Medicare Advantage on the Rise

Medicare Advantage on the Rise

Continued growth, strong performance and new guidelines are good news for plans and their members

Already the choice of more than one-third of the 59 million people with Medicare, the Medicare Advantage (MA) program is growing and changing in ways that will help even more seniors maintain good health and independence as they age.

Strength in Numbers

The number of eligible seniors opting for MA plans over fee-for-service Medicare has grown year after year — and shows no signs of slowing down. Medicare managed care plans now provide coverage to more than 21 million people with another 2 million expected to join in 2019. If that happens, MA plan members will represent 39 percent of the total Medicare population.

Among the largest MA plans in California, SCAN has witnessed this trend first-hand, increasing market share and experiencing significant growth in Los Angeles, Orange and Sonoma counties during the 2018 annual enrollment period.

Bigger and Better, Too

MA plans improve the health of seniors in ways that other coverage options haven’t, and this is fueling increased enrollment. With a focus on preventive services, care coordination, access and continuous improvement, MA plans continue to outperform fee-for-service Medicare in key quality measures. A recent study by Avalere Health shows Medicare Advantage beneficiaries had 23 percent fewer inpatient room visits and better health outcomes overall than individuals enrolled in FFS Medicare at similar costs to regular Medicare. People with chronic conditions, such as diabetes, in particular benefit from the extra benefits and programs available through Medicare managed care, experiencing better health outcomes and fewer complications, including serious complications, from their conditions.

Findings like these are important for several reasons. For one, they confirm that what providers of MA plans like SCAN and others like us are doing is making a meaningful difference in the lives of members, particularly those who need help the most. They also underscore plan’s commitment to providing high quality benefits and services that meet members’ individual needs related to health and independence.

Knowing that MA plan members have better experiences can also be useful to our broker partners, because when you present an MA plan to your clients, you can be confident you are offering them coverage they can rely on for high-quality care, improved access and better health. When it comes to MA, quality begets even greater quality. Since Medicare pays a bonus to plans demonstrating the highest quality, well-performing plans can reinvest these bonuses, continuously improving benefits, access and quality of care for the member.

SCAN’s 4.5 star rating for 2018 from the Centers for Medicare & Medicaid Services is not only a reflection of our efforts to improve quality and services, but an investment that pays off in a meaningful way for us, our provider partners, and our members.

New Laws, New Opportunities

A’s success in providing high-quality, value-driven and cost-effective care has not been lost on lawmakers. At the federal level, MA plans have earned bipartisan support, with more than 360 members of Congress pledging to preserve the program. They showed their support in an even more tangible way earlier this year with legislation that will make it possible for plans to further improve services and health outcomes: Special Needs Plans, which until now were temporary demonstration projects, can now be offered by MA plans on a permanent basis. This change will allow more of the nation’s frailest seniors to benefit from programs that help them age successfully at home for as long as possible.

Health plans that already offer SNPs can begin to think in the long term, while other plans that were put off by the uncertainty of past SNP rules will likely begin exploring these options. The result: More seniors with chronic illnesses and other special needs will have access to programs and services
designed to support them.

The definition of “primarily health related” supplemental benefits has been expanded to allow MA plans to offer food, counseling and other nonmedical services as long as they can help prevent, cure or reduce illness or injury. TeleHealth made headlines when the Bipartisan Budget Act was signed into law in February. The legislation allows MA plans to include delivery of telehealth services in a plan’s basic benefits. This can enable a member to access mental health services from the privacy of their own home, or provide a convenient way to ensure post-hospitalization follow-up care is received.

While plans in the past have been required to offer the same benefits to all their enrollees, new regulations also allow MA plans to tailor benefits to groups within their membership with specific health conditions. For example, a plan could offer all members diagnosed with diabetes additional coverage for podiatry services, offering another way to better tailor plan coverage to member need. Many MA plans have likely incorporated the new benefit flexibility into 2019 plan bids for approval by Medicare.

