Medicare Advantage Private Fee-for-Service (PFFS) plans dropped by Health Insurance Carriers

Health insurance carriers are dropping their Medicare Advantage Private Fee-for-Service (PFFS) plans, according to recent announcements by some health insurance providers, including Coventry and WellCare. A PFFS is a Medicare Advantage (MA) plan that is available through a state licensed, risk-bearing entity, or a PFFS Medicare Advantage Organization (MAO).

As a result of PFFS coverage drops by Coventry and WellCare alone, more than 500,000 Medicare plan holders will have to find new coverage.

At this point, Medicare Advantage plans receive government subsidies so that they can offer beneficiaries more benefits than simple Medicare plans. Medicare Advantage plans are offered to Medicare-eligible individuals by private health insurers. However, analysts are expecting the reimbursement rates for these PFFS programs to fall by approximately 5%, making them less profitable for insurance carriers.

How PFFS Currently Work

PFFS are popular amongst consumer s because they allow Medicare beneficiaries to choose their own healthcare providers, rather than having to select their providers from a limited number of in-network of Medicare-approved providers. Beneficiaries can see any provider, as long as the provider agrees to charge based on the PFFS fee schedule. This fee schedule is the same as the Medicare schedule.

PFFS MAOs have yearly contracts with the Centers for Medicare and Medicaid Services to provide Medicare beneficiaries with their Medicare benefits as well as additional benefits that a company opts to provide. A PFFS provider pays for healthcare instead of Medicare when a beneficiary has such a plan.

The main benefit (which makes PFFS so popular) is that individuals who join PFFS MAOs are not required to use providers within a network and can, therefore, see any provider as long as the provider is able to receive payment from Medicare and the PFFS MAO.

More Changes to PFFS Plans

In addition to the decreased government reimbursement amount for PFFS plans, PFFS plans will be required to develop healthcare provider networks beginning in 2011. The change will force PFFS plan holders to select their healthcare providers from within the plan network, limiting their freedom to see providers that they prefer.

Experts predict that more healthcare insurance providers will follow Coventry and WellCare by dropping their PFFS plans in coming months. Individuals should contact their healthcare insurance providers if they are currently enrolled in a PFFS or are considering enrolling in a PFFS to get more information about how their provider will respond to the upcoming PFFS changes.

More Information About Medicare Advantage Plans

Medicare Advantage plans are specific types of Medicare plans that are in place to cover the cost of healthcare related expenses for Medicare participants. These plans are similar to traditional Medicare plans in that they provide financial support for individuals seeking medical or health-related services. However, Medicare Advantage plans generally have more benefits and lower copayments than other types of Medicare plans. In order to have a Medicare Advantage plan, Medicare participants need to have Medicare Part A and Medicare Part B plans.

One major difference between Medicare Advantage plans and other types of Medicare plans is that Medicare Advantage participants may need to see only doctors that are members of the Medicare Advantage provider plan. However, plans may allow participants to use a wide variety of services, including Medicare Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service providers, and Medicare Special Needs providers.

Medicare participants should be aware that Medigap policies do not provide gap coverage for individuals that participate in the Medicare Advantage program.

Benefits Of A Medicare Supplement Policy

There is a lot of debate regarding Medicare, Medicare supplement policies, and their funding. The Medicare program has been around since the 1960s, when President Lyndon B. Johnson signed it into law. At that time, only about one quarter of the American elderly population was covered by insurance.

Currently, the elderly are the only age group that basically has universal coverage. Medicare supplement policies came about more recently than that. However, there is a lot of concern that the Medicare funds are running out, that Medicare supplement policies are not doing enough to help the elderly, and that there is not enough incoming money to continue to meet the program's financial needs.

Many people do benefit from Medicare, even though it does not cover 100% of all medical costs. Many people purchase Medicare supplement policies to help offset the costs that are not covered by traditional Medicare. These premiums will also go towards funding Medicare. To offset these gaps in coverage, many American older adults will also purchase Medicare supplement policies that will help them pay some additional costs.

Other people get their Medicare benefits from Medicare Advantage Plans through a private health insurance company. This is another way the Medicare program is trying to share costs and risks, by allowing private health insurance companies to also offer Medicare benefits. The insurance carriers get paid from Medicare to offer benefits to older Medicare-eligible adults.

A member who buys a Medicare Advantage Plan cannot also purchase a Medicare supplement policy because that would be considered being eligible to have double benefits for the same things. Medicare Advantage Plans include many of the benefits of a Medicare supplement policy.

Medicare Supplements and Medicare Advantage Plans Are Not the Same Thing

Medicare Advantage Plans, are health plans from insurance companies that have a contract with CMS (Center for Medicare and Medicaid). Individuals who have Medicare Part A and B are eligible to choose a Medicare Advantage plan. Specialized plans exist for people with certain health conditions, but beyond that the general plans are not allowed to decline based on health except for very specific reasons.

When an individual is enrolled in the plan they do not lose their Medicare. They are entitled to cancel their Medicare Advantage plan, and the next month, they can go back to original Medicare. While enrolled in Medicare Advantage, they will have to use the insurance card provided by the Medicare Advantage plan instead of their Medicare card.

