Daily Kos: Another fiscal crisis? Paul Ryan’s answer: Medicare vouchers

Posted by:  :  Category: Medicare

Rogue Magazine (October 1964)  Volume 9 Number 5 - Water Balloons ...item 1.. routinely use devious devices -- wears us down like rabid trial lawyers until we give in (August 15, 2011 / 15 Av 5771) ... by marsmet542On March 4, 2008, McClintock announced his candidacy for the U.S. House of Representatives in California’s 4th congressional district, which is hundreds of miles away from the district McClintock represented in the state Senate. The district’s nine-term incumbent, fellow Republican John Doolittle, did not seek re-election In typical GOTP fashion, why bother with rules (involving taking Calif. state pay for legislators who do not live in/near Sacramento)?: McClintock maintained that the payments were justified because his legal residence was in Thousand Oaks, in his State Senate district. He stated, “Every legislator’s [Sacramento area] residence is close to the Capitol. My residential costs up here are much greater than the average legislator because my family is here.” However, Ose’s campaign commercials argued McClintock does not own or rent in home in the 19th district, but uses his mother’s address. These attacks prompted a response from McClintock’s wife, Lori, who said McClintock stays with his mother in order to better care for her after she fell ill and after the death of her husband. Just when I thought his time under a rock was taking hold, he popped up on local news with his “take” on the sequester of all things.  This guy is a radical with nothing other than his own pocket as his guiding light.  It is pathetic that he is once again being given a voice.
Source: dailykos.com

Video: Medicare vs Medicaid 612-309-9184 Minnesota Medical Assistance Minneapolis Elder Law Attorney

Medicare is Sacred, Medicaid Expansion is Meaningless; Contradictions of the Anti

The weekly outrage alarms have been set to orange alert as talk returns of potential reforms to Social Security and Medicare. Liberal commenters are out in droves with their tired gripes about Obama’s weak and Republicanesque leadership. But I can’t get over the contrast and contradictions of their statements. First, they say the top 1 percent has taken over, they are SO POWERFUL. But then, they assert that President Obama could easily have _________ and we’d have thwarted their interests. Which is it? Are the 1 percent incredibly powerful or are they a tweak or two from being brought to their knees by the just right words from the leader of the executive branch? Second, they say the Affordable Care Act was a corporatist sell-out, even though it expanded Medicaid to cover those at 133% of the Federal Poverty Line. This could provide insurance to 20 million more people. It’s a Republican idea they say, even though it has Bernie Sanders’ provision for $11 billion for new community health centers, that’s $11,000,000,000. For those of us that are rightly worried about austerity, that kind of smart government spending should be news to cheer. As should the trillion dollars over ten years that is expected to be spent on this Medicaid expansion. Next we hear that the expansion of Medicaid is so weak that Democrats should be abandoned (in 2010 and now), but Medicare and Social Security CAN NOT BE CHANGED IN ANY FORM. How can Medicare and Social Security be forever-Democratic-nirvana but a bill that expands Medicaid is Republicanism never to be forgiven? The truth is the top .1% do have extraordinary power that is distorting our economy and politics to give them ever more wealth and power at our expense. They aren’t an overton window shift away from being put into place. In 2007, the six human beings who are heirs to the Wal-Mart fortune had a net worth of $87 billion, equal to the wealth of the bottom 30% of the population. Forbes says that number in 2012 was up to $115 billion. Our wealth is flying to the hands of the top few and demand is suffering as most people don’t have enough to spend to fuel a strong and growing economy. The biggest company we as a nation allow to exist is built on; climate destroying goods from overseas, below living wages and benefits for employees, and the degradation of mom and pop stores. That’s the horror story. The law that’s going to save my neighbors from going bankrupt due to a rare medical illness is not the problem. In any other time that sort of reform would be called progress and be cheered by people who label themselves progressives. EDITED: My original version said that the funding for community health centers had been expanded by $50 billion dollars. The real number was $11 billion from the Affordable Care Act. I got my numbers mixed up, 50 was the number of health centers in each Congressional district that would be funded with the funds.
Source: thepeoplesview.net

CMS’s Privacy Problem: Data Breaches, Medicare Numbers, and Inaction : Data Privacy Monitor : Lawyers & Attorneys for Information Security, Breach Notifications, Online Privacy, Cloud Computing & Financial Privacy: Baker Hostetler Law Firm

CMS’s continued use of social security numbers as Medicare numbers has been under scrutiny for several years. Since 2002, the U.S. Government Accountability Office (GAO) has repeatedly recommended that CMS use a different methodology in assigning Medicare numbers in order to protect social security numbers. In May 2008, the OIG issued a report urging CMS to remove social security numbers from Medicare cards in order to prevent identity theft. CMS has consistently refused to modify its methodology, citing logistical and cost constraints. In an August 2012 hearing before the House Ways and Means Committee, Tony Trenkle, CMS’s Chief Information Officer, testified that transitioning to a new methodology “would be a task of enormous complexity and cost that, undertaken without sufficient planning, would present great risks to continued access to healthcare for Medicare beneficiaries.” Mr. Trenkle estimated that the cost of a smooth transition could be as high as $845 million, and he cautioned the committee that the transition would mean a substantial change for physicians treating Medicare patients. This recent string of CMS data breaches has captured the attention of lawmakers, who once again are calling for CMS to act.
Source: dataprivacymonitor.com

Common Medicare Scams and Identity Theft

Be suspicious of doctors, health care providers, or suppliers who: • Ask for your Medicare number in exchange for free equipment or services or for “record keeping purposes” • Tell you that tests become cheaper as more of them are provided • Advertise “free” consultations to people with Medicare • Call or visit you and say they represent Medicare or the federal government • Use telephone or door-to-door selling techniques • Use pressure or scare tactics to sell you expensive medical services or diagnostic tests • Bill Medicare for services you never received or a diagnosis you do not have • Offer non-medical transportation or housekeeping as Medicare-approved services • Bill home health services for patients who are not confined to their home, or for patients who still drive a car • Bill Medicare for medical equipment for people in nursing homes • Bill Medicare for tests you received as a hospital inpatient or within 72 hours of admission or discharge • Bill Medicare for a power wheelchair or scooter when you don’t meet Medicare’s qualifications
Source: fayettewoman.com

Plutocrats Misdirecting Social Security And Medicare Debate With Ageism

It will matter far more to our children and grandchildren whether they share in the gains of economic growth than if they have to pay higher tax rates for Social Security and Medicare. The rich, with the full complicity of the media, are doing their best to keep national policy focused on the cost of Social Security and Medicare. But the arithmetic says that the upward redistribution to the wealthy is the far more important issue for future living standards.
Source: firedoglake.com

Beware of Medicare Fraud Calls

These calls are completely fraudulent. Medicare will NEVER ask for a beneficiary’s Medicare number unless the beneficiary initiates the call, and they will NEVER ask for a bank account number under any circumstances. The only beneficiaries that need to get new Medicare cards are those who are first applying for Medicare coverage, or those who have asked for a new card because their card is lost or damaged.
Source: mauryriversc.org

In the Donut Hole…I Need “Extra Help”!!! » Toni Says

Posted by:  :  Category: Medicare

Stella Johnson On The Impact Of Health Insurance Reform by Leader Nancy PelosiTo qualify, your 2013 income must be limited to $17,232($1,436) for an individual or $23,268($1,939) for a married couple living together.  This year they have raised the amount for resources which can be real estate, bank accounts, stocks, CDs, mutual funds, IRAs and cash at home but they no longer count your house, car and life insurance as a resource.  The value of what you own must be limited to $13,300 for an individual or $26,580 for a married couple.            What is so great about LIS (extra help) is that when you are approved; then, there can be different levels that you can qualify for, depending on how much your annual income and resources are. You may qualify to have your Part B $104.90 premiums paid for.  That income level is below $1,313 for an individual and $1,765 for couples.  Also you may qualify to have covered your Part A and Medicare Part B premiums, deductibles and co-pays expenses if your monthly income is below $975 for an individual or $1,313 for a couple.
Source: tonisays.com

Video: Medicare Part D – The Donut Hole

Managed Markets Monday: Who Ate My Donut Hole? The Ins and Outs of Medicare Part D

Fortunately, most common medications, especially generics, are relatively inexpensive. But what if Maude doesn’t have $5560 a year for the medications she needs? Medicare does offer low-income subsidies for patients who qualify. In addition, some Medicare patients are eligible for charitable programs offered by foundations such as the National Patient Advocate Foundation and the National Organization for Rare Disorders. Additional information is available at http://www.medicare.gov/, and at the websites of individual charitable foundations.
Source: palio.com

The Affordable Care Act: Saving Prescription Drug Costs for Medicare Beneficiaries : The Shriver Brief

on Medicare drug spending. This report revealed that 6.1 million Americans with Medicare saved $5.7 billion on their prescription drugs—money that otherwise would have fallen into the “donut hole” prescription drug coverage gap that forces beneficiaries to pay for 100 percent of their drug costs once they have reached their prescription drug plan limit.
Source: theshriverbrief.org

Antidepressant Use Among Seniors: Falling Through Medicare’s Doughnut Hole?

