Medicare Supplement Insurance Helps With Expenses Not Covered by Medicare

Just when you are ready to relax and enjoy retirement, you realize that medical insurance has become even more complicated. You're presented with Medicare Advantage Insurance, Medicare Supplement Insurance (also called Medigap Insurance), and Medicare Part A, B, and D. What's it all mean?

Let's Start at the Beginning

Medicare is divided into four parts. Part A deals with home health care, hospice, hospital, and skilled nursing care. Part B handles doctors' services, other medical services, and supplies not covered by Part A. Part C allows you to receive Medicare benefits through private health insurance (Medicare Advantage Insurance) in place of Parts A and B. Part D provides prescription drug coverage.

What Is Medicare Advantage Insurance?

With a Medicare Advantage Plan, generally all of your Medicare-covered health care is provided through that plan, which can include prescription drug coverage. These plans may offer more benefits, and lower co-payments than Medicare Part A and B.

Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), private Fee-for-Service Plans, and Medicare Special Needs Plans.

Private Fee-For-Service plans are offered by state-licensed risk-bearing entities with yearly contracts to provide Medicare benefits. They may also offer additional benefits, and do not usually require you to use a network of providers.

Special Needs Plans focus on certain vulnerable groups, such as those who are institutionalized, are dual-eligible, and/or have severe or disabling chronic conditions.

What Are HMOs?

Doctors, hospitals, and insurers participate in HMOs, which provide medical treatment on a prepaid basis. HMO members pay a fixed monthly fee regardless of how much care is needed in a given month. Most HMOs provide a wide variety of services, but members must usually obtain medical treatment from in-network facilities and physicians.

With HMOs, you must see a primary care physician before you can see a specialist. Rather than paying a percentage of the bill every time you receive medical care, you pay a fixed monthly fee, and HMOs often have nominal co-payments rather than deductibles. HMOs generally do not limit lifetime benefits, but will not pay for non-emergency care from a non-HMO physician.

What Are PPOs?

PPOs are made up of doctors and/or hospitals that provide medical services only to a specific group or association at discounted rates. PPO members pay for services as they are rendered, and are generally reimbursed for treatment costs minus co-payment percentages. Physicians may submit bills directly to insurance companies so members pay only a co-payment.

PPO members are not required to seek care from PPO physicians, but members may receive 90-percent reimbursement for in-network care as opposed to 60 percent for non-network treatment. PPOs may also require a deductible. You may have to fill out paperwork for reimbursement, and most PPOs have larger co-payments than HMOs.

You must have Medicare Part A and B to join a Medicare Advantage Plan. You will have to pay a monthly Part B premium, and may also have a monthly premium for the Medicare Advantage Plan for the extra benefits it offers.

When you join a Medicare Advantage Plan, your Medicare Supplement Insurance or Medigap Insurance will not pay co-payments, deductibles, or other cost sharing under your Medicare Health Plan.

What Is Medigap Insurance?

If you do not have a Medicare Advantage Plan, Medigap Insurance can cover expenses that Medicare does not cover. When you have Medicare and a Medigap policy, both pay their share of covered health care costs.

Medigap policies must have standardized benefits, but costs can vary. You may be able to choose up to 12 different Medigap policies (Plans A through L), which have different sets of basic and extra benefits. The benefits of any Medigap Plan (A through L) are the same for every insurance company, and companies choose which policies to offer.

Generally, you must have Medicare Part A and B to buy Medigap Insurance. You will pay a monthly Part B premium, and a premium for the Medigap policy. Medigap Insurance will not cover your spouse, so you both need separate policies.

With some basic insight into how Medicare works, you can select the Medicare Advantage Insurance or Medicare Supplement Insurance that best fits your needs. If you have questions, expert advisors are available online to answer questions, and explain terms. These types of plans can make your retirement more secure so take advantage of sources that can answer your questions before you need Medicare.

By Wiley Long - President, MedigapAdvisors.com - The nation's leading independent agency specializing in Medigap coverage. Our professional medigap advisors will help you choose the best Medigap plan for your needs.