These plans may cost the participants nothing, or very little, though many still require the Part B participation amount. A Medicare Advantage plan is not free however. The plans receive a contribution from CMS every month, instead of having that tax money go to original Medicare. That is how the bulk of the plan is paid for, from tax money.

Traditionally, Medicare Advantage Plans were thought of as HMO plans were an insured person had to use the plan hospitals, doctors, and other medical providers to be covered. Many Medicare Advantage Plans are HMO plans. However, PPO Medicare Advantage plans also exist. Fee for Service Medicare Advantage Plans, or plans that will cover any medical providers who accept the insurance, are being marketed aggressively these days.

Your own medical needs and preferences will determine which plan will work out well for you. If your current medical providers contract with the plan's HMO, then you may be very satisfied with comprehensive coverage with very little extra payments. If you like more choice, and area doctors will accept a Free For Service plan then you might consider an "Any Doctor" plan. Be aware that not all doctors work with the Fee For Service plans, even though the insurance company claims it will work with any doctor! A great compromise is provided by PPO plans. You get the greatest coverage at the lowest price inside the network, but will still be covered by other medical providers.

Most, but not all, Medicare Advantage plans also contain Part D, or prescription drug coverage. Medicare Advantage plans may have very low, or no, premium for the insured people beyond their normal Part B premium. Some plans even refund the Part B premium. Also, Medicare Advantage Plans are not allowed to do a lot of risk selection based upon health, so they may be a good choice for less healthy applicants.

A traditional Medicare Supplement is very different from Medicare Advantage. With Medicare Supplements you still use your original Medicare Card, and add your Medicare Supplement health card. These plans are also provided by insurance companies, but they simply supplement the coverage gaps and deductibles not provided by original Medicare Part A and Part B.

If you have Medicare Part A and Part B, your Medicare supplement plan will pay the portion of your medical bill that Medicare will not pay. Of course, Medicare supplement plans differ, and so you need to be aware of exactly which portions a Medicare Supplement plan will pay before you sign up. For instance, Medicare may be 80% of your hospital bill, and your supplement will pick up the other 20%.

Medicare supplements come with premiums, and also may exclude unhealthy individuals. However, they generally provide the broadest access to health care.

Choosing a Medicare health plan can be one of the most important decisions a Medicare beneficiary will make. Let us help you find the right plan to fit your needs, lifestyle, and budget.

Compare Supplemental Medicare Health plans with simple online zip code searches

Medicare Health Plan Options

If you or someone you know is about to go on Medicare, you should know that you'll be able to choose how you receive your Medicare benefits including your prescription drug coverage. This brief article will explain some of the more popular options as well as give you specific phone numbers to call with you Medicare questions. Medicare health insurance is currently for people who are age 65 or older, under age 65 with certain disabilities, and at any age living with End-Stage Renal Disease (ESRD). ESRD is permanent kidney failure requiring dialysis or a kidney transplant.

While Medicare covers a lot of different health care services and supplies, it does not cover all of the costs associated with your health care. There are "gaps" associated with Medicare that require the beneficiary to pay out of their pocket. These Medicare costs include coinsurance, copayments and deductibles. Depending on the Medicare health plan you choose, you'll have varying degrees of costs.

Medicare Health Plan Options

Original Medicare is managed by the Federal Government and provides Part A and Part B health coverage. Original Medicare pays for many of the health care services and costs associated with normal services and supplies. Original Medicare does not pay for all of your health care costs. It is important that you understand your coinsurance, copayments and deductible. These are called out-of-pocket costs, or also known as cost-sharing.

Many Medicare beneficiaries choose to buy a Medicare Supplement policy (a.k.a. Medigap Policy) to help fill these out-of-pocket costs. Before you can buy a Medicare Supplement policy, you'll generally have to have both Part A and Part B. A Medicare Supplement policy can only generally help you if you have Original Medicare. If enrolled in Original Medicare and you would like to have prescription drug coverage, you'll need to buy a seperate policy to cover your prescription drugs. These are simply called Medicare Prescription Drug Plans.

Medicare Advantage Plans are known as Part C. They are health plans that are similar to traditional HMO or PPO insurance plans. These plans are another way to get your Medicare benefits. These are plans that are approved by Medicare, but run by private insurance companies. You'll find that your out-of-pocket costs may be different in a Medicare Advantage Plan. Check to find out what your coinsurance, copayments and deductibles will be for any Medicare Advantage Plan by using the online comparison tool found at Medicare.gov.

Medicare Prescription Drug Coverage is also called Part D. Prescription drug coverage is available for everyone with Medicare. These prescription drug plans are run by private insurance companies and approved by Medicare. There is a separate premium associated with Part D plans. You have to enroll in the plan and pay the premiums to get Part D prescription drug coverage.

In the next article we'll explore Medicare Supplement insurance policies. These plans are specifically designed to cover the gaps in Original Medicare.

Michael D Coday II is a licensed insurance agent in Texas. He offers free medicare supplement quotes for Texas residents at his website. Find him online now: http://www.medigapmedicareinsurance.com

Medicare Part D Prescription Drug Plans

Medicare Part D: What is it?

