Archive for the ‘Medicare’ Category

PostHeaderIcon Medicare Supplement – Medigap – policies

Most Medicare enrollees know that Medicare has parts, A, B,C, and D.

It is necessary to detail Medicare part A and B benefits and cost shares to understand Medigap Policies.

Medicare part A is a hospitalization benefit. It covers medical, mental health,  and skilled nursing facility.   For hospital admissions and mental health inpatient admissions portion of the bill is left for the beneficiaries to pay. That is called a deductible.  In 2013 the Medicare part A hospitalization deductible is $1,184. It covers the first 1-60 days. The 60 days counter runs even if the patient is discharged and readmitted within this 60 day window. From days 61-90 the patient enters a per day coinsurance liability period, which will cost them $296 per day. From days 91-150 days, called a “lifetime reserve days” carries a $592 per day coinsurance.

The complication comes in how Medicare provides these benefit periods.  Once discharged from a hospital the counter starts and ends at 60 days. Once a person is “facility free” (not hospitalized) for 60 days the Medicare benefit periods starts from day 1 again.  This is good in a sense that benefits are available again, but bad because they are liable for the deductible yet again.

Skilled Nursing Facility services are covered only if it followed by a minimum of 3 days hospitalization and the patient is in need of rehabilitation.  There is no liability for the first 20 days. From day 21-100 there is a $148 per day coinsurance. Medicare does not cover Skilled Nursing Facility services behind 100 days.

Lifetime reserve days don’t start over; once they are used they are gone. Medicare does not pay medical hospitalizations behind the continuous 150 days. In addition there is a lifetime limit of 190 days for mental health hospitalizations.

Medicare part B covers doctors, laboratory, outpatient hospital, medical equipment, infusions, diagnostic services, etc.  Basically part B is coverage for anything that is not hospitalization. There is an annual deductible and a cost share of 20% in most cases. In 2013 the annual deductible is $147.  Medicare pays most other services at 80% of a locally approved Medicare rates.

Medicare supplemental polies are purchased by beneficiaries to cover the above mentioned additional cost.  These plans are formulated and approved by the Federal government. Policies lettered from A to N. There are slight differences in actual plan offerings from state to state. However, the actual benefit package remains the same. Plan A offers basic benefits, plan B to D gives slightly more with each progression of the letter. The full Plan F offers the most benefit, including part B excess charges.  Plan G covers most, with the exception of part B deductible.  Plan K to N are the mixed plans with partial benefits and higher cost shares.  Plan N offers a unique mix of regular and copayment based benefits.

Prices for these plans are based on the state and often county where the beneficiary lives.  Cost is between under $100 to about $400. Again, it is based on geographic location, plan coverage, and insurance company.

PostHeaderIcon Enrolling on Medicare – Initial Enrollment

Turning 65 years old and enrolling in Medicare seem to be a pleasant change. Getting rid of the expensive health insurance is a welcome transformation, until one is faced with all the choices they have to make.

Medicare has parts which are A, B, C, and D.

Part A covers hospitalization, qualified nursing home rehabilitations, and mental health hospitalizations. Part B covers outpatient hospital services,  doctor visits, diagnostic services, such as blood tests, x-ray, MRIs, CT Scans, injectable drugs, durable medical equipment, etc. Part D is a drug plan for pharmacy based prescriptions. Medicare part C is an exchange of all of the above to convert Medicare into a “private insurance”.

Medicare does not pay for medical care in full; therefore there is a need for a supplemental plan. So, to further confuse matters those supplemental plans comes lettered as well. Presently those letters run from A to N. Some counties are skipping some letters in between.

Moreover, through the Medicare program there are about 40 prescription plans available in each state. Prices, coverage, administrative rules, deductibles, co-pays, and cost shares vary between these plans. Medicare made every effort to streamline and explain all these details, but unfortunately there are so many rules and details, that most people get lost in the information overload.

We are at MedBillsAssist explain all parts of Medicare and help you chose the best possible solution for your specific needs.

PostHeaderIcon Donald Berwick – Medicare Chief Resigned

Due to political pressure Donald Berwick resigned from his post as a Center for Medicare and Medicaid (CMS) administrator.

