Category: Medicare Coverage
Articles explaining what Medicare covers.
Change will save millions by preventing fraudulent claims
Prior authorization will now be necessary before Medicare will cover medical equipment such as wheelchairs and prosthetics. Prior authorization has always been required, but now it will be earlier in the process.
Why?
Fraudulent billing for these types of equipment costs Medicare millions. They expect to save big: $10 million in the first year, $200 million within five years and $580 million within ten years. In 2014, “the error rate among durable medical equipment billing was 53.1%, which accounted for $5 billion in improper payments that year.” Not all of those were intentionally fraudulent, but this new rule intends to correct many of those cases.
What is prior authorization?
Before an insurance company will cover something- a prescription or procedure- they will need to talk to your doctor and determine if they will cover it. If not, they could cover a substitute, change the dosage, or provide an alternative.
In this case, before Medicare will cover a piece of medical equipment, they will need to talk to your doctor earlier in the process than they previously had.
What equipment is affected?
The Master List of equipment that requires prior authorization includes items with “a high rate of fraud or unnecessary utilization.” They are also items that have an average purchase cost over $1,000 or an average rental cost over $100.
After 10 years, items are removed from the list. They will also be removed if the prices fall before then. In addition to wheelchairs and prosthetics, equipment like oxygen supplies, orthotics, and braces are listed.
Are there any concerns with this plan?
Some groups are concerned that the new rule will increase wait times for equipment that patients need ASAP.
To read the Centers for Medicare and Medicaid Services’ press release on the change, click here.
For more information on the prior authorization process, see this article from Healthcare Finance.
Aims to improve quality and cost of care
Medicare will implement new system for hospitals performing hip and knee replacements, which are the most common surgeries among Medicare beneficiaries. If hospitals don’t meet the standards, they will have to pay back a part of the cost to Medicare. If they do perform well, they will get a monetary reward.
What is the new program?
The Comprehensive Care for Joint Replacement model (or the CCJR model) aims at better quality care. It will begin April 1, 2016.
67 geographic areas are included in the program. The Staunton-Waynesboro area is the only one in Virginia.
How does it work?
Hospitals will be evaluated for an “episode of care,” which lasts 90 days after the surgery. The cost of the episode of care, including the procedure and any related care, is in question for the hospital.
If the hospital’s care doesn’t meet the cost and quality standards, they will owe Medicare for a portion of the cost for the episode of care. If they succeed, Medicare will give the hospital a financial reward.
The program is meant to create incentives not only for hospitals, but skilled nursing facilities, nursing homes, and other health providers to providing comprehensive, coordinated care.
Why start this program?
The Centers for Medicare and Medicaid Services say on their website that these surgeries are the most common among beneficiaries, but the care varies from hospital to hospital. They want to not only coordinate the quality of care and its costs, but improve care nationwide. The inconsistencies in the health of patients after these surgeries reflects the state of the entire health care system.
Though you may happy with your current plan, you should see what’s on the market.
- “Even if you loved last year’s plan, it’s important for Medicare recipient to shop around from scratch this year.”This is what we always say. It doesn’t hurt to shop around, and you may find an even better plan than your current one.”They really need to do their homework,” says Patricia Barry, author of “Medicare for Dummies” and a features editor at AARP. “If they do, they’re likely to find their best deal, and they’re likely to save a lot of money.”
- “On Medicare.gov, you can enter those drugs (including dosage and quantity) and a tool on the site will rank the plans by which would be cheapest for you, showing how much those drugs would cost on each plan and how much you’ll pay in premiums.”The Medicare Plan Finder on Medicare.gov is the program we use to find the best plans for you. We show you all of the results, and can explain what the differences are: copays, deductibles, prior authorizations, quantity limits, step therapies, etc. We know this program is the best out there.
- “It is complicated,” says Jack Hoadley, a research professor at Georgetown University’s Health Policy Institute. “The differences among plans can be hard to sort out. For those who aren’t Web-savvy, it’s even harder.”The daunting plans, the confusing terms, and the time it takes to make sense of it all can make it seem like it’s not worth it. It is! Plans change every year, and it’s not worth waiting until next year to realize there may be a better plan.
- “I recommend that people have help for doing this,” says Lita Epstein, author of “The Complete Idiot’s Guide to Social Security and Medicare.” “You can go into the drugstores… but obviously they’re going to gear you toward the plans they use.”One of our biggest strengths is that we are not beholden to any companies. We offer all plans to give our clients the greatest amount of choice. We are 100% objective; it truly doesn’t matter to us which plan you choose. We just want to help you find the right one.
Here’s a sample of how clients can save when comparing plans using the Medicare Plan Finder (click to enlarge).
The Annual Enrollment Period is from October 15 – December 7. Contact us today to make sure we have you on our call list to schedule an appointment.
Tom Says:
“This has always been the way to go, and now people are recognizing that. Even if you love your current plan, it will never hurt to see what else is out there.”
To read the article, How to Pick the Right Medicare Part D Plan for You, click here.
Hospice patients in selected facilities will be able to use both palliative care and medical treatments, rather than choosing one or the other, as they currently must.