Medicare's prescription drug program was created as a result of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). Although the Act was written into law in 2003, Medicare eligible individuals did not start enrollment into these plans until January 1, 2006. This plan is commonly referred as PDP (Prescription Drug Plan) or simply Part D.

Part D is available to everyone who has Medicare regardless of income or health history. Private insurance companies provide the coverage. The enrollees select a plan from those available in their geographic region and pay the insurer a monthly premium for the coverage. Even though enrollment is voluntary there is a penalty for late enrollment which will be discussed a bit later in this article.

You can elect to enroll in a Medicare Prescription Drug plan in one of two ways:

(1) Stand along prescription drug plans (PDP); or

(2) Medicare Advantage Prescription plans (MA-PD).

The first type of plan covers prescription drug benefits only. These plans were designed for people who choose to stay with traditional fee for service Medicare and need the prescription drug coverage along with a Medicare supplement to round out their medical coverage. Most States have several carriers who offer this coverage on a free standing basis. The plans do vary in areas of monthly premiums, deductibles, copays, formularies, and other cost sharing arrangements.

Medicare Advantage plans, the second broad category of prescription drug plans, not only cover medications but also Medicare approved medical services. These plans are available through private insurers and include HMO, PPO, and Private-Fee-for-Service programs. In the case of Medicare Advantage Plans, the Medicare beneficiary has actually "traded" their traditional Medicare benefits for a Medicare Advantage program. Medicare Advantage plans sometimes provide enrollees wish additional benefits. However, there are frequently restrictions on the doctors and hospitals that they may use for covered medical services.

Enrolling in a Plan

Generally speaking, an individual may enroll in a Prescription Drug Plan during their initial open enrollment period when they first qualify for Medicare Part B. For someone turning age 65, this would be the three months prior to their birthday month, the month of their birthday, and the three months following their birthday month. After, their initial enrollment period (IEP), there is an annual open enrollment period (AEP) when they can change plans. Historically, the annual open enrollment period commences on November 15th and closes on December 31st with enrollments effective the following January 1st. There are other special enrollment periods available to medicare beneficiaries such as when they relocate or leave employer sponsored plans.

For the 2011 plan year, the annual open enrollment period will commence a bit earlier and end prior to the holidays to avoid confusion over deadlines in past years.

The "Standard" Prescription Drug Plan

All of the insurers that participate in the PDP program must offer at least the Standard plan of coverage. Monthly premiums will vary from State to State. However, the average premium for 2010 is expected to be $46.58. The plan deductible for 2010 is $310.

After you pay the yearly deductible, you pay the following amounts for the remainder of 2010,

- 25% of the cost of drugs after the $310 annual deductible until total charges reach $2830

(the plan pays the other 75% of charges); then

- 100% of the next $3610 in total drug charges (often called the donut hole or coverage

gap); then

- 5% of your drug charges or a copay of $2.50 for generic medications or $6.30 whichever is lesser; for the rest of the calendar year after you have spent a total of $4550 out of pocket.

Even though, at a minimum, an insurer must provide a Standard plan, they are permitted to offer plans that do differ in benefits. These other plans usually do away with the deductibles and impose fixed dollar copays for covered medications instead percentage copays. Some of these other plans even cover generic mediations in the "donut hole."

The Late Enrollment Penalty

If you do not have "creditable coverage" from another source, such as an employer plan or the Veterans Administration, and do not sign up for a Medicare prescription drug plan when first eligible, you will, in all likelihood, be charged a penalty for late enrollment. The penalty is based on the number of months that have elapsed since you were first eligible to enroll and when you finally do enroll. A penalty of 1% per month will be levied and that penalty will last for as long as your remain enrolled in a plan. The penalty is based on the average cost of a plan in the year that you finally enroll. For example, if 50 months have elapsed since you were eligible to enroll and the national average cost for a plan in that year was $50, the cost for your plan would be $75- (1.50 times $50). Again, this penalty would be assessed each year into the future for as long as you remain enrolled in a plan.

Financial Help for Those of Modest Means

The Social Security Administration has a program available for those with qualifying incomes called Extra Help. Extra Help can save qualifying individuals as much as $3900 per year. Extra Help can assist with premiums, paying deductibles and copays associated with a Medicare prescription drug plan. To qualify for Extra Help, an individual must be enrolled in a Part D prescription drug plan and for 2010; resouces must be limited to $12,510 for an individual or $25,010 for a married couple. Resources would include things like bank accounts, stocks, bonds, and mutual funds. Houses, cars, life insurance cash values, and money received from relatives or others to pay household expenses do not count as resources. Some individuals with higher annual income may qualify for the Extra Help program. To inquire if you qualify, you can contact the Social Security Administration at 800-772-1213 or visit your local Social Security office.

Using Information Sources To Choose a Plan

There are a number of useful sources to help you learn about the PDP plans available to and help you compare so that you can select the plan that works best for you.

Medicare's Medicare & You 2010 Handbook available at http://www.medicare.gov is an excellent source of information. The handbook lists plans in your area and basic information about cost and plans benefits.

State Health Insurance Assistance Programs and Community Organizations quite are excellent places to find help.

Also, do not forgot your local Medicare certified health insurance agent. Should you or your parents need assistance in selecting a Medicare prescription drug plan, please feel free to contact us at 818-597-2890.

