will come in service and cost from different insurance agencies. A company such as Senior Health Direct which is web based can offer assistance and free information on Medicare and Medigap Supplemental Insurance Plans. Another source of information that can be easily accessed through Internet is the Medicare government’s site.
Source: articlesaffair.com

CBO: Raising Medicare Eligibility Age Would Save $148B Over Decade

The remaining 2.3 million individuals would be forced into Medicaid, receive Medicare disability benefits or buy coverage through state insurance exchanges under the federal health reform law. The report stated that “many more people would become uninsured” if the health reform law was not in place (Reichard,
Source: californiahealthline.org

Roth IRA Withdrawals Not Included in Medicare Part B Assessment

In the 2003 Medicare Act, Congress added an income-based surcharge to the Medicare Part B premium for beneficiaries in higher tax brackets. This add-on was started in 2007 and it is completely phased-in now. Before 2007, everyone paid the same premiums for Medicare Part B, which covered only 25 percent of the cost of coverage. The remaining 75 percent was subsidized by the government and the current assessment based on income, allows the federal government to cover more of the cost (the program still runs at a deficit).
Source: retirement-income.net

Doctors contemplate opting out due to continued Medicare hassles

Physician participating in the Medicare program are scheduled to face a 27.4% cut in their payments, effective 1st January, 2012, and with providers anyway complaining about current reimbursement rates, the cut is likely to considerably impact both patients as well as doctors adversely. As a result of the cut the Medicare physician conversion factor will decrease to $24.67, approximately $15 less than it was in 2001. In this scenario, the Association of American Physicians and Surgeons reports that various physicians are declining to take on new Medicare patients and many are thinking about cancelling enrollment from the program.
Source: ezinemark.com

THE Consortium: Important Upcoming Dates for the Medicare EHR Incentive Program and Information on the Payment Threshold for EPs

As 2012 begins, CMS wants to remind eligible professionals (EPs) participating in the Medicare Electronic Health Record (EHR) Incentive Program of important deadlines approaching and what can still be completed in 2012 in order to receive an incentive payment for calendar year (CY) 2011. Important Medicare EHR Incentive Program Dates On December 31, 2011, the reporting year ended for EPs who participated in the Medicare EHR Incentive Program in 2011. What does this mean? For participating EPs, they must have completed their 90-day reporting period by the end of 2011. However, EPs have until February 29, 2012, to actually register and attest to meeting meaningful use to receive an incentive payment for CY 2011 through the Medicare & Medicaid EHR Incentive Program Registration and Attestation System. Payment Threshold Information February 29, 2012, is also the deadline for EPs to submit any pending Medicare Part B claims from CY 2011, as CMS allows 60 days after December 31, 2011, for all pending claims to be processed. This means that EPs have 60 days in 2012 to submit claims for allowed charges incurred in 2011. Medicare EHR incentive payments to EPs are based on 75% of the Part B allowed charges for covered professional services furnished by the EP during the entire payment year. If the EP did not meet the $24,000 threshold in Part B allowed charges by the end of calendar year 2011, CMS expects to issue an incentive payment for the EP in April 2012 for 75% of the EP’s Part B charges from 2011. Note for Medicaid Participants: Medicaid incentives will be paid by the States, but the timing will vary according to State. Please contact your State Medicaid Agency for more details about payment.
Source: blogspot.com

A decline in the Medicare Part B deductible is a poor long

Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items. By law, the standard premium is set to cover one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over, plus a contingency margin. The contingency margin is an amount to ensure that Part B has sufficient assets and income to (i) cover Part B expenditures during the year, (ii) cover incurred-but-unpaid claims costs at the end of the year, (iii) provide for possible variation between actual and projected costs, and (iv) amortize any surplus assets.  Most of the remaining Part B costs are financed by Federal general revenues.  (In 2012, about $2.9 billion in Part B expenditures will be financed by the fees on manufacturers and importers of brand-name prescription drugs under the Affordable Care Act.)
Source: quinnscommentary.com

News from Monroe County Area Agency on Aging

In 2012, the Affordable Care Act requires Part D enrollees whose taxable income is less than $85,000 for a single person and less than $170,000 for a married person to pay an income related adjustment to Medicare. Beneficiaries with higher income levels can pay as much as an additional $66.40 per month.
Source: photobandito.com

Selecting Medicare Insurance Supplements Insurance That Suits Your Company Needs

The expense for Medicare supplement insurance may very well be based on plenty of criteria. Californian homeowners above 65 years or below 65 years with disability predicament can opt for such ten plans as outlined by his existing Medicare health coverage plans. To supply an example this Medigap plan A is the standard plan, and all other plans from T to L offers every benefits associated with Plan A and most of them have their own personal set of additional coverage. The monthly premiums for Medicare Aspect A (hospitalization) are usually paid for you (by way of the taxes you paid) as well as the Part B premium is barely $110 per month for those newly getting Medicare truly. The rewards in plans A as a result of L range, but they are the same for any insurance coverage company. This is the sort of health insurance policy that assists you pay for most of the costs in the first Medicare program along with for the part going without shoes doesnt cover.
Source: parkawholesale.org