Medicare Reimbursement Cuts - A Policy Perspective

This article will evaluate the challenges associated with Medicare reimbursement cuts. The amount of expenditure in this program has skyrocketed since its inception in 1965 despite various measures to control growth. Short-term legislative fixes have been buying time for the development of long-term solutions while various stakeholders stand to win and lose as they are faced with forthcoming reimbursement cuts. Among these stakeholders are the federal government, politicians, third-party payers, Medicare recipients, and healthcare providers. Foreseeable problems exist in implementing reimbursement cuts including barriers to patient care and the financial viability of healthcare providers who rely on Medicare patient revenues. Continual debate over short-term Medicare cuts will be eclipsed by policy changes related to the viability of the program and long-term sustainable healthcare funding and delivery systems.

Introduction

Health care spending currently accounts for 16% of the gross domestic product of the United States (Getzen, 2007). New technology and higher incomes have increased overall healthcare spending and driven up costs. The question raised, is how health care expenditure will be controlled within government programs like Medicare. The formation of Medicare and Medicaid by the Social Security Acts of 1965 established the government as a major payer in health care. Regular reimbursement through government funding allowed hospitals and other institutions to grow in size, capacity, and capital. Controlling growth and costs has become a major concern as proportional expenditure on healthcare has increased. Of the various cost-containing measures employed to control expenditure, reimbursement cuts are some of the most contentious issues.

Background and Significance

Medicare has evolved in numerous ways since its inception in 1965. Physicians were initially reimbursed by the program for services covered and were able to bill patients for non-covered costs. Hospital reimbursement methods also followed similar patterns until a change was made in 1983 from "reasonable cost" to the prospective payment system based on diagnostically-related groups. In 1992 the physician fee schedule replaced the charge-based system. The Sustainable Growth Rate (SGR) of 1998 was created to control spending even further. Annual targets for spending are established and physician payments are reduced if spending exceeds these limits.

The bulk of today's Medicare costs are different than those of the past. A larger portion of expenditure is attributable to outpatient services covered by Part B of Medicare. This expenditure has consistently exceeded the established formula as specified in the SGR. Forthcoming adjustments in the form of reimbursement cuts propose major problems for physicians receiving reimbursements for services rendered to their Medicare patients. "Whereas over the next several years the SGR formula will cut doctors' reimbursement by an estimated 25 to 35 percent...[and] deep cuts in physician reimbursement will force many doctors out of the Medicare program and leave many patients without access to a physician (H.R. 863 IH, 2007)." These cuts will have a significant impact on physicians and hospitals, and may exacerbate healthcare access barriers to Medicare recipients. New reimbursement cuts are especially troubling in light of evidence that the expansion of Medicare reimbursements to new areas of care can benefit patient health (Gross et al., 2006). The types and amounts of cuts to be made are largely dependent on legislation and actions on Capitol Hill.

Legislation

Legislative action on Medicare cuts is ongoing. A recent (February 14th, 2008) amendment was proposed in the House of Representatives to adjust conversion factors in Part B of title XVIII of the Social Security Act, increasing Medicare payments for physicians' services through December 31, 2009. These adjustments are temporary fixes in the challenge to create long-term solutions: "The purpose of this Act is to allow adequate time for Congress to determine an appropriate long-term solution for Medicare physician reimbursement rates (H.R. 5445 IH, 2008)." Legislative fixes are influenced by the various groups that are potentially affected by these cuts. Language in these resolutions seems to indicate this. A resolution on December 11th, 2007 in the House expresses the sentiment "...that the Medicare physician payment system must be immediately reformed in a long-term manner in order to stabilize Medicare payment to doctors, return equity to the program, and ensure that Medicare patients have access to a doctor of their choice (H.R. 863 IH, 2007)." Congress is continuously tuning reimbursement-related legislation to slow uncontrolled growth while appeasing powerful constituencies and interest groups.