Edward Walden, CLU, RHU, REBC

An Overview of Medicare Supplement Plans A Through L

You'll find twelve Medicare supplement policies that handle expenses not covered by regular Medicare program. Each of these policies is required to pay for particular fundamental items.

The policies are identified as Plan A through Plan L. Each one provides a different set of benefits targeted at filling "gaps" in Medicare insurance coverage. They're each listed consequently. Plans K and L are similar in benefits to Plans A and J, but are less costly every month yet have higher limits.

If you are looking for a high allowable choice, Plans F and J have a $2000 deductible limit. This insurance plan allowable must be paid before the plan insures any expenses whatsoever. The amount of the insurance deductible on these plans aren't fixed and, consequently, may increase annually. Your premium itself is lower, although your out-of-pocket fee will be much higher.

Please be aware: Medicare SELECT is really a Medicare medigap health care insurance policy offered in addition to the twelve common A-L plans. SELECT usually costs less than the standard A-L plans. The downside to Medicare SELECT is the fact that you will have limits on which health professionals and hospitals you'll be able to decide on. If you wish to learn more about which Medicare SELECT plans can be obtained in your area, speak to your state insurance plan department.

Are you presently in a Medicare Advantage Program? (Medicare Health Maintenance Organization HMO is a Medicare Advantage Plan.) If you are, you no longer require a Medigap coverage plan.

People of Massachusetts, Minnesota, and Wisconsin have different normal Medigap plans from which to pick.

Simple Benefits:

Paid for by Plans A-J:

? Medicare Part A copayments along with insurance coverage for 365 more days after Medicare benefits end

? Medicare Part B copayments (typically 20 % of Medicare-approved expenses), or copayments for hospital services

? Initial 3 pints of blood annually

Paid for by Plan K:

Medicare Part A copayments plus coverage for 365 more days after Medicare benefits expire

? 50 % of hospice cost-sharing

? 50 percent for the initial three pints of blood every year

? 50 % Medicare Part B copayments, except 100 % copayments for Part B preventive services

Covered by Plan L:

Medicare Part A coinsurance plus insurance coverage for 365 additional days after Medicare benefits end

? 75 percent of hospice cost-sharing

? 75 % for the first three pints of blood on a yearly basis

? 75 % Medicare Part B coinsurance, except 100 % coinsurance for Part B preventive services

Medicare Part A Hospital Insurance deductible

Dealt with by Plans B-J:

$1,068 in 2009 for each benefit period for hospital services

Paid for by Plan K:

50 percent of the $1,068 Part A hospital insurance deductible

Covered by Medigap Plan L:

75 % of the $1,068 Part A hospital insurance deductible

Skilled Nursing-Home Costs

Dealt with by Medigap Plan C-J:

Your cost ($133.50 in 2009) for the days 21 through 100 in a skilled nursing home

Dealt with by Medigap Plan K:

50 % of $133.50 for days 21 through 100 in a skilled nursing home

Insured by Plan L:

75 percent of $133.50 for days 21 through 100 in a skilled nursing home

Medicare Part B Deductible

Covered by Medigap Plans C, F, J:

Yearly insurance deductible for doctor services ($135 in 2009)

Medicare Part B Excess Charges

Insured by Medigap Plan F (100 percent), G (80 %), I (100 percent), J (100 percent):

If your doctor doesn't accept assignment, the difference between what your medical professional bills and the Medicare-agreed upon amount.

Foreign Travel Emergency

Paid for by Plan C-J:

? Outside the United States: 80 percent of the expense of emergency care

? Up to $50,000 in your lifetime

? Yearly deductible of $250

At-Home Recovery

Paid for by Plans D, G, I, J:

? If already receiving skilled home care dealt with by Medical insurance Help, assistance with daily living activities, such as bathing and getting dressed.

? After you no longer must have skilled care, assistance for up to eight weeks

? Will pay up to $40 a visit, seven visits each week, or a total of $1,600 each year

Non-Medicare-Covered Preventive Services

Paid for by Medigap Plans E, J:

Up to $120 annually for non-Medicare-covered preventive services ordered by your general practitioner

To learn the main features of every single Medigap Insurance plan alternative, visit the Medicare Supplemental Insurance (Medigap) Reference at http://medicaresupplementalinsurances.com now!

Prescription Drug Coverage With Supplemental Medicare Insurance and Medicare Advantage Plans

If you are about to turn 65, you have probably been studying up on how Medicare works and the various plans it offers. Because some of the plans are similar, the differences between them are often blurred, leaving potential beneficiaries confused about what plan is right for them.

Medicare Part C, known as a Medicare Advantage Plan, is one of the four basic parts of the Medicare system. It allows users of the original Medicare Parts A and B to get coverage from a government approved private insurance company of their choice. Medicare Advantage Plans include plans like Health Maintenance Organization Plans (HMO) and Preferred Provider Organization Plans (PPO). The biggest weakness the original Medicare plans have is that they do not cover the cost of prescription drugs. If you want additional coverage, you have a few options.

