Medicare only pays for 80 percent of a standardized amount for procedures

Many of those over 65 who saved for retirement have retained greater economic flexibility than those hit by layoffs while still trying to amass savings. That makes seniors a very desirable market for several industries. In fact, senior marketing is the fastest growing marketing segment today.

In sharp contrast, one of the biggest marketing failures that can have seriously harmful complications for those over 65 surrounds Medicare. With multiple parts, two deductibles, partial coverage (only 80 percent) for doctors' services, no coverage at times (such as when you travel outside of the U.S.) and no reconciliation when doctors charge above what Medicare will pay, Medicare is a maze of contradictions. How do seniors calculate and plan for their health care costs?

In truth, both people under and over age 65 find Medicare often to be obscure and some simply give up in confusion. It's a sad comment on the "information age" that we haven't explained Medicare's coverage in a way that allows many seniors to estimate their expected health care costs and plan accordingly.

Medicare Supplement Plans Help to Translate Medicare's Coverage

Private insurers marketing Medigap insurance must explain Medicare, at least in part, to show the need for their plans to protect seniors from all the health care charges that Medicare won't cover. For many, private insurance companies discuss Medicare in ways that are more direct and more comprehensible to give seniors a better overall understanding of where the holes in Medicare's coverage put them at risk. The risk is real because hefty doctor and hospital bills far too often devour retirement savings forcing seniors to reduce their standard of living. Health care costs may be the single biggest concern for many seniors because their need for health care grows as they age and because health care prices are spiraling out of control.

A Medicare Supplement Can Cut Seniors' Medical Bills down to Size

With existing Medicare benefits in jeopardy (Medicare was extended beyond it's predicted bust in just eight years), baby boomers and seniors are exploring alternatives, such as Medicare Advantage plans and Medicare Supplement plans.

In the face of the new health care laws, Advantage plans are beginning to lose their subsidies. It's expected that these plans will become increasingly expensive with the decline of government subsidies. Medigap insurance, often called Medicare supplement insurance, is a viable alternative. With 10 different plans, each one fills the gaps in Medicare in a slightly different way so seniors are free to choose only the benefits they need without paying for any extras. Medigap plans cover Medicare's Part A and Part B deductibles to make seeing the doctor and going to the hospital when you need more affordable. These plans can also cover Medicare's co-pays and co-insurance charges, and certain plans expand Medicare's coverage to services beyond Original Medicare, such as emergency medical care when you're out of the country.

Confusion over Medicare Has Left Seniors Unprepared for Health Care Debt

Although millions are now enrolled in Medicare in order to pay for their health care needs, many remain unprotected simply due to a lack of understanding about the intricacies of the Medicare system. One of the biggest misunderstandings involves the Medicare "pre-approved" amount. Medicare only pays for 80 percent of a standardized amount for procedures. That doesn't stop doctors from charging more; it just shifts the burden of payment onto the patient. Doctors can continue to charge their regular fee, Medicare can continue to pay its standard payment and it's up to you to make those ends meet. Getting the right information is crucial to getting the most out of Medicare, and Medicare supplement insurance is one key to bridging the gaps in Medicare coverage.

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.

The New Medicare Prescription Drug Plan Pitfalls

Coverage for the New Medicare Prescription Drug Plan begins on January 1, 2006. Many seniors are feeling confused and concerned about this plan. Here are some of the pitfalls associated with this plan that Medicare eligible individuals will want to be aware of.

1. To join the Medicare Prescription Drug Plan (Medicare Part D) you must choose one Prescription Drug Plan from dozens of plans that are available (there are up to 50 plans in some states). Once you have chosen a plan you are "locked-in" until the enrollment period the following year.

2. Prescription Drug Plan (PDP) providers can change the particulars of their plans at any time with a short warning period for plan enrollees. These changes can include changes to which drugs are covered under the plan, which pharmacies are in the plans network, the charges associated with being a part of the plan and any other detail of the plan. These changes are at the discretion of the plan administrator and can be implemented at any time.

3. For 2006, once you have used $2250 worth of medications, you are 100% responsible for paying for the full amount of the drug until you reach the $5100 Catastrophic coverage limit. This range between $2250 and $5100 where you have to pay for 100% of your drug expenditures is known as the "donut hole".

