The Centers for Medicare & Medicaid Services (CMS)
announced on February 1, 2007 that it is proposing to expand its coverage policy for carotid artery stinting (CAS).
A proposed National Coverage Determination (NCD) posted on February 1, 2007 includes a coverage
expansion that reflects the latest evidence on the effective use of stinting, a procedure that reduces the occurence of stroke
in the Medicare population. Stroke is the third leading cause of death in the United States and the leading cause of serious
long-term-disability. Approximately 70 percent of all strokes occur in people age 65 and older.
To view the entire press release go to:
Help Save Your Mom $3,600
From the Social Security Administration 5-09-08:
We all know the high cost of medicine can be a burden on mothers who have limited income and
resources. But there is extra help- available through Social Security- that could pay part of her monthly premiums, annual
deductibles and prescription co-payments. The extra help could be worth up of $3,600 per year.
To figure out whether your mother is eligible, Social Security needs to know her income and the
value of her savings, investments and real estate (other than the home she lives in). To qualify for the extra help, she must
be receiving Medicare and also have:
Income limited to $15,600 for an individual or $21,000 for a married couple living together. Even
if her annual income is higher, she still may be able to get some help with monthly premiumsa, annual deductibles and prescription
co-payments. Some examples where income may be higher include if she or her spouse:
. Suppoprt other family members who live with them;
. Have earnings from work; or
. Live in Alaska or Hawaii; and
Resources limited to $11,990 for an individual or $23,970 for a
married couple living together.
Resources include such things as bank accounts, stocks and bonds. We do not count her house and
car as resources.
Social Security has an easy-to-use online application that you can complete for your mom (www.socialsecurity.gov). To apply by
phone or have an application mailed to you, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) and ask for the
Application for Help with Medicare Prescription Drug Plan Costs (SSA-1020). Or go to the nearest Social Security office.
To learn more about the Medicare prescription drug plans and special enrollment periods, visit www.medicare.gov or call 1-800-MEDICARE (1-800-663-4227; TTY 1-877-486-2048).
CMS PROPOSES NEW PROTECTIONS FOR MEDICARE BENEFICIARIES IN MEDICARE
ADVANTAGE AND PRESCRIPTION DRUG PROGRAMS
Dated: May 8,2008 from CMS Office of Public Affairs.
MEDICARE TIGHTENS MARKETING STANDARDS AND PROTECTS BENEFICIARIES FROM INAPPROPRIATE COST SHARING
The Centers for medicare & Medicaid Services (CMS) today proposed enhanced protections for beneficiaries
who are enrolled in Medicare Advantage (MA) health plans and Medicare prescription drug plans. CMS'actions today will strengthen
marketing standards and extend additional protections to all beneficiaries including those receiving the low-income subsidy
(LIS) and beneficiaries enrolled in special needs plans.
"These proposed changes will have a direct, positive impact on people with Medicare."said Kerry
Weems, Acting Administrator of CMS. "The Medicare Advantage is a valuable source of enhanced benefits and coordinated
care for beneficiaries, and it should not be undermined by the actions of a limited number of unscrupulous sales agents."
This proposed regulation is a continuation of CMS' efforts to enhance compliance and oversight of
the Medicare Advantage program over the past ten months. Recent compliance and oversight actions include, posting the summaries
of corrective actions taken against MA plans on the CMS web site; establishing five-star ratings for plan performance; embarking
on an extensive secret shopping program of plan marketing events that have led to compliance actions and more accurate sales
presentations; and requiring private-fee-for-service plans to call new enrollees to verify their desire to join the plan.
The proposed rule would incorporate into regulation a number of requirements that CMS previously
imposed through operational guidance. It would also introduce several new MA and prescription drug plan requirements. The
new proposed prohibitions on door-to-door marketing and cold-calling as well as new proposed requirement pertaining to broker/agent
commissions go beyond what the insurance industry recently endorsed as necessary regulatory changes to the program for
improvement.
Speifically, the proposed market standards would:
. Prohibit cold-calling and expand the current prohibition
on door-to-door solicitation to cover other unsolicited
circumstances. Any appointment with a beneficiary to
market health-care-related products would have to be
limited to the scope that the beneficiary agreed in advance.