Medicare Part D is available to anyone with original Medicare (Parts A and B), and can help cover the costs of prescription drugs. You must get this coverage through a private insurance company approved by Medicare. If you have a Medigap policy, the same as supplemental Medicare insurance, it may already cover the costs of drugs. But if it does not, you are allowed to get a Medicare Prescription Drug Plan as part of Medicare Part D, but must alert your insurance company if you do so. Not all supplemental Medicare plans will cover drug costs, so it is important to make sure the plan you choose offers this benefit. If it does not, just remember that you can still get drug coverage through a Medicare Plan.

If you are not going to utilize Medicare Part D, or get supplemental Medicare insurance, consider Medicare Part C - the Medicare Advantage Plan. These plans, provided by private insurance companies, may offer prescription drug coverage at an additional cost. If you have one of these plans, you will not need supplemental Medicare insurance at all; it is simply an alternative. Make sure to check your coverage history from past employers; you might have additional coverage choices if your former or current employer provided you with prescription coverage.

Make sure not to buy a supplemental Medicare plan if you already have a Medicare Advantage Plan. Doing this is illegal, unless you are completely dropping your Medigap plan and returning to original Medicare. Be very careful before ever dropping your supplemental Medicare insurance, because it is possible that you may not be able get it back in the future. Discuss the issue with your State Health Insurance Assistance Program and your insurance company before ever making a decision that could affect your long-term health coverage.

Getting prescription drug coverage is an important element in any health coverage plan, and only gets more important as you get older. You should seriously consider getting a plan that helps cover the costs of prescriptions, as you never know what types of health issues you may have in the future. Whether you choose to get supplemental Medicare insurance or a Medicare Advantage Plan, having some kind of drug coverage will have you prepared for any twists or turns life may bring.

Richardt Insurance has over 35 years of experience helping seniors find the best supplemental Medicare insurance and prescription drug coverage that is available in their state.

Medicare Coverage For Mental Health and Alzheimer's Care

Modern medicine recognizes that many mental and emotional problems are in fact physical illnesses or related to them. So, with either Medicare Part A hospital insurance plus Medicare Part B medical insurance, or with a Part C Medicare Advantage managed care plan, participants have extensive coverage for treatment of mental or emotional illness, including depression, Alzheimer's disease, and other forms of dementia. This includes both inpatient and outpatient care, and treatment not only by doctors but also by other Medicare-certified healthcare providers. The amount of coverage Medicare provides depends on the kind of hospital where the person receives care.

Care in a general hospital.If the inpatient care she receives is in a general, nonpsychiatric hospital that treats patients for all types of illness, the rules of coverage are the same as for any other hospital stay. That is, under Medicare Part A, she must pay a deductible, plus daily co-payments for a stay of more than 60 days within any one benefit period. If she's in the hospital for more than 90 days in any one benefit period, Medicare Part A pays part of the cost of up to 60 more once-in-a-lifetime "reserve days". However, there's no lifetime limit on the number of hospitalizations that Medicare Part A will pay for. If she has a Part C Medicare Advantage managed care plan, it pays for at least this same amount of inpatient care, and some plans pay more of the cost.
Care in a psychiatric hospital.If she's an inpatient in a psychiatric hospital -- meaning one that accepts patients only for mental health care -- the rules of payment are the same as for a general hospital but the total amount of coverage is different. Medicare Part A covers only a total of 190 days in a patient's lifetime for inpatient care in a psychiatric hospital.

Nursing facility care. The single most important thing to understand about Medicare and nursing facilities is that Medicare does not pay for long-term care. However, under limited circumstances and for a short time, Medicare Part Aor a Medicare Advantage managed care plan can cover a stay in a skilled nursing facility while the person is recovering from a severe mental health episode that landed her in the hospital. The nursing facility stay must follow, within 30 days, a hospital stay of at least three days. And the nursing facility stay must be medically required and prescribed by her doctor to provide her with daily skilled nursing or rehabilitation services while she's recovering from the medical event that put her in the hospital. The coverage can last for up to 100 days, with Medicare paying the full amount for the first 20 days and your family member having to make a co-payment of $133.50 (in 2009) per day for days 21 through 100. For more details about Medicare Part A nursing facility coverage, see our article Understanding Medicare Part A (Hospital Insurance). Home care. Home care is available under Medicare Part A, Part B, or Part C (managed care) if it's medically necessary for any illness or condition, including mental illness, Alzheimer's, and other forms of dementia. But the rules under which Medicare coverage is available for home care are quite strict, and coverage usually lasts only a short time. The key thing about Medicare coverage for home care is that it applies only to home healthcare. That means your family member must need skilled nursing care or rehabilitation therapy while she's confined to home because of an injury or illness. It doesn't cover assistance with the activities of daily living such as dressing, bathing, walking, or eating unless these are provided incidentally, alongside required skilled medical care. A doctor must prescribe the home care and it must be provided by a Medicare-certified home healthcare agency. If the person in your care qualifies, Medicare pays 100 percent of the agency's costs. But the care can continue only as long as the skilled nursing or therapy is required, while she's actually recovering. Home healthcare is covered by Medicare Part A following a hospital stay, or by Medicare Part Bif there has been no prior three-day hospital stay. If she's enrolled in a Part C Medicare Advantage managed care plan, that plan provides home care under the same rules, except that the home care agency must be associated with the specific managed care plan.