Philadelphia Inquirer/HealthDay News: Medicare Coverage Gap May Cause Seniors To Forgo Antidepressants The Medicare Part D drug plan’s gap in coverage — often referred to as the “donut hole” — has long been a concern, and a new study links it to cutbacks by seniors in the use of antidepressants and other medications. An estimated 13 percent of seniors aged 65 and older suffer from depression, experts say. Antidepressants can stop depression from returning, but the Part D benefit — especially the coverage gap — “imposes a serious risk for discontinuing maintenance antidepressant pharmacotherapy among senior beneficiaries,” the study authors found (Dotinga, 7/2).
Source: kaiserhealthnews.org

What Is The Medicare “Doughnut Hole”?

During each month you have a prescription filled your drug plan sends you and Explanation of Benefits notice, which you’ll often see or hear shortened to EOB. This monthly EOB form tells you how much you’ve spent during the month on covered drugs and if you’ve reached your coverage gap, signalling you’re now responsible for the entire cost of drugs for the remainder of the year. It’s human nature, no matter how well informed we were when we read the plans fine print, it’s always a shock when prescription payments abruptly end. Out of pocket costs, especially on a fixed income, are always a bitter pill to swallow.
Source: medigapandyou.com

Medicare Prescription Drug Coverage, Medicare Part D, Doughnut Hole

Medicare has an optional program — called Medicare Part D — that provides insurance to help you pay for prescription drugs. If you select to have the coverage, you pay a monthly premium. This guide explains how the program works and helps you make decisions in choosing a plan that’s right for you.
Source: aarp.org

Casey B. Mulligan: Health Reform, the Reward to Work and Massachusetts

Posted by:  :  Category: Medicare

Tax Penalties and Bureaucratic Burden of Domestic Partner Health Insurance by Third WayBut it is wrong to assume that the law will have little effect on the reward to working among covered workers. Their employers could drop coverage, or the employee could switch to a job without coverage. More important, the subsidies are available to the unemployed and others who do not work, even if their previous jobs had provided coverage. If and when they go back to work in a covered job, federal law will welcome their return by taking their subsidy away.
Source: nytimes.com

Video: Newborn with Birth Defect Denied Health Care Coverage Because of ‘Pre-existing Condition’

Health insurance on your W

Bankrate wants to hear from you and encourages comments. We ask that you stay on topic, respect other people’s opinions, and avoid profanity, offensive statements, and illegal content. Please keep in mind that we reserve the right to (but are not obligated to) edit or delete your comments. Please avoid posting private or confidential information, and also keep in mind that anything you post may be disclosed, published, transmitted or reused.
Source: bankrate.com

Can I deduct health insurance on my tax return?

Itemize medical expenses while you can – Not everyone has medical expenses high enough to deduct them on their federal tax returns, but even fewer will be able to do so next year. 2012 is the last year you’ll be able to itemize and deduct medical expenses in excess of 7.5% of your adjusted gross income. As a result of health reform, that threshold is being raised to 10% for the 2013 tax year. So, if you itemize on your federal tax return, do the math. Qualifying medical expenses in excess of 7.5% of your adjusted gross income for 2012 may be itemized. You can refer to IRS Publication 502 for more information about qualifying medical expenses, but these may include monthly premiums you pay for coverage (including some Medicare premiums), copayments, deductibles, dental expenses, and costs for some services not covered by your insurance plan. You may even deduct mileage accrued while driving to and from regular appointments. This deduction isn’t for everyone, but if you (or one of your dependents) were seriously ill or hospitalized last year, you may qualify.
Source: ehealthinsurance.com

Payroll taxes would fund universal health care proposal

Freidman estimates that health care costs will continue to climb under the Affordable Care Act or under Aguilar’s plan because in both cases, more people will be covered. His models also found that costs would have kept climbing without any health reform. But creating one giant risk pool composed of all Coloradans would dramatically cut administrative costs and allow Coloradans to cut better deals for care, prescriptions and medical devices. Overall, in 2016, Friedman predicts a statewide health co-op would drive down costs by 10 percent or $900 per person.
Source: healthpolicysolutions.org

After Newtown Shootings, Questions About Mental Health Insurance Coverage

While the ACA “provides enormous potential and opportunity to make sure than many millions more Americans obtain the services they need,” says Samuels, “that will only happen if the implementation of those reforms is effective.” Samuels worries that the rules from HHS will not be clear or strong enough to make the parity laws meaningful. He also worries about getting everyone who is eligible for coverage enrolled, particularly those with severe mental health disorders who be may homeless or living on the fringes of society.
Source: kaiserhealthnews.org

Health Insurance Brokers, Small Employers Fear Higher Prices as Health Exchanges Roll Out

March 3–President Barack Obama’s ambitious goal that all Americans have access to health care will take a huge step forward this fall with the opening of federal and state insurance exchanges. But it is too soon to tell whether these bold creations of the Affordable Care Act will actually bring “affordable” care to consumers. Some observers say that escalating health care costs will still find ways to tap and drain the bank accounts of small businesses, individuals and families. With less than seven months until health insurance exchanges begin open enrollment in Missouri and other states, regulators are scrambling to implement the new law’s most sweeping — and most expensive — changes. Health exchanges are a key part of the president’s plan to make health insurance coverage available to tens of millions of Americans who are currently uninsured. And his overhaul of the U.S. health care system also is certain to impact the lives and checkbooks of many Americans who already have health insurance. Among the 2,500-page law’s myriad provisions, individuals with pre-existing conditions who have been unable to purchase health insurance no longer will be excluded for chronic illness or a history of medical claims. Insurers won’t be able to drop coverage when someone gets sick. Plans will have to offer more generous benefits, such as capping out-of-pocket expenses and providing free preventive care. Premiums for older consumers cannot be more than three times the cost for younger consumers. Federal and state exchanges were designed to create a robust, competitive market for private insurers to provide affordable coverage to individuals and small businesses. And the Obama administration is gambling that enough small employers and young and healthy Americans will purchase health insurance to ensure the affordability of health premiums for all. “Maximizing participation in the exchanges is absolutely critical to the success of the law, which was all about expanding coverage,” said Sarah Dash, a project director at Georgetown University’s Center on Health Insurance Reforms. “But I think success is going to be in the eye of the beholder, and the success of it will play out over a few years. … From a consumer’s perspective, what matters most: Did people get coverage? Is the coverage affordable to them? And does it ultimately connect people to the care they need?” Government subsidies in the form of tax credits will help lessen the impact of more costly premiums on low-income Americans, but the incomes of many households will be too high to qualify for subsidies. This will be even more of a problem in states such as Missouri that refuse to expand Medicaid, leaving many working poor unable to qualify for help. New policy rates have not yet been made public, but there will surely be winners and losers as insurance companies redistribute the costs of these benefits as well as begin paying a new tax on health coverage. And pricing for many Americans could run even higher if many of the young and healthy decide to “opt out” of the law’s individual mandate — choosing to pay fines rather than buy costly insurance. Federal officials are forecasting that an expanded and highly competitive individual and small group health insurance market will help slow the growth of health care spending in the long run. Yet fewer consumers will take advantage of the new market if insurance prices are high at the start.
Source: hispanicbusiness.com

Medicare Claim Rejected? Fight Back!