Dr. Berwick was appointed by president Obama in 2010 during a congressional recess, effectively forcing his position to be reconfirmed by congress this year. Prior to this pending confirmation 42 Republican senators signed a letter pledging to block his confirmation, effectively ending any chance of him serving beyond 2011.

What is so wrong with Dr. Berwick? What did he do to make many republicans angry?

He praised the UK National Health Services when he was visiting the UK. He also made some comments that can be interpreted as rationing. Honestly I don’t know too much about the UK National Health Services. All I know that everyone gets basic medical care free of charge, and they have problems with waiting for advanced imaging and surgeries. I would say the first part is admirable, the second part no so much.

I am still puzzled the anger of congress regarding rationing. If you think about it healthcare rationing is a way of life in the US. We just call it Utilization Management in the case of insurance, Local Policy Determination in the case of Medicare. When we are considering Medicaid we simply have no doctors whom are willing to treat patients for the assigned cost. Our last group is the uninsureds, whom can’t afford insurance, therefore can’t afford healthcare. Presently in the US we are rationing by ability to pay.

I am a believer that Dr. Berwick would have made a difference in our health care system if congress gave him a chance to continiue on the path he already started.

Dr. Berwick came to CMS following enactment of the controversial Patient Protection and Affordable Care Act (PPACA). In his 18-month tenure, Dr. Berwick supervised the rollout of essential health reform regulations that promised to reshape both the private insurance market and the Medicare program. CMS drafted rules for the new health insurance marketplaces, called exchanges, where Americans will be able to compare and buy health insurance plans in 2014. He is responsible for putting in place a pilot program to move Medicare away from paying doctors based on volume of services to quality of care.

Dr Berwick advocates patient centered care; hospital care that works with the needs of the patient; not the medical staff. He doesn’t want a patient or himself “to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep.”

I am personally sad to see him go. His medical values and believes would significantly improved our overall health care.

PostHeaderIcon Medicare open enrollment is here and will close in 3 weeks

The time frame to change current Medicare plans has been moved up. This year, open enrollment started on October 15 and ends on December 7.
Actual changes will take effect, as usual, on January 1.
This is the time to review cost, coverage and convenience. It is time to consider a return to traditional Medicare or to check out if there is a Medicare Advantage plan that may offer better benefit options.
It is also time to change prescription plans. It is the perfect time to review all letters arriving from the present drug plan. There may be changes in the formulary for next year, which can adversely effect your bottom line. As always information is available at
Of course people that are satisfied with their current choices don’t have to make any changes.

PostHeaderIcon The High Cost of Poor Care

Nearly 388,000 nursing home residents’ deaths each year are attributed to infections. Approximately 25% of all hospitalizations of nursing home residents are caused by infections; the costs range from $673 million to $2 billion.

The FDA issued “black box” warnings against prescribing atypical antipsychotic drugs for patients with dementia, cautioning that the drugs increased dementia patients’ mortality. At the same time CMS reports that, nationwide, 39.4% of nursing home residents who had cognitive impairments and behavior problems but no diagnosis of psychosis or related conditions received antipsychotic drugs.

Use of chemical restraints is a major cause of nursing home falls, including hip fractures, which are estimated to cost $746.5 million.

Lack of toileting leads to urinary incontinence, in turn it leads to skin irritation, decubitus ulcers, urinary tract infections, and additional nursing home admission and hospitalization. Estimated cost $3.26 billion annually.

Poor hydration, along with poor nutrition, decreased mobility and cleanliness leads to pressure ulcers. Treatment costs are estimated to range between $1.2 and $12 billion.

Hospitalization of a dehydrated nursing home resident costs, on average, more than $18,000. Dehydration is often avoidable if residents are given more fluids. Insufficient staffing leads to less fluid intake by residents.

Three-quarters of all nursing home residents have at least one fall each year, and a quarter of the falls require medical attention. Twenty to thirty percent of the falls are preventable. Falls cost, on average, $19,440 and hip fractures, more than $35,000.

Poor care leads to excess hospitalizations, costing nearly $1 million.