4. At its greatest level of savings Medicare provides a 49% savings. This is only 7% better than the average savings experienced with a licensed Canadian pharmacy. This greatest savings occurs when people spend exactly $2250 on medication in one year (if you spend more or less than that the savings go down). That means that the greatest savings anyone on Medicare can experience above a Canadian pharmacy's average savings is $157.50 annually (7% of $2250) or $13.13 a month. Is $13 a month worth the risk of being "locked-in" to paying monthly premiums for a plan that can be switched on you at any time. (Note: Some people can save more than 49% if they spend well over $7100 per year. This is in the catastrophic coverage range).

5. If you do not sign up with at Medicare Prescription Drug Plan before May 15th, 2006 then you will be penalized with a cumulative 1% increase to your premiums for every month that you do not enroll in a plan after that date. This penalty is the governments way of forcing people, who do not really need a drug plan, into joining a plan and thus "subsidizing" the Medicare program. 1% of the average plan is 32 cents. So for every month after March 15th, 2006 that people are not in a plan, 32 cents will be added to your monthly premium or basically $1 for every 3 months you do not join. This penalty is however applied to your premium for all future monthly premiums. What many seniors groups are advocating is for people to wait until the May 15th, 2006 deadline and then join the cheapest possible plan (approx. $10 monthly premium) and still order medicines from a licensed Canadian pharmacy like Universal Drugstore.

6. Average monthly premiums, the annual deductible and the Out-Of-Pocket expenditure limits are expected to increase substantially every year. This means you will be required to spend more and more money every year that you are part of the Medicare prescription plan.

7. Unless you are spending more than $800 on medications in 2006 there is no real savings with the Medicare Prescription Drug Plan. This required minimum amount of expenditure to experience savings will increase every year as the annual deductible, the monthly premiums and the Out-Of-Pocket expenditure limits are also increased every year.

8. It will be extremely time consuming and difficult to decipher myriad plans available in each state (all providing different coverage) and to try and figure out which plan is best for you personally. This will be twice as hard for a couple as the prescription drugs used by each person in the couple will be different and therefore they may require different plans. Even once a plan is chosen, there is still the risk of having the plan changed once you have made your decision and you are "locked-in".

9. Drug companies stand to make a ton of money off of the Medicare program. That is why they spent millions of dollars lobbying to get the legislation passed to make Medicare Part D a reality. It is also why Senator Bill Tauzin, a major advocate and motivating force behind getting the Medicare Prescription Drug Plan passed, is now a $2 million a year executive in Big Pharma's trade organization. On Sept. 5, 2003, Sen. John R. McCain (R-Ariz.) told the New York Times, "There's no doubt in my mind that the drug industry got everything it wanted and more," he said. "It perhaps should be called the 'Leave-No-Lobbyist-Behind Bill.' "

10. Plan providers have the ability to negotiate better drug pricing with the drug companies but they do not have to pass the savings on to the consumer or the government.

11. If you join a Medicare Prescription Drug Plan (PDP) at any time after Dec 31, 2005 your coverage is not available to you until the first day of the following month.

12. Action is required to enroll in Medicare Part D (the Prescription Drug Plan part) unlike Medicare parts A and B which are automatic. You are not simply enrolled in the best plan for you. You have to wade through piles of information to decide what is best for you.

13. It is very difficult for persons who qualify for Medicare Part D to be sure if their drugs will be covered under their plans formulary (which can change at any time anyways.) A formulary is a list of drugs covered under particular drug plan.

14. You may not qualify for Medicare Prescription Drug Benefits if your annual income is too high or if you own too many assets.

15. Different plans will have different monthly premiums. The plan you need may have a really high monthly premium. $32.20 is simply the "predicted" average monthly premium.

16. Will your plan cover temporary-use medications (such as antibiotics or heartburn medications) or only chronic medications (such as drugs used for diabetes or heart conditions)?

17. Plans with lower monthly premiums may have higher deductibles and co-pays.

18. Payments for drugs which are not on your plans formulary are not counted towards your Out-Of-Pocket expenditure limit.