Posted by:  :  Category: Medicare

Joe the Plumber - To Flush The System ... More scams aim to ensnare Brevard seniors - Their ingenuity is boundless, Archer said. (Jul 2, 2012) ... by marsmet524Consumer’s Guide to Hospice Care in Florida – It’s Much More Than You Think. Most people never get the true benefit from this fully Medicare covered service. In addition to bursting the myths and legends about Hospice, our guide will walk you through the legal steps a family should take as soon as the Hospice decision is made to protect assets and provide for an orderly transition after the passing. Includes an all-new Bonus Section on Long Term Care Needs and Incapacity Planning.
Source: florida-elderlaw.com

Video: Senator Harkin Addresses False Claims That Health Reform Will Hurt Medicare Recipients

Seniors Need To Be Tenacious In Appeals To Medicare

Medicare officials say appeals are rare, though they would not provide statistics on how many appeals came from beneficiaries rather than from health-care providers, such as hospitals, doctors and nursing homes.  The inspector general’s office in the Department of Health and Human Services reported last month, however, that 85 percent of appeals in 2010 that reached the third level of review, which are decided by an administrative law judge, were filed by health care providers.  And for those who persevere and do appeal a third a third time, the OIG found that the judges reversed 56 percent of all unfavorable decisions in 2010.
Source: kaiserhealthnews.org

Plutocrats Misdirecting Social Security And Medicare Debate With Ageism

It will matter far more to our children and grandchildren whether they share in the gains of economic growth than if they have to pay higher tax rates for Social Security and Medicare. The rich, with the full complicity of the media, are doing their best to keep national policy focused on the cost of Social Security and Medicare. But the arithmetic says that the upward redistribution to the wealthy is the far more important issue for future living standards.
Source: firedoglake.com

Navigating the Health Care System: How To Complain

Whether it’s a car repair that didn’t fix the problem or a bad meal in a restaurant, many of us don’t hesitate to complain. Making our voices heard when something isn’t right is the first step in getting it corrected. But when we’re sick or need health care services, it’s hard to know where to direct a complaint. And it can be difficult to question people who may know more than we do, especially when we aren’t feeling well.
Source: ahrq.gov

The Smart Act Addresses Medicare Conditional Payments : Personal Injury Law Journal : New Jersey Product Liability Lawyers & Attorneys : Stark & Stark Law Firm

What does this mean to a workers’ compensation claimant?  If their case settles and they receive their Workers’ Compensation Award during this 120 day period then the last statement of conditional payments made by Medicare that was downloaded during this period shall constitute the final amount subject to recovery by Medicare.  This is a joy to behold.  Before this law was made, we would have to wait months for a statement of conditional payments.  Even after we received the statement there was no guarantee that Medicare would then not issue another statement after the settlement asking for more money to be reimbursed to Medicare than was requested prior to settlement.  The process as it stands now is a nightmare for workers and their attorneys.  The Secretary of Health and Human Services has until September 10, 2013 to implement these regulations. Congratulations to Congress for passing this SMART Act.
Source: personalinjurylawjournal.com

Medicare Quality Reporting for ASC Clients

Quality Reporting for Ambulatory Surgical Centers A quality reporting program for ASCs was finalized by the Centers for Medicare and Medicaid Services (CMS) in the Calendar Year (CY) 2012 OPPS/ASC Final Rule with Comment Period (CMS-1525-FC). Five claims-based measures (four outcome measures and one process of care measure) were adopted for the CY 2014 payment determination. For the CY 2015 payment determination, two structural measures (surgical procedure volume and safe surgery checklist use) were adopted in addition to the five original claims-based measures for a total of seven quality measures. For the CY 2016 payment determination, the same claims-based and structural measures as adopted for the CY 2015 payment determination and one process of care measure were adopted.
Source: abeo.com

Williston Rescue Squad fined $800,000 for fake claims

Investigators with the United States Justice Department say the rescue squad billed Medicare for routine, non-emergency ambulance rides that were not medically necessary and created false documents to make those rides appear to be covered under Medicare guidelines.
Source: wrdw.com

Williston ambulance service fined over false claims

Federal officials are ordering the Williston Rescue Squad to pay back $800,000 in false Medicare claims. The U.S. Justice Department said Monday that the company has agreed to the fine. Investigators say the rescue squad billed Medicare for non-emergency ambulance rides for patients. The law only allows ambulance reimbursements for patients who are confined to their beds or who have medical conditions that require transportation in an ambulance.
Source: southcarolinaradionetwork.com

Daily Kos: Medicare cuts: Is it about the pain, or the politics?

is that cutting the program is going to pave the way for more cuts in the future and we all know that GOP’s intentions towards Medicare (or Social Security) sure as hell ain’t pure.  It ain’t going to be a one-time “take one for the team” kind of thing either.  We may need to look at some ways to restructure the program to reflect the current reality of things and curb some of the waste, fraud, and abuse (which ACA is already doing) but simply cutting benefits for the sake of cutting benefits (which is what the GOP really seems to be for) doesn’t help anybody in the short- or long-term IMHO.  One of the biggest problems with Medicare that the “very serious people” don’t bring up often (if at all) is that one of the big drivers of Medicare costs are our country’s insane health care costs and that getting those costs under control would go a long way towards helping address the financial solvency of Medicare.  Also, given what we saw in 2010 when ACA cut out some of the Medicare Advantage program, I wouldn’t volunteer any cuts to Medicare if I were a Democrat.  Frankly, if the Republicans think that proposing cuts to Medicare and Social Security is such a brave and manly thing to do, well, why don’t they go ahead and do it????
Source: dailykos.com

Medicare Paid Claims for Inmates, Undocumented Residents, Reports Find

Although CMS already has a system to flag charges for inmates and undocumented residents, the reports recommended that federal officials establish a better system. The reports found that the current system does not flag payments until after they are paid and that CMS does not instruct its contractors to recoup such payments (Cheney,
Source: californiahealthline.org

Education Week: OH school official wants school Medicaid expansion

Posted by:  :  Category: Medicare

Attorney General Richard Cordray Announces Candidacy for Re-election by ProgressOhioAKRON, Ohio (AP) — A member of the state school board wants the Medicaid program for Ohio schools expanded to cover tens of millions in additional services, including school nurses, classroom aides and special education transportation.
Source: edweek.org

Video: KasichCare is Obamacare in Ohio – Stop Medicaid Expansion!

How Ohio Health Centers are Pushing for Medicaid Expansion

The Ohio Association of Community Health Centers (OACHC) continues to actively reach out and meet with stakeholders around an Ohio Medicaid expansion, including other providers, payers, philanthropic community, advocates, religious leaders, and business communities. We also continue to meet with members of the General Assembly while keeping in close contact with the Kasich Administration. Click here to see OACHC’s letter to the Governor. While optimistic that when the Governor rolls out his budget this Monday, February 4th, it will include a Medicaid expansion (possibly with certain “protections”), we must be ready for the next leg of the marathon to start, and folks it’s a steep one! [Note: See UPDATE below] It is imperative that all Health Center Advocates be ready to continuously act and be engaged with their legislators and their local media outlets too. To that end, OACHC has been and continues to be thrilled with the press many Ohio CHCs have generated locally. Our hats go off to them for their collective efforts with both media, and in making the time to come to the Statehouse to participate in one of the seven regional Medicaid expansion coalition Lobby Days, and educate elected officials firsthand on what Medicaid expansion means to their Health Center, patients, community – i.e their legislative districts!
Source: saveourchcs.org

Tea party groups in Ohio oppose Medicaid expansion

The state would see $13 billion from the federal government over the next seven years to cover those newly eligible for Medicaid, according to the Kasich administration. Roughly 366,000 Ohio residents would be eligible for coverage under the expansion beginning in 2014.
Source: northcoastnow.com

Daily Kos: Kasich: Ohio will expand Medicaid under Obamacare

“Betrayal!” howls the conservative base. “I think it’s definitely going to weaken him with the conservative base,” said Chris Littleton, the Ohio director for American Majority Action. “It’s not a good idea to expand your number-one budget item in the middle of this kind of instability. The conservative grassroots and average voters are not going to support this in any way, shape or form.” On the other hand, all of the non-crazy people in Ohio, including the business community and the hospital associations and the medical provider groups, are celebrating this lapse into sanity by their governor. It means that hospitals will be providing less uncompensated care; more jobs in health care; community and rural hospitals will be able to stay open. Then there’s the fact that something like 275,000 uninsured people will now be covered. The state’s calculus is that the state will receive about $13 billion over the next seven years from the federal government, and in the next two years, the state will save $235 million.
Source: dailykos.com

The guide to why Ohio should not partner with Washington on Medicaid expansion

For Governor Kasich, who faces re- election next year, Medicaid expansion is a means to balance the budget in the short term while reducing state income taxes. It will also further promote the implementation of Obamacare, a policy categorically rejected by 66% of Ohio voters in 2011 when they passed the Health Care Freedom Amendment. Kasichʼs short sighted and self serving proposal to expand Medicaid will harm the long term financial solvency of our state.
Source: teapartypatriots.org