Psychological care. Psychological counseling is not technically medical care. But under some circumstances, Medicare Part B or Medicare Part C managed care will cover counseling by a clinical psychologist. The person's doctor must prescribe the treatment. The psychologist must be certified by Medicare. And the psychological care must relate to a problem -- such as depression or anxiety -- arising out of a medical condition for which the doctor is treating her. If she's suffering emotionally from the strain of a physical illness, suggest that she discuss the problem with her doctor. If she and the doctor believe she might benefit from psychological counseling, Medicare Part B or her Medicare Advantage managed care plan might cover the care. The office of the psychologist she's referred to can find out in advance from Medicare whether it would cover her treatment there. Adult daycare. In general, adult daycare provides personal monitoring and attention with structured activity in a secure environment. Medicare usually considers this type of care "custodial" rather than medical and so usually doesn't cover it. Medicare can cover services from an adult daycare center only in very limited circumstances. Medicare might cover actual mental health treatment, prescribed by a physician, provided at an outpatient mental health clinic. If this clinic is also an adult daycare center, the patient can get the benefit of the center's other care services while receiving treatment there. Medicare will cover this kind of care only if, and for as long as, it involves actual medical treatment -- administration and monitoring of medication, for example, or help with recovery from a medical crisis. Also, some Part C Medicare Advantage managed care plans offer limited adult daycare coverage as part of their comprehensive home care services. Medicare doesn't require that these plans offer this, so the nature and extent of what they cover depends entirely on the plans themselves. Finally, Medicare partners with Medicaid to sponsor what's called the Program of All-Inclusive Care for the Elderly (PACE). This provides comprehensive home and community care, including adult daycare, for frail elders who would otherwise require nursing home care. PACE is only available in certain states, however. And in those states, it may be available only to those who are eligible for both Medicare and Medicaid. See Medicare's official website at medicare.gov for a list of PACE programs.

Therapeutic services for Alzheimer's patients. For a long while, Medicare didn't consider various therapies for people who had been formally diagnosed with Alzheimer's disease medically necessary, and so did not cover them. This policy has changed. If the person in your care has been diagnosed with Alzheimer's, Medicare Part B can now cover physical, occupational, and speech therapy for her, as well as psychological counseling and other mental health services. Her doctor must prescribe the treatment, however, and it must be provided by a Medicare-certified therapist or mental health provider. Medications for mental health conditions.Any medication administered to someone when she's a hospital or nursing facility inpatient, whether or not she's an Alzheimer's patient, is covered by Medicare Part A. Any medication given to her at her doctor's office or at any outpatient health facility is covered by Medicare Part B. Things get much trickier with prescription drugs taken at home. The only coverage Medicare provides for at-home medications is through a Medicare Part D prescription drug plan. Coverage for specific drugs the doctor may prescribe for mental health issues depends on the formulary -- the covered list of drugs -- that her plan maintains. There's a special prohibition, however, on certain drugs that are often prescribed to cope with mental health issues. Medicare doesn't permit a Part D prescription drug plan to cover any medication within the categories of barbiturates (certain sedatives) and benzodiazepines (certain tranquilizers), even if a physician has prescribed it. So if she's taking one of these drugs, and she'd like to have coverage from her Part D drug plan, ask her doctor whether a similarly effective drug might be available that does not technically fall into either of these categories.

http://www.caring.com/articles/mental-health-coverage
http://www.caring.com/articles/medicare-coverage-for-long-term-care

Medicare Supplement - Common Terms

Medicare Supplement plans plug the Medicare holes so you do not have the out of pocket costs Original Medicare will leave you with. So let us talk about some of the common terms you need to be aware of with Medicare and a Medicare Supplement plan:

Common Terms:

California Open Enrollment - (Unique to California) the ability of a Medicare Supplement member to switch to another company each year on the month of their birthday. This is a guaranteed issue option. You cannot be denied the transfer because of health status.

Original Medicare - Run by the Federal government and provides both Part A and Part B coverage.

Medicare Part A - is the hospital coverage Medicare pays for. You are responsible for the $1,100 deductible each benefit period (60 days) you enter a hospital.

Medicare Part B - the out patient Medicare coverage for physician, specialist and surgery services. There is a $155 Part B annual deductible you will need to pay the beginning of each calender year when you see a physician.

Part B premium - All Medicare beneficiaries are required to pay for their Part B premium. In 2010 the monthly premium is $96.40. If your annual income is higher than $85,000 your premium increases to $110.50. (other rules apply).
Assignment - an arrangement whereby a physician or hospital agrees to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. Medicare usually pays 80% of the approved amount directly to the physician after the beneficiary satisfies the Part B deductible of $155.00. The Medicare Supplement member pays the other 20%.

Skilled Nursing Facility - (Medicare Part A) A medical care facility used primarily for rehabilitation. Patients are typically in a Skilled Nursing Facility when they are recuperating from an accident, illness or surgical procedure. Medicare typically pays all costs except $137.50 per day. Medicare will not continue to pay for this service is the person has a degenerative condition. In other words, the patients condition should be improving, if not, the coverage is stopped and a long term care policy or medicaid is necessary to continue to pay for these services.

