CHA Blog

• 07May

  New Agreement Between AMR & Advocates Gives Beneficiaries More Time to Resolve Ambulance Appeals

  Medicare appeals, Medicare basics No Comments

  With ambulance rides being one of the most expensive modes of transport, Medicare has strict medical necessity guidelines to prevent overuse of this benefit. If Medicare has reason to doubt medical necessity in a beneficiary’s ambulance transport, Medicare will often deny payment of the claim. While these strict guidelines are understandable, advocates across the state have seen a rise in denied payment of beneficiaries’ ambulance services, even when medical necessity is seemingly a given.

  One problem we’ve seen is that often the billing codes submitted by the ambulance transport company determines whether a beneficiary’s transport meets the medical necessity requirements. If the ambulance company doesn’t submit the proper codes that denote medical necessity, Medicare will often automatically deny a claim and then it is up to the beneficiary to file an appeal. Also, American Medical Response (AMR), one of the primary ambulance transport service providers in California, has had a policy that if Medicare denies an ambulance service, the beneficiary must pay the bill, or set up a payment plan within 30 days; otherwise, their bill goes to a collection agency. This 30-day policy is hardly enough time, especially if a beneficiary has been in the hospital and/or rehab, for s/he to find out about Medicare’s denied payment and file an appeal.

  To remedy this situation, two Medicare advocates in Santa Cruz County, Health Insurance Counseling and Advocacy Program (HICAP) Program Manager, Debbie Reed, and Senior Medicare Patrol (SMP) Liaison, Evelyn Taylor set up a meeting with AMR and also arranged for them to speak at our recent biannual Medicare training conference in Pasadena, California. The meetings were a success and as a result, HICAP Program Managers and their volunteer counselors have a specific contact at AMR to call regarding ambulance billing questions. Also, if a HICAP/SMP advocate calls and states they are working with a beneficiary to appeal/resolve their ambulance trip directly with Medicare, AMR’s billing service, Patient Business Services (PBS) will automatically put the beneficiary’s account on hold for 90 days; this is two times as long as the previously noted 30-day policy. This will prevent the beneficiary’s claim from going to a collection agency while an appeal is filed and awaiting Medicare’s redetermination on the claim.

  This is a great step forward in advocate and provider collaboration and a great win for beneficiaries. An article on a beneficiary whose successful ambulance appeal relates directly to this new agreement will be posted soon.

  See Medicare’s Coverage of Ambulance Services (PDF), for more information on Medicare’s coverage of ambulance services.

   

  Tags: ambulance services, Medicare

• 16Mar

  The Cost and Causes of Heart Disease: Can We Reverse the Epidemic?

  Medicare basics No Comments

  Heart disease is the number one cause of death here in the U.S., with 1 in 3 Americans developing the disease in their lifetime and over 2 million Americans suffering from a heart attack or stroke each year. While some people’s first “wake-up call” on their heart health ranges from a mild or fatal heart attack, most people’s heart health begins deteriorating years before such an event. The most common attributing factors to heart disease are a diet high in fat and sugar and low in nutrients, smoking, lack of exercise, obesity and stress. Some or all of these factors overtime clog and harden people’s arteries, increase people’s cholesterol, cause weight gain and generally wear people’s health – their bodies, minds and spirits – down.

  Heart disease costs our country over $444 billion per year in health care costs and loss of economic productivity. It also amounts to 2,200 deaths per day, or 815,000 American lives each year. In addition to the fatalities, heart disease can also result in serious illness, disability, and decreased quality of life. Suffering a stroke may lead to significant disability, such as paralysis, speech difficulties, and emotional problems. Following a heart attack, many people experience fatigue and depression, and find it more difficult to engage in physical activities. Heart disease and stroke are among the leading causes of disability in the United States, with more than 3 million people reporting disability from these causes.

  For all the deaths, disability, decreased quality of life and high costs attributed to heart disease, last fall the federal government formed a collaborative partnership and launched a national initiative with communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country to fight heart disease and stroke. The initiative, called Million Hearts™ aims to prevent 1 million heart attacks and strokes over five years.