While 2019 benefits have not been released as of press time, I’m confident that many in our industry are thinking of new and creative ways to provide the most value for members under the new guidelines.

A Strong Choice for Seniors

These “new developments” align with SCAN’s history as a social HMO and our decades of experience caring for the frailest seniors. As a long-time advocate for changes that would allow greater flexibility in meeting seniors’ individual needs, we are excited to be looking at ways to once again provide benefits that can more directly help each member age safely in the setting of their choice.

When evaluating which MA plan is right for each client, think about both the nature of the benefits and the stability of the plan. While it’s exciting to offer “more” and “different” benefits, it’s also imperative that the plan will be there for the long-term. Make sure the plan under consideration is adding benefits and services at prices that are sustainable year over year. While more customized coverage options will only add to MA’s appeal, plan members— your clients—depend on stability of cost and coverage.

The plan should work as hard to retain existing clients as it does to gain new ones. The bottom line is this: 2018 has been a good year for seniors! The many benefits that already come with membership in a Medicare Advantage plan will inevitably get even better.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

 

The New Medicare and You

The New Medicare and You

WHY MEDICARE’S FOCUS IS CHANGING TO CHRONIC CONDITIONS

By RON STOCK

“It ain’t your father’s or grandfather’s Medicare.” After 48 years Medicare is changing its health care focus from treatment of acute diseases to caring for Medicare beneficiaries with chronic diseases. Why?Simple! Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions. About 65 percent of Medicare beneficiaries have two or more chronic diseases, and 43 percent have three or more. Reducing chronic expenses is the fastest way to bring the exploding Medicare costs under control.

CHRONIC DISEASES

Chronic diseases are often caused by unhealthy behaviors that increase the risk of disease—poor nutrition, inadequate physical activity, overuse of alcohol or smoking. Social, emotional, environmental and genetic factors also play a role. As people age, they are more likely to develop one or more chronic disease.

How ill is America’s health? The picture isn’t pretty:
• During 2011–2014, more than one-third of adults (36 percent), were obese.
• 36.5 million adults in the United States (15.1 percent) said they currently smoked cigarettes in 2015.
Cigarette smoking accounts for more than 480,000 deaths each year.
• 90 percent of Americans aged two years or older consume too much sodium, which can increase their risk of high blood pressure. Of course, obesity, smoking-related disease and high blood pressure are key chronic diseases. Chronic diseases are painful diseases; example quotes of chronic patients taken from an online site:
• “Sitting down in the shower to shave because it’s easier on my joints. I sometimes forget that many
people stand to shave.”
• “I have a habit of collecting my hospital bracelets after I get out of the hospital as it reminds me that I won yet another battle. It seems odd, but for some reason, I hold onto the bracelet feeling empowered that I walked away from what tried to defeat me again.”

SELLING C-SNP MEDICARE ADVANTAGE PLANS

You better get to know how to present C-SNP plans as ‘chronic’ is the new buzzword with Medicare. The Center for Medicare and Medicaid Services (CMS) has opened the door for health plans to add Value-Based Insurance Design (VBID) benefits such as air conditioners for asthma patients, home health benefits, healthy groceries, home-delivered meals and installing safety items like grab bars.

As an example of a health plan’s preparation for the expansion of VBID, Humana recently purchased Kindred Healthcare. Kindred Healthcare owns an array of businesses including home health, hospice, long term care hospitals and inpatient rehabilitation facilities. Humana has a significant business administering Medicare health benefits for the elderly, and the Kindred deal helps Humana form closer ties with a provider of home care and related services predominantly used by the elderly.