Claims: CPID 2465 Idaho Medicare: Medicare Contractor Change

CollaborateMD has been notified that the clearinghouse will be converting CPID 2465 Idaho Medicare from CIGNA Government Services (CGS) to Noridian Administrative Services (NAS) on 02/01/2012. CollaborateMD has identified the following items for you to be aware of with the transition to NAS Jurisdiction F: The new Contractor ID for the Idaho Medicare Part B MAC is 02202. Payer agreements for Electronic Funds Transfer (EFT) are required and providers MUST complete a new copy of Form CMS-588,Authorization Agreement for Electronic Funds Transfer prior to 02/01/2012 to avoid an interruption in EFT payment. Groups should not submit an EFT agreement for each of its members, instead only one EFT agreement is necessary for the entire Group. To complete the Electronic Funds Transfer agreement, go to http://www.cms.gov/cmsforms/downloads/CMS588.pdf Action Required: Idaho Medicare B customers should re-enroll for EFT as soon as possible. If you have any questions, please contact Client Services at 1-888-348-8457, option 2.
Source: collaboratemd.com

Important Information Surrounding Medicare Plans and Coverage

Posted by:  :  Category: Medicare

READ THE HEALTHCARE BILL NOW... by roberthuffstutterMany insurance companies offer to explain the different Medigap policies but it is best to find assistance from a company that looks into each situation and explores the options and costs associated through many different insurance agencies. The coverage is completely regulated by the government so the plans consist of the same coverage the differences will come in service and cost from different insurance agencies. A company such as Senior Health Direct which is web based can offer assistance and free information on Medicare and Medigap Supplemental Insurance Plans. Another source of information that can be easily accessed through Internet is the Medicare government’s site.
Source: articlesaffair.com

Video: Guide to Medicare Part A and Part B

The Cost of Enbrel and Medicare Part D

Medicare Part D has been a blessing for many senior citizens who are on a fixed income and have a limited budget to spend on prescription medications. The Medicare Part D gap in coverage for those seniors who have a lasting illness, can be tough realization. At this time of year you hear a lot of talk regarding the donut hole or coverage gap. Why is it there, what is it, and how does it work? Medicare?s Part D cost was reduced by creating the coverage gap. Each year, a limit for Part D is determined. The annual amount in 2007 was $2400. The yearly amount was increased in 2008 to $2510. The amount is $2700 in 2009. The total dollar amount of the prescription drugs that you receive is how the amount is determined. This includes your co-pays and what the insurance company pays. For instance, if a dr Anything Goes Diet Review ug is priced at $850 and the recipient pays $150 and the insurance company pays $700, the amount that is applied toward the yearly amount is the full $850. When you are in the donut hole, you must pay for the cost all of your drugs. While in the donut hole or coverage gap, several Medicare Part D plans will offer limited coverage for generics. The cost of most generics is so low that the benefit of having them covered by a plan is not that much of a benefit. Everyone?s situation varies so for some patients it might be worth it to have coverage for their generic drugs. The donut hole or coverage gap can be reached in a matter of months by Medicare people with chronic illnesses which often require high priced medications for treatment. We have seen patients reach the donut hole as early as February.
Source: briskbrightside.com

Older Americans With Cirrhosis Suffer High Rates Of Disability

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

News from Monroe County Area Agency on Aging

In 2012, the Affordable Care Act requires Part D enrollees whose taxable income is less than $85,000 for a single person and less than $170,000 for a married person to pay an income related adjustment to Medicare. Beneficiaries with higher income levels can pay as much as an additional $66.40 per month.
Source: photobandito.com

What Does Medicare Part D Cover?

When medically necessary to prevent illness, all commercially-available vaccines, such as the shingles vaccine, must be covered, either by Part B or by your Part D provider. However, the drugs you get in places such as an emergency room are not covered by Part B. Many times, you will need to pay out-of-pocket for these drugs and then present a claim to your provider.
Source: medicarepart.us

Reminder: Medicare Covers Obesity Prevention with No Cost

[1] CMS Press Release available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4189&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr [2] See §4104(a) of the Affordable Care Act (ACA), Pub. L. 111-148 (March 30, 2010), inserting preventive services in §1861(ddd) of the Social Security Act, 42 U.S.C. §1395x(ddd). [3] See the full decision on the national coverage determination at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253& [4] Finkelstein EA, Trogden JG, Cohen JW, Dietz W.  "Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates." Health Affairs. 2009; 28(5):w822-w831.
Source: medicareadvocacy.org

Medicare launches accountable care program

An ACO advance payment model, also formally announced last month, will provide physician-owned health care practices and rural providers, who participate in the shared savings program, with additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems, according to the HHS. 
Source: newsfromaoa.org

A decline in the Medicare Part B deductible is a poor long

Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items. By law, the standard premium is set to cover one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over, plus a contingency margin. The contingency margin is an amount to ensure that Part B has sufficient assets and income to (i) cover Part B expenditures during the year, (ii) cover incurred-but-unpaid claims costs at the end of the year, (iii) provide for possible variation between actual and projected costs, and (iv) amortize any surplus assets.  Most of the remaining Part B costs are financed by Federal general revenues.  (In 2012, about $2.9 billion in Part B expenditures will be financed by the fees on manufacturers and importers of brand-name prescription drugs under the Affordable Care Act.)
Source: quinnscommentary.com

CVS Caremark looks to purchase Health Net's stand

“We believe this proposed transaction is in the best interests of our Medicare PDP members and our stockholders,” stated Jay Gellert, president and CEO of Health Net. “Our Medicare PDP members, who have received certain services from CVS Caremark for five years, will now be affiliated with one of the nation’s largest Medicare PDP sponsors.
Source: drugstorenews.com