Gov. Kasich Will Support Medicaid Expansion in Ohio

Since the Supreme Court made Medicaid expansion optional it has created a real divide among Republican governors. Many, like Texas Gov. Rick Perry, have rejected the Medicaid expansion in an effort to continue opposing Obamacare and hopefully cripple the new law. A handful of Republicans governors though believe that as long as it is the law of the land not accepting the money would be detrimental to their states.
Source: firedoglake.com

How Ohio’s Medicaid Expansion Will Increase Health Insurance Premiums for …

Except it’s not a joke, because the consequences are quite serious. Hospitals will try to make up for their mounting Medicaid losses by charging higher rates to people with private insurance. In 2008, Milliman, the leading insurance consulting firm, estimated that the average American family with private health insurance paid $1,800 extra, because of Medicaid and Medicare’s underpayments to providers. With the number of people on government-subsidized insurance set to double, cost-shifting is destined to go up. And that’s on top of the 55 to 85 percent that Obamacare will increase premiums in the non-group market.
Source: actuallyhealth.com

Ohio GOP Gov To Accept Obamacare Medicaid Expansion

Ohio Gov. John Kasich (R) announced on Monday that he would accept an Obamacare provision to expand the Medicaid program in his state, becoming the fifth GOP governor to do so, the Cleveland Plain Dealer reports. Kasich added that he would reverse his decision should the federal government fail to cover the full cost of the expansion, as provided in the law.
Source: talkingpointsmemo.com

Ohio Health Policy Review: Preliminary findings of the Ohio Medicaid Expansion Study released

A summary of the findings (revised Jan. 18, 2013) can be downloaded here The U.S. Supreme Court decision on the Affordable Care Act last June gave states the option to expand Medicaid eligibility for nearly all residents with incomes up to 138 percent of the federal poverty level. The preliminary findings provide state policy makers with an analysis of the impact of a potential Medicaid expansion on:
Source: healthpolicyreview.org

Ohio Might Join Ranks Of Red States Opting For Medicaid Expansion

MPR News: Expanded Medicaid Eligibility Could Cover Additional 145,000 Minnesotans Gov. Mark Dayton’s plan to expand eligibility for Medicaid in Minnesota would provide health coverage for an additional 145,000 Minnesotans, including 47,000 children, said Minnesota’s Human Services Commissioner. Medicaid is a joint federal state safety net program that serves low-income, disabled and vulnerable residents. It’s called Medical Assistance in Minnesota. The expansion plan would raise income limits and cover some childless adults. Last summer, the U.S. Supreme Court ruled that states could opt out of the expansion. But Commissioner Lucinda Jesson said the legislature should approve the plan because it covers more Minnesotans and is a good deal for taxpayers (Stawicki, 1/30).
Source: kaiserhealthnews.org

Ohio seeks to overhaul Medicaid eligibility system

The move comes as the gov­er­nor says he plans to expand the Med­ic­aid pro­gram to cover more low-income peo­ple under Pres­i­dent Barack Obama’s health care law. Gov. John Kasich unveiled his deci­sion on Med­ic­aid expan­sion in his two-year state bud­get pro­posal on Monday.
Source: galioninquirer.com

Plutocrats Misdirecting Social Security And Medicare Debate With Ageism

Posted by:  :  Category: Medicare

Social Security Adminstration building on Edsall Rd - 100-0027 by Rev. Xanatos Satanicos Bombasticos (ClintJCL)It will matter far more to our children and grandchildren whether they share in the gains of economic growth than if they have to pay higher tax rates for Social Security and Medicare. The rich, with the full complicity of the media, are doing their best to keep national policy focused on the cost of Social Security and Medicare. But the arithmetic says that the upward redistribution to the wealthy is the far more important issue for future living standards.
Source: firedoglake.com

Video: Social Security: Just the Facts

Report: Unemployed most at risk for job, social security scams

In fact, merely reading a blog post such as this one causes most internet browsers to generate targeted ads for questionable recruitment websites. Unfortunately, the traditional method of searching for jobs is no picnic either.  When job fairs happen they are chronically over-attended and designed to quickly dismiss applicants on the margins.
Source: msnbc.com

Social Security — more for less

@ Sam Heche what makes you think fed workers do not pay into SS nor contribute to a pension plan? As a fed worker, I do both and just like the rest of the country, my check was reduced another 2% when the SS witholding rate went back up. My pension plan is called FERS but I cant tell you the percentage, as I dont know. My LES came out yesterday… OASDI – 123.63 and FERS 16.60. You can find out the percentages based on being a GS-07 Step 10 in the Denver area. Are you telling me I am the only one paying into these?
Source: bankrate.com

Career Connection Series: I Am Getting Social Security Disability Benefits and Want to Work. How Do I Get Started?

When you are ready to explore your work options, we have a national call center where you can talk directly with us about work, benefits or our work incentive programs.  Just call 1-866-968-7842, Monday through Friday, between 8 a.m. and 8 p.m. EST. If you are deaf or hard of hearing, you may call our TTY number, 1-866-833-2967. Or you can call our toll-free number and ask for a free copy of the publication, Your Ticket to Work (Publication No. 05-10061). 
Source: govdelivery.com

“Strengthening Social Security” and Other Euphemisms | MyFDL

Victor sat in the den surrounded by mementoes of his long political career. His eyes scanned over the walls covered with pictures of himself with presidents and other congressmen. There were assorted awards and trophies imparted by a mixture of lobbyists, corporations and organizations, pictures of himself on the podium at the Republican National Convention, CPAC, playing tennis at Kennebunkport. His eyes fell on the picture given pride of place in the room that had hung in his congressional office for years. It was a picture taken when he visited an industrial hog farm many years ago. It showed him and the farmer in the foreground, and as far as the eye could see were pigs, tightly penned in row after row of cages with mounds of food in front of them and a conveyor belt behind them to take away their poop. The picture had become for Victor a visual metaphor for his constituents and the public in general.
Source: firedoglake.com

Leavenworth woman sentenced for Social Security fraud

A Clay County judge ordered today that a bipolar 17-year-old man found last month handcuffed to a support beam of a Kansas City, North, townhouse will remain in foster care, at least for now. His father and stepmother (pictured) told investigators they handcuffed him because they did not have money to buy prescription medicine for his condition.
Source: kansascity.com

Social Security Advice That Harms Wives

I prepared for my recent retirement by doing financial reading. I also spoke to Social Security employees also many times. Seasoned, compentent workers (and I think I could tell who they were) were happy to explain the system to me. I called multiple times to get consensus answers. I just discounted the new workers who had to check before answering. I read and re-read articles in the business and money magazines. I believe there really was a paucity of informative non-repetitive articles about Social Security however.
Source: bc.edu

Social Security: The Inherent Contradiction

In this video, Ferrara lectures at a Libertarian Party of New York conference on his first book, Social Security: The Inherent Contradiction (1980). He describes in detail the problems built into the way the U.S. Social Security system was designed and offers a method of transitioning to a fully privatized retirement-savings model.
Source: libertarianism.org

Daily Kos: Medicare cuts: Is it about the pain, or the politics?

Posted by:  :  Category: Medicare

Grand Bargain Watch - Save Social Security by DonkeyHoteyis that cutting the program is going to pave the way for more cuts in the future and we all know that GOP’s intentions towards Medicare (or Social Security) sure as hell ain’t pure.  It ain’t going to be a one-time “take one for the team” kind of thing either.  We may need to look at some ways to restructure the program to reflect the current reality of things and curb some of the waste, fraud, and abuse (which ACA is already doing) but simply cutting benefits for the sake of cutting benefits (which is what the GOP really seems to be for) doesn’t help anybody in the short- or long-term IMHO.  One of the biggest problems with Medicare that the “very serious people” don’t bring up often (if at all) is that one of the big drivers of Medicare costs are our country’s insane health care costs and that getting those costs under control would go a long way towards helping address the financial solvency of Medicare.  Also, given what we saw in 2010 when ACA cut out some of the Medicare Advantage program, I wouldn’t volunteer any cuts to Medicare if I were a Democrat.  Frankly, if the Republicans think that proposing cuts to Medicare and Social Security is such a brave and manly thing to do, well, why don’t they go ahead and do it????
Source: dailykos.com

Video: What is a Medicare health insurance exchange?