Starting in 2019, health plans in California and other targeted states can expand their benefits to include more Medicare beneficiaries with chronic conditions than previously identified by CMS, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories. The new chronic list will include beneficiaries with lower back pain, chronic kidney disease, obesity/pre-diabetes, asthma, and tobacco use. Beginning in 2018, CMS also allowed benefits for enrollees with dementia and rheumatoid arthritis. Medicare Advantage plans can cover adult day care services, and in-home help with activities such as dressing, bathing and managing medications. Seema Verma, the administrator CMS, told insurance company executives at a recent conference that “CMS hopes its new ‘reinterpretation’ of the Medicare Advantage program benefits rules will help unleash private-sector innovation and creativity.”

CMS further states, “Plans adding benefits based on the supplemental benefits interpretation must make sure the benefits are ‘primarily health related,’ and not primarily for a patient’s comfort. The services covered must be recommended by a physician or other licensed medical professional as part of a care plan.

The new benefits must not include items or services used to induce enrollment. “The primary contributor to the shift in focus to chronic diseases is Congress passing “The Chronic Care Act of 2018,” February 9, 2018, which opened the doors to the inevitable expansion of C-SNP or “Look-Alike” C-SNP Medicare Advantage Plans that provide VBID benefits. Two of the main sections of the bill that impacts health plans and the brokers that sell them are:

1. Allows MA plans to offer an expanded set of supplemental benefits to the chronically ill enrollee. Enables MA plans to experiment with different types of benefit packages to meet the needs of chronically
ill beneficiaries.
2. Permanently authorizes three types of SNPs: D-SNP (dual eligibles), C-SNP (those with severe disabling chronic conditions), and I-SNP (those in institutions). C-SNPs must meet additional care management requirements starting in 2020. By 2022, and every five years after that, the Health and Human Services (HHS) Secretary must update the list of chronic conditions eligible for participation. The list must include HIV/AIDS, end-stage renal disease and chronic/disabling mental illness.

CDC AND THE STATE OF CALIFORNIA

The Centers for Disease Control and Prevention (CDC) established a comprehensive chronic disease program.The four major components are:

1. Implemented systems that track chronic diseases and their risk factors.
2. Promotes health and support healthy behaviors across the nation, in states and communities, and in settings such as schools, child care programs, work sites and businesses.
3. Developed programs and policies that allow doctors to diagnose chronic diseases earlier and manage them better.
4. Established community programs linked to clinical services to help patients prevent and manage their chronic diseases, with guidance from their doctor. The State of California Chronic Programs, http://www.cahealthierliving.org/programs/, includes services for health self-management, fall prevention and physical activity, and caregiver and memory programs. The VBID benefits cannot cure chronic diseases but can aid in reducing the hospitalizations due to chronic illnesses. CDC recommends six healthy aging suggestions (as seen by the graph on this page).

VBID BENEFITS

The New Medicare and You has a chronic condition focus. You can count on the majority of your Medicare
clients having one or more chronic diseases and they would probably like to to hear about the VBID benefits
of a C-SNP or an MA plan with VBID benefits. Already, there are MA and C-SNP health plans with added benefits, such as:

• Health Coach
• Care Management
• Acupuncture
• Telehealth
• Chiropractic
• OTC Supplies
• International
• Lower Cost Travel Tiered Copays
• Gym Membership
• Transportation
• Quit Smoking Programs
• Nutritional Programs

The emphasis on chronic and CSNP plans also creates a yearlong enrollment opportunity for brokers. Eligible Medicare beneficiaries can enroll anytime during the year into a C-SNP plan with their PCP’s confirmation of their chronic illness. ‘Lockin’–where you can only enroll new to Medicare beneficiaries – is becoming antiquated given C-SNPs. With the new OEP now January 1 to March 31 and AEP October 15 to December 7 and C-SNP’s and New-to-Medicare, enrollments are now a full-time enrollment opportunity. Oh, not forgetting D-SNPs for Dual Eligibles and I-SNPs for Institutional members, brokers have unlimited enrollment opportunities.

