I just posted information about changes to the tobacco cessation counseling preventive service, and in the interests of completeness should also post info on this rather new screening service.
Medicare will cover, as a preventive screening service, an annual test for HIV (human immunodeficiency virus). While this test is targeted at those at high risk for HIV, it is available to any beneficiary who asks for it. This was done so that beneficiaries do not have to respond to questions about their sex life or drug use to get the test.
In addition, as it is strongly recommended that all pregnant women be routinely screened, more frequent HIV testing is available for pregnant beneficiaries. Specifically, this test is covered when they are first found to be pregnant, during their third trimester, and at labor.
As with any lab test, the Part B deductible and coinsurance do not apply.
Interestingly, unlike a most other screening services, this test is covered under both Part A and Part B, so if you have it as a hospital inpatient, for example, you are a woman in labor and have been admitted to a hospital, it is covered under your Part A stay.
Monday, August 30, 2010
Thursday, August 26, 2010
Tobacco Cessation Counseling
A Centers for Medicare & Medicaid Services decision has just expanded Medicare coverage of Tobacco Cessation Counseling.
Specifically, Medicare will now cover tobacco cessation counseling for Medicare beneficiaries who use tobacco, regardless of whether the patient has signs or symptoms of tobacco-related disease. The counseling may be provided by a physician or other Medicare-recognized practitioner. Medicare's decision to expand this coverage is based on evidence showing that stopping the use of tobacco, at any age, is highly beneficial.
This coverage decision expands not only (1) what is covered (it used to be “smoking cessation,” now it is “tobacco cessation,” which includes smoking, chewing, and so forth); and, (2) which beneficiaries are covered (it used to be that you had to have a disease that is caused or complicated by tobacco use, or took a medicine that is affected by tobacco usage; now any beneficiary who uses tobacco may receive the service).
This benefit will cover two individual tobacco cessation counseling “attempts” per 12-month period. Each attempt may include up to four “sessions,” with a total annual benefit thus covering up to eight sessions. The sessions in each attempt may be either intermediate (more than three minutes) or intensive (more than ten minutes). This is identical to the old benefit.
It will be subject to the Part B deductible and coinsurance this year, but will fall under the Health Care Reform rule that preventive services will be paid 100% by Medicare effective January 1, 2011.
Specifically, Medicare will now cover tobacco cessation counseling for Medicare beneficiaries who use tobacco, regardless of whether the patient has signs or symptoms of tobacco-related disease. The counseling may be provided by a physician or other Medicare-recognized practitioner. Medicare's decision to expand this coverage is based on evidence showing that stopping the use of tobacco, at any age, is highly beneficial.
This coverage decision expands not only (1) what is covered (it used to be “smoking cessation,” now it is “tobacco cessation,” which includes smoking, chewing, and so forth); and, (2) which beneficiaries are covered (it used to be that you had to have a disease that is caused or complicated by tobacco use, or took a medicine that is affected by tobacco usage; now any beneficiary who uses tobacco may receive the service).
This benefit will cover two individual tobacco cessation counseling “attempts” per 12-month period. Each attempt may include up to four “sessions,” with a total annual benefit thus covering up to eight sessions. The sessions in each attempt may be either intermediate (more than three minutes) or intensive (more than ten minutes). This is identical to the old benefit.
It will be subject to the Part B deductible and coinsurance this year, but will fall under the Health Care Reform rule that preventive services will be paid 100% by Medicare effective January 1, 2011.
Monday, August 23, 2010
The 2011 Medicare Part D Benefit Structure
The good news is that the Centers for Medicare & Medicaid has announced that based on their review of the Part D drug plans proposed “bids” for 2011, that the monthly premiums that beneficiaries will have to pay will rise only by about $1 a month. And while it won’t be until next month that the specifics on what plans will be available, what their formularies will be, and what their premium and benefit structure will be, we now know what the Part D benefit will look like in 2011. And while much of the structure (and even the dollar amounts associated with it) will look very much like 2010’s, the Health Care Reform legislation has radically changed one “band” of the benefit – the 100% coinsurance band where the beneficiary pays all of the cost of their drugs, also known as “the donut hole.” It is being partly plugged in a way which will delight beneficiaries who ever have fallen into it. Here is the 2011 structure:
Recommended Part D Benefit Structure for 2011
Annual Deductible Band (from $0 to $310) The beneficiary pays $310.00 and Medicare, nothing. Many plans have no or a lower deductible
25% Coinsurance Band (from the deductible to $2,240 add’l) The beneficiary pays $632.50 (25%) and Medicare pays $1,897.50 (75%) of the next $2,240.
Total Spending to this point is $2,840.00, of which the beneficiary has paid $942.50 and Medicare, $1,897.50. This $2,840 is called the "initial coverage limit”
Donut Hole – the beneficiary is responsible for an additional $3,607.50, while the Medicare responsibility varies.
At this point, the beneficiary goes into the “donut hole,” but it is very different from 2010 and previous years. Once a total of $2,840 has been spent on drugs, Health Care Reform legislation provides that:
For brand name drugs, the manufacturer has to give a discount of 50% off the price of the drug itself, and the beneficiary has to pay the remaining 50%, plus any dispensing fee.
For generic drugs, the government will pay 7 percent of the cost of the drug itself. The beneficiary pays the other 93 percent, plus the dispensing fee.
The beneficiary will remain in the donut hole until all their drug expenses total $4,550. This includes their deductible, anything they spent in the 25% coinsurance band and in the donut hole, plus whatever the dollar amount of the discounts that drug manufacturers had to give them on brand name drugs while they were in the donut hole. (But not the amount the government paid for generics in the donut hole.)
While it will be different for every beneficiary, it is likely that a beneficiary will actually have to spend perhaps $1,900 or $2,000 out-of-pocket while in the donut hole to get out of it, as the 50% manufacturers' discount will count toward their spending.
And once the beneficiary has reached their $4,550 drug expense total (this is called the "out-of-pocket threshold") the beneficiary goes into the:
Catastrophic Band and is responsible for 5% of their drug costs, and Medicare, 95%.
That is, in the catastrophic band, the beneficiary will be responsible for 5% for the total cost of