Cross-selling of non-health care-related products to a
prospective MA or Part D enrollee would also be prohibited.
.Prohibit sales activity at educational events such as health
information fairs and community meetings or in areas such
as waiting rooms where patients primarily intend to receive
health care-relatewd services, as well as limit the value and
type of promotional items offered to potential enrollees.
.Require that MA organizations that use independendent
agents to market MA and Part D plans use State-licensed
agents for such marketing, and require that MA
organizations report to States, in a manner consistent with
State appointment laws, that they are using those agents.
.Require MA organizations to establish commission
structures for sales agents and brookers that are level
across all years and across all MA plan product types
(for example HMOs, PPOs, and private fee-for service plans).
Commission structures for prescription drug plans would
have to be level across the sponsors'plans as well. These
requirements are designed to discourage "churning"of
beneficiaries from plan to plan each year in a manner that
earns agents and brookers the highest commissions and
would ensure that beneficiaries are receiving the information
and counseling necessary to select the best plan based on their needs.
Provisions to streamline elgibility determinations for extra help and limit beneficiary liability
would:
.Codify earlier guidance to plan sponsors about using
"best available evidence" (BAE) to determine an enrollee's
eligibility for extra help through the LIS program.
Recognizing that the monthly files from the States and the
Social Security Administration that Medicare uses to
establish LIS elgibility sometimes do not reflect an
applicant's current elgibility status, the regulation would
require Part D sponsors to use the CMS-developed BAE
process to establish the appropriate cost-sharing for low-
income beneficiaries whose information in CMS systems
is not correct or up to date. This change would help protect
low-income beneficiaries from unnecessary cost sharing
charges at their pharmacy counters.
. Set other premium and cost sharing protections related to
Social Security premium withholding and point-of-sale drug
prices. For example in cases when premiums are not
deducted even though the beneficiary has chosen the
withholding option, plans would not be permitted to disenroll
the beneficiary for not paying premiums.
The rule would claify one approach to calculating fines, or civil monetary penalities, against Medicare
Advantage or Part D plans that violate Medicare rules in ways that adversely affect beneficiaries. Under the proposal, CMS
would have greater flexibility in determining penalty amounts and would have clear authority to levy a penalty of up to $25,000
for each enrollee affected, or likely to be affected, by the violation.
The rule also proposes new protections for beneficiaries enrolled in special needs plans (SNPs).
SNPs are a type of MA plan that provides coordinated care to individuals in certain institutions such as nursing homes, and
those who are eligible for both the Medicare and Medicaid programs and/or have certain severe or disabling chronic conditions.
Provisions in the proposed rule would:
. Require that 90 percent of new enrollees in SNPs be
special needs individuals, to ensure that SNPs focus on
the population for which these MA plans are designed.
. More clearly establish and clarify delivery of care standards
for SNPs.
. Protect beneficiaries from being billed for cost-sharing that
is not their responsibility. For SNPs that target beneficiaries who are eligible for both
Medicare and Medicaid, the rule would establish standards designed to ensure that those beneficiaries are able to access essential
services that are available through Medicaid in addition to those benefits available through the SNP.
The proposed regulation is available on the CMS website. Comments must be submitted by 5:00 pm.
Eastern time on July 15, 2008.
Medicare's Home Health Care Benefit
Sometimes, people with Medicare need
medical care at home. You may have just been discharged from the hospital; or perhaps you're dealing with a flare-up of a
chronic ailment. Medicare covers care and treatment in your home if you meet specific criteria. Here's how Medicare's home
health care benefit works.:
First, your doctor must certify that you are homebound, and that home care is medically necessary.
Homebound means that it requires considerable and taxing effort for you to leave your home. Second you must need skilled physical,
speech or occupational therapy services, or skilled nursing on an intermittent (less than seven days a week) or part-time
(less than eight hours a day) basis. Skilled nursing services are those services that can only be performed safely and effectively
by a licensed nurse. Tube feedings, catheter changes, management and evaluation of a patient's care plan are examples of skilled
nursing. If you require only skilled
nursing, you must either need it fewer than seven days a week (even as little as once every 60 to 90 days) or daily (seven
days a week) for a short period of time ( usually two to three weeks). Your
care must be provided through a Medicare-certified home health agency (HHA).
Medicare's home health benefit pays in full for skilled nursing services.