Effects of Sequestration Cuts on Medicare

Garrett Ball is the owner of Medicare-Supplement.US, as well as several other Medicare-related web resources. As an independent broker, Garrett assists people going on, or already on, Medicare with comparing the various Medicare plan options in an unbiased way and in a centralized place. Garrett’s position as an independent agent and experience specializing in this field give him the unique ability to help others navigate the Medicare “maze”.
Source: medicare-supplement.us

Privately Run Medicare Plans are Really Expensive

Austin Frakt draws my attention today to a new article about the administrative costs of Medicare. Exciting stuff! Long story short, Kip Sullivan of the Minnesota chapter of Physicians for a National Health Program wants everyone to understand just what’s involved in figuring out the true administrative costs of Medicare. The cost of collecting payroll taxes is one frequently overlooked element, for example. More interestingly, though, there’s a large and growing gap between the overhead calculations of the Medicare Trustees and those of the National Health Expenditure Accounts. Why is that?
Source: motherjones.com

Sun and Shield: Letting private insurance companies run Medicaid and Medicare: Arizona’s good experience

I confess that I have had grave doubts about turning our nation’s healthcare “system” completely over to private companies. My Medicare works well for me, and seems to be inexpensive to run, compared to the high salaries and bloated bureaucracy of some private insurance companies, and their desire to turn a profit, no matter what, as their primary reason for existence, rather than patient care being primary. (I know — Medicare expenses have to be brought more under control. But the increasing expenses aren’t because it’s a government-run program. They are because more and more people are becoming eligible for Medicare, and living longer while on it.)
Source: blogspot.com

The Useful Information For Getting Medicare Insurance

Prove useful . of your age, there are occasions when when a quest to Las Vegas might be just exactly what you have need of. Those of all of who love “Sin City” know where it’s a stellar place to proceed to just release it all choose for a while. When you’re enjoying the slots or it may be checking out the latest Cirque du Soleil show, your corporation can let these kind of every day cares about like changes to successfully Medicare, the health benefits of Medigap (Medicare supplemental insurance), and prescription drug approach options just disappear altogether. Medicare supplemental insurance works in gonna do it . way as more complex health insurance. It is convinced by private firms but approved a Medicare. The policies are standard ordinary coverage policies, vary type of only slightly throughout Plans (A-L) and after that slightly through a number of companies in premium. The standard coverage for the 12 plans must stay the corresponding no matter precisely company provides in the plan. To be able to conclude, following you could have picked to policy that fits your family very best, ensure that you obtain the insurance policy for supplement of your Medicare that has the lowest premiums. It could present pricey at 1st but the expenses will not grow every year an individual expand older. More info behind Medicare supplemental insurance plan coverage . Our own expensive healthcare resources have made the following very difficult for all those to manage their medical expenses without unforeseen support. Feasible of a proper financial insurance damages the savings of persons. This applies more to elderly people who are faced with chronic medical trouble and little cash flow or savings. For such people, the presence of just a medical insurance really like Medicare Supplement programs is critical. It helps in providing them more desirable health facilities at negligible prices. The use in the Medicare supplement insurance policies in addition so that it will medical insurance support people to avail hospital and medical assistance for almost able and ensure a more favorable quality of circumstances for them. Now, some may definitely believe that through process of obtaining further insurance, these are leaving on their very own and their futures more to my hands of persons rather then consistently command. Nonetheless, this can choose to be just not the. Northern The state of california see there website here is supposed to assist so guard your forthcoming. Who understands everything could happen? You possibly can undergo from an incredible enormous coronary midst assault and phone call for a dealership more than the medicare will buy from you. By obtaining supplemental insurance, you might be able to lower the stress typically the payments will place on both you and your friends and as well as family. As well as the difficulty needed for many people to help pay for necessary health care, there are a no . of different variants of government-provided health insurance. Many people assume the fact this type related with insurance requires many to be dirt-debris poor to qualify, but this are not actually all of the case. Via on for a fabulous review of pretty of the alternatives offered by both federal and think governments to keep you and consequently your family healthier. Medigap – A boost or Medigap insurance policy is an insurance insurance plan that is supplied by a private insurance corporation to fill that this gaps left for Medicare. when Medicare was passed in 1966, it wasn’t meant to be totally comprehensive dental coverage. The beneficiary is responsible for the level of charges sharing. Generally terms, the assignee is responsible for hospital deductible, co-pays after extended clinic stays and 20% of outpatient repair bills. That report which talks about the state’s customari acute care (GAC) hospitals shows that the number of issue and beds minimal between 2001 and 2007 while the state’s population became. Californians who are 80 and older, Medicare beneficiaries or not, use a healthcare facility services the all.
Source: typepad.com

Possible Medicare Advantage Pay Reductions Cause Insurer Stocks To Slip

Modern Healthcare: Insurers See Proposed Medicare Advantage Rates Hitting Revenue Health insurance companies are expecting reduced Medicare Advantage payments to unfavorably impact revenue next year. The CMS on Friday released its proposed 2014 rates for Medicare Advantage plans, prompting negative reaction from payers and investors. Shares of health insurance plans such as Humana, Universal American Corp. and Health Net took a dive on the news when they opened for trading this morning. The CMS proposal calls for a 2.2% decline in Medicare Advantage benchmark payment rates. Humana, which derives most of its revenue from Medicare Advantage, saw one of the largest decreases in its share price (Kutscher, 2/19).
Source: kaiserhealthnews.org

Texas Medicare Supplement Insurance Plans

Make sure that you are getting the right coverage that you want. This will not be hard if you already know your options. There are ten different supplement plans that you can choose from. Taking time to carefully examine all you have to choose from will enable you to compare the gaps filled with each plan to determine the one that is going to be ideal for your needs.
Source: zambiadaily.com

Assisted Living Expansion and the Market for Nursing Home Care

Posted by:  :  Category: Medicare

"Citizenship is a tough occupation which obliges the citizen to make his own informed opinion and stand by it." ~ Martha Gellhorn  by eyewashdesign: A. GoldenResearchers wanted to see how an increase in the local supply of assisted living was associated with fewer private pay—and sicker—residents in nursing homes. They looked at 13 states for which there was detailed data available on assisted living facilities. For data on nursing homes, they turned to the Centers for Medicare & Medicaid Services (which certifies facilities), and to the Minimum Data Set for facility case mix, and resident clinical and functional status.
Source: rwjf.org

Video: Medicare Provider, Assisted Living

Therapy Plateau No Longer Ends Coverage

Beneficiaries also often lose Medicare coverage for outpatient therapy because they hit the payment limit. But under the exceptions process Congress continued for another year, the health care provider can put an additional code on the claim that indicates further treatment above the $1,900 limit is medically necessary. When treatment costs reach $3,700, the provider can submit medical documentation to support a request for another exception to cover 20 more sessions. (A Medicare fact sheet provides some additional details, but has not been updated for 2013.)
Source: topangaparkassistedliving.com

Miami Assisted Living Facility Owner Sentenced For Medicare Fraud

           The owner of a Miami-Dade County assisted living facility (ALF) was sentenced today to 15 months in prison for her role in a kickback scheme that funneled ALF patients to fraudulent mental health providers American Therapeutic Corporation (ATC) and Health Care Solutions Network (HCSN), announced U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; Michael B. Steinbach, Acting Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.
Source: browardnetonline.com

LeadingAge: OIG Report: Assisted Living Facilities Not Complying With All Medicaid HCBS Requirements

It’s important to understand that the report in question addresses requirements imposed by the Center for Medicare and Medicaid Services (CMS) on assisted living communities that receive funds from Medicaid waiver programs. It does not address issues related to citations that assisted living communities receive from state licensors.
Source: leadingage.org

OIG Report: Assisted Living Facilities need better compliance with federal regulations for HCBS

In its December 2012 Report, “Home and Community-based Services in Assisted Living Facilities,” the Office of the Inspector General (OIG) took a deeper look into the Centers for Medicare & Medicaid Services (CMS) waivers that allow coverage of HCBS by State Medicaid Programs. The waivers examined in this report include 1915 (c) and Section 115 research and demonstration. HCBS services, according to 42 CFR § 440.180(b), can include case management and homemaker services, personal care services, home health aide services as well as other services that are meant to aid in keeping people from being moved to a more traditional long term care setting.
Source: cmscompliancegroup.com

Medicare Assisted Living Ratings

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Source: comforcare.com

Medicare Assisted Living Facilities

Finding the best services for patients who need extensive medical care takes a little time and patience as you investigate various factors such as the cost of assisted living facilities. You will need to locate Medicare assisted living facilities that offers the direct doctor’s care that Medicare will require to pay for the facility. When you visit the facilities look around and identify the options that make the unit perfect for older patients. People who need doctor’s care may not be willing to go into a nursing home. Although for Medicare to pay the patient will need the type of care a nursing home provides. The community you choose should have scheduled meal times and activities to help your loved one stay active and not become bored. Keeping patients busy with different activities will help the person settle in and enjoy the change in lifestyle.
Source: assistedlivingfacilities.net