The executive branch also plays a major roll in the determination of alternate Medicare cuts. The Bush Administration recently proposed a measure to control the explosive growth in the program. On February 18th, 2008, "the Bush administration...submitted a measure to Congress to reduce Medicare spending by increasing prescription drug plan premiums for higher-income beneficiaries and by increasing the use of health information technology, such as electronic health records, among other provisions (Carey, 2008, p.1)." This move was triggered by a condition of the 2003 Medicare law. When a financial warning is issued by Medicare trustees the administration is mandated to submit legislation reducing program spending or increasing revenue. "The warning is issued when trustees for two consecutive years predict that federal general fund revenue must be used to pay for 45% or more of total Medicare costs within seven years (Carey, 2008, p.1)." Monies required to pay for Medicare exceed allotted funds and the program's encroachment on other fund sources is closely monitored.

Stakeholders

Among the major stakeholders in this issue are the federal government, politicians, third-party payers, Medicare recipients, physicians and hospitals.

The federal government stands to win by moderating uncontrolled growth in the Medicare program. In recent years total expenditure and federal reimbursement has exceeded target rates. "By the 2000-2004 period, society was willing to devote over 20 percent of the cumulative increase in GDP and the cumulative increase in Federal outlays towards health care (Hartman, Smith, Heffler, & Freeland, 2006, p.41)." The growing size of Medicare threatens to encroach on other fund sources and programs. It is in the best interest of the federal government to reform Medicare and keep expenditure within manageable boundaries. Despite the benefits involved in implementing cuts, the types of cuts which are made have the potential for backlash. Cuts to reimbursements are exceptionally contentious in the healthcare community. The federal government must seek and implement responsible controls to mitigate harm while effectuating reform.

Politicians are another group affected by policies on reimbursement cuts. Their role is fairly complex as their duties and functions are reflective of the competing interests of different populations, groups, and political parties. Expenditure reduction and reimbursement cuts affect a wide range of constituents in different manners. The role of Medicare reimbursement cuts in political decision-making depends on how these groups are impacted. Politicians may win or lose depending on how the effects of these cuts unfold. The amount of healthcare lobbying that takes place on Capitol Hill speaks to the magnitude of interests involved.

Third party payers are heavily influenced by Medicare reimbursement methodologies. Medicare reimbursement cuts may likely equate to reimbursement cuts by other third-party payers, thus exacerbating many of the problems experienced by healthcare providers. Significant resentment already exists from problems associated with current reimbursements models and additional cuts may hurt payers in the short-run. In the long-run payers will benefit from moderated expenditure and more stable growth rates.

Medicare recipients are another prime group affected by cuts. A major concern associated with reimbursement cuts is the reduction of benefits and programs to these recipients. Technological advancement has provided patients with a vast array of services, procedures, and pharmaceuticals. Benefit and program cuts may translate into a reduction of these features which they have become reliant on. Reimbursement cuts may also contribute to barriers in accessing care. Lower reimbursements from Medicare may lead providers to be less inclined to accept new Medicare patients. Studies have already been conducted on barriers associated with general and specialized care related to payer type. In a study conducted on appointment setting for dermatology patients, "...some access limitations in hot spots where Medicare payments are low relative to commercial insurers suggest that patients in these areas may be most sensitive to further payment reductions (Resneck, Pletcher, & Lozano, 2004, p.85)." The case can be made that additional reimbursement cuts may further expand these "hot spots" for Medicare recipients. Additional barriers may emerge as the expected cuts related to the SGR come to fruition. In the short-term seniors stand to lose from reimbursement cuts but may benefit in the long-run from a more sustainable delivery system that can result from Medicare reform.

Physicians and hospitals stand to lose in the short-term. The healthcare community is at odds with current reimbursements models and believes that further cuts will significantly erode revenues. A study featured in Pain Physician acknowledges that "physicians in the United States have been affected by significant changes in the pattern[s] of medical practice...and escalating healthcare costs have focused concerns about the financial solvency of Medicare (Manchikanti & Giordano, 2007, p.607)." The payment rate cut which was released on July 12th, 2007 includes a 9.9% reduction. Many physician practices and hospitals will be drastically affected but may benefit in the long-run from programs that are moderated in growth and can remain solvent.