  The Centers for Medicare and Medicaid Services (CMS) plays a major role in promoting this campaign and also educates Medicare beneficiaries on some of Medicare’s new and existing preventive benefits that aim to reduce hearth disease. These include:

  • Cardiovascular disease behavioral therapy
  • Cardiovascular screenings
  • Medical nutrition therapy
  • Obesity screening and counseling
  • Smoking cessation

  See Medicare Preventive benefits for a full list of all covered preventive services.

  Prevention is one of the best medicines for individual, community and national health. While following the ABCS (appropriate aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) promoted in the Million Hearts™ initiative are helpful guidelines for heart disease prevention, some medical professionals offer more radical, yet natural approaches to reverse heart disease without drugs. Dr. Joel Fuhrman, author of Eat to Live,  discusses the science, safety and effectiveness of eating a radically nutrient dense diet for reversing heart disease, diabetes and obesity. It’s a simple, natural, drug-free and low-cost approach to reversing disease and enjoying life-long health and vitality. Read the article, Heart Disease: reversing heart disease without surgery and more effectively than with drugs, for more information.

   

  Tags: heart disease, Medicare, nutrition, obesity, prevention, preventive services, smoking cessation

• 13Feb

  President’s Budget Proposal Holds Several Medicare Cost Changes for New Beneficiaries

  Health Care Reform, Medicare basics No Comments

  We recently got word on the President’s budget proposal which contains some significant Medicare changes. Below are some excerpts regarding these changes, including: higher income-related premiums under Medicare Parts B and D, a new Part B premium surcharge for new beneficiaries who purchase first dollar coverage with a Medigap plan, a modified Part B deductible for new beneficiaries, and a home health care copayment for new beneficiaries.

  • Increase Income-Related Premiums Under Medicare Parts B and D (from from the budget for fiscal year 2013,  pages 34-35). Under Medicare Parts B and D, certain beneficiaries pay higher premiums as a result of their higher levels of income. Beginning in 2017, the Administration proposes to increase income-related premiums under Medicare Parts B and D by 15% and maintain the income thresholds associated with income-related premiums until 25% of beneficiaries under Parts B and D are subject to these premiums. This will help improve the financial stability of the Medicare program by reducing the Federal subsidy of Medicare costs for those beneficiaries who can most afford them. This proposal will save approximately $28 billion over 10 years.

  • Introduce a Part B Premium Surcharge for New Beneficiaries That Purchase Near First-Dollar Medigap Coverage (from page 35). Medigap policies sold by private insurance companies provide beneficiaries additional support for covering healthcare costs by covering most or all of the cost sharing Medicare requires. This protection, however, gives individuals less incentive to consider the costs of health care services and thus raises Medicare costs and Part B premiums. Of particular concern are Medigap plans that cover substantially all Medicare copayments, including even the modest copayments for routine care that most beneficiaries can afford to pay out of pocket. To encourage more efficient health care choices, the Administration proposes a Part B premium surcharge equivalent to about 15% of the average Medigap premium (or about 30% of the Part B premium) for new beneficiaries that purchase Medigap policies with particularly low cost-sharing requirements, starting in 2017. Current beneficiaries and near-retirees would not be subject to the surcharge. Other Medigap plans would be exempt from this requirement while still providing beneficiaries options for protection against high out-of-pocket costs. This proposal will save approximately $2.5 billion over 10 years.

  • Modify Part B Deductible for New Beneficiaries. Beneficiaries who are enrolled in Medicare Part B are required to pay an annual deductible. This deductible helps to share responsibility for payment of Medicare services between Medicare and beneficiaries. To strengthen program financing and encourage beneficiaries to seek high-value health care services, the Administration proposes to apply a $25 increase in the Part B deductible in 2017, 2019, and 2021 for new beneficiaries. Current beneficiaries or near retirees would not be subject to the revised deductible. This proposal will save approximately $2 billion over 10 years.