Medicaid Providers Beware Failure to Appeal Audit Results or Pay Medicaid Overpayments May Result in Termination of License

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Healthcare Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Often other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies participate. Don’t wait until it’s too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today.  Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.
Source: thehealthlawfirm.com

In Arizona, Poorest, Sickest Patients Get Coordinated Care

Joseph Ford sits in his well-worn easy chair in the living room of his suburban Phoenix home. He’s 42 years old and disabled from a car accident. His attendant has just arrived and makes her way into the kitchen to prepare dinner. Later, she’ll change the sheets on Ford’s hospital bed. It’s pushed against the wall in the entry way where he sleeps every night, since Ford can’t make it up the stairs. His house is busy today: the case manager from his health insurance company, Dave Oxford, is here too.
Source: kaiserhealthnews.org

A Closer Look at Mom’s Medicare: Part II

The first option that many families utilize when an extra set of hands is required is non-skilled Home Care.  Home Care agencies can provide assistance with the activities of daily living, but can also provide things like transportation to doctor’s appointments, light housekeeping, and light meal prep.  This is a great way to get another set of eyes routinely into a home situation when you cannot be there all the time.  It is an out-of-pocket expense that generally runs $20-$25/hour (depending on your area of the country).  Many agencies require a minimum number of care hours (often 3 or more during any one visit) but shorter time allotments may be available at a higher rate.  This can still be an economical way to ease the burden on a family caregiver for several hours a week or for certain tasks.
Source: wordpress.com

Reforming Medicaid for Assisted Living Homes

A new report offers numerous recommendations for changing how Medicaid applies to assisted living homes. This issue is critical because elder individuals are many times more comfortable in assisted living homes. The current Medicaid framework, however, may not make it financially feasible for many Medicaid eligible individuals.
Source: elderparenthelp.com

Paying For a Nursing Home

Long term care insurance (LTCI) is a private insurance policy.  The benefits and costs vary widely.  It is designed to pay for custodial long-term care services required due to a chronic illness or a condition lasting a prolonged period of time.  This type of insurance covers skilled care and, more importantly, custodial care or personal care – i.e., when a person needs assistance with certain daily activities such as bathing, dressing and eating.  LTCI is not designed to cover acute care services or to be a substitute for Medicare, Medigap or senior HMO plans.  Depending upon the policy, long-term care can be provided at home, in the community, in assisted living facilities or in nursing homes.  Many LTCI policies cover a certain dollar amount per day for a specified period of time.  For instance, a policy may provide a daily benefit level of $250 for three years of coverage.  Other policies may give a “bucket” of money and coverage lasts until it is gone.
Source: massestatelawyer.com

Mental health counselor Nichole Eckert sentenced to 48 months prison in $205 million fraud scheme

Eckert was a therapist at ATC’s Ft. Lauderdale, Fla., center from September 2005 to September 2007, and returned to ATC as a therapist from late 2009 to October 2010, when ATC closed its doors as a result of federal charges.  Evidence at trial revealed that Eckert fabricated therapist notes and other documents for patient files and submissions, and taught others to fabricate them, to make it appear both that ATC patients were qualified for PHP treatment and that they were receiving the intensive, individualized treatment PHP is supposed to be.  ATC used those patient files to substantiate false and fraudulent claims to Medicare.  Included in these submissions were claims for patients who were in the late stages of diseases causing permanent cognitive memory loss and patients who had substance abuse issues and were living in halfway houses.  These patients were ineligible for PHP treatments, and because they were forced by their assisted living facility owners and halfway house owners to attend ATC, they were not receiving treatment for the diseases they actually had.
Source: wordpress.com

Louisiana Law Blog: Recent Developments in Medicare Set Aside

Posted by:  :  Category: Medicare

Running Amok Again by elycefelizSpecifically, the District Court held that no federal law requires an MSA in personal injury settlements for future medical expenses. The District Court held that while MSA’s are prudent in settlements for future medical expenditures in the workers’ compensation context, they are not required outside that context. The District Court further commented that to require personal injury settlements to specifically apportion future medical expenses would prove burdensome to the settlement process and, in turn, discourage personal injury settlements. Finally, the District Court dismissed the September 29, 2011 advices of the CMMS described above by pointing out that “interpretation such as those in opinion letters, like interpretations containing policy statements, agency manuals, and enforcement guidelines lack the force of law.” Christensen v. Harris County, 529 U.S. 576, 587 (2000).
Source: louisianalawblog.com

Video: Medicaid Set Aside

The Value of Using Structured Settlements When Addressing Medicare Set Asides

To see how a structured settlement saves money, consider the following hypothetical example.  The injured employee is a former motel maid Jane Doe, age 45, who injured her back lifting a heavy bag of trash.  She is morbidly obese, has diabetes, hypertension and gout.  She has had 3 unsuccessful back surgeries and is expected to be permanently and totally disabled.  Due to her on-going pain management treatment, medical appointments and narcotics, it is estimated that her medical care over her 30 year rated life expectancy will be $10,000 per year or $300,000 in total. There are two ways to pay for the future medical care.  The first way is to write Ms. Doe a check for $300,000. 
Source: reduceyourworkerscomp.com

Dawson Disantis & Myers, LLC: Ohio BWC Implements New Medicare Set

As most Ohio self-insured employers know, one of the most difficult hurdles in settling a workers’ compensation claim is the Medicare Set-Aside.  On November 5, 2012, BWC Administrator Stephen Buehrer announced a new BWC policy which addresses the MSA threshold for state funded settlements.  BWC will issue a Medicare set-aside letter only if 1.) the settlement is $100,000 and over or 2.) if the settlement is over $10,000 and the injured worker is already on Medicare or has a reasonable expectation of receiving Medicare within 30 months. While Buehrer’s policy announcement appears to address settlement of state fund claims, self-insured employers can look to the BWC’s MSA thresholds for guidance.  Of course, Dawson Disantis & Myers, LLC encourages SI employers to discuss MSA for Ohio workers’ compensation settlements further with legal counsel. Buehrer’s MSA policy letter is below:
Source: blogspot.com

What Is The Medicare Set Aside?

There are three main situations where the government gets involved with the settlement. In all three cases, funds must be allocated for use in payment of expenses that would otherwise pass to the government insurance program. This is referred to as a set aside, and requires appropriate Medicare set aside administration. This is required in three situations. If the individual is currently benefitting from Medicare, the fund must be established and will be the initial source of funding for all payments that would regularly have been paid by the government organization. If the individual is expected to become a beneficiary within 30 months from the date of settlement (not the date of injury) then money must be set aside. Finally, if the amount is over $250,000, MSA administration and creation will be necessary.
Source: webjason.com

SMART Act Amends Medicare Secondary Payer Statute, Creates Three

Posted by:  :  Category: Medicare

The SMART Act requires the Secretary of Health and Human Services (“Secretary”) to establish a process by which a claimant (or his or her authorized representative) can dispute discrepancies with the statement of reimbursement amount. A claimant or authorized representative must submit documentation of the potential discrepancy and a proposed resolution to the Secretary. The Act states that the Secretary must determine whether there is a reasonable basis for including or removing a claim and provide a response within eleven (11) business days. Lack of a response is a deemed acceptance of the claimant’s proposal. If the Secretary determines that there is not a reasonable basis to include or remove claims, the proposal will be rejected. If the Secretary concludes that there is a discrepancy, but rejects the proposed resolution, documentation showing good cause for why the Secretary has rejected the proposal and establishing an alternate discrepancy resolution must be provided to the claimant. This process does not create an appeals process, however, and the SMART Act expressly forecloses the possibility of administrative or judicial review of the Secretary’s determinations. Final regulations must be promulgated by October 10, 2013, nine (9) months after the date of enactment, the effective date of this provision.
Source: crowell.com

Video: Navigating the Medicare Secondary Payer Act

Medicare Secondary Payer: Conditional Payment Reimbursement Policies for Certain Liability Settlements

Beginning February 21, 2011, CMS implemented an option permitting certain Medicare beneficiaries the ability to self-calculate Medicare’s conditional payment amount prior to settlement. As with other recent policies, the option is available only to liability insurance (including self-insurance) settlements and not workers’ compensation or no-fault claims and only when involving a physical trauma based injury and not ingestion, implantation or exposure. The dollar threshold was established at $25,000 or less and the date of incident must have occurred at least six months prior to the submission of the self-calculated amount to Medicare for review. The beneficiary must demonstrate that treatment has been completed and that no further treatment is expected through written physician attestation or a written certification by the beneficiary that there was no treatment for at least the 90 days prior to submission and that there is no further care expected. The election of this option bars the beneficiary from appealing the amount or existence of this debt, but the right to pursue waiver of recovery will remain.
Source: lexisnexis.com