THE ‘NEW MEDICARE AND YOU’

The ‘New Medicare and You’ is BetaBenefits’ title for our Medicare educational classes in which we discuss Medicare’s milestones (see chart) and the benefits each milestone provides Medicare beneficiaries. With CMS’ emphasis on chronic diseases and VBID benefits, shouldn’t you rethink how you present Medicare to your clients?

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

Medicare Fraud – Learn How to Help your Clients Protect Themselves

Medicare Fraud – Learn How to Help your Clients Protect Themselves

Medicare fraud costs an estimated $60 to $90 billion a year. Losing billions of dollars to fraud is a waste of taxpayer money, and fundamentally increases the cost of healthcare for everyone. It can also jeopardize beneficiaries’ personal and medical identity, and their ability to access entitled benefits and services. Knowing about fraud is key to protecting yourself and your loved ones.

Types of Medicare Fraud

Medicare fraud comes in all shapes and sizes reflecting Medicare’s huge and complex program with its Parts A, B, C and D (for readers who don’t sell Medicare yet: Part A is hospital insurance, Part B is outpatient medical insurance, Part C is Medicare Advantage plans and Part D is prescription drug
coverage).

This is a lot of information, so let’s get started….

Overview on various types of fraud

Medicare fraud most commonly occurs in:
(1) Billing for institutional facilities such as nursing homes, residential facilities, hospitals, home health and hospice.
(2) Billing for physician visits and services not rendered or not medically necessary.
(3) Billing for durable medical equipment such as wheelchairs, body jackets, incontinence supplies or diabetic supplies without a doctor’s prescription.
(4) Improper marketing of health insurance plans through phone calls, door-to-door sales and misleading flyers.

Provider Fraud

(1) Providers can commit fraud if they submit bills for services not provided, or unnecessary services.

(2) They can also commit fraud if they upcode a service. This is when a provider charges Medicare for a more expensive service than was provided. For example, a provider may bill for surgery, when only a bandage was placed over a cut.

(3) Unbundling services can also be fraud. This occurs when a provider submits separate bills for lab services that combine three or four tests, which are intended to be billed as one service.

Billing for non-covered services as covered services is also fraud. This occurs when a provider bills a service such as routine toenail clipping (non-covered service) as foot surgery (covered service).

Suppliers and Recruiters Fraud

Suppliers can commit fraud if they:
Bill for different equipment than what the beneficiary received, bill for home medical equipment after it is returned or solicit, offer or receive a bribe or kickback.

Recruiters may stop Medicare beneficiaries on the street or make an at-home visit, offering money and promotional gifts as incentives to take “free” medical exams, after which they give the beneficiary medical
equipment they do not need.

Insurance Broker Fraud

Insurance brokers can commit fraud if they bribe, mislead, or coerce a beneficiary to enroll into or switch plans just to make a commission even though the plan may not be the best choice. Or if they enroll a beneficiary into an MA plan without the beneficiary’s consent or make unsolicited phone calls, emails or home visits.

Pharmacists Fraud

Pharmacists can commit fraud if they dispense expired drugs or short the beneficiary on the number of pills in the prescription they deliver.

Beneficiary Fraud

A beneficiary can commit fraud if they provide their Medicare number in exchange for money or a free gift. In some cases, beneficiaries may unknowingly commit fraud in this way. One of the best ways for your Medicare clients to detect fraud is to examine both their Medicare Summary Notice (MSN) they receive from Medicare after their claims are paid, and the Explanation of Benefits (EOB) they receive from their Part C and D plans. (Clients can access their Medicare account at mymedicare.gov).

These are some helpful questions to ask when clients review their MSN and EOB:

(1) Did they receive all the services/prescriptions listed?
(2) Were they billed for something they didn’t get? Or billed for the same thing twice?
(3) Did the doctor order the services?
(4) Do the prescriptions listed match their prescriptions?
(5) Are the dates of the services/prescriptions correct?

If after answering these questions, your clients suspect fraud, they can call our California Senior Medicare Patrol (SMP) at 1-855-613-7080.

