Medicare.gov: the official U.S. government site for Medicare

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Source: medicare.gov

Medicare Plan Finder for Health, Prescription Drug and Medigap plans

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Source: medicare.gov

2011 Medicare Part D Program Compared to 2010, 2009, 2008 and 2007

Pharmaceutical manufacturers will be required to provide certain beneficiaries access to discount prices for certain brand drugs purchased under Medicare Part D. The manufacturer discount prices will be equal to 50% of the plan’s negotiated price defined (minus any applicable dispensing fees). These discount prices must be applied prior to any prescription drug coverage or financial assistance provided under other health benefit plans or programs and after any supplemental benefits provided under the Part D plan. The discounted prices will be charged at the pharmacy (point-of-sale). The beneficiary will not have to do additional paperwork, etc. to receive the benefit. These manufacturer discount prices will be made available to Part D enrollees who are in the coverage gap or donut hole (they have reached or exceeded the initial coverage limit and have incurred costs below the annual out-of-pocket threshold). Medicare beneficiaries will not be eligible to receive these discount prices if they are enrolled in a qualified retiree prescription drug plan or are eligible for the low-income subsidy. The costs paid by manufacturers towards the negotiated prices of drugs covered under this manufacturer discount program shall be considered incurred costs for eligible beneficiaries and applied towards their out-of-pocket threshold. This means that the total negotiated retail drug price will be applied to the TrOOP and will count toward getting out of the doughnut hole.
Source: q1medicare.com

Medicare Supplement Plans Archives

When you apply for a Medigap policy (Medicare Supplement insurance), you have certain rights, which, by federal law, can protect you from being denied coverage. If you already have a policy, you also have rights to protect you from having to keep a plan that… Read more
Source: medicare.com

Medicare.gov: the official U.S. government site for Medicare

Posted by:  :  Category: Medicare

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Source: medicare.gov

Contact Information and Websites of Organizations for Medicare

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Source: medicare.gov

Medicare :: Washington State Dept. of Health

Many public health services are reimbursed through Medicare. Local health departments can be reimbursed for furnishing and administering the influenza and pneumococcal vaccines to Medicare Part B enrolled clients. LHJs may bill for immunization services using the roster billing process or as a group practice. Medicare part B clients have the right to receive the influenza and pneumococcal immunization services as well as many other preventive services without incurring any out-of-pocket expense.
Source: wa.gov

Medicare Health Plans, Coverage And Online Enrollment

Posted by:  :  Category: Medicare

*Plan performance summary star ratings are assessed each year and may change from one year to the next. (Centers for Medicare & Medicaid Services Health Plan Management System, Plan Ratings 2012. Kaiser Permanente contract #H0524, #H0630, #H1170, #H1230, #H2150, #H6360, #H9003). This page was last updated: October 1, 2012 at 12 a.m. PT
Source: kaiserpermanente.org

Affordable Health Coverage

Rating and national average are based on Controlling High Blood Pressure 2013 ratings from the Healthcare Effectiveness Data and Information Set (HEDIS) for commercial plans published by the National Committee for Quality Assurance. HEDIS is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. HEDIS is a registered trademark of the National Committee of Quality Assurance (NCQA). For more information, visit ncqa.org.
Source: kaiserpermanente.org

Medicare.gov: the official U.S. government site for Medicare

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Source: medicare.gov

Kaiser Permanente Medicare Plans Score Top Ratings for Quality and Service

About Kaiser Permanente Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 10 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: kp.org/share.
Source: kaiserpermanente.org

Medicare.gov: the official U.S. government site for Medicare

Posted by:  :  Category: Medicare

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Source: medicare.gov

How to compare Medigap policies

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Source: medicare.gov

Medicare Resources for Children with Special Needs

Posted by:  :  Category: Medicare

There are other benefits available to “dual eligibles” who are entitled to both Medicare and Medicaid benefits. Medicaid can help pay for out-of-pocket medical expenses and play a critical role filling in Medicare’s gaps in coverage. It can provide additional services and supplies that are available under the individual’s state Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the state’s payment limit. Medicaid can pay for nursing facility care beyond the 100 day limit covered by Medicare, prescription drugs and monthly premiums, eyeglasses and hearing aids. An individual may want to have Medicare in addition to Medicaid because the combination can provide better access to care. Because Medicare reimbursement is higher than Medicaid, more physicians will accept Medicare patients over Medicaid patients. Most physicians who treat adults accept Medicare but very few accept Medicaid. Medicaid would cover premiums and co-pays for Medicare.
Source: cincinnatichildrens.org

Does Medicare Cover Children?