Medicare will cover the full cost of physical, speech and occupational therapy in your home to maintain your condition and prevent you from getting worse (you do not need
to have the potential to improve to receive these services).
The costs of a home health aide are
covered in full only if you
are also receiving skilled nursing services in your home. A home health aide provides personal care services such as help
with bathing, dressing, and using the toilet. If you require only personal care, you do not qualify for the Medicare home
health care benefit.
Medicare will also cover in full the cost of medical
social services (such as counseling) that help you with social and emotional
concerns related to your illness; the medical supplies (wound
dressings, for example) used by the Medicare-certified home health agency; and evaluations
by a skilled nurse or therapist. The Medicare home health care benefit covers
80% of the Medicare-approved amount for some medical equipment, such
as a wheelchair or walker.
There are some home care services that are not covered by Medicare's home health care benefit. These include 24-hour care at home, homemaker
or custodial care services (housekeeping services such as cooking, shopping, and doing laundry) or meals delivered to your
home. Most prescription drugs are covered under Medicare's drug benefit (Part D) and not by the home health care benefit.
(Medicare's hospice benefit, however may pay for some of these items and services for people at the end of life.)
If you are eligible for home health care benefits, a Medicare-certified home health agency
will draw up a plan of care that describes the types of services that will be provided, how often you need these services,
and the doctor in consulation with the HHA, must review and evaluate the plan at least every 60 days. At the end of 60 days,
the HHA can draw up a new plan of care as long as you continue to qualify for the Medicare home health benefit.
To learn more about what is covered under Medicare's home health care benefit, log on to Medicare
Interactive Counselor at the Medicare Rights Center's website at www.medicarerights.org/help.html .
Medicare Interactive Counsellor is a resource provided by the Medicare Rights Center, the largest independent source of health care information and
assistance in the United States for people with Medicare.
Marci's Medicare Answers
Marci's Medicare Answers is a service of the Medicare Rights Center
(www.medicarerights.org), the nation's largest independent source of information and assistance for people with Medicare. To subscribe to "Dear Marci,"
MRC's free educational e-newsletter, simply e-mail dearmarci@medicarerights.org.
Dear Marci,
My husband was just diagnosed as diabetic, and his doctor prescribed medical nutrition therapy.
Does Medicare cover this?
Polly.
Dear Polly,
Medical nutritional therapy, which may include diet counseling, is designed to help you learn to
eat right so you can better manage youe illness. With a doctor's referral, Medicare will cover 80 percent of the cost
of medical nutritional therapy for people with diabetes after they pay their annual Part B deductible. Medicare will generally
cover three hours of medical nutritional therapy for the first year and two hours every year thereafter, although it will
cover more hours if your doctor says you need them. Medicare will only cover these services if you receive them from a registered
dietitian or other qualified nutrition professional.
Dear Marci:
I fell and broke my arm two months ago, and my son says I should
install safety rails in my bathroom. Will Medicare pay for it?
Otto.
Dear Otto,
No Medicare will never cover home modifications (such as the installation of grab bars near the
toilet or tub) or assistive devices (such as large-button telephones or flashing doorbell signals for persons who have a hearing
problem). Medicare will however, cover durable medical equipment
(DME)- equipment that is medically necessary, able to withstand
repeated use, and is generally not useful to someone in the absence of illness or injury. DME includes items like wheelchairs,
walkers, scooters and hospitals beds.
Dear Marci:
I'm on Medicaid and am about to turn 65 in a few months. Will my drugs be covered
by Medicaid or Medicare?
Meredith
Dear Meredith,
Once you have both Medicaid and Medicare, you must get
your drugs covered by the Medicare prescription drug benefit (Part D). You will
automatically enrolled in a Medicare private drug plan if you do not choose one yourself. You will also automatically get
"Extra Help". federal assistance that pays for most of the cost of Medicare drug coverage. You do not need to apply for this
assistance. When you get the letter from Medicare telling you what plan you have been enrolled in, you should call 800-Medicare
or visit www.medicare.gov to make sure your assigned plan covers the drugs you need and
that the pharmacies you use regularly are part of that plan's network. If not ask the counselor to help you enroll in a different
plan that meets your needs. People who have Medicaid are allowed to change drug plans once a month.