Common Recent Scams

The most common fraud schemes our California SMP currently sees are hospice fraud, new Medicare card scams and “free” back brace scams. Medicare’s hospice benefit provides palliative care for people who are terminally ill and have 6 months or less to live. Yet scammers are signing up healthy people for this benefit while offering them “free housekeeping services covered by Medicare,” or “free milk for an entire year covered by Medicare!” They get beneficiaries’ Medicare numbers in exchange for the “free” benefit and sign them up.

In addition, some beneficiaries residing in low-income housing units are offered assistance with cooking and cleaning while unknowingly being placed in home health or on hospice. Help keep a look out and spread the word on these schemes to stop this fraud.

Beneficiaries should have received their new Medicare cards by now in California. If they haven’t, though, it is coming soon in the mail. Of course, there is no charge for the new card, so remind clients not to be tricked into sending money to scammers. Postcards, TV commercials, ads offering a “free” Medicare-approved back brace in exchange for your Medicare number.

Medicare only covers braces and other durable medical equipment (DME) that are medically necessary with a doctor’s prescription. Scammers, however, hope people don’t know that. They just want beneficiaries’ Medicare numbers to bill Medicare for equipment they never deliver, or to bill Medicare for much more expensive equipment. If clients think they need a back or knee brace, they should call their doctors first.

Open Enrollment Fraud Tips for Clients

In addition to all the scams we’ve covered thus far, more scams come during Medicare’s annual open enrollment (October 15 through December 7). This is the time beneficiaries can enroll into or change their Medicare Advantage and/or Part D plan, or return to Original Medicare. As MA and Part D plan coverage can change annually, it’s important for beneficiaries to review the changes in their coverage for the coming year. Navigating this information can be confusing and hence makes open enrollment a ripe time for scams.

Below are a few tips for clients to protect themselves from fraud during this time.

(1) Beware fake Medicare sales representatives: Make sure clients understand not to believe a salesperson who claims to be a Medicare representative. Of course, Medicare does not send “representatives” to solicit anyone’s business. Federal regulations prohibit unsolicited telephone calls, door-to-door visits, emails and other forms of sales without permission. Make sure clients understand that if they have not requested that someone contact them, it may be a scam.

(2) Guard personal info: Tell clients to never give out personal information such as a Social Security number, bank account numbers, or credit card information over the telephone.
(3) Keep good records: Advise clients to keep records of who they speak with – even you! — and the information that they provide.
(4) Take their time: Clients shouldn’t feel pressured to make a quick decision. Tell clients to be sure that they understand the details of a plan before they enroll. They should verify copayment amounts and whether their medical providers participate in the plan that they are considering.
(5) Change isn’t mandatory: If clients are satisfied that their current plans will meet their needs for the coming year, they don’t need to change plans. They should confirm the details of their current plan before making a switch.

Thanks to all of you for being the “eyes and ears” of Medicare and watching out for scams. Please share this information and report any suspected fraud to our California Senior Medicare Patrol at 1-855-613-7080.

More information on Medicare fraud, resources for education and outreach are in the fraud and abuse section of our website at calhealthadvocates.org.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

Medicare Advantage – Plans need Effective Risk, Quality and Care Strategies

Medicare Advantage – Plans need Effective Risk, Quality and Care Strategies

Licensed Medicare insurance brokers provide invaluable guidance for retirees making healthcare coverage decisions that can have serious consequences on their health and financial well-being. Therefore, it’s critical that they have a firm grasp on trends, innovations and helpful solutions in the Medicare Advantage (MA) space. First of all, the nation’s untenable rate of healthcare spending has sparked a growing reliance on MA plans, which provide an alternative to traditional fee-for-service (FFS) Medicare.

In fact, MA plans now represent 30.6 percent of all Medicare enrollees and 28.9 percent of Medicare’s 2017 gross spending budget. Second, individuals can get Medicare benefits from original Medicare or a MA plan, such as an HMO or PPO. With the former, the government pays for Medicare benefits. With MA plans, the coverage is offered by private companies approved by Medicare.