  • Encourages Beneficiaries to Seek High- Value Services (from page 112). The Budget includes structural changes that will help encourage Medicare beneficiaries to seek high-value health care services. To help improve the financial stability of the Medicare program, the Budget reduces the Federal subsidy of Medicare costs for those beneficiaries who can most afford them, and also introduces a modified Part B deductible for new beneficiaries beginning in 2017. To encourage ap propriate use of home health services that are not preceded by inpatient care, new beneficiaries beginning in 2017 would be responsible for a modest copayment for home health services in certain cases. Research indicates that beneficiaries with Medigap plans that provide first dollar or near-first dollar coverage have less incentive to consider the costs of health care services, thus raising Medicare costs and Part B premiums for all beneficiaries. The Budget applies a premium surcharge for new beneficiaries beginning in 2017 if they choose such Medigap coverage. In addition, it strengthens the Independent Payment Advisory Board to reduce long-term drivers of Medicare cost growth.

  • Introduce Home Health Copayments for New Beneficiaries. Medicare beneficiaries currently do not make copayments for Medicare home health services. This proposal would create a home health copayment of $100 per home health episode, applicable for episodes with five or more visits not preceded by a hospital or other inpatient post-acute care stay. This would apply to new beneficiaries beginning in 2017. This proposal is consistent with a MedPAC recommendation to establish a per episode copayment. MedPAC noted that “beneficiaries without a prior hospitalization account for a rising share of episodes” and that “adding beneficiary cost sharing for home health care could be an additional mea­sure to encourage appropriate use of home health services.” This proposal will save approximately $350 million over 10 years.

• 19Jan

  January is National Glaucoma Awareness Month

  Medicare basics No Comments

  Medicare has designated January as National Glaucoma Awareness Month as a way to increase people’s awareness of glaucoma and Medicare’s covered glaucoma screening benefit. More than 2.2 million Americans age 40 and older have open angle glaucoma, the most common form of glaucoma, and at least half of them don’t even know they have it.  Through early detection and treatment, blindness can be prevented.

  As mentioned, Medicare provides coverage of an annual glaucoma screening for beneficiaries in at least one of the following high-risk groups:

  • Individuals with diabetes mellitus
  • Individuals with a family history of glaucoma
  • African-Americans age 50 and older
  • Hispanic-Americans age 65 and older.

  Medicare’s coverage of glaucoma screening includes a dilated eye examination with an intraocular pressure (IOP) measurement and a direct ophthalmoscopy examination or a slit-lamp biomicroscopic examination.

  What you can do to help spread the word to beneficiaries…

  If you are a Medicare advocate or healthcare professional who provides care to seniors and others with Medicare, you can help protect the vision of your high-risk patients by educating them about their risk factors and reminding them of the importance of getting an annual glaucoma screening exam covered by Medicare.

  For More Information:

  • The CMS Glaucoma Screening Brochure
  • The CMS Guide to Medicare Preventive Services (see Chapter 7)
  • The MLN Preventive Services Educational Products Webpage
  • The National Eye Institute

  Thank you for partnering with Medicare to promote increased awareness of glaucoma and Medicare’s covered glaucoma screening benefit.

• 20Dec

  Proposed Rise in Medicare Premiums for Upper-Income Beneficiaries Would Also Affect Middle Class

  Medicare basics No Comments

  Bonnie Burns, our Training and Policy Specialist, has made many statements over the last few years related to the “camel’s nose under the tent” with regard to the creation of increased Medicare premiums for people with high incomes. And, as she predicted, those thresholds for high income seniors are likely to be set lower, in addition to the freeze on cost of living adjustments. Below is link to a story related to Congressional attempts to raise premiums for higher income beneficiaries that will ultimately also affect middle income beneficiaries. In addition, our President’s own proposals include freezing the high income threshold until 25% of beneficiaries would be subject to higher Part B and D premiums, and also include a higher Part B deductible for that same group. It’s important to note that high income with regard to workers is much, much greater than high incomes for retirees, an interesting contrast.

  For example, when Obama talks about raising taxes on the rich, he means individuals making more than $200,000 a year and families above $250,000. But his health care law fixed the level for paying “high-income” Medicare premiums at the current $85,000 and above for an individual, $170,000 for families. And the new Republican plan would drop the thresholds to $80,000 for an individual and $160,000 for families.

  See the article, Plan to raise Medicare premiums for upper-income retirees would affect middle class as well.