CVS To Pay $5 Million To Seniors, Disabled Consumers

And now, to settle the FTC charges and reimburse affected Medicare Part D consumers for the price discrepancy, CVS has agreed to pay $5 million.   "This settlement puts money back in the pockets of older Americans who struggle to pay for their medications," said FTC Chairman Jon Leibowitz. "With the cost of health care on the rise, the FTC is especially focused on protecting consumers from any deceptive claims that would cause them to pay more than they should."   According to the FTC complaint, CVS offers Medicare Part D prescription drug plans through subsidiaries like RxAmerica, which CVS acquired in October 2008. Many consumers choose their Medicare Part D drug plans by looking up plan benefits and drug prices on RxAmerica’s website, by going to the Centers for Medicare & Medicaid Services website and using the web-based tool Plan Finder, or by visiting other third-party websites where such information is posted.   The FTC charged that from 2007 through at least November 2008, RxAmerica posted on its website and supplied for posting to Plan Finder and third-party websites incorrect prices for Medicare Part D prescription drugs at two pharmacy chains, CVS and Walgreens. In some instances, the actual prices for these drugs were as much as 10 times more than the posted prices, according to the FTC. As a consequence of the deceptive price claims, many elderly and disabled consumers chose RxAmerica plans and paid significantly more than they expected for their drugs at CVS and Walgreens, the FTC alleged.   The proposed settlement order bars CVS Caremark from misrepresenting the price or cost of Medicare Part D prescription drugs or other prices or costs associated with Medicare Part D prescription drug plans. It requires that CVS Caremark pay $5 million in consumer refunds. The FTC will be mailing checks to eligible consumers who were harmed by these misrepresentations after the order becomes final. The settlement also contains standard record-keeping provisions to allow the FTC to monitor compliance with its order.
Source: financialfraudlaw.com

Man sentenced in Medicare fraud case

Posted by:  :  Category: Medicare

George W. Bush by cliff1066™The man faced a charge of conspiracy to commit health care fraud in connection to these allegations. The man pled guilty to this charge. According to the Florida Times-Union article which reported this story, a federal judge in Georgia recently gave the man his sentence in this case. Reportedly, the man was sentenced to serve three and a half years in prison. The man also reportedly has been ordered to pay restitution.
Source: criminallawsarasotafl.com

Video: Leesburg Medicare

Occupational therapist accused of Medicare fraud in Florida

Being accused of having engaged in a scheme to defraud Medicare can be a very serious matter. Major criminal charges can be brought against a person in connection to such an allegation. A person can be given serious criminal punishments if he or she is convicted of such charges. Such punishments can be very impactful on a person.
Source: miamiflcriminaldefenseattorneyblog.com

GetOnlineQuotes.com Adds Medicare Section to Its Website

Bill also provides some good news for Florida’s Medicare population: Rates will rise less than expected next year. Bill noted that “The government’s announcement on Thursday will help Florida’s senior population given that we are living in a tough economy.” Rates for Medicare Part B will only rise by $ 3.50 per month. A much higher jump had been predicted as recently as May. Premiums were frozen for the last two years because there was no increase in many people’s Social Security benefits. But benefits are increasing to cover inflation. The premiums for Medicare Advantage will actually decrease by 4%. That is the second consecutive decrease for those who opt for Medicare Advantage plans.
Source: bestlongtermcare.org

Florida’s senators: Room for improvement in health care reform bill

Both of Florida’s senators say there’s plenty of room for improvement to the health care reform bill being brought to debate by Senate Majority Leader Harry Reid. Republican Sen. George LeMieux said Thursday he’s still trying to figure out everything the 2,074-page bill does. “I’m going to be one of those sitting up all night on the Senate floor trying to read this bill and figure out all that’s in it,” he told Scripps Howard. “But what I do know is that it cuts Medicare by $500 billion, increases taxes by $500 billion and does nothing to reduce the cost of health care.” Noting that 4 million Floridians lack health insurance, LeMieux said, “We all agree there are things that need to be done, but this is the wrong path, especially in terms of taking money from health care for seniors.” Democratic Sen. Bill Nelson said in a statement issued by his Washington office that “regardless of where anyone stands on specifics, most folks agree the current system can be unfair and too costly and it needs to be fixed. We can’t afford to sit by and do nothing anymore. “There are good elements to the bill Senator Reid unveiled. It will provide affordable coverage for millions of uninsured Americans, prevents insurance companies from dropping folks who get sick, and denying coverage for pre-existing conditions. The legislation will also reduce the deficit.” LeMieux vowed, “We’re going to take as much time on the floor as we need to improve this bill. There are ways to do this without so much government. Republicans will come in with amendments as honest brokers, but the Democrats have to be ready to work with us.” Nelson also said he will “work to improve it (the health bill) on the Senate floor, particularly by trying to force drug companies to lower prices for prescriptions covered under Medicare.” Nelson has been one of several vocal Democrats who are accusing drug companies of bumping up prices in the past year in order to create phantom savings that support the industry’s pledge to trim $8 billion a year in drug costs as health reforms kick in. He said he plans to resume efforts to trim the amount the government pays for drugs for about six million seniors under the Medicare prescription drug program through an amendment to the main reform plan.
Source: emailkenny.com