Medicare Part D - Medicare Prescription Drug Coverage. Helps cover the cost of prescription drugs. Must be purchased from a private insurance company.

Part B Coinsurance - After the Part B deductible, Medicare requires you to pay 20% of all Medicare eligible expenses for physician, specialist, ambulance and hospital outpatient services and supplies.

Excess Charges - When your medical bill for Part B services exceeds the Medicare eligible expense. For example; if the Medicare allowable charge for a certain visit or procedure is $100. Medicare Part B pays $80 and the Medicare Supplement pays the remaining $20, if the Medicare Supplement pays for Excess Charges. Some plans do not cover this extra charge.

Initial Enrollment Period - (IEP) Your enrollment is guaranteed if you apply for coverage before or within six months of enrolling in Medicare Part B.
The terms above are some of the most common terms pertaining to a Medicare Supplement plan and you should become familiar with these terms when purchasing a plan. Please contact a Medicare specialist for more information.

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Medicare Now Required Check For Fraud Before Paying Claims

The Miami Herald wrote today: "The behemoth Medicare bureaucracy will have to act more like a credit card company in flagging suspicious bills under a new federal law that could save taxpayers billions of dollars a year in wasteful government healthcare spending. The anti-fraud provision, tucked into the Small Business Lending Act that became law Monday, would force Medicare to end its 45-year-old policy of paying claims quickly without verifying them" (Weaver, 9/30).

Meanwhile, chronic fraud in the Medicare program continues, such as one court case now unfolding in Michigan.

The Detroit Free Press: "A Detroit-area man faces 10 years in prison after pleading guilty Monday to running a health care fraud scheme that involved billing the government for home health visits that were unnecessary or never happened" (Baldas, 9/28).

The Detroit News: Hassan Akhtar, 26, entered his plea to one count of conspiracy to commit health care fraud and faces a maximum $250,000 fine when sentenced Jan. 27. Akhtar admitted to federal investigators he and co-conspirators at Oak Park-based All American Home Care Inc. billed Medicare for home health-care visits that were medically unnecessary and/or never provided, according to the U.S. Departments of Justice and Health and Human Services" (Snell, 9/28).

This is part of Kaiser Health News' Daily Report - a summary of health policy coverage from more than 300 news organizations. The full summary of the day's news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

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Avoid Rising Health Care Costs With Medigap Insurance

New York medicare supplement coverage is a health insurance and it is generally sold by the private insurance companies. Their basic intention is to cover the gaps in expenses which are not covered by original medicare. There are 10 standardized medicare supplement plans that are currently available in New york, they are labeled A through N.

Though every Medicare insurer offers both the categories A and B, all the insurance companies do not cover all the standard plans of this coverage. Every standard supplement policy is bound to provide the basic core benefits like covering the cost of some of the Medicare co-payments and may be some other deductibles. Some of the companies offer some extra benefits which can be foreign travel and care taken during emergency or recovery care taken at home.

If a person wants to become eligible for medicare coverage in New York, then he will have to enroll in both Part A and B. The state law states that the insurance company will have to accept an enrollment application for coverage throughout the year.

The insurance company cannot deny any such enrollment application and also while making premium calculations the health condition of the individual or his claim history or medical condition cannot be considered as a factor.

Experts feel that New York citizens above the age of 65 must purchase a medicare supplement. Choosing the most suitable plan for you from the right company is really a very tricky matter. It has been seen that the premium may vary by a few hundred dollars from one company to another for the same set of coverage. It has also been seen that rates are varying due to factors like age and gender and the amount of coverage you need. There is no point in delaying taking the policy as in that case rates generally go up.

Let us consider the case of a person paying original medicare (Part A and B) and then having a Medicare supplement policy. At the first level, Medicare will pay their share of the approved amounts and Medicare supplement will pay for the rest of the health care cost of the individual. The medicare insurance policies need to be clearly noted as Medicare Supplement Insurance.

The benefits offered by New York supplement coverage policies are many. Some of them can be mentioned as inpatient hospital care, medical costs and first three pints of blood needed every year. But if you are enrolled in a Medicare Advantage Plan, there is no need to buy a medicare supplement.

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Helpful Tips About Medicare Supplement Insurance

Medicare supplement insurance is known as Medigaps. This is because it is designed to fill in the gaps in your Medicare coverage. You can buy this supplemental insurance from private insurance companies. They must adhere to strict guidelines to ensure consumer protection. Nonetheless, it is important to be aware of some facts before you choose your Medigaps health insurance provider.

There are twelve different Medigap policies that you can choose from. These are simply named A-L for simplicity. These are standardized policies and by law, the insurance companies must not alter them in any way. This is to protect you, the consumer. A "Plan A" from one provider will be identical to the same plan from another.

In addition to the basic benefits outlined in each of the Medicare supplemental plans, each plan will also have a list of extra benefits. Again, these are standardized and do not vary from one insurance company to the other.

On the surface, then, it seems as if it wouldn't matter who you bought your supplemental health insurance policy from. After all, every company offers exactly the same plans. However, they do have differing pricing structures and not all companies offer all twelve plans. In addition, it is their job to sell you insurance and each company will emphasize aspects of the insurance that protect their company from financial risk as much as the law allows.