19. Payments made by insurance plans do not count towards your Out-Of-Pocket expenditure limit

20. Is your regular pharmacy included in your plans network of pharmacies? Like many people you have most likely come to rely on a pharmacist that knows you and your medical conditions well. However, you may be forced to go to another pharmacy if your pharmacy is not included in your plans network of pharmacies.

21. How many days of medicine can you get at one time? Do you need to keep going back to the pharmacy every month or can you get 90 days?

22. Will your drug be covered by your plan the next time you go into your pharmacy?

23. Does your plan require step-up therapy or prior authorization? Step-up therapy means using drugs in a series of stages or steps in order to treat your condition. For example if you have GERD your plan may not cover Nexium unless you have previously tried ranitidine (Zantac) and/or omeprazole (Prilosec) first. Prior Authorization means that for certain drugs, your plan will not cover the drug without first reviewing your medical and drug history to determine if your treatment steps have been appropriate.

24. The Prescription Drug Plan providers stand to make a ton of money from the Medicare program (drug companies stand to make the biggest windfall).

25. Net cost to the government for Medicare Prescription Drug Benefits is estimated to go from $37.4 Billion in 2006 to $109.2 Billion in 2015 (estimate by Health and Human Services department). However, much higher estimates of the costs of Medicare Part D can also be found from non-government resources. Two years ago Congress reluctantly approved for the plan at a cost of no more than $395 billion dollars over 10 years. A few months later the cost ballooned to $534 billion and earlier this year it shot to $795 billion. Big Pharma is the biggest recipients of the increased dollars added to the costs of this program.

26. Plan may force you to use generics when you are used brand name medications and may not be able to tolerate generic versions.

27. The appeals process for some plans is very confusing and convoluted. (You can appeal to your plan if your drug is not covered.)

28. Many of the big pharmaceutical companies are now making anyone eligible for Medicare Part D, ineligible for their assistance programs. These companies are effectively forcing seniors into a "voluntary" program that may not be right for them. The AstraZeneca Foundation was the first to take such steps.

29. Many people are finding it difficult to obtain accurate, updated lists of what medications each plan will cover.

30. Medicare's own hotline can only answer general questions. For more specific questions you must contact each individual insurance provider.

31. Many people have waited 30 minutes or more when calling the Medicare hotline to get information that they need.

32. Rep. Dan Burton (R-Ind.) in a 60 Minutes segment televised March 14, 2004 said, "Seniors, when they find out what's in that bill, are going to be very angry. The problem is, they're not going to find out about it until after this next election."

Jeremy Cockerill is a licensed Canadian pharmacist who owns and operates htttp://www.UniversalDrugstore.com/ , one of the top Canadian mail-order pharmacies. Mr. Cockerill graduated from the Faculty of Pharmacy at the University of Manitoba with Honors in 1998. Mr. Cockerill recently won the 2005 Manager of the Year award from the Manitoba Customer Contact Association. Mr. Cockerill has been studying the new Medicare Prescription Drug plan since early 2005.

New Medicare Supplement Plans Are Available Now

Medicare does not cover all health costs. There are gaps in the coverage. Some or all of these gaps can be filled by additional insurance purchased from private insurance companies. These plans are known as Medicare Supplement Insurance Plans or Medigap Plans. There are currently twelve plans available, identified by letters A through L.

Since Medicare Supplements are standardized by government regulations, all Medicare Supplement insurance companies are regulated as to what provisions and what policies they can offer. That does nott mean the prices are the same. There can be a big difference in premium costs for the same plan, depending on which insurance company you choose.

First, a little background information:

The Medicare Prescription Drug Improvement and Modernization Act of 2003 (also called the Medicare Modernization Act) was signed into law In December of 2003. Prior to this Act, Medicare did not provide for outpatient prescription drug benefits. This Act created Medicare Part D, to give access to prescription drug insurance coverage for those eligible for Medicare Part A or who were enrolled in Medicare Part B. This coverage began on January 1, 2006 and is administered by private health plans.

The Medicare Modernization Act (MMA) also encouraged the National Association of Insurance Commissioners (NAIC) to modernize the Medicare supplemental insurance marketplace. NAIC developed a revised Medigap Plan model.

