Medicare_and_Medicare_Hmo's

Cherie Kinney Medicare and Medicare HMO’s There are four different parts of the Medicare program that are offered to enrollees. These four parts are Medicare part A, Medicare part B, Medicare part C and Medicare part D. Each special part offers coverage for different services, costs and out of pocket options for today’s healthcare. This is an attempt to sum up what is the “web we have woven” that we call “Medicare”. Medicare is a U.S. health insurance program that is referred to as a “social insurance program” supervised by the United States of America government. This is a form of healthcare insurance provided to cover people who are: 65 and over, under 65 whom are disabled/meet certain prerequisites or suffer from End Stage Renal Disease (ESRD). Medicare was primarily an amendment to social security legislation signed into law on July 30, 1965, by then President Lyndon B. Johnson. [6] This is why the Social Security Administration (SSA) is responsible for all aspects of ascertaining whom is eligible and whom is not. Additionally they are responsible for processing the premiums. That same day after LBJ signed the directive there was a ceremony in which former President Harry S. Truman was signed on as the first Medicare beneficiary and he was presented with the first Medicare card. [6] In contrast to that that first card, in 1965 the numbers for 2007 showed there were 44,009,689 signed up for Medicare benefits. [4] What’s funny about the fact of the former president Truman being the first card totter is that it was originally he, Harry S. Truman whom in 1945 envisions a “Medicare” type answer but congress were skeptical about having “socialized medicine.” It’s nice to know that he got to see that his ideas were indeed eventually realized. [1] Throughout the years Medicare’s costs, coverage’s, plans and options have changed and been shaped with each of the shifting of generations needs. As stated above there are 4 parts to this coverage; Medicare plans A, B, C, and D. Part A covers hospital stays this may include stays in a skilled nursing facilities, if particular criteria are met, including the following- a direct quote from wikipedia.org [6]: 1. The hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. For instance, a hospital stay for a broken hip and then a nursing home stay for physical therapy would be covered. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADLs) such as personal hygiene, cooking, cleaning, etc. *The max stay that Medicare Part A will cover in a skilled nursing facility / ailment is 100 days. *The first 20 days would be paid for in full by Medicare. The remaining 80 days requiring a co-payment (as of 2008, $128.00 per day). [6] Part A has these guidelines as outlined in the “HHS.gov Centers for Medicare and Medicaid” website: “… The $1,068 deductible for 2009, paid by the beneficiary when admitted as a hospital inpatient, is an increase of $44 from $1024 in 2008. The Part A deductible is the beneficiary’s only cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay an additional $267 per day for days 61 through 90 in 2009, and $534 per day for “lifetime reserve days” that can be used for hospital stays beyond the 90th day in a benefit period. The corresponding amounts for calendar year 2008 are $256 and $512, respectively. Daily coinsurance for the 21st through 100th day in a skilled nursing facility will be $133.50 in 2009, up from $128 in 2008…” [4] Part B aids in paying for some of the services and products not covered by Part A. This is usually based on outpatient services, x-rays lab and diagnostic tests, vaccinations for the flu or pneumonia, doctor and nursing services and services rendered in doctors offices to name a few. People must realize that meds administered by the attending physician for each episode will be cover within that visit but it does not include prescriptions however, it does help with DME’s (durable medical equipment). These include but are not limited to; canes, walkers, and wheelchairs these as well as oxygen for home use and breast implants are covered as well as 1 pair of eyeglasses after cataract sx.. [6, 5 pgs 26-38] Part B is an optional decision for the patient depending on his/her spouse and the degree of active working statuses and other insurances. Be aware though that there is a lifetime penalty, 10% per year for not enrolling in Part B unless actively working. [6] In the 2008 and 2009 editions of “Medicare and You”, there is a stated deductable of 135$/year for part B. [5 pg121] Part C was passed in 1997 and was called the “Balanced Budget Act of 1997.” Medicare beneficiaries were optioned to choose private plans INSTEAD of the A and B benefits. These programs were called the “Medicare + Choice” plan at a capitated rate and they were approved by Medicare and include copayments much like the HMO’s/PPO’s we are used to working with. They include the parts A and B but it