Beginning in 2016, the program will be conducted over five years in 40 states, including Virginia. Medicare and the federal government hope to find a better way to provide care to those in hospice facilities, and to see if beneficiaries take advantage of having access to both options: hospice care and hospital care.
Currently, many people deny hospice treatment in favor of medical care that treats their illnesses and symptoms.
Hospice care is valued for it’s multifaceted approach to treating the physical, emotional and spiritual needs of the patient and their family. A hospice team typically includes doctors and nurses, grief counselors, social workers and other aides and volunteers that include not only the patient, but the patient’s family, in the process.
The test program relates to a previous announcement by Medicare that they will reimburse doctors for end-of-life care, sometimes referred to as “death panels.” For more information, see our past newsletter on the subject, or visit our Email Archive.
What does Medicare hope to get out of the experiment?
Medicare wants to see if implementing this policy would increase their own costs. Since many beneficiaries already opt for medical care over hospice treatments, and the cost of hospice care is far less than medical care, some speculate that Medicare’s costs won’t go up. If more patients choose hospice care over medical care, then Medicare’s costs could decrease significantly.
Who will the patients be?
Hospice generally serves patients in the last six months of their lives. In addition to those patients, this new program will be open to Medicare beneficiaries with advanced-stage cancer, chronic obstructive pulmonary disease, congestive heart failure or AIDS.
Instead of having to choose between medical treatment and hospice care, Medicare patients in the selected facilities will have access to both. It is a voluntary program.
What else will Medicare be looking at in the study?
In addition to paying attention to their costs with the new policy, Medicare will be evaluating if more patients are using hospice, the quality of care, and the satisfaction of patients and families.
What happens when the program ends after 5 years?
If if the program succeeds in providing patients with more flexibility and lowering Medicare’s costs, Medicaid will likely adopt a similar policy.There are three Virginia hospice facilities included in the program, each with multiple locations.
- Capital Caring, with locations in Aldie, Alexandria, Arlington, Falls Church, Fredericksburg, and the counties of Loudoun/Western Fairfax, and Prince William/Fauquier.
- Mountain Valley Hospice and Palliative Care, which has branches in Hillsville and Stuart.
- Carilion Clinic Hospice, located in Roanoke, Franklin and New River Valley.
The full list of hospices can be found here.
Tom Says:
“I want to hear from you. What do you want to see in our newsletter? Are you interested in any Medicare or senior-related topics you want us to cover? Or, if you like our current newsletters, I want to know that too. Let us know by responding to this email, or emailing me at [email protected].
If the federal government doesn’t prevent it, the rate increase will take effect in 2016. Find out if you will be affected.
Three groups will likely see higher premiums:
- Those new to Medicare in 2016
- Those whose Part B is not paid through Social Security
- Those with single incomes over $85,000 (or joint incomes over $170,000)
Why might premiums increase?
Medicare’s guidelines require that the prices of Part B premiums cover 25% of Part B expenses. The majority of Medicare beneficiaries pay their Part B premiums through Social Security. There’s a rule that prevents Medicare beneficiaries who pay the lowest amount for Part B from being charged more unless their Social Security is given a Cost of Living Adjustment. This year, a Cost of Living Adjustment is not expected due to low levels of inflation. 70% of Medicare beneficiaries fall into this category, and their premiums can’t be increased. The remaining 30% face a price hike to reach the necessary quota.
What are the chances that the increases won’t occur?
No one can say for sure, but the U.S. Department of Health and Human Services can intervene until this October, when the rates will be finalized. The HHS Secretary has expressed that she would like to prevent an increase of this scope, and could lower the rates if there is enough money in Medicare’s program funds.
Seniors new to Medicare with incomes…
Less than $85,000 ($170,000 if joint)
Could see premiums rise from…
$104.90 to $159.30
Seniors already in Medicare with incomes from…
$85,000 – $107,000 ($170,000 – $214,000 if joint)
$107,000 – $160,000 ($214,000 – $320,000 if joint)
$160,000 – $214,000 ($320,000 – $428,000 if joint)
$214,000 and up ($428,000 and up,
if joint)
Could see premiums rise from…
$146.90 to $233.00
$209.80 to $318.60
$272.20 to $414.20
$335.70 to $507.80
For more information on the potential premium increases, click here.
We’re right in the middle of the open enrollment period for Medicare, which runs until December 7th of this year. What does this mean for you? If you are unhappy with your current plan or would just like to reevaluate and get to know your options, now is your chance, and we would love to help you! Here at My Medicare Planner we take the confusion and difficulty out of Medicare at no cost to you, so call us today at 804-788-1965 to schedule an appointment.
“Specifically, if it decides that Congress exceeded its constitutional authority in enacting the part of the law that requires most Americans to either have health insurance starting in 2014 or pay a penalty, does that invalidate the rest of the law? And if not, how much, if any, of the rest of the law should it strike down?…”
read the full article at: http://www.npr.org/blogs/health/2012/03/27/149497762/court-looks-at-whether-mandate-can-separate-from-rest-of-health-law