On July 15, 2008, Congress enacted the Medicare Improvements for Patients and Providers Act (MIPPA) that authorized the states to put the NAIC's changes into effect. Congress felt that Medigap insurance had not kept up with some of the changes in Medicare, so the 2010 Medicare Supplement changes are, in effect, an effort to modernize the Medigap Insurance market by dropping some coverage options and adding others.

Summary of changes for 2010 Medigap plans purchased on or after June 1, 2010:

? Preventative Care will be dropped from all 2010 Medicare Supplement plans

? At-Home Recovery benefit will be dropped from all 2010 Medicare Supplement plans

? Medigap Plans E, H, I and J will no longer be available for new sales

? Two new Medigap Plans -Supplement Plan M and Supplement Plan N will be available in June 2010

? Plan G will be modified to increase excess charges from 80% to 100%

? A New Hospice Benefit will be added to all plans

? Insurance carriers will be allowed to offer plans that include New or Innovative Benefits, such as hearing aid benefits or eye wear. They may not include outpatient prescription drug benefits.

Current underwriting guidelines for these new 2010 Modernized Plans allow the application dates to be written 60 days prior to the effective date of coverage. This means that the new Plan M and Plan N can be acquired now.

The new Medicare Supplement Plan M will be standardized as is all the current plans available.

This plan uses what is known in the insurance industry as cost-sharing in an effort to reduce monthly premium costs. You would see a slightly lowered premium, but would split the cost of Medicare Part A deductible ($1,100 in 2010) with the insurance company. This means that your Part A deductible would be $550.

Medicare Supplement Plan M does not cover any of the Medicare Part B deductible. Once you meet this Part B deductible ($155 in 2010) you would not have any co-pay for doctor visits. We think this will in effect reduce this plans monthly premiums by 15% compared to the popular existing Medicare supplement Plan F premiums.

Medicare Supplement Plan M does cover the basic Core Benefits including full coverage for the Part A daily inpatient hospital coinsurance charges, all costs of hospital care after the Medicare benefit is used up, Part B coinsurance charges, the first three pints of blood, and now the Part A hospice coinsurance charges for palliative drugs and has the foreign travel emergency benefits. Hospice care is included (as it is in all Medicare Supplement Plans for 2010).

Take a close look at Plan N. From what I have learned so far, it looks to become one of the most popular plans because of its affordability. Plan N also uses cost-sharing in an effort to reduce monthly premium costs. In order to lower the monthly premium costs, unlike Plan M, Supplement Plan N uses co-pays. Co-payments for doctor visits are $20 and $50 for emergency visits. Currently the co-pay system is set to go into effect after the Medicare Part B deductible is met.

Look for Plan N as a cost effective alternative to Medicare Advantage Plans. It offers a better solution than Medicare Advantage because Plan N has no network restrictions and much lower out-of-pocket liabilities to the client.

Medicare Supplement Plan N has 100% coverage for the Part A inpatient deductible. It does not cover the Part B deductible. Insurance companies are estimating this will in effect reduce this plans monthly premiums by 30% - 35% compared to the popular existing Medicare supplement Plan F premiums.

Medicare Supplement Plan N does cover the basic Core Benefits including full coverage for the Part A daily inpatient hospital coinsurance charges, all costs of hospital care after the Medicare benefit is used up, Part B coinsurance charges, the first three pints of blood, and now the Part A hospice coinsurance charges for palliative drugs and has the foreign travel emergency benefits. Hospice care is included (as it is in all Medicare Supplement Plans for 2010).

It's almost impossible to call all the insurance companies that offer Medicare Supplement Plans in your state to find the best prices on premiums. Your best bet is to contact a company that can find the best prices among all the insurance companies that service your area. One such source would be http://www.medigap4seniors.com

Senate Republicans Examining Health Reform's Effect On Medicare Advantage

Topics: Delivery of Care, Medicare, Politics, Health Reform

Sep 27, 2010

The Hill: "A quartet of Senate Republicans is calling on Medicare's top accountant to release the numbers behind his analysis of health reform's impact on the Medicare Advantage (MA) program. The lawmakers ... say the steep cuts to MA under the new reform law will cause many plans to fold, while many others will be forced to drop benefits to remain profitable. In April, Richard Foster, chief actuary at the Centers for Medicare and Medicaid Services (CMS), issued a report that largely supported those claims.  … The letter [to Foster] arrived just a few days after the Obama administration announced that enrollment in MA plans is projected to jump 5 percent next year, while average premiums will fall by 1 percent. Those figures, CMS officials said, belie the charges that the new law will cut benefits and hike costs" (Lillis, 9/27). 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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Medicare Advantage Plans Draw Attention

News outlets examine several issues dealing with Medicare Advantage plans.