is worked into the private plans. [2 pg. 31] Alongside these plans included the "Medicare Advantage" (MA) and Medicare Advantage Prescription plan (MAPD drug coverage plans). This made a more “attractive package” for some social security members. [6] Part D covers the costs of prescription drugs and was first enacted as the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.” [6] If you are eligible for Part A or B then are for Part D as well. A person with Medicare must enroll in a “Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD).” [6] Although they are approved and regulated by Medicare, they are in fact not administered by them. The private sectors of health insurance companies do it for Medicare. These come with monthly premiums and copays. [2 pgs. 52-69] The downside is the plans choose which drugs or classes of drugs they wish to cover and sometimes they choose not to cover some important ones at all!. If someone is dually covered [Medicare / Medicaid coverage] then sometimes the Medicaid portion will pick up the costs. [6] Part D is the newest help/improvement bill for us members. This year there are a few new things offered to the newly signed S.S. beneficiary applying for Medicare… i.e. a newly revamped “One-Time Welcome to Medicare” physical exam [5 pg 33] Fraud and Identity Theft [5 pgs 94–97], a guideline on planning ahead -Plan for your current and future health care needs. [5 pgs 99–106], New Technology—Electronic and Personal Health Records [5 pg 101]… …And these are what you can’t miss, the important dates for filing for new or reviewed/changed insurance choices…in October you should ready yourself and review the prior year. See if a better plan is there for you or is it adequate enough to meet your future and present needs! November 15-December 31 of each year is the “round up” time. This is when new and prior members can alter or signup for plan choices There is also the “Medigap” coverage offered and some participate in the PACE program. The Medigap is a supplement insurance policy that pays the “gaps” or “donut holes” that Medicare plans do not cover. These include the copayments, co insurance and deductibles. These only work with the original Medicare plans not the “Advantage” plans. [2 pgs 72-74] in addition to a part B premium you have to pay a Medigap premium, monthly, as well. PACE is the “Program of All-Inclusive Care for the Elderly.” This is a combo of medical, social, and LTC for the frail, elderly people who live within their community and is available in most states. To qualify you: “… must be at least 65, live in a serviceable PACE area, and be certified by your state as eligible for nursing home care. …” [2 pg 82] Modern U.S. society’s healthcare has been criticized over the years and a topic of great concern. These have been repeated concerns for each president throughout the last few decades with no real substantial answer. Healthcare is one of the top three biggest concerns for the president elect. Most private insurances base their course of action on Medicare guidelines… i.e. the PET registry in which if there is a call for Alzheimer’s, cancer resurgence tests (to name a few) through the PET/CT modality they will step up and cover them for these particular claims. When the private sector sees this they will in turn move toward Okaying these tests for others. The upcoming amount of retiring babyboomers is going to be staggering for the workforce and the Medicare claims and members are going to be astronomical. . this is an issue that needs to be addressed and resolved by 2010 so they can be prepared for the future projections listed below. The release by the “Medicare Trustees Release Annual Report” from the date; Monday, May 1, 2006 states… “…In the estimate released today, Medicare’s Hospital Insurance (HI) Trust Fund is projected to be exhausted in 2018, two years earlier than estimated in last year's report. This change results from slightly higher costs in 2005 than previously estimated and some upward revisions in the short-range assumptions about utilization of HI services. Expenditure growth is estimated to average 7.1 percent per year over the next 10 years….” [4] Total spending for 2007 fiscal year was determined to be 440 billion dollars. This was 16% of all the government spending. [6] the Wikipedia website cites the facts: “…According to the 2008 report by the board of trustees for Medicare and Social Security, Medicare will spend more than it brings in from taxes this year (2008). The Medicare hospital insurance trust fund will become insolvent by 2019.” [6] This seeming a better odd since it’s a newer projection then I had stated above via the Medicare Trustees Release Annual Report from Monday, May 1, 2006, nonetheless still a worrisome statement. The current release on 2009 Medicare deductions and premiums were at least status quo with last years. The press release from CMS public affairs dept on September 19, 2008 professes: “… The standard Medicare Part B monthly premium will be $96.40 in 2009, the same as the Part B premium for 2008. This is the first year since 2000 that there was no increase in the standard premium over the prior year…… This monthly premium paid by beneficiaries enrolled in Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items…… Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2009 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage. In addition to the standard 25 percent premium, such beneficiaries now have to pay an income-related monthly adjustment amount. These income-related Part B premiums have been phased-in over three years, beginning in 2007. 