MA plans provide all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage. The Best Possible MA Plan, The most effective MA plans on the market look at the full spectrum of the patient and apply an end-to-end solution. When done effectively and efficiently — and combined with payment reform — it’s possible to enhance care coordination using analytics, in-home care, retrospective solutions and care management to significantly improve outcomes.

Value-based contracting generates cost efficiencies and improves clinical outcomes in MA. For MA plans and risk-bearing entities to remain sustainable, however, they must adopt innovative quality and risk adjustment programs to meet the growing demand for effective care strategies. For example, MA plans can gain clinical insight into risk-adjusting conditions to enhance their traditional analytical platforms.

How Does a Risk Adjustment Model Work?

Risk adjustment is an actuarial tool used to calibrate payments to health plans based on the relative health of the at-risk populations. If insurers are limited in the extent to which premiums can vary by health status or other factors that are associated with health spending, risk adjustment can help ensure that health plans are appropriately compensated for the risks they enroll.

Significantly, most claims in fee-for-service Medicare are paid using procedure codes, which offer little for providers to record more diagnosis codes than necessary to justify ordering a procedure. In contrast, MA plans have a financial incentive, since the current risk adjustment model was introduced, to ensure that their providers record all possible diagnoses because higher enrollee risk scores result in higher payments to the plan.

Consider two examples of how an MA plan can be optimized: Advantmed’s Physician Record Review (PRR) is a two-stage retrospective chart review process from a 1) certified coder and 2) board-certified physician. Advantmed’s Prospective Health Assessments (PHA) provide a robust view of members and their care needs.

Providers can also rely on PHAs to lay the groundwork for developing more accurate reporting documentation, improving patient engagement and compliance, enhancing disease management and reducing utilization. This kind of full-spectrum, end-to-end approach to care helps providers identify gaps in care and manage plan members more productively. It also helps health plans that are serving as intermediaries, executing solutions and assuming risk.

Ultimately, the greatest benefit goes to the plan member, who will be guided toward more preventive care and self-management early in the care process. Innovative Approaches Value-based contracting can drive
utilization patterns and improve clinical outcomes among chronically ill, elderly MA members. One study tested the hypothesis that payer-provider risk contracting promotes high-value care and concluded that in the future, more clinicians will have to bear the monetary risks associated with healthcare utilization.

The MA program provides a unique milieu for investigating provider groups that have either risk-bearing or fee-for-service contracts with private health plans. Full-risk capitation combined with a revenue gain share agreement sparked a clinical practice transformation at the provider group level, associated with increased office-based care and decreased hospital-based services.

The clinical practice transformation resulted in a 6 percent survival benefit and lowered the hazard of death by 32.8 percent. Value-based contracting benefits all stakeholders The intervention group’s overall survival rate was 82 percent, and the control group’s was 76 percent. This 6 percent survival benefit first became apparent at 16 months after the intervention, coinciding with the first year that the intervention group had higher office-based utilization than the control group.

Age provided a natural time-scale for calculating the hazard of death for this elderly population with multiple comorbidities and a higher risk of all cause mortality. Intervention-group members had a 32.8 percent lower hazard of dying (P <.001). The survival benefit was more apparent among those aged 82 to 96 years. Randomization inference confirmed these survival data, whether time (P <.001) or age (P <.001) was the time scale.

Improved survival is related to and attributable to the Centers for Medicare and Medicaid Service’s (CMS) Hierarchical Condition Category (HCC) data and value-based contracting, which then transform primary care delivery. Brokers should also be aware that CMS expanded how it defines the “primarily health related” benefits that private insurers are allowed to include in their MA policies, with insurers including these extras on top of providing the benefits of traditional Medicare.