The Boston Globe: "Harvard Pilgrim Health Care has notified customers that it will drop its Medicare Advantage health insurance program at the end of the year, forcing 22,000 senior citizens in Massachusetts, New Hampshire, and Maine to seek alternative supplemental coverage." The reason is that federal reimbursements for such plans have been frozen, and Harvard's particular Advantage product, a private fee-for-service plan, would have to develop a network of contracted providers for the first time under the new rules (Weisman, 9/28).

Also in Advantage news, PolitiFact examines a claim by former New York governor and health overhaul repeal advocate George Pataki that Florida seniors get a special deal on planned Medicare Advantage cuts. The conclusion: Pataki is wrong. "Congress is scaling back the payments to Medicare Advantage plans to bring them more in line on average to what is paid in Medicare. But it's too soon to say what that means for the average senior in various parts of the country while the reductions are being phased in over a few years" (Sherman, 9/28).

In other Medicare news, Crain's Detroit Business reports, "A pilot project begun last year to reduce hospital readmissions is being expanded this month to all of Michigan's 144 hospitals, according to the Michigan Health and Hospital Association. The purpose of the four-year study — called the State Action on Avoidable Rehospitalizations, or MISTAAR — is to reduce avoidable readmissions by 30 percent, save millions of dollars in unnecessary costs and improve quality and patient safety" (Greene, 9/27).

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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Bloomberg Analysis Finds 'Doughnut Hole' Deal To Cost Drugmakers Less Than 1% Of Profits

News outlets report how closing the Medicare 'Doughnut Hole' affects drugmakers and seniors.

Bloomberg: "Drugmakers led by Pfizer Inc., AstraZeneca and Bristol-Myers Squibb Co. may provide more than $2 billion in drug discounts to senior citizens next year under a deal pharmaceutical companies made with the White House, according to data compiled by Bloomberg." The data came from a recent report released by Medicare. "Pfizer, the world's largest drug company, will cede less than half of 1 percent of its $50 billion in annual revenue under the arrangement." Les Funteyder, a health care analyst in New York, calls it "a good deal for pharma."

The arrangement "provides Medicare beneficiaries who fall into a coverage gap known as the 'doughnut hole' 50 percent off brand-name medications. Worldwide sales by brand-name drugmakers in 2008 totaled $288 billion, according to data from the drug industry's trade association." As part of the deal struck between Democrats and drugmakers, "In return for providing the price breaks and other concessions, pharmaceutical companies avoided policies such as allowing importation of drugs and having the government negotiate drug prices for Medicare beneficiaries" (Armstrong, 10/1).

In a reported column, NorthJersey.com explains the seniors' perspective: "Over time, the Affordable Care Act will close the doughnut hole entirely. In 2011, pharmaceutical companies will provide a discount of 50 percent on brand-name drugs to low- and middle-income beneficiaries who find themselves in the gap. Then, the doughnut hole itself will shrink a bit every year, ultimately disappearing entirely in 2020. But for starters, doughnut-hole victims get a one-time, tax-free $250 rebate check this year" (Miller, 10/1).

Meanwhile, in a second story, Bloomberg reports that "Wal-Mart Stores Inc., the world's largest retailer, said it will team with health insurer Humana Inc. to offer the cheapest prescription drug plan in the U.S., as the companies seek to take sales of medications from rivals. The companies will begin marketing the plan today to Americans in Medicare ..., William Fleming, a Humana vice-president, said in a conference call yesterday. The policies, which take effect Jan. 1, will cost $14.80 a month, less than half the average premium this year, and will boost sales for both companies" (Nussbaum and Boyle, 10/1).

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.

View the original article here