Implementation issues

Various groups are involved in seeking solutions to this problem including the Medicare Payment Advisory Commission (MedPAC), the Government Accountability Office, physician and hospital organizations, economists, and other interest groups. The U.S. Senate and House of Representatives are separately working on two different ways to alleviate the inconsistencies in costs and corresponding reimbursements while trying to establish long term sustainable solutions. One of the most significant implementation challenges is the financial fallout to providers relying on reimbursements (physicians, hospitals, and other affected providers). Medicare accounts for a sizeable portion of revenues to some health facilities and healthcare providers. Further reducing reimbursements for services will have a major financial impact and the healthcare community has been especially active in resisting additional cuts. Some of the most vocal groups have been providers and their affiliated interest groups. It is common to find multiple reimbursement-related articles in trade journals and specialty magazines. Certain specialties will be impacted more heavily than others and this is reflective in payment changes by CPT code.

Impact to Medicare recipients is another major implementation issue. Cost-containment may have negative effects on patient access to services and resulting health outcomes, though this is not generalizable across the board. At least one study has shown that health outcomes were not impacted for patients receiving treatment in hospitals affected by past reimbursement cuts (Volpp et al, 2005). Counterintuitive results from studies like this make implementation even more intricate and perplexing. Legislation must be drafted based on truly measurable effects to recipients, providers, and cost-containment goals.

Future direction

Medicare reimbursement reduction is a major policy issue affecting large strata of interests. Within government it is recognized that more time is required to generate sustainable strategies. Balancing long-term objectives with the immediate effects of cuts is a delicate matter. Policymakers will need to make difficult and calculated decisions about efforts to reduce healthcare spending. Some believe that a greater focus on preventive care has the potential to alleviate expenditure trends. A significant portion of current expenditure in Medicare and other programs comes from long-term maintenance of chronic conditions. This trend accounts for a large portion of uncontrolled growth. Medicare reimbursement cuts are merely stop-loss strategies in a losing equation rather than robust long-term solutions. A greater focus on preventive care has the potential to extend the viability of U.S. healthcare systems.

Chris Majdi
Transition Consultants
The practice sales and financing company
http://www.transitionconsultants.com/

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 Disability Benefits Are More Comprehensive When You Enroll in a Medicare Advantage Plan

Medicare benefits are available for people under 65 due to a disability or ESRD (end stage renal disease). If you or someone you know is eligible for Medicare benefits due to a disability, you will have the same benefits as a Medicare beneficiary who is over 65. That is the good news. The bad news is, you may not have as many options for supplemental coverage as the person over 65.

Generally, when you turn 65 and enroll in Medicare, you have three options.

Enroll in Medicare and pay out-of-pocket for the portion of charges that Medicare does not cover.
Purchase a Medicare supplement (Medigap policy) during your open enrollment period.
Enroll in a Medicare Advantage plan that may even include the Part D Medicare drug coverage.

If you are receiving Medicare disability benefits, you can choose the first option and pay the out-of-pocket charges that Medicare does not cover. This will include a hospital deductible, hospital co-pays for extended stays and 20% of the charges for outpatient services. This can be a slippery slope. You are more than likely on a fixed income of SSI and the gaps in Medicare can be unpredictable and potentially financially devastating. Due to the nature of your Medicare eligibility, a qualifying disability, your health care costs may be higher than someone becoming eligible due to turning 65.

The second option, purchasing a Medicare supplement, may not even be available to you. Federal law does not currently require insurance companies to sell you a Medicare supplement if you are younger than 65. Although, some States require companies to do so, it generally means that you will pay a much higher premium than someone who is 65.

A Medicare Advantage plan is available to all beneficiaries, including those receiving Medicare disability benefits. If you have both parts A and B of Medicare, live in the plans service area and do not have ESRD, you are allowed to enroll in a Medicare Advantage plan.

These are the benefits of an Advantage plan for those receiving Medicare disability benefits.