Medicaid, however, is a different federal health insurance program which can cover children if their families have low income and few assets other than their home. If a family qualifies for Medicaid coverage, almost all of a child’s health care needs can be paid for, with only very small copayments by the family. To find out more about eligibility for Medicaid for children, and to find out about specific programs that expand coverage to children beyond standard Medicaid coverage, go to the Medicaid page of the web site of the Centers for Medicare and Medicaid Services.
Source: caring.com

How Much You’ll Pay
For Medicare in 2011

Posted by:  :  Category: Medicare

Medicare just announced the 2011 rates for monthly premiums for Part B coverage of doctor’s visits and outpatient treatment and Part D coverage of prescription drugs. The big news for next year: For the first time, higher-income beneficiaries (about 5% of all Medicare recipients) will pay a Part D surcharge. They’ll pay the regular Part D premium to their private insurance plan and will pay the income-related adjustment to Medicare.
Source: kiplinger.com

2011 Medicare Hospital Cost Reports

All hospitals in Illinois, those hospitals in contiguous states providing 100 or more paid acute inpatient days of care to Illinois Medicaid Program participants, and all hospitals located in states contiguous to Illinois that elect to be reimbursed under the methodology described in 89 Ill. Adm. Code 149 (the Diagnosis Related Grouping (DRG) Prospective Payment System (PPS)), shall be required to file Medicaid and Medicare cost reports within 150 days after the close of that provider’s fiscal year.
Source: illinois.gov

MEDICARE Part A, B, C, & D PREMIUMS, DEDUCTIBLES FOR 2011

Part A premiums are decreasing because spending in 2010 was lower than expected and the Affordable Care Act implemented policies that lower Part A spending due to payment efficiencies and efforts related to waste, fraud and abuse.  Part B premiums are increasing because of growth in the use of services like outpatient hospital care, home health and physician-administered drugs.  In addition, the premium accounts for a likely Congressional action to avert a precipitous decrease in physician payments, which the Administration supports, and has occurred every year since 2003.  The Administration is committed to permanent reform of the physician payment formula. 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 appropriate to (i) cover incurred-but-unpaid claims costs, (ii) provide for possible variation between actual and projected costs, and (iii) amortize any surplus assets or unfunded liabilities.  The remaining Part B costs are financed by Federal general revenues.  (In 2011, $2.5 billion in Part B expenditures will be financed by the new fees on manufacturers and importers of brand-name prescription drugs under the Affordable Care Act.  The revenue from these fees reduces the standard Part B premium by $0.90.)
Source: q1medicare.com

Annual Statistical Supplement, 2011

Beginning January 1, 2006, upon voluntary enrollment in either a stand-alone PDP or an integrated Medicare Advantage plan that offers Part D coverage in its benefit, subsidized prescription drug coverage. Most FDA-approved drugs and biologicals are covered. However, plans may set up formularies for their drug coverage, subject to certain statutory standards. (Drugs currently covered in Parts A and B remain covered there.) Part D coverage can consist of either standard coverage or an alternative design that provides the same actuarial value. (For an additional premium, plans may also offer supplemental coverage exceeding the value of basic coverage.) Standard Part D coverage is defined for 2006 as having a $250 deductible, with 25 percent coinsurance (or other actuarially equivalent amounts) for drug costs above the deductible and below the initial coverage limit of $2,250. The beneficiary is then responsible for all costs until the $3,600 out-of-pocket limit (which is equivalent to total drug costs of $5,100) is reached. For higher costs, there is catastrophic coverage; it requires enrollees to pay the greater of 5 percent coinsurance or a small copay ($2 for generic or preferred multisource brand and $5 for other drugs). After 2006, these benefit parameters are indexed to the growth in per capita Part D spending (see Table 2.C1). In determining out-of-pocket costs, only those amounts actually paid by the enrollee or another individual (and not reimbursed through insurance) are counted; the exception is cost-sharing assistance from Medicare’s low-income subsidies (certain beneficiaries with low incomes and modest assets will be eligible for certain subsidies that eliminate or reduce their Part D premiums, cost-sharing, or both) and from State Pharmacy Assistance Programs. A beneficiary premium, representing 25.5 percent of the cost of basic coverage on average, is required (except for certain low-income beneficiaries, as previously mentioned, who may pay a reduced or no premium). For PDPs and the drug portion of Medicare Advantage plans, the premium will be determined by a bid process; each plan’s premium will be 25.5 percent of the national weighted average plus or minus the difference between the plan’s bid and the average. To help them gain experience with the Medicare population, plans will be protected by a system of risk corridors, which allow Part D to assist with unexpected costs and to share in unexpected savings; after 2007, the risk corridors became less protective. To encourage employer and union plans to continue prescription drug coverage to Medicare retirees, subsidies to these plans are authorized; the plan must meet or exceed the value of standard Part D coverage, and the subsidy pays 28 percent of the allowable costs associated with enrollee prescription drug costs between a specified cost threshold ($250 in 2006, indexed thereafter) and a specified cost limit ($5,000 in 2006, indexed thereafter).
Source: ssa.gov