National Academy of Elder Law Attorneys and Aging Leadership Join Efforts to Stop Harmful Medicaid Florida Waiver Proposal

Elder and Special Needs Law are specialized areas that involve representing, counseling and assisting seniors, people with disabilities and their families in connection with a variety of legal issues, with a primary emphasis on promoting the highest quality of life for individuals. Typically, Elder Law and Special Needs Law address the convergence of legal needs with the social, psychological, medical and financial needs of individuals. The Elder Law and Special Needs Law attorney handles estate planning and counsels clients about planning for incapacity with health care decision-making documents. The Elder and Special Needs Law attorney also assists clients in planning for possible long-term care needs, including at-home care, assisted living or nursing home care. Locating the appropriate type of care, coordinating public and private resources to finance the cost of care and working to ensure the client’s right to quality care are all part of the Elder and Special Needs Law practice.
Source: grapevinetrail.com

Florida Tests New Medicare Payment System

Florida is the lone testing ground in America for a new program for certain types of Medicare hospital payments. As a well known hot bed for Medicare fraud, Florida was chosen by government officials to determine if the new method could reduce the number of improper payments made under the system. The program targets heart operations and a few other specific medical procedures that are commonly used in health care fraud schemes. This particular program requires that all payments for these particular treatments be pre-approved by Medicare contractors.
Source: miamifederalcriminaldefenseattorney.com

Medicare Florida Information

Everyone is getting old. No one can stay healthy forever yet no one can live forever. When you getting older you want to think about getting a social insurance program that covers health program. Aging process is unavoidable and tend to produce disease that related to age. This disease need a proper treatment and we are all know that it is not cheap. We need a proper health plan before it is too late.
Source: medicarewikipedia.com

Home Care Agency Office Manager Sentenced to 78 Months in Prison for Fraud

According to plea documents, as office manager, Alonso taught the owners and operators of ABC how to operate a fraudulent home health agency. Alonso explained the importance of recruiters, kickbacks, doctors, beneficiaries and Medicare billing. In this role, Alonso negotiated the kickback payment rates between the patient recruiters and the owners and operators of ABC. Alonso distributed the kickback payments to the patient recruiters on behalf of the owners and operators of ABC.
Source: wordpress.com

What Is Medicare Supplements and Why You Should Get It

Posted by:  :  Category: Medicare

What's In My Bag... by Amy DiannaIn order to get Medicare Supplemental Plans positive aspects, you have to be enrolled in Component A or Component B of Medicare already. For the duration of the open enrollment period, a individual can obtain a Medigap strategy on a assured concern basis, in which no medical screening is required. This open enrollment period starts within six months of turning 65 or enrolling in Medicare Component B at 65 or older. Outdoors of the open enrollment period, the insurance organization that is issuing the Medigap Insurance may possibly demand that you obtain an attending physician’s statement or a medical screening in order to get a strategy. If you are beneath the age of 65 but are nevertheless receiving Medicare, it may be a small far more hard to get South Carolina Medigap. A slight majority of states demand that insurers offer you at least a single variety of Medigap insurance to everybody, and 25 of them demand that Medigap policies be presented to all Medicare recipients, though, so it is critical to appear into the guidelines for your state if you fall into this category.
Source: carinsurance-texas.org

Video: Medicare

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

Medicare Enrollment: So What Is Medicare Part D Anyway?

Medicare Part D has a standard Medicare Part D drug benefit, but in reality plans and premiums vary widely. Health insurers must offer the standard benefit set out by law or a benefit package that is at least as comprehensive as the standard package. Although there is no standard drug formulary, there are minimal requirements that major classes of drugs necessary to treat common diseases are covered. Plans vary greatly as to the specific drugs covered and the co-pays/coinsurance for individual drugs. For more information on Medicare Part D benefits and the Donut Hole, see our article “Medicare Part D-The Donut Hole and Me”.
Source: myhealthcafe.com

The Cost of Enbrel and Medicare Part D

Medicare Part D has been a blessing for many senior citizens who are on a fixed income and have a limited budget to spend on prescription medications. The Medicare Part D gap in coverage for those seniors who have a lasting illness, can be tough realization. At this time of year you hear a lot of talk regarding the donut hole or coverage gap. Why is it there, what is it, and how does it work? Medicare?s Part D cost was reduced by creating the coverage gap. Each year, a limit for Part D is determined. The annual amount in 2007 was $2400. The yearly amount was increased in 2008 to $2510. The amount is $2700 in 2009. The total dollar amount of the prescription drugs that you receive is how the amount is determined. This includes your co-pays and what the insurance company pays. For instance, if a dr Anything Goes Diet Review ug is priced at $850 and the recipient pays $150 and the insurance company pays $700, the amount that is applied toward the yearly amount is the full $850. When you are in the donut hole, you must pay for the cost all of your drugs. While in the donut hole or coverage gap, several Medicare Part D plans will offer limited coverage for generics. The cost of most generics is so low that the benefit of having them covered by a plan is not that much of a benefit. Everyone?s situation varies so for some patients it might be worth it to have coverage for their generic drugs. The donut hole or coverage gap can be reached in a matter of months by Medicare people with chronic illnesses which often require high priced medications for treatment. We have seen patients reach the donut hole as early as February.
Source: briskbrightside.com

Hospitals preparing for cuts

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

What Is Medicare Part A and B?