An Advantage plan offers the certainty of fixed costs, including; co-pays, co-insurance and deductibles. The uncertainty of outpatient costs (20%) are eliminated with co-pays and co-insurance.
The premium (if required) is usually a fraction of the premium for a Medicare supplement.
The Part D Medicare drug plan is often included.
Advantage plans often include benefits beyond what Medicare includes. Extras can include dental, vision, hearing, gym memberships, discounts on alternative health services and transportation to and from medical appointments.
A Special Needs Plan may be available for qualifying chronic conditions. These plans include a comprehensive level of managed care related to your health condition.

An Advantage plan can give you a more comprehensive health plan than Medicare alone while costing considerably less than a Medicare supplement. When you compare the choices available to you, it is easy to see that a Medicare Advantage plan has a great deal to offer you if you are receiving Medicare disability benefits.

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

Sign up for your Free Mini-Course on Medicare Plans at http://www.affordablemedicareplan.com/

Medicare and Medicare Advantage Update 2010

Q. What are the changes to Medicare in 2010?

A. Medicare is made up of three parts: Hospital Insurance (Part A), Medical Insurance (Part B), and Drug (RX) Insurance (Part D). Part A Deductible for 2010 is $1,100 for a hospital stay of 1 - 60 days, $275 per day for 61-90 days, and $550 day for 91-150 days of a hospital stay (lifetime reserve days). After 150 days, you pay all costs for the hospital. Part A also includes Skilled nursing facility and some home health care but not long term care. Skilled nursing facilities is subject to a $137.50 per day co-insurance for days 21-100. Part B covers Medicare eligible physician services, outpatient hospital services and certain home health services and durable medical equipment. You pay 20% of the Medicare-approved amount after you meet the $155 deductible.

Part D coverage is for both short and long-term prescription needs not given in the hospital, coverage for both brand name and generic drugs and can differ dramatically from one company to the other. Part D is not deducted from your Social Security check.

Q. Can you explain the difference between a Deductible, co-pay(ment) and out of pocket.

A. The deductible is the amount you must pay for health care before Medicare begins to pay. These amounts can change every year. A co-payment is a partial cost you will spend to see the doctor. These can be zero or more. These are out of pocket which are costs that you must pay on your own because they are not covered by Medicare.

Q. What are the differences in HMO, PPO, PFFS, SNP and MSA plans?

A. Health Maintenance Organizations (HMO)- Just like the private sector, HMO is a group of doctors, hospitals and other care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You get your care from the provider in the plan.

Preferred Provider Organization (PPO)- Doctors, hospitals and providers that belong to the network and with most PPO plans, you can use doctors, hospitals and providers outside the network for an additional cost.

Private Fee for Service (PFFS)- These are sometimes referred to as regional PFFS since the doctor or hospital accepts payments from the insurance plan rather than Medicare. The Insurance plan decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare covered benefits.

Special Needs Plan (SNP) - A type of plan for people with chronic illnesses or conditions with special needs.

Medical Savings Plans (MSA) - A type of savings plan for those people who do not go to the doctor often but need a savings plan to pay some of the costs of the deductibles and co-payments.

Q. My Doctor takes Blue Cross but he does not take Medicare Advantage Blue Cross. What does that mean?

A. Medicare Advantage plans are a hybrid of coverage offered from an insurance company. When you are eligible for Medicare at age 65, you select Part C--Medical Insurance offered by a company. You still pay your premiums out of your social security check for Part B but the government pays the insurance company to administrate the benefits. These Medicare Advantage Plans appear to have many benefits and include Drug coverage (Part D). Medicare Advantage plans are the best of both worlds but they have some drawbacks. If your doctor is not a Medicare Advantage plan doctor, you will pay additional costs to see him/her but with most plans you can see another doctor (usually not available with HMO plan). You will be subject to separate deductibles and separate co-payments and often need a referral for approval before you can get care from the specialist. If you do not get a referral, the plan may not pay for your care.

Q. Since Medicare Advantage provides all Medicare health care through that plan, what if I don't like it? I have heard Doctors payments will be cut and the company I sign up with may stop insuring them. What protection do I have?