  Tags: beneficiaries, Medicare, premiums, rising costs

• 06Dec

  Open Enrollment Ends on Dec 7 But Some Beneficiaries Have More Time

  Medicare basics No Comments

  Medicare’s Open Enrollment, also referred to as the Annual Election Period (AEP), ends in on Wednesday Dec 7. The AEP allows Medicare beneficiaries to join, switch or disenroll from a Medicare Advantage (MA) or Part D plan.  Some beneficiaries have more time to make choices.

  Beneficiaries who are in an MA or Part D plan that is not renewing next year have until Feb 29, 2012.  “Almost 151,000 beneficiaries in California are in Medicare Advantage plans that are not renewing for 2012,” observed Elaine Wong Eakin, Executive Director of California Health Advocates.  “In addition, there are beneficiaries in Part D plans that are not renewing.  All these beneficiaries get a Special Election Period (SEP) from Dec 8, 2011 to Feb 29, 2012 to join another plan.”

  If your MA or Part D plan is not renewing and you use your SEP to join another plan, your new plan will be effective the first day of the next month.  (See table below for effective date depending on when change is made.)

  	Dec 8, 2011                 Special Election Period         Feb 29, 2012
  Change made between	Dec 8 and 31	Jan 1 and 31	Feb 1 and Feb 29
  Effective date of change	Jan 1	Feb 1	Mar 1

   

  Even if you made a change during the AEP, you can make another change using your SEP.

  But, if you do not make any change before December 31, 2011, what happens Jan 1, 2012?

  • If you are in an MA plan with prescription drug coverage and it is not renewing, Original Medicare automatically becomes your medical coverage and you will have no drug coverage effective January 1, 2012 unless you qualify for Extra Help. (If you have Extra Help, Medicare will automatically enroll you into a Part D plan.)
  • If you are in a Part D plan that is not renewing, you will have no prescription drug effective January 1, 2012 unless you qualify for Extra Help. (If you have Extra Help, Medicare will automatically enroll you into a Part D plan.)
  • If you are in an MA plan that is not renewing and the MA plan has no prescription drug coverage, Original Medicare automatically becomes your medical coverage effective January 1, 2012.

  After December 31, 2011, beneficiaries who have not made use of their SEP can still enroll in a stand-alone Part D plan or MA plan. The SEP ends February 29, 2012 or when they make a change, whichever is earlier.

  Beneficiaries in non-renewing MA plans also have a guaranteed issue period to buy a Medigap.  The guaranteed issue period started when you first received the notice that your MA plan was not renewing, and ends 123 days after your Medicare Advantage plan ends (May 2, 2012).

  Resources:

  • See the list below for Part D plans in California that are not renewing for 2012.  The two MA plans available statewide that are not renewing are Freedom Blue Plan I and Freedom Blue Classic (both sponsored by Anthem Blue Cross.)  Other MA plans that are not renewing are county-specific.

  Plan name	Contract-Plan ID	Premium
  Sterling Rx	S4802-067	$51.10
  CIGNA Medicare Rx Plan Two	S5617-202	$71.40
  Advantage Star Plan by RxAmerica	S5644-084	$28.10
  Aetna Medicare Rx Costco Plus Plan	S5810-236	$60.80
  Envision Rx Plus Gold	S7694-066	$91.40

  • HICAP – Contact your local Health Insurance Counseling and Advocacy Program (HICAP) to review Medicare Advantage plans available in your county, compare Part D prescription drug plans, or learn about Medigap plans in your area. Individual appointments are available with volunteer counselors.
  • CHA fact sheets – For more info, please read: When Medicare Advantage Plans Terminate Coverage, Medigap Plans and Your Rights to Purchase a Medigap Policy (PDFs).
  • Part D Prescription Drug Comparison Charts – Review the Part D stand-alone plans (PDF) and benchmark plans (PDF) available in California in 2012.
  • Medicare Plan Finder – Visit the official Medicare website at Medicare.gov to compare Medicare Advantage and Part D drug plans, find out which plans cover the drugs you’re taking with Medicare’s Formulary Finder, and enroll in a health or drug plan.