Generally speaking, before you can buy Medigap policy you must first have Medicare Part A and Part B and you must pay a monthly Medicare Part B premium. This is on top of the premium you will pay to your Medigap insurance company. Roughly speaking, you should expect to pay more for your policy the higher up the alphabet you go. Plan J is the most expensive policy.

It is important to remember that these are individual policies. They do not cover your spouse. Each of you must have your own individual policy.

When you are comparing insurance companies, bear in mind that no matter what a salesperson may say, the medical coverage for each plan, from Plan A to Plan L, is identical, no matter who you buy it from. The companies are not required by law to charge the same amount for the identical product. Therefore, if Plan D, for example, seems to suit your needs the best, get the cheapest Plan D you can.

Another important consideration is to purchase your Supplement Insurance within six months of enrolling in Medicare Part B. If you do so, the insurer is required to accept your application no matter what your previous medical history is.

If you keep these tips in mind, you will get the most out of your Medicare Supplement Insurance. If you are still in doubt, consult the official U. S. Government Medicare agency for further information.

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Medicare Health Plans - Knowing Your Options Can Save You Money

If you are new to Medicare, you may find your Medicare health plan options and some of the terminology confusing. When choosing a plan, a little knowledge can keep you from making some costly mistakes. First, you need to know the difference between a Medicare supplement and a Medicare Advantage plan. Many people just assume that any plan that is offered by an insurance company is a supplement. This is not the case. An Advantage plan is not a supplement.

An Advantage plan is offered by a private insurance company as another way to receive your Medicare benefits. The insurance company offering the plan has a contract with CMS (Centers for Medicare and Medicaid Services) to administer your benefits. Some features of an Advantage plan include:

You will have cost sharing by way of co-pays, co-insurance and deductibles. Plans are often a PPO or HMO and have a network of providers. May have a low, or in some cases, no monthly premium. Will often include the Part D Medicare drug coverage. May offer benefits beyond original Medicare, i.e. dental, vision, and gym memberships.

A Medicare supplement, or Medigap insurance plan, fills the gaps left by original Medicare by paying your share of the charges. This is typically the hospital deductible, hospital co-pays if required, and the 20% outpatient charges that Medicare does not pay. Some features of a supplement include:

They are standardized plans that may require some medical underwriting. May be more costly the older you are. You pay your monthly premium, which is typically higher than an Advantage plan, but have less out-of-pocket expenses when services are rendered. Stand-alone Part D Medicare drug coverage will be necessary. Benefits beyond original Medicare are not included.

Once you know the difference between the types of Medicare health plans, you need to ask yourself some questions. The questions typically revolve around your health and your budget. Other considerations will include your choice of medical providers and whether you require or can pay out-of-pocket for the extra services not offered by Medicare.

Can you afford a monthly premium for a supplement, even if you do not use it? If not, you may want to consider an Advantage plan. Do you have health problems and are not in an open enrollment or guaranteed issue period? If so, you may need to consider a Medicare Advantage plan. Are you willing to accept a provider network? If not, you may want to consider a Medicare supplement. Can you live with the fact that insurance companies that offer Advantage plans, can change benefits annually or discontinue the plan? If not, you may want to check out a supplement.

Everyone has different circumstances and these are just some of the questions you will want to answer before you choose your Medicare health plan. Once you decide which type of plan is best for you, you will then want to compare plans that are available to get the best possible plan for your health and money.

David Forbes is President of Alliance Marketing Associates, Inc. David offers helpful advice on topics related to insurance for seniors, including finding an affordable Medicare Plan

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What Can I Do If My Medicare Advantage plan gets canceled in 2010?

Health insurers withdraw plans for different reasons, e.g. when they introduce a new similar plan or because of their inability to meet CMS enrollment thresholds.

For 2010, many Medicare Advantage Plan providers canceled their private fee-for-service (PFFS) plans in anticipation of the termination of all PFFS plans after December 31, 2010.

When insurers cancel plans, the plan members may be automatically enrolled in a similar plan. This automatic roll-over however does not mean that the insured cannot select other plans that are more suited to their needs, even if that means opting for another carrier.

Contact a local health insurance broker or visit plan comparison sites like Medicare Advantage Supplement Info to obtain information on other Medicare Advantage Plans available to you.

What is the difference between a Medicare Supplemental Insurance (Medigap) and Medicare Advantage?

While Medicare Supplement Plans, also called 'Medigap', and Medicare Advantage plans both provide additional coverage on top of the Medicare Part A and Part B coverage, they offer uniquely different benefits.

While Medicare supplemental insurance plans typically have higher monthly premiums, these plans pay a member's share of the costs of Medicare-covered services thus eliminating or reducing out-of-pocket payments, including coinsurance, deductibles, preventive services and at-home recovery services.

Enrollees would have to purchase a stand-alone Part D drug plan.

Under Medicare Advantage, you typically have lower monthly premiums with a Part D drug plan included, but you will have some out-of-pocket expenses. Usually, you have to use the services of the health insurers' provider networks to be covered.

Advantage Plans offer many value-added benefits, including discounts on gym memberships, health and wellness service and a variety of discount programs, at no additional charge.

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