For instance, air conditioners for people with asthma, healthy food, rides to medical appointments and home-delivered meals may be among the new benefits offered to Medicare beneficiaries choose private sector health plans, when new federal rules take effect. This means MA beneficiaries will have more supplemental benefits and be better able to lead healthier, more independent lives.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

7 Ways Medicare Will Improve in 2019

7 Ways Medicare Will Improve in 2019

Changes range from an early close of the donut hole to expanded Medicare Advantage plan benefits

Now 53 years old, Medicare has higher rates of satisfaction from its 60 million members than almost any other form of health insurance. It is about to get better. Here are seven improvements to Medicare that will take effect in 2019. Some of the changes will affect all beneficiaries while others will apply just to individuals who select Medicare Advantage plans.

Donut hole

An expensive element of the Medicare Part D prescription drug benefit requires enrollees with high prescription costs to pay more for their medicines after they reach a certain level of spending in one year. This creates a coverage gap – also called the “donut hole.” After a beneficiary’s out-of-pocket spending reaches a second threshold, they enter catastrophic coverage and pay substantially less. Under the Affordable Care Act (ACA), the donut hole was scheduled to close in 2020. But the spending bill Congress passed in March will close the donut hole for brand-name drugs in 2019. The gap will close for generic drugs in 2020.

Therapy cap gone

Beneficiaries of original Medicare won’t have to pay the full cost of outpatient physical, speech or occupational therapy because Congress permanently repealed the cap that has historically limited coverage of those services.

Better information

Medicare is updating the handbook it sends to beneficiaries every fall. It will include checklists and flowcharts to make it easier to decide on coverage. The online Medicare Plan Finder tool will be easier to use and an improved “coverage wizard” will help enrollees compare out-of-pocket costs and coverage options between original Medicare and Medicare Advantage.

More telemedicine

Medicare is steadily broadening the availability of telehealth programs that let patients confer with a doctor or nurse via telephone or the internet. In 2019, it will begin covering telehealth services for people with end-stage renal disease or during treatment for a stroke.

Lifestyle support

Beginning in January, Medicare Advantage plans have the option to cover meals delivered to the home, transportation to the doctor’s office and even safety features in the home such as bathroom grab bars and wheelchair ramps. To be covered, a medical provider will have to recommend benefits such as home-safety improvements and prepared meals.

In-home help

Medicare Advantage plans also will have the option to pay for assistance from home health aides, who can help beneficiaries with their daily activities including dressing, eating and personal care. These benefits represent a revised and broader definition of the traditional requirement that Medicare services must be primarily health related.

Plan test drives

New regulations will let people try an Advantage plan for up to three months and, if they aren’t satisfied, they can switch to another Medicare Advantage plan or choose to enroll in original Medicare. Congress required this flexibility in the 21st Century Cures Act, designed to accelerate innovation in health care.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage

New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage

In November, after a bad fall, 85-year-old Elizabeth Cannon was taken to a hospital outside Philadelphia for six and a half days of “observation,” followed by nearly five months at a nearby nursing home for rehabilitation and skilled nursing care. The cost: more than $40,000.

The hospital insisted that Ms. Cannon had never been formally admitted there as an inpatient, so under federal rules, Medicare would not pay for her nursing home stay. The money would have to come from her pocket.

The experience of Ms. Cannon and thousands like her inspired a new Medicare law — in force as of Saturday — that requires hospitals to notify patients that they may incur huge out-of-pocket costs if they stay more than 24 hours without being formally admitted. Because of the Notice Act, passed by Congress last year with broad bipartisan support, patients can expect to start receiving the warnings in January.

“It was extremely distressful to my mother, who was frugal her whole life,” said Cynthia Morgan of Chadds Ford, Pa., Ms. Cannon’s daughter. “She asked, ‘How can I pay into Medicare for so many years, and now Medicare won’t help pay for my care?”’ Ms. Cannon died in April.