   

• 01Dec

  Medicare’s Open Enrollment Ends Dec 7th

  Medicare basics 2 Comments

  Medicare’s Open Enrollment, also referred to as the Annual Election Period (AEP) ends in less than one week on Wednesday December 7. This year’s AEP started earlier and ends earlier than previous years, and is an important time for beneficiaries to closely evaluate their current health coverage, whether or not they’d like to switch health plans, return to Original Medicare or join a health plan if they are already in Original Medicare.

  Options abound and knowing one’s options and how to compare them are important for making a good choice. Here are some resources to make the most of the AEP’s  final week:

  • Read our page on the AEP. It gives the details on what you can do during the AEP, has links and resources for information on health care options and your rights, and lists frequently asked questions on the topic.
  • Contact your local Health Insurance Counseling and Advocacy Program (HICAP) to review your current plan and plans (Medicare Advantage plans, Part D prescription drug plans and Medigap plans) in your area.  Individual appointments are available with volunteer counselors. Educational presentations may also be available in your county.
  • Review our Part D plan comparison charts (PDFs): Part D stand-alone prescription drug plans and Part D benchmark plans (for people receiving the Extra Help, aka the low-income subsidy (LIS)).
  • Visit Medicare.gov to compare health and drug plans, compare Medigap policies, find out which plans cover the drugs you’re taking with Medicare’s Formulary Finder, and to enroll in a health or drug plan.

  Tags: annual election period, Medicare, Medicare Advantage, Medicare open enrollment, Part D, prescription drug plans

• 01Nov

  Medicare Costs for Part B Services Decrease for 2012

  Medicare basics No Comments

  Medicare costs for 2012 are out, and for the most part, Part B cost-sharing will be less than projected for all beneficiaries in 2012. The Part B deductible will decrease by $22 in 2012, from $162 per year in 2011 to $140 in 2012. In addition, the Part B monthly premium will only slightly increase for those beneficiaries who have not had an increase in the last 2 years. The 3.6% cost-of-living increase for Social Security recipients in 2012 will cause the Part B premium to increase by just $3.50 – from $96.40 in 2011 to $99.90 in 2012. Beneficiaries who were new to Medicare in 2011, however, have been paying $115.40 for their Part B premium. For them, the 2012 premium will actually decrease by $15.50.

  These Part B premium reductions directly relate to the slower growth in Part B expenses, due in part to health care reform. The Affordable Care Act’s lower payment rates, reduced payments to private Medicare plans, and increased efforts to fight fraud and abuse all contribute to this trend. Health care reform has also increased Medicare’s value by reducing beneficiary costs for prescription drugs, adding preventive care coverage, and eliminating cost-sharing for most preventive services.

  For detailed information on all 2012 Medicare Part A and B cost-sharing, see our fact sheets:

  • Original Medicare: An Overview
  • 2012 Premiums, Coinsurance & Deductibles (Original Fee-for-Service Medicare)

  You can also read the Center for Medicare and Medicaid Services (CMS) fact sheet, Medicare Premiums and Deductibles for 2012.

• 09Aug

  Clarifying “Free” Screening Colonoscopies for Medicare Patients

  Health Care Reform, Medicare basics No Comments

  I’m re-posting this article by Maria Selor. She’s the Supervising Attorney at the Elder Law Center in Wisconsin and wrote this article early this summer…

  On Jan. 1, 2011, the preventative services provision of the Affordable Care Act was extended, making all Medicare patients eligible for free, important preventive services – including colonoscopies. However, not all colonoscopies are created equal, and this could impact whether it is truly without cost to you. This article explains what you should be aware of when receiving this important and life-saving test.

  Screening Colonoscopy vs. Diagnostic Colonoscopy
  The free Medicare exam only covers screening colonoscopies – not diagnostic colonoscopies. A screening colonoscopy is a procedure performed on a patient of screening age in order to find colon polyps or cancer. A colonoscopy that is performed in order to explain symptoms (e.g. blood in stools, change in bowel movements, etc) is called a diagnostic colonoscopy, which is not covered under the Affordable Care Act. Patients are usually fully liable for at least 20% (and maybe more) of the cost related to a scheduled diagnostic colonoscopy.