About Advantage Affordable Arizona Benefits Business California Cheap Citizens Costs Cover Coverage Different Disability Finding Future Getting Health Healthcare Individual Information Insurance LongTerm Medicaid Medical Medicare Medigap Overview Plans Policy Premiums Private Providers Really Reform Retirement Right Security Senior Should Social Supplement Supplemental Travel Understanding
Source: programonlineeducation.com

What is Medicare? What does Medicare cover?

The area between the limit on the prescription payments and the limit on out-of-pocket expenses is the gap or “donut hole.” During this time, prescription drug manufacturers will only charge a participant 50% of the prescription drugs’ costs. However, 100% of the prescription drugs’ costs will count towards the out-of-pocket limit. Other expenses that count towards the out-of-pocket limit are the costs of the yearly deductible other insurance and any copayments.
Source: lowcosthealthinsurance.com

All About Part A Medicare: What is Part A Medicare?

Part A Medicare is what can cover hospital charges, nursing charges, hospice and home health care charges for inpatients. This is what people need to take better care of them when they are sick. These are being paid for by the taxes you pay monthly or annually so there is no need to purchase one for yourself.  Anyone who is under the employ of a big company is actually entitled to medicare of this kind.
Source: atthecon.com

Medicare to allow using its data to rate doctors, hospitals ~ what IS working

Picking a specialist for a delicate medical procedure like a heart bypass could get a lot easier in the not-too-distant future. The government announced that Medicare will allow its extensive claims database to be used by employers, insurance companies and consumer groups to produce report cards on doctors and hospitals. By analyzing masses of billing records, experts can glean such information as how often a doctor has performed a particular procedure and get a general sense of problems such as preventable complications. Doctors will be individually identifiable through the Medicare files, but personal data on their patients will remain confidential. Compiled in an easily understood format and released to the public, medical report cards could become a powerful tool for promoting quality care. “There is tremendous variation in how well doctors do, and most of us as patients don’t know that. We make our choices blind,” said David Lansky, president of the Pacific Business Group on Health. “This is the beginning of a process to give us the information to make informed decisions.” His nonprofit represents 50 large employers that provide coverage for more than 3 million people.Medicare acting administrator Marilyn Tavenner called the new policy “a giant step forward in making our healthcare system more transparent and promoting increased competition, accountability, quality and lower costs.” Early efforts to rate physicians using limited private insurance data have thus far focused on primary care doctors, but Medicare’s rich information could provide the numbers to start rating specialists as well, Lansky said. Consumers will see the first performance reports by late 2012, a Medicare spokesman said. Medicare officials say they expect nonprofit research groups in California, Massachusetts, Minnesota, Wisconsin and other states to jump at the chance to use the data. With 47 million beneficiaries and nearly every doctor and hospital in the country participating, Medicare’s database is considered the mother lode of healthcare information. read source article
Source: whatisworking.com

Gym Memberships In Medicare Advantage Plans Cater To Healthy Seniors

Posted by:  :  Category: Medicare

NEW REPORT HIGHLIGHTS MEDICARE ADVANTAGE INSURERS’ HIGHER ADMINISTRATIVE SPENDING by Leader Nancy PelosiThe implication that Medicare Advantage plans are offering this benefit to attract healthier members in unfair and untrue. In fact, they offer these types of benefits to improve the attractiveness of their product such that membership increases, and with an expectation that these programs will help lower overall health care costs. With the advent of risk adjusted Medicare Advantage premiums, health plans have no financial incentive to cherry-pick very healthy members. They do, however, have an incentive to enroll members who want to be healthy (in other words, people who take their health care seriously), regardless of their current health status, and fitness programs are one way to attract those types of members. Remember that many of these fitness programs consist of stretching, modest weight-bearing exercise and water activities that help older people from falling, improve their mental health and assist in the management of expensive chronic diseases such as diabetes.
Source: kaiserhealthnews.org

Video: What Is Medicare Advantage?

Do Gym Memberships Help Medicare Advantage Plans Attract Healthy Seniors?

Bloomberg: Insurers Offer Gym Memberships With Medicare Programs The offer of a fitness club membership is helping insurers including UnitedHealth Group Inc. (UNH) and Humana Inc. (HUM) draw healthier and less costly patients to their Medicare programs, said researchers reporting in the New England Journal of Medicine. The study found 35.3 percent of new enrollees in a fitness membership benefit plan reported “excellent” or “very good” health, compared with 29.1 percent in the group without the benefit. The number of plans offering the memberships rose to 58 in 2008 from 4 in 2002, the researchers said (Frier, 1/12).
Source: kaiserhealthnews.org

United Healthcare Medicare Advantage Nj

urinary and repair the damage our organs and systems in the workforce and the block might benefits are actually looking to restore your balance during golf running and taking us a step closer to our goals. Groups can select from either one or two day packages with meals including improving physically that have been shown to yield tremendous improvements in productivity and insurance costs absenteeism illness turnover and insurance costs. According to a report by TLNT 74% of workers with it you choose their health care costs and research process.
Source: yourhealthwellness.org

Competition Improves Quality: The Case of Medicare Advantage

3rd Party Studies ACOs Admin Costs Cadillac Tax cbo Cost-Shift Dual Eligibles Employers Essential Benefits Exchanges GRP HAIs Health Plan Satisfaction House hearings House legislation KI MA Makena McCarran-Ferguson Medical Prices Medical Tests medicare medigap MedMal MLR Morning Headlines MT NHE Patient Safety PCR premiums Premium Tax Profits Provider Consolidation PWC Quality Rate Review Readmissions Reform RZ Senate hearings Senate legislation Small Business Vilification Waste Fraud and Abuse
Source: ahipcoverage.com

Disease Management Care Blog: Coverage of Fitness by Medicare Advantage Plans: Which Causes Which?