Regence Medicare Advantage Medical Policy and Review Process

Posted by:  :  Category: Medicare

Medicare Advantage Medical Policies are the property of our Plans and their affiliated or subsidiary companies, but may be used for purposes related to the health care of a Medicare Advantage Plan member.  You are strictly prohibited from using Medicare Advantage Medical Policies for purposes not related to the health care of a Plan member, including but not limited to commercial use.
Source: regence.com

Regence Medicare Advantage Medical Policy and Review Process

Medicare Advantage Medical Policies identify the clinical criteria for determining when medical services are considered ‘reasonable and necessary’ (medically necessary).  Medicare Advantage plans are required by CMS to provide the same medical benefits to Medicare Advantage members as Original Medicare.  As such, whenever possible, Medicare Advantage Medical Policies are based on Medicare coverage manuals, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs) when available.  If there is no applicable NCD or LCD for the service under review, then other evidence-based criteria may be applied.  In addition, each member’s unique, clinical situation is considered in conjunction with current CMS guidelines.
Source: regence.com

Medicare Supplement Plan F

Posted by:  :  Category: Medicare

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **This high deductible plan pays the same or offers the same benefits as Plan F after you have paid a calendar year $2110 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Source: medigap360.com

Medicare Supplement Plan F

Under Fire: Many politicians and health economists believe plan F should be eliminated or modified because it provides first dollar coverage for people who purchase the plan. They believe people who do not have co-payments or deductibles to pay use medical services more often, which hurts the Medicare system as there are more claims submitted. There have been many attempts by various political figures to modify these plans by adding co-payments or a small deductible. However, a study completed by the National Association of Insurance Commissioners found people who have plans that offer first dollar coverage (Plan F & Plan C) do not seek more medical services than those who have a co-pay or deductible. For now, it seems Medicare Supplement F is safe.
Source: medicaresupplementshop.com

Medicare Supplemental Insurance Plans

With a variety of standardized Medicare supplement insurance plans available, it’s important to know your options. Learn about the benefits and how a Medicare supplement insurance plan could be the right fit for you
Source: aarpmedicaresupplement.com

How to compare Medigap policies

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Source: medicare.gov

Medicare.gov: the official U.S. government site for Medicare

Posted by:  :  Category: Medicare

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Source: medicare.gov

CMS National Training Program

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Source: cms.gov

Medicare & Medicaid Cost Report l Owner Administrator Forum Seminar

Medicare Training & Consulting, Inc., was founded by Jim Plonsey in the Chicago area. After training Medicare auditors for Blue Cross Association, Jim established a business training Medicare auditors. This lead to doing cost reimbursement seminars for providers, most notably, home health agencies. Medicare Training & Consulting, Inc. has become a leader in providing Owners and Administrators with the reimbursement strategies.
Source: medicareconsulting.net

Medicare, Medicaid and Medical Billing

When a Part A claim is processed by Medicare, Medicare pays the provider directly for the service rendered by the provider. On the other hand, in a Part B claim, who pays depends on who has accepted the assignment of the claim. If the provider accepts the assignment of the claim, Medicare pays the provider 80% of the cost of the procedure, and the remaining 20% of the cost is passed on to the patient. You should recognized that 80-20 breakdown: it’s a classic example of coinsurance.
Source: medicalbillingandcoding.org