  There are some cases where a scheduled screening colonoscopy can become a diagnostic colonoscopy, and in those cases a patient becomes responsible for any out-of-pocket costs related to their deductible, co- insurance or co-pays for standard costs like physician and facility fees. A screening colonoscopy becomes a diagnostic colonoscopy when a physician removes a polyp or takes a biopsy during the procedure. For Medicare patients, a family history of colon cancer or polyps will not automatically transform a screening colonoscopy into a diagnostic one. Some private insurers, however, will do this.

  Beware! Related Services Not Always Covered
  Medicare patients who are eligible to have a colonoscopy screening will pay no deductible, co-pay or co-insurance. However, please be forewarned – Patients may still be responsible for other services, such as anesthesia or medication, associated with the procedure. Some of those who have taken advantage of the “free services,” have been unpleasantly surprised to receive hefty bills. If you receive a bill after a “free” Medicare exam, contact the Elderly Benefit Specialist in your county immediately. He or she can help you determine if these charges are allowable.

  How often is it covered?
  Medicare rules dictate how often you can get a free screening colonoscopy. If you get the test sooner that the time periods listed below, you will likely be fully responsible for the cost.

  • Fecal Occult Blood Test: Once every 12 months.
  • Flexible Sigmoidoscopy: Generally, once every 48 months, or 120 months after a previous screening colonoscopy for people not at high risk.
  • Screening Colonoscopy: Generally once every 120 months (once every 24 months if you’re at high risk), or 48 months after a previous flexible sigmoidoscopy.
  • Barium Enema: Your doctor can decide to use this test instead of a flexible sigmoidoscopy or colonoscopy. This test is covered every 24 months if you are at high risk for colorectal cancer and every 48 months if you aren’t at high risk.

  How do I qualify?
  A Medicare patient can qualify for a screening colonoscopy if they:

  1. Are of the recommended screening age (for people of average risk = age 50 or over, though recent studies indicate that African-Americans may need to start screening at age 45.)
  2. Do NOT have any symptoms
  3. Do NOT have personal history of colon polyps or colon cancer

  A Medicare patient can still qualify for a screening colonoscopy despite having a family history of colon cancer or colon polyps.

  Costs: Screening Colonoscopy

  • Clarifying “Free” Screening Colonoscopies for Medicare Patients
    $0 annual deductible for procedure
  • $0 co-insurance for procedure

  Costs: Diagnostic Colonoscopy

  • $0 annual deductible for procedure
  • 20% co-insurance must be paid for procedure

  Why Should I Get a Screening Colonoscopy?
  Colorectal cancer is the third most commonly diagnosed cancer and the 3rd leading cause of cancer death in both men and women in the US. The great majority of these cancers and deaths could be prevented with early screening. This is because most colorectal cancers develop from
  adenomatous polyps. Polyps are noncancerous growths in the colon and rectum. Detecting polyps through screening and removing them can actually prevent cancer from occurring. Furthermore, being screened at the recommended frequency improves the chance that colorectal cancer will be detected at an earlier stage, when it is more likely to be cured by surgery alone, the surgical procedure is less extensive, and the recovery is much faster.

  (statistics excerpted from AMERICAN CANCER SOCIETY, Colorectal Cancer Facts & Figures 2008-2010.)

• 22Jun

  June Marks the 1st National Prevention and Wellness Month

  Health Care Reform, Medicare basics No Comments

  This June is the first-ever National Prevention and Wellness Month. That makes it a great time to review Medicare’s preventive health benefits, especially with their reduced costs due to health care reform’s Affordable Care Act (ACA).

  Medicare Covered Preventive Services Report
  The Centers for Medicare & Medicaid Services (CMS) recently released this report showing that over 5 million Americans with Original fee-for-service Medicare have taken advantage of one or more of the recommended preventive benefits that are available for free thanks to the ACA.

  Medicare also recently launched a nationwide public outreach campaign, including a letter to doctors and a new Public Service Announcement to raise awareness about preventive benefits now covered at no charge to patients, including the new Annual Wellness Visit benefit.

  A Review of Medicare’s Preventive Benefits
  See what Medicare covers when it comes to prevention and wellness as listed on Medicare.gov. Medicare also has a convenient checklist for beneficiaries to bring to their doctors to discuss which preventive services are best for them.

  For more information on covered preventive services and the cost changes due to health care reform, see our article, “Top 7 Medicare Changes in 2011.”

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