Present plans by our government to fix nursing home expenses for Medicare and Medicaid patients:

Medicare-Medicaid Coordinating Office (MMCO) was established under the authority of the PPACA to address cost of care and improve access.

There are three initiatives in the works.

1. Capitated model – basically contracting with insurance companies to create a blended Medicare-Medicaid rate

2. Fee-for-service model- this model supposed to share savings from Medicare hospitalization reduction due to better quality care in dual eligible nursing home residents within each state.

3. Improved Care Quality for Nursing Facility Residents – this project plans to contract with independent entities to implement better practices to prevent conditions that leads to hospitalizations. The project aims to target 150 Skilled Nursing Facilities with high rate of hospitalizations. (Will observation be counted into these admissions?)

The real fix is simply having more nurses and nurse aides to provide better care.

PostHeaderIcon Health Reform – Implementation 2011

Below are some highlights in phase two of the Health Care Reform Bill.

This is the year when our tax codes are going through significant changes driven by the health care law.  Overall, health care is getting more regulated, therefore it is forcing businesses, health care providers and insurance companies to spend more money on administration.  There are a lot of plans that are studying and “advising” on how to make health care better.  Sadly, those groups and advisory bodies should have been created prior to the enactment of this law.

  • Minimum Medical Loss Ratio

Health plans, including grandfathered plans, must report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

  • Consumer Protection

Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage as well as rescinding coverage except in cases of fraud.  Annual limits are still in effect until 2014.  The provision also prohibits plans from denying children coverage based on pre-existing medical conditions.

  • Standardizing the Definition of Qualified Medical Expense

Match the definition of qualified medical expenses for HSAs, FSAs and HRAs to the definition used by the IRS itemized deduction.  Over-the-counter medicine will now only be considered as medical expense of accompanied by a doctor’s prescription.

  • Reporting Health Coverage Costs on Form W-2

Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2.

  • Creating Simple Cafeteria Plans

Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax‐free benefits to their employees.

  • Appealing Health Plan Decisions

Appoints the right to appeal medical claim and/or policy decisions made by any health plan and the right to appeal decisions made by the health plan to an outside, independent decision-maker, no matter what state a person lives in or what type of health coverage a person may have. This includes, for the first time, new self-funded plans.

Read the rest of this entry »

PostHeaderIcon Healthcare Reform Update

Many health care reform provisions went into effect on September 23, but as with any new law some will start right away, and others will slowly be implemented over time.

Small business tax credits for companies with fewer than 25 employees are now in effect. Provisions to rescind policies are banned. People now are afforded federally protected appeals rights.
Some provisions are not welcome by the insurance industry and are being challenged in their own way. For example, insurers are now prohibited from denying coverage for children with pre-existing medical conditions. Insurance companies have responded by eliminating children’s policies in several states.
The ugly duckling, known as the medical loss ratio, is being legislated at 80% for small groups and 85% for large groups with a mandated rebate if the insurer fails to meet these ratios. Insurance companies have responded by reclassifying certain expenses as medical services.
Although other provisions are already in effect, such as dependent coverage for adult children up to age 26 for all policies, and requiring qualified health plans to provide minimum coverage for certain preventive services without cost sharing, these will only start when policies are renewed. In many instances, this will be in January 2011.
Interstate insurance exchange programs should already be in place, but they are running far behind schedule. The federal government does not know how to run them and state programs are so different from each other that most states have decided not to run their own.

Most states estimate serious financial shortfalls in this program; therefore they are hesitant to get it started.

Medicare changes are taking effect as well, such as cuts in all hospital payment rates, payment reduction to Medicare Advantage plans and a significant start in eliminating the prescription coverage gap.

PostHeaderIcon Medicare Prescription Benefits in 2010

Read the rest of this entry »

PostHeaderIcon Health Care Reform

The Patient Protection and Affordable Care Act was signed into law last week by the President. According to estimates it will afford coverage for an additional 31 million legal US residents; an estimated 24 million remains uninsured.