A. Since Medicare is a government provided plan for those 65 and older, you have many options for coverage. Every November 15 through December 31 you can switch from one Medicare Option to another--you can enroll in any Medicare Advantage or Part D at this time. This is called the Annual Enrollment Period. (AEP) Your new coverage would begin on January 1. From January 1 to March 31 Medicare members can make ONE plan change to a like kind. For example, you can change to another MA plan. The member CANNOT change Part D coverage during this time unless they have it with the plan they are leaving. This is called Open Enrollment Period (OEP). During Special Enrollment Period (SEP), members must enroll within 63 days of a special event. This is if you move outside the service area, move into or out of a long term care facility, loose credible prescription drug coverage, return to the US from another country or get assistance from the state in which you live, loose coverage under an employer or union either voluntarily or involuntarily.

Q. What other benefits do I get with a Medicare Advantage Plan?

A. You may get extra benefits by selecting a Medicare Advantage Plan. These may include vision, hearing, dental and/or health and wellness program including membership to a specific gym. Because you do not need to buy a Medigap or Medicare Supplement policy, the premium are supplemented by the government and are less expensive than a traditional supplemental plan.

Q. I hear there are many gaps in the Part D (Drug) coverage and I take 5 prescriptions a day. How do I get most of my drugs covered?

A. Every insurance company that offers Part D coverage has a written list of drugs. These include generic and brand name drugs. (Check the web sites or ask your agent for a printed formulary drug book.) Your plan may have several tiers and your co-payment amount depends on which "TIER" your drug is listed. Not all brand names will be covered and these can be very expensive if you have a high copayment or it is not listed. Always ask your doctor whether the drugs prescribed are available as generic. Be sure to ask your doctor whether you can split a high-dose version of the prescribed drugs as

they are often the same price as low-dose version or go to http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C7%7CWinXP&language=English&defaultstatus=0&pagelist=Home&ViewType=Public&PDPYear=2010&MAPDYear=2010&MPDPF%5FMPPF%5FIntegrate=N to compare drug plans in California.

Q. I like what I see--a policy issued by a leading insurance company that does not cost me the same as a Medigap or Medicare Supplement. Why should I buy a Medicare Supplement instead of a Medicare Advantage Policy?

A. That is a good question. If you can afford the individual premiums for a Medicare Supplement with a separate part D, you should do that. You can choose you own doctor as long as that doctor takes Medicare patients. Today many plans are a hybrid and some cost ZERO monthly premium and include a RX plans are also a PPO so people have the freedom of a PPO. As Seniors age, options and benefits become very important and we are here to help you decide which plan is best for you. Be confident in your Medicare Choices.

For the past 30 years, Karen Adams has been an independent insurance agent working primarily in Southern California. She has help hundreds of clients find the right insurance program to meet their needs. Rapidly approaching age 65, she decided to become as knowledgeable as possible about Medicare solutions. "I have written articles about Medicare Supplements and have insured clients who have reached Medicare age. Most Medicare Supplements (MS) are about the same and as long as a doctor takes Medicare he/she must accept the supplement their patient uses (not an HMO plan). Therefore, the advantage from one company over another is how easy they make their payment process, how patient orientated the company is, how large their network of Doctors and the premium they charge for the plan," says Karen. "Then came highly government regulated Medicare Advantage (MA) plans and the ball game changed. Now there is ZERO premiums with Drug coverage. What cost from $200 to $300 a month in premium in a supplement with a prescription drug card now appears to be free. What's that all about? Karen can help you untangle the web of MEDICARE insurance. Call her today or go to http://adamsinsuranceagency.com/ for your personalized quote.