Many years ago, the newly-minted managed care medical director Disease Management Care Blog accompanied a marketing VP on a business visit to a fitness club. We were interested in knowing if the club would offer a discount to our health plan members.  During the tour of the facility’s weight rooms, basketball courts and group exercise rooms, we came across a large swimming pool filled with bathing-capped seniors. “Those people,” thought the DMCB, “are precisely the ones we want in our insurance plan.” Enter the paradox of offering fitness and wellness as a covered health insurance benefit. While the assumption has been that fitness causes an enrolled population to be healthier, it’s just as possible for persons who are already healthy in the first place to be attracted to health plans that cover fitness.  Managed care executives have known about this for a long time, but until now, no one has really measured the effect. Enter this elegant study by Alicia Cooper and Amal Trivedi, just published in the January 12 New England Journal. Eleven Medicare Advantage (MA) health plans that added fitness as a covered benefit in either 2004 or 2005 were matched to 11 plans that did not add a fitness benefit. On average, the plans were predominantly nonstaff and nongroup models and median duration of being in business was just over ten years. The “fitness” plans had a median population of 31,540 members while the control plans had a median membership of 18,241 The authors next looked for Medicare beneficiary members in those 22 plans who had completed a “Medicare Health Outcomes Survey” (MHOS) at the time of their enrollment. This yielded 4,852 beneficiaries who were in one of the eleven “fitness MA plans” and 5,064 beneficiaries in one of the eleven “no fitness MA plans.” Age, gender and the burden of illness was similar in both groups, while they differed slightly with respect to race, education and income. The key question from the survey that was used in this analysis was self-reported health status. In the years prior to instituting the fitness benefit, the percent of newly enrolled persons reporting excellent or very good health in the MHOS was 29.1%.  After the fitness benefit was instituted, it increased to 35.1%.  Plans without fitness programs during that same period went from 28.5% to 30%. This contrast between a 6% increase versus a 1.5% increase was statistically significant. The good news is that the folks in Medicare are well aware of the impact of unequal enrollment between MA plans and use risk adjustment to even out the payment levels. The bad news is that risk adjustment is notoriously inaccurate and, to the DMCB’s knowledge, probably doesn’t capture that 6% shift described above.  Assuming the MHOS survey results translate into lower claims expense, that could represent some serious money in a program that is already under fire for over-payment. Before readers condemn the MA plans for consciously using their fitness plans to attract a lower cost population, note that the same MA plans have been offering disease management programs for persons with chronic and costly conditions.  When compared to fee-for-service Medicare, these programs may be attracting sicker seniors.  Between MA plans, those with a better reputation for investing in chronic care population health management are more likely to attract a higher percent of persons with diabetes and heart disease. In other words, it works both ways. What should the next step be?  Follow-up MHOS results for those individuals who entered with a low score to determine if there was any improvement among those in “fitness” MA plans versus those plans without the fitness benefit.  The DMCB looks forward to seeing those results hopefully soon. In retrospect, the DMCB should have suspected something was up years ago.  After all, it was accompanying a marketing VP and, whether we knew it or not, the visit was really all about those seniors in the pool.
Source: blogspot.com

Learn About Medicare Advantage Plans In Wisconsin

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

The Different Types Of Medicare Advantage Plans In Wisconsin

Health Maintenance Plans: Plans of this type require patients to pick a PCP, or primary care physician, which is the only doctor which can refer you to other medical services. Primary Care Physicians (PCP) are usually general practitioners, family doctors or pediatricians. When your PCP refers you to a specialist, it is almost always a doctor within your network. This is because only specialists that in your network will be covered by an HMO. HMOs provide general care at comparatively lower cost because certain, more expensive, treatments are less likely to be covered. The goal of this type of insurance plan is exclusively maintenance.
Source: goldenwisdomnuggets.info

The Cherry Picking Problem In Medicare Advantage http://t.co/4ESCUHa1 [ThinkProgress]

2011 2012 about after Bachmann Bill Cain Campaign DailyKos Debate debt fearandvoting From Gingrich health House HuffPost jobs Jones Maddow more Morning Obama Occupy open Over Paul Perry Plan President Rachel Republican Republicans ReutersPolitics Rick Romney Says Senate Street TalkingPointsMemo ThinkProgress Thread U.S. Wall Wonkette
Source: fearandvoting.com

Annual Enrollment Starts October 15 and Ends December 7 for Medicare Part C & Part D Plans  

Note that there are additional enrollment periods available when someone first becomes eligible for a Medicare Advantage plan and a Part D plan.  These periods are known as the Initial Coverage Election Period (ICEP) for MA plans (see, e.g., §30.2, Chapter 2 of the Medicare Managed Care Manual), and the Initial Enrollment Period (IEP) for Part D (see, e.g., §30.1, Chapter 3 of the Medicare Prescription Drug Manual).  There are also separate enrollment periods relating to enrolling in Part B of Medicare, including the Part B Initial Enrollment Period (IEP), General Enrollment Period (GEP) and Special Enrollment Period (SEP) (see, generally, Chapter 2 of the Medicare General Information, Eligibility and Entitlement Manual (CMS Pub 100-01) at:
Source: medicareadvocacy.org