The most significant changes to the current health care system are:

  1. Elimination of pre-existing conditions limitations.
  2. Elimination of calendar-year and lifetime maximums.
  3. Establishment of community rating with variation for age and geography.
  4. Permitting young adults to remain on their parent insurance plan until age 26

The Congressional Budget Office (COB) estimates that the coverage provisions in the bill will cost 848 billion over ten years. Most of the major provisions will not take effect until January 1, 2014. Therefore, the current COB estimate uses 10 years of revenue to cover 6 years of coverage. In contrast, Republican staff on the Senate Budget Committee estimates that the total spending in the bill for 10 years will exceed 2.5 trillion.

The bill creates an estimated 150 new government entities to the teeming bureaucracy and countless new additions to the already overly complex tax codes.

More regulations will force everyone involved to spend more money on administration, driving the ultimate cost of health care even higher.

Large business entities and insurance companies will pay higher taxes, and those not providing insurance will be penalized. Small businesses, with less than 25 employees, will receive subsidies.

Extended coverage will be achieved by extending Medicaid for lower income individuals and families, providing tax credits for people above the Medicaid income threshold and by interstate insurance exchanges for the presently uninsured.

The law is promising protection from exorbitant out of pocket costs in the form of yearly caps on co-payments and co-insurance charges. However, it does not address the small print, such as usual and customary rates and non-covered (medically needed, but excluded from policy coverage) charges. It appear that the burden is entirely left on the insurance companies, but in reality the public will remain unprotected from overcharges and non-covered expenses. We are still at the mercy of deals made by insurance companies and large hospitals.

Physicians, the backbone of health care, are still affected in several ways. They are still forced to take contract of adhesions, limiting their ability to negotiate fees with insurance companies. They are still waiting for the permanent fix to the faulty Medicare formula, that was removed from the bill and replaced with a temporary fix. Tort reform, a major player in health care cost, hasn’t been addressed.

This legislation missed the mark of real reform. It only added several layers to an already fragmented system. It missed the opportunity to address real cost control, both by insurers and medical providers.

Regulatory authority between the federal and state governments is still divided and will be clarified via regulations in the coming years.

Regardless of what we think about this bill, it has been passed. Now it is time to move forward and make it work, hopefully, for all Americans.

PostHeaderIcon Temporary fix to what seem like permanent problem


President Obama signed H.R.4691 – Temporary Extension Act of 2010 into law on 3/2/10

Time and money spent on administering health care is a necessary cost, but when this goes to the extreme, one must take note and wonder. Medicare, our largest “insurance” in the nation is closely controlled by government rules and regulations. One would say that the government, that wants to lower health care cost, would not create additional burden for providers and insurance companies in the form of, well, additional administrative cost.

The freshly signed H.R. 4691 is a prime example of administrative government squander. This bill allows two Medicare fixes on the temporary basis; patches a 21.5% physicians pay cut, and extends the physical therapy exception process.

Pay rates for doctor services are calculated by a formula based on the GDP, the number of beneficiaries, and other variables. It has been in place for 13 years.  Due to drop in the GDP and increase in the number of beneficiaries, the doctors were to receive a 21.5% pay cut on January 1st. This law allows a temporary override, leaving doctors pay at present level until March 31, 2010.  

Physical therapy enables patients to regain their mobility after surgery, injury, illness, etc. Caps on therapy services were put in place to control Medicare expenses. The cap exception process allows some individuals to continue therapy, above the annual limit, when suffering from additional complex medical conditions.  For example, Parkinson’s disease qualifies a Medicare beneficiary to receive more physical therapy services under the exception rule.

A physical therapy service exception has expired on December 31, 2009. Once a beneficiary reaches their limit, they are notified and must pay out of pocket for additional services.  The new extension allows payment and now, claims need to be resubmitted, or reprocessed.

Starting on April first the same, insane, process will begin.  Medicare intermediaries will hold claims and wait for the government to fix payment rates.

The administrative nightmare is going on behind the scenes.  The Medicare contractors (actual insurance companies) are holding claims for two weeks, and then release them, applying rates that is in effect at that time. Most certainly these insurance companies had and will have administrative cost increase related to the frequently changing regulations that need to be added to their systems. Would someone remind the government that they suppose to lower the administrative cost instead of increasing it?