Statement to the Record on the Medicare Secondary Payer and Workers’ Compensation Settlement Agreement Act

HR 5284 creates a system of certainty and allows the workers’ compensation settlement process to move forward while eliminating millions of dollars in administrative costs.  It will help create clear and consistent standards, currently lacking in the process, to address workers’ compensation issues.  Most importantly, it will benefit all parties involved – injured workers, employers, insurers and CMS.  
Source: house.gov

Summary of SMART Act which amended Medicare Secondary Payer Act

The SMART Act requires parties to notify CMS of when they reasonably anticipate settling a claim (any time beginning 120 days before the settlement date). CMS then has 65 days to ensure the portal is up to date with all of the appropriate claims data. CMS can have an additional 30 days on top of the 65 days to update the portal if necessary. At the expiration of the 65 and potentially the 30 day periods, the parties may download a final conditional payment amount from the website. The final conditional payment amount is reliable as long as the claim settles within 3 days of the download.
Source: thehamiltonfirm.com

CMS officials issue reminder on Medicare secondary payer laws

Participating Medicare providers, physicians, and other suppliers must not accept from beneficiaries any co-payments, coinsurance payments, or other payments, for services rendered when the primary payer is an employer-managed care organization (MCO) insurance plan, or any other type of primary insurance such as an employer group health plan, U.S. Centers for Medicare & Medicaid Service (CMS) officials warned in a new Medicare Learning Network (MLN) Matters® article last month.
Source: newsfromaoa.org

Medicare Quality Reporting for ASC Clients

Quality Reporting for Ambulatory Surgical Centers A quality reporting program for ASCs was finalized by the Centers for Medicare and Medicaid Services (CMS) in the Calendar Year (CY) 2012 OPPS/ASC Final Rule with Comment Period (CMS-1525-FC). Five claims-based measures (four outcome measures and one process of care measure) were adopted for the CY 2014 payment determination. For the CY 2015 payment determination, two structural measures (surgical procedure volume and safe surgery checklist use) were adopted in addition to the five original claims-based measures for a total of seven quality measures. For the CY 2016 payment determination, the same claims-based and structural measures as adopted for the CY 2015 payment determination and one process of care measure were adopted.
Source: abeo.com

House Panel Approves Changes to Medicare Secondary Payer (MSP), Medical Loss Ratio Rules : Health Industry Washington Watch

On September 20, 2012, the House Energy and Commerce Committee approved by voice vote H.R. 1063, the Strengthening Medicare and Repaying Taxpayers (SMART) Act. The legislation would make a series of procedural changes to MSP rules intended to “speed up the process of returning money to the Medicare Trust Fund while reducing costly legal barriers for both large and small employers.” The panel also approved on a 16-14 vote H.R. 1206, the Access to Professional Health Insurance Advisors Act. The legislation would amend the Affordable Care Act’s (ACA) health insurance medical loss ratio (MLR) rules to exclude from the calculation of the MLR certain commissions paid to independent insurance brokers and agents. H.R. 1206 also would require HHS to defer to a state’s determinations as to whether enforcing the MLR requirement will destabilize their respective individual or small group health insurance markets. Neither bill has been considered by the full House to date.
Source: healthindustrywashingtonwatch.com

Gould & Lamb to Host Medicare Secondary Payer Compliance Breakout :Gould & Lamb

Program Moderator, Bret Cade, Executive VP of Sales at Gould & Lamb, LLC will lead the day long seminar. Planned presentations include Medicare Secondary Payer Act 101: The Reader’s Digest Version by Roy Franco, Esq., Principal at Franco Signor, LLC, The Eye in the Sky: Mandatory Insurer Reporting by Scott Huber, Vice President of Information Technology at Gould & Lamb, LLC and Jeff Gurtcheff, VP and General Manager at PMSI, Render Unto Caesar What is Caesar’s: Conditional Payments  Resolution by Wanda Reas, Esq., Partner at Znosko & Reas, P.A. and John Cattie with the Garretson Resolution Group, So Let It Be Written, So Let It Be Done: A Legislative and Case Law Update by Mark Popolizio, Esq., Senior Legal Counsel at Crowe Paradies and Roy Franco, Esq., Principal at Franco Signor, LLC, Seeing the Forest Through the Trees: MSA/LMSA Trends by Rafael Gonzalez, Director of Medicare Compliance & Post Settlement Administration at Gould & Lamb, LLC, Celia Mendez, Esq., Mediator & Attorney at Moreland & Mendez, P.A., and Cynthia Sage, Esq., Corporate Counsel at FCCI Insurance Group. The program will end with MSP Compliance in the Real World: A Roundtable Discussion where all of the previously mentioned speakers will be joined by Skip Brechtel, Chief Technical Officer at CCMSI, Wade McGuffey, Esq., of Goodman, McGuffey, Lindsey & Johnson, LLP, and the Honorable David Langham, Deputy Chief Judge of Workers’ Compensation Claims.
Source: themedicarecomplianceblog.com

Medicare Secondary Payer and “Future Medicals” A Movement Toward a Standardized Process?

CMS states that its interests should be considered in every settlement where the claimant, “reasonably anticipates receiving, or should have reasonably anticipated receiving Medicare covered…services after the date of “settlement…”.  To accomplish this purpose, CMS proposes options  ranging from absolute exemptions on one end of the spectrum (i.e., CMS defined a set of circumstances in which no further action would be necessary / no “set aside” required) to alternatives on the other end of the spectrum that involve a) the beneficiary paying for all future injury-related care out of his/her settlement proceeds until they are exhausted or b) submitting a proposed Medicare Set Aside arrangement (similar to the current process in workers’ compensation).With regard to the latter options, it is important to note that CMS acknowledges that perhaps thresholds could be established (i.e., a dollar amount below which no action is necessary even if one of the other exemptions do not apply).
Source: dritoday.org

Louisiana Law Blog: The Medicare Secondary Payer Act And Mandatory Reporting Requirements: Driving Through the Fog

Our White Paper is designed to provide parties involved in toxic tort liability suits with knowledge of the key provisions of the MSP and the MMSEA. The manuscript focuses on the practical aspects of obtaining information needed for compliance, common misconceptions and risk avoidance. The manuscript also discusses the significance of cases involving incidents that pre-date the December 5, 1980 MSP, practical aspects of determining when the December 5, 1980 policy may be applied and recent guidance from the CMS on that issue.
Source: louisianalawblog.com

CARR ALLISON Medicare Compliance Group: Looking Back on 2012 and Looking Ahead to 2013