Medicare launches accountable care program

Posted by:  :  Category: Medicare

day 6 365 days Hipstamatic by drivebybiscuits1An ACO advance payment model, also formally announced last month, will provide physician-owned health care practices and rural providers, who participate in the shared savings program, with additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems, according to the HHS. 
Source: newsfromaoa.org

Video: Medicare Provider Enrollment 3.wmv

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

DXA Reimbursement Slated to Plummet March 1

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

5 Things to Know About ACOs on ADVANCE for Respiratory Care and Sleep Medicine

With respect to tax law, when a nonprofit tax-exempt organization is paying something of value to “insiders” of the entity, the anti-inurement rules of section 501(c)(3) of the Internal Revenue Code can be triggered. To avoid revocation of tax exemption, some main principles in the guidance include requirements that the tax-exempt organization’s participation in the ACO must be set out in writing in advance and negotiated at arm’s length; that CMS has accepted the organization as part of the ACO; that the organization’s share of the profits is proportional to its capital contributions; that the organization’s share of the losses does not exceed the share of the economic benefits to which it is entitled; and that all transactions are at fair market value.
Source: advanceweb.com

Genesys Physician Hospital Organization to participate as Medicare Pioneer Accountable Care Organization

“The Genesys PHO is honored to be selected by CMS to participate in such a progressive and important national health initiative. Over the past 17 years, the Genesys PHO has solidified its position as one of the nation’s leading physician and health system collaborations capable of serving several hundred thousand people. As a mature and well-developed PHO, we have demonstrated the ability to improve care coordination between providers and to effectively provide cost-efficient high-quality care, all of which has made us well-positioned to be a Pioneer ACO,” said Michael James, who has served as the President and CEO of the Genesys PHO since its inception in 1994.
Source: hcwreview.com

Drugs and Supplements: Medicare Supplement and Part D Drug Plans In Plain English

If you are about to turn 65, you, no doubt, have already signed up for Medicare or at least you’ve read the info about signing up. So the first question to resolve is should you get a Medicare supplement plan and prescription coverage from Part D or should you go into a Medicare Advantage plan? For the sake of this article, let’s assume you already have your Medicare set up. So the next question becomes, now what? Medicare was easy, mostly because there’s only one place you can get it, namely, the federal government. After you have your Medicare in place, however, you’re only a third of the way done. Medicare covers 80% of your hospital and physician fees, but there are still two other health insurance plans you need. Medicare Supplement Insurance Plans The first is called Medicare supplement insurance, and it does exactly what its name implies. It supplements your Medicare plan. What that means in plain English is that your Medicare supplement insurance pays the difference between what Medicare pays, which in most cases is 80%, and the total amount of your hospital and doctor bills. So far it’s all pretty easy to understand, right? Medicare pays 80% and your supplement insurance plan pays the remaining 20%, assuming you choose the right plan. But this is where the major private insurance companies come into the picture and make it as difficult as possible for the average person to understand. Each year they come up with different Medicare supplement plans to choose from, they assign them each a letter of the alphabet so, assumingly, you can tell them apart. IN 2010, for example, at the time of this writing, Medicare supplement plans A through N are available, except for E, H, I, and J, which are no longer available. Medicare Part D Drug Plans The major private insurance companies offer several part D drug plans to choose from. The difference here from plan to plan is in the amount of your deductable, which can range from no deductable at all to a $310. Your deductable, of course, is the total amount you must spend yourself on prescription drugs before your coverage kicks in. The lower your deductable, the higher the monthly premium you pay. So with zero deductable, you’ll pay the highest monthly premium. There’s also something called gap coverage that you’ll need to understand, because after your coverage kicks in, either at zero or $310, when your total prescription drug cost reaches $2700 per calendar year, the major insurance companies actually stop paying until your total drug cost reaches $4350. Again, these figures are based on 2010 plans at the time of this writing, and so, are subject to change. My insurance agent advised that this will become perfectly clear if you think of the coverage gap as a donut hole, as it’s sometimes called. What The Major Private Insurance Companies Don’t Want You To Know The major private insurance companies are not likely to tell you that the government requires each insurance company to offer exactly the same Medicare supplement and Part D drug plans within each specific state. What this means in plain English is that Medicare supplement plans A through N, for example in Texas, must have exactly the same features from each insurance company. In other words, Plan A from one provider must be exactly the same as plan A from any other provider. Plan B from one provider must be exactly the same as Plan B from any other provider, and so on. The good news is that if you find supplement plans A through N a bit difficult to understand, at least you’ll only have to understand them once because each letter plan must be exactly the same from one insurance company to the next. With regard to Part D Drug plans, the same holds true. Each provider offers three Part D drug plans to choose from, sometimes referred to as good, better, and best, but the federal government also requires each of those plans to be exactly the same from one provider to another. How to Choose the Right Medicare Supplement and Drug Plan Because each specific plan must be exactly the same from one provider to the next your first step is to choose the best Medicare supplement plan (A-N) and the best Medicare Part D drug plan for your specific needs and situation. While defining each plan (A-N) goes beyond the scope of this article, I will make a few suggestions of what to look for. Also keep in mind that although the individual plans may change from year to year, the one constant is that whatever Plan A is from one provider, Plan A from any of the others is required to be exactly the same. Last year, for example, I chose Medicare Supplement Plan F and a $310.00 deductable drug plan. As you’re only able to change plans in a small window of time, which this year is from November 15th through December 31st, it’s important to choose the right plans from the beginning. So far so good with both. My Plan F has actually covered the full 20% in every instance and my drug plan is looking like it was the right choice as well, especially after I met my deductable. Even before, however, my drug plan was getting me discounted prices on non-generic prescription drugs. So, to recap, if each individual plan is exactly the same from one company to another, how do you choose the right insurance company? First you learn everything you can about each of the individual plans from your independent health insurance agent, which makes choosing the right health insurance agent your first priority. You need a licensed, experienced agent who will take the time to explain the various plans in a way that you can understand. Next, customer service will vary from company to company, so word of mouth, either good or bad, can help you decide. Because past history is the best predictor of future results, consider past experiences with the claim or customer service department either you or someone you know may have had with any of the major insurance companies. And finally, now that you know that all plans must be exactly the same from one company to another, why not go with the company that offers the lowest monthly premiums, assuming, of course, that it’s a national brand that you’ve heard of? In other words, if company A, the one that sends you a mailing every other day for three months before you turn 65 until three months after, charges a lot more than company B for exactly the same coverage, then why not go with company B?
Source: blogspot.com

Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)

All Medicare physician accountants, providers, and suppliers who offer physician accounting services and supplies to QMBs must be aware that they may not bill QMBs for Medicare cost-sharing. This includes deductible, coinsurance, and copayments, known as “balance billing.” Section 1902(n)(3)(B) 4714 of the Social Security Act prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers, or physician Accountants, who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.
Source: vieracpa.com

How to Choose Your Medicare Provider?

Selecting an appropriate Medicare provider to take care of your healthcare needs is an extremely important step when you become eligible for Medicare. A health insurance program developed by the American government, Medicare caters to citizens above the age of 65 and individuals battling with End Stage Renal Disease or certain disability. There is a huge presence of Medicare providers across United States so that they can be located easily. However, citizens should think carefully when they choose such providers in order to get the maximum coverage and associated benefits. Mentioned below are few guidelines, which can be helpful in deciding on a suitable Medicare provider:
Source: canadiandrugsaver.com

NRHA testimony on expiring Medicare provider payment policies

Since the creation of the Medicare program, independent laboratories have been allowed to bill Medicare directly for certain clinical laboratory services. These independent laboratories allow small and rural hospitals to access high quality services when they do not have the volume or financial resources to support their own state-of-the-art laboratory. Independent laboratories provide pathology services to multiple hospitals, receiving the volume necessary to purchase the most up-to-date equipment and employ skilled laboratory staff. A hospital can utilize any independent laboratory for these services, creating competition among laboratories for delivery services and allowing hospitals to choose the laboratory that best meets their needs. Without this extension, hospitals would have to absorb new costs without a payment increase. This could result in limited access to surgical services for Medicare beneficiaries near their residence.  This could result in beneficiaries delaying treatment leading to poorer outcomes and increased costs when complications arise. Congress has recognized the importance of this hospital and independent lab arrangement throughout the years by “grandfathering” independent labs into this program. Under certain circumstances these “grandfathered” facilities are allowed to continue billing Medicare directly for services. An extension would allow independent laboratories to bill Medicare directly for certain clinical laboratory services.
Source: ruralhealthweb.org

Understanding Medicare Wikipedia

Posted by:  :  Category: Medicare

Gang of Six - Cartoon by DonkeyHoteyMedicare Wikipedia can save you thousands of dollars every year. If you are tight on money and need help then you should really look into it. They have made it so simple with being able to fill out the paperwork online. You can also even research and find out what doctors and hospitals accept Medicare ahead of time so that way you can go ahead and put everything together and know what doctor you can see. You will feel much better once you are enrolled and can start getting benefits from the medicare health program.
Source: medicarewikipedia.com

Video: “Hardball”: Katy Abram Told Medicare Is “Successful Socialism”

New Hampshire Results CoveritLive!

My rules of the road for primary season. Rule #1: Vote for YOUR first choice in the primaries Rule #2: Vote for the R in the general. Rule #3: Don’t let anyone convince you to violate Rule #1 or Rule #2 Rule #4: When in a center-right argument, reaffirm Rules #1-#3–it will help us all to get along better. Rule #5: If you are using the language of the left, you probably aren’t furthering conservativism Rule #6: The priority is issues first, candidates second, and supporters third. Nobody is bigger than the issues. Conversely, if you spend your time focusing on supporters, you are wasting everyone’s time. STOP THE MADNESS! A reduction in the rate of spending increases is NOT a cut! In-state tuition for illegals is NOT amnesty! Requiring someone to pay their medical bills is NOT an individual mandate! Reducing tax rates is NOT a tax increase!
Source: redstate.com

When does Medicare require the referring doctor’s name on electronically filed claims?

Effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and UPIN (or NPI) of the ordering/referring physician on the claim form, if that service or item was the result of an order or referral from a physician. If the ordering physician is also the performing physician, the physician must enter his/her name and assigned UPIN as the ordering physician. If the ordering/referring physician is not assigned a UPIN, the biller may use a surrogate UPIN, e.g., until an application for a UPIN is processed and a UPIN assigned. (See §14.9.2.)
Source: whenwiki.org