2009 is the first year in which affected Part B enrollees will pay the full amount of the income-related premiums. About 5 percent of current Part B enrollees are expected to be subject to the higher premium amounts….” [4] These are all facts and numbers that will continuously change day to day depending on economy, voter choice of new incumbent president ect. There are watchdog groups i.e. AARP that try to keep the senior citizens informed and fight for their rights in all areas but mostly healthcare issues. The Office of the Inspector General receives reports on acts on fraud through Medicare. The annual estimation on fraud is 60 billion, that’s just unacceptable. In a 2001 there was a study given by the “Government Accountability Office”and they evaluated the quality of answers given… “by Medicare contractor CSR to provider questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%...” Another atrocity that is completely unacceptable. A better way must be found to get “across the board” evaluations and get some sort of adherence to protocols and bylaws. And there has got to be a way to reel in those who are stealing from the public pool of funds through fraudulent claims and unnecessary procedures! It’s almost like taming the wild west of the 1880’s into shape. To end this paper I would like to add the comments received from Joseph and Ella Rowe of Oxford N.J. He being 66 and retired and her being 64, just retired and awaiting Medicare benefits makes a good interview from the aspects of the newly awaiting member and “seasoned pro” if you will. They are married, naturally so they have the same comments about the set up of the Medicare options since Ella controls the household bills and does all the research for the two. Her first question was “What was her satisfaction level with the coverage of Medicare program'” Ella stated “Medicare wasn’t set up initially to pay 100% of healthcare costs when it originated in 1965. Knowing this was to be a stepping stone for help, it is a great help to all esp. them. However it would be nice if more drugs were covered and a and b were 100% coverage …if she had a wish!” When asked about the ease of the billing system she replied “it was so confusing at first and they are still running into problems as the re-up time is coming in November because they cannot afford the advantage plan for both and actual money amounts for Medigap insurance still eludes them. She is afraid to trust any private insurances and it’s like a maze to her with all the exceptions and choices. They had never had HMO’s due to the fact he always had union insurance [meat cutters local] so the advantage plans didn’t seem fair to her because they were fortunate enough not to have to use the insurance for anything but 1 major sx 23 years ago and up until he retired the coverage was 100%. They never abused the system Joseph said because he has honor and pride.” I did explain to them that most people are the same but obviously the latter is out there making money for themselves and I quoted them the above mentioned facts on 440 billion spent and 60 billion was fraud.. They were not amused and felt that something had to be done about this! Ella and Joseph both agreed that they like the original (A and B) because they can go to whomever they like pretty much, not that they would consider leaving their family doctor of the last 20 years though. For their overall satisfaction with all aspects of Medicare on a scale from 1-10 she gives it a 5 and he gives it a 4 based on what they are used to having and for those who are even more unfortunate then them there needs to be a better way! Bibliography 1- Web-http://seniorjournal.com/news/2000files/aug00/fir-08-04-00medcarhisry.htm 2- Book- Centers for medicine & Medicare Services…Medicare & you 2008 3- Web- factfinder/census.gov 4- Web- http://hhs.gov/ 5- Book –Centers for medicine and Medicare services … Medicare and you 2009 6- Web- http://en.wikipedia.org/wiki/Medicare_(United_States) 7- General knowledge and learning materials based on thoughts and workings taught this year from Bua 211 class and from the book-Delivering Healthcare in America…a systems approach … 4th edition…….Leiyu Shi & Douglas A. Singh….Jones and Bartlett publishers….2008