Hospitals have been keeping patients like Ms. Cannon in limbo — in “observation status” — for fear of being penalized by Medicare for inappropriate admissions. While under observation, patients can be liable for substantial hospital bills, and Medicare will not pay for subsequent nursing home care unless a person has spent three consecutive days in the hospital as an inpatient.

Time spent under observation does not count toward the three days, even though the patient may spend five or six nights in a hospital bed and receive extensive hospital services, including tests, treatment and medications ordered by a doctor.

Under the new law, the notice must be provided to “each individual who receives observation services as an outpatient” at a hospital for more than 24 hours. Medicare officials estimate that hospitals will have to issue 1.4 million notices a year.

“The financial consequences of observation stays can be devastating for seniors,” said Senator Susan Collins, Republican of Maine and the chairwoman of the Senate Special Committee on Aging.

Senator Benjamin L. Cardin, Democrat of Maryland, the chief sponsor of the Senate version of the legislation, said it would “save seniors from the sticker shock that comes after they are discharged from the hospital and realize that Medicare will not cover the cost of care in a skilled nursing facility.”

The median cost for a private room in a nursing home is roughly $92,000 a year, according to a survey by Genworth Financial, an insurance company. Medicare covers up to 100 days of skilled nursing home care at a time.

The text of the standard “Medicare outpatient observation notice” is subject to approval by the White House Office of Management and Budget. In its current form, the notice to beneficiaries says: “You’re a hospital outpatient receiving observation services. You are not an inpatient.” And it explains that Medicare will cover care in a skilled nursing home only if the beneficiary has had an inpatient hospital stay of at least three days.

Patients can then consult their doctors and may ask to be reclassified as inpatients.

Hospitals have found themselves in a squeeze. They increased their use of “observation status” in response to close scrutiny of their billing practices by Medicare auditors — private companies hired by the government to review claims. In many cases, these companies challenged decisions by doctors to admit patients to a hospital, saying the services should have been provided on an outpatient basis. The auditors then tried to recover what they described as improper payments.

Doctors and hospitals said the auditors were like bounty hunters because they were allowed to keep a percentage of the funds they recovered.

But patients now will at least be better informed. The Senate Finance Committee explained the reason for the law this way:

“The number of Medicare beneficiaries receiving outpatient observation care over the last several years has been steadily increasing. Some beneficiaries are surprised to learn that although having received treatment overnight in a hospital bed, the beneficiary was never formally admitted as an inpatient but was instead a hospital outpatient.”

Federal officials acknowledged that Medicare beneficiaries sometimes had to pay more as outpatients under observation than they would have paid if they had been formally admitted to the hospital and received the same services as inpatients.

The administration issued rules last week to carry out the new law. The purpose, it said, is “to inform beneficiaries of costs they might not otherwise be aware of.”

“Even if you stay in a hospital overnight, you might still be considered an outpatient,” the administration said in a publication for beneficiaries.

Consumer advocates and nursing homes support the new requirement.

“Medicare beneficiaries are spending more and more time in the hospital without being formally admitted,” said Joyce A. Rogers, a senior vice president of AARP, the lobby for older Americans, adding that this “can expose beneficiaries to unexpectedly high out-of-pocket costs amounting to thousands of dollars.”

Mark Parkinson, the president and chief executive of the American Health Care Association, a trade group for nursing homes, said, “Patients often have no idea what their status is in a hospital.” Observation stays impose a “financial burden on seniors,” he said, and increase the likelihood that they will have to turn to programs like Medicaid, the federal-state program for low-income people.

“The new law is an important first step, but Congress and the administration need to do more to protect beneficiaries,” said Judith A. Stein, the executive director of the nonprofit Center for Medicare Advocacy.

Under the law, hospitals can still keep Medicare patients in observation status, and some of the patients will be responsible for nursing home costs. Twenty-four senators and more than 120 House members are supporting bipartisan legislation to address that concern. Under that bill, time in a hospital under observation would count toward the three-day inpatient stay required for Medicare coverage of nursing home care.

Source: The New York Times

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