2012 REVIEW The year 2012 proved to be an active one for CMS.  New contracts were awarded, a Medicare Secondary Payer Recovery Portal was implemented, Medicare Set-aside proposals were log-jammed then cleared in December, comments were requested on a very interesting proposal and courts spoke out about Medicare Secondary Payer issues.  Read more about those topics below. New Medicare Secondary Payer Contracts Awarded During 2012 The task of Medicare Secondary Payer Integrity Contractor (MSPIC) was awarded to StrategicHealthSolutions, LLC (Strategic). The MSPIC task is the systems integration component of the new Coordination of Benefits and Recovery matrix program created by CMS. Strategic, along with its contractor Neil Hoosier and Associates, will provide program management support to ensure that all components of the matrix program function together as efficiently and effectively as possible. See Strategic’s Press Release here.  The Medicare Secondary Payer Business Program Operations Contract (BPOC) was awarded to Integriguard LLC, doing business as HMS Federal. According to the contract award notice, this contractor will centralize the Coordination of Benefits (COB) and Medicare Secondary Payer Recovery (MSPR) operation by consolidating the activities of collection, management, and reporting of information related to Medicare beneficiaries’ insurance coverage and the collection of conditional payments.    General Dynamics Information Technology was awarded a contract by CMS to provide information technology services for the MSP program. View the press release here. CMS Implements the Medicare Secondary Payer Recovery Portal The Medicare Secondary Payer Recovery Portal (MSPRP) went live in July 2012. The portal allows users to access and update information online and eliminates the need for some correspondence and telephone calls. Users can electronically perform the following activities: 1. Upload Proof of Representation and Consent to Release documents, 2. Request updated conditional payment amount or a copy of the current conditional payment letter, 3. View and dispute claims listed on a conditional payment letter, and 4. Input settlement information and upload settlement documents. Documentation Needed to Dispute or Appeal Conditional Payment Claims In order to dispute or appeal conditional payment claims, CMS currently requires a Proof of Representation form authorizing the party filing the dispute or appeal to do so. In workers’ compensation claims, the Proof of Representation must be signed by the workers’ compensation insurance carrier if the insurance carrier has retained a third party to handle the conditional payment claim issues. In liability claims, the Proof of Representation form must be signed by the Medicare beneficiary. This effectively prevents a liability insurance carrier from challenging conditional payment claims and the liability insurance carrier is left to rely on the assistance of the Medicare beneficiary and his or her attorney to dispute or appeal conditional payment claims. In light of the SMART Act, we anticipate that there will be changes regarding the documentation needed to challenge conditional payment claims in the near future.  We will keep you posted. New MSA Review Contractor’s Review of Submissions As many are aware, on July 2, 2012, Provider Resources, Inc. took over review of Workers’ Compensation Medicare Set-aside (WCMSA) proposals. Since then, the turnaround time on many proposals that were submitted after July 2 has been 60 days or less, although some have taken 90 days or more. This is a definite improvement from the 10 months to one year timeframe we were seeing with the previous review contractor. While we are hopeful that CMS will continue to review submissions in a more timely fashion, parties settling any workers’ compensation case in which CMS approval is sought should still allow adequate time for that process. CMS Finally Issues Determinations on Backlogged Files As of November 29, 2012, CMS began issuing approval letters on all files that have been pending review prior to the new CMS review contractor taking over on July 2, 2012. Some of these files had been pending at CMS for over one year. This will finally allow many parties to settle claims that have been sitting stagnant for months. In addition, CMS indicated in their approval letters for these backlogged files that the submitter is responsible for calculating the annuity terms if the Medicare Set-aside is to be funded through a structured settlement. This is very good news as it eliminates the burden and costs of revising settlement documents, Medicare Set-aside Agreements and structured settlement documents which is necessary when CMS slightly revises the terms submitted. CMS Considering Comments on Proposed Rulemaking for Protecting Medicare’s Interests as it Pertains to Future Medical Treatment On June 15, 2012, the Federal Register issued a notice that comments would be accepted and reviewed for proposed rulemaking related to protecting Medicare’s interests as it concerns future medical treatment. The proposed rulemaking consisted of seven options that CMS is considering for claims involving automobile and liability insurance (including self-insurance), no-fault insurance, and workers’ compensation and in which future medical care is claimed or released. The overall intention of these proposed options is to provide a more efficient and clear means that beneficiaries may use to ensure that Medicare’s interests have been adequately protected. The period for accepting comments ended on August 14, 2012. Comments that were received before the end date can now be viewed here.  We still await a response to the comments and clarification of which of the proposed options will be enacted. Medicare Coverage of a TENS Unit CMS recently changed its guidelines with regard to Medicare-coverage of a Transcutaneous Electrical Nerve Stimulation (TENS) unit. CMS indicated that a TENS unit is not reasonable and necessary treatment for chronic low back pain and will not be covered by Medicare when prescribed for treatment of the same. Chronic low back pain is defined as “an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity.” For claims settled before June 8, 2012 that include an MSA that contains pricing for a TENS unit, CMS will consider funds spent for a TENS unit prescribed for treatment of chronic low back pain as an appropriate expenditure of the MSA funds. For claims not settled prior to June 8, 2012, CMS will re-review the MSA proposal and remove pricing for the TENS unit prescribed for chronic low back pain. After this has been done, a claimant should not use the MSA funds for a TENS unit prescribed for chronic low back pain as doing so would be an inappropriate expenditure of MSA funds. Court Orders MSA in Liability Case In a recent liability case, Cribb v. Sulzer Metco (US) Inc., NO. 4:09-CV-141-FL, 2012 U.S. Dist. LEXIS 134900 (E.D.N.C. September 5, 2012), the plaintiff, a Medicare beneficiary, filed a motion seeking the court’s approval of the settlement and determination of the need for and amount of a Medicare Set-aside.  The parties were unable to obtain a determination from CMS regarding the appropriate MSA amount, as the Atlanta CMS Regional Office, which serves North Carolina, is currently not reviewing MSAs in liability cases. The court considered a letter from the treating physician recommending medical surveillance and providing a cost estimate of $4,330.00 for the same.  The court found that the estimated costs of the plaintiff’s future medical expenses were reasonable and that the parties were not attempting to maximize other aspects of the settlement to Medicare’s detriment.  The court concluded, as a matter of law, that the plaintiff was responsible “for future medical items or services which would otherwise be covered by Medicare, that are related to what was claimed and released in this lawsuit.”  Id. at *4. Based on its consideration of the evidence and law, the court found that an MSA in the amount of $4,500.00 adequately protected Medicare’s interests.  As such, the court ordered the plaintiff to establish an MSA in the amount of $4,500.00, to be “deposited into an interest bearing account, which will be self-administered by him for the purpose of paying any future medical items or services that would otherwise be covered or reimbursable by Medicare that are related to what was claimed and released in this lawsuit.”  Id. at *6. The court in Cribb is one of a number of federal courts that have recognized that MSAs are appropriate in liability cases.  Parties who take the opposite position would likely find a court unsympathetic if they settle without considering Medicare’s interests and Medicare later asserts a claim. Medicare Advantage Plan Recovery is not Prevented by New York’s General Obligations Law Sec. 5-335 In Trezza v. Trezza, 2012 N.Y. App. Div. LEXIS 9000 (decided December 26, 2012), a plaintiff settled a claim stemming from a motor vehicle accident. After settlement, a Medicare Advantage plan asserted a reimbursement claim against the settlement proceeds, and the plaintiff argued that reimbursement was unavailable because of New York’s General Obligations Law Sec. 5-335, a statute enacted in 2009. The New York statute provides that parties who enter into a settlement are not subject to a claim for reimbursement unless there is a statutory right for the same, and the plaintiff argued that this meant the Medicare Advantage plan had no right to any of the settlement proceeds. The Supreme Court of New York, Appellate Division, decided that under Medicare Part C, Medicare Advantage organizations have the ability to create a contractual right to reimbursement, but this is not a statutory right. Because the New York statute at issue is preempted by Part C of the Medicare Act, however, the Medicare Advantage plan is still entitled to reimbursement from the settlement proceeds. This decision comes on the heels of Medicare Advantage plan’s repeated attempts to seek post-settlement reimbursement from defendants (i.e., “primary plans”). These efforts have seen mixed results: in the Third Circuit – i.e., Delaware, New Jersey, and Pennsylvania – a reimbursement claim based upon the Medicare Secondary Payer Act against a primary plan has been successful. Outside of the Third Circuit, however, Medicare Advantage plans’ reimbursement claims against primary plans (when based upon the Medicare Secondary Payer Act’s private right of action) have been rejected by various courts. COMING UP IN 2013 There is no doubt that 2013 will be filled with numerous changes as far as Medicare Secondary Payer issues are concerned.  Below are some of the changes we can expect early on. CMS Will Begin Covering Benzodiazepines on January 1, 2013 Beginning January 1, 2013, Medicare will begin covering benzodiazepines. Medicare will also begin covering barbiturates, but only when they are prescribed to treat epilepsy, cancer, or a chronic mental disorder. Benzodiazepines include medications such as Diazepam (Valium), Restoril (Temazepam), Clonazepam (Klonopin) and Ativan (Lorazepam) and are often prescribed to treat anxiety, insomnia and for muscle relaxation. If a claimant is prescribed a barbiturate for one of the above conditions or a benzodiazepine, as of January 1, 2013, the medication will need to be included in the Medicare Set-aside. CMS Adopts New Life Table for MSA Calculations Beginning January 19, 2013, CMS will begin using the Center for Disease Control’s life table for the total population (2008) for calculations of life expectancies for workers’ compensation Medicare Set-asides. This will apply to new files submitted on or after January 19, 2013, as well as files that are re-opened on or after that date.  For your reference, the 2008 life table can be found here. Final Rule Promulgated Which Clarifies When ICD-10 Codes Will be Used: October 1, 2014 HHS has announced that CMS and Section 111 reporting will convert from ICD-9 codes to ICD-10 codes on October 1, 2014. These codes are used by primary plans to identify the alleged injury when a plan assumes ongoing responsibility for medicals, or a settlement occurs, with a Medicare beneficiary. Prior to September of this year, when the final rule was promulgated, interested parties anticipated the transition to occur in October of 2013.
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