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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Some Minn. Insurers Will End Certain Medicare Plans; Utah Issues Rule On Child-Only Plans; Fla. Law On Pain Clinics Takes Effect

[St. Paul] Pioneer Press: "Five insurance companies including Minnetonka-based Medica next year will stop providing a particular type of Medicare health plan in much of Minnesota, a state official said Thursday. That means some 44,000 beneficiaries will need to shop for new coverage in the coming months. The insurers compete in the market for Medicare Advantage health plans — where some 350,000 state residents buy their coverage — and the companies are dropping a type of Medicare insurance provided through 'private fee-for-service' plans. Beginning next year, private fee-for-service plans must offer care through defined networks of doctors and hospitals. Previously, the plans lacked such networks, and some insurance companies across the country are discontinuing the plans rather than create the networks" (Snowbeck, 9/30).

Salt Lake Tribune: "Utah health insurance companies must offer open enrollment to children twice a year under a new state rule intended to clear up confusion about guaranteed coverage for youngsters. Last month, just as new federal health reform safeguards barred health plans from rejecting children because they're sick, Utah's largest insurers stopped selling child-only plans. Intermountain HealthCare's SelectHealth is accepting children as long as all insurable members of the family are on the same plan. But Regence BlueCross BlueShield and other insurers are refusing to do that. Their reasoning: They're waiting for the state or federal government to define an enrollment period" (Stewart, 9/30).

(Jacksonville) Florida Times-Union: "A Florida law intended to reform pain management clinics and take aim at disreputable 'pill mills' takes effect today amid questions about its effectiveness and potential loopholes that problem pain clinics could slip through. The new law is intended to set standards for the kind of care chronic pain patients can expect when visiting a pain management clinic in the state. The reforms were supposed to be paired in short order with a prescription drug monitoring database, slated by law to begin on Dec. 1, but a bid dispute has put a halt to implementation. The problem is pronounced through Florida, including the Jacksonville area, where 56 pain clinics are registered with the state" (Howard, 10/1).

Medscape: "A long-simmering turf war between anesthesiologists and certified registered nurse anesthetists (CRNAs) across the country erupted this week into a legal battle in Colorado. As it is with healthcare in general, the conflict centers on matters of quality and quantity — quality of care for patients, quantity of dollars for providers. The Colorado Medical Society and the Colorado Society of Anesthesiologists yesterday sued Colorado Gov. Bill Ritter Jr. over his decision, announced earlier in the week, to opt out of a Medicare requirement that a CRNA must work under physician supervision for his or her work to be reimbursed. The Centers for Medicare and Medicaid Services gave states this option in 2001, and Colorado is the sixteenth state to exercise it. Most are Western and Great Plains states, where remote rural hospitals may lack an anesthesiologist to supply the supervision" (Lowes, 9/30).

Kansas Health Institute: "Veterans in rural areas have different health care needs than their urban counterparts and the U.S. Department of Veterans Affairs is working to improve services to them, a Utah doctor said during a conference of the National Rural Health Association. For example, the VA is collaborating with rural, critical access hospitals on the exchange of electronic medical records so that patient records from the VA can be shared with the hospitals closer to veterans' homes and vice versa" (Karash, 9/30).

Florida Tribune: "Gov. Charlie Crist's Cover Florida program was supposed to provide options to uninsured residents seeking health care coverage at an affordable price. But the number of insurance carriers offering the plans is diminishing. United HealthCare stopped selling new Cover Florida policies earlier this month, at least temporarily, said Mary Beth Senkewicz, Office of Insurance Regulation Deputy Commissioner of Life and Health. United Healthcare spokesperson Tracey Lempner said the company stopped selling new plans amid concerns that the low-cost health insurance program conflicts with the insurance reforms contained in the federal health care overhaul known as the Affordable Care Act" (Sexton, 9/30).

The Washington Post: "The red-robed judges of the Maryland Court of Appeals had tough questions Wednesday for Kevin Karpinski, the lawyer representing Montgomery County's Board of Elections, peppering him with openly skeptical queries and comments about why thousands of residents who sought to challenge a county law imposing ambulance fees saw their signatures scratched by elections officials. More than 52,000 people signed a petition to put the ambulance fee before voters Nov. 2, but elections officials, and later a Montgomery Circuit Court judge, blocked the referendum, citing problems with the way people signed their names. Thousands of signatures were junked, for example, because they were illegible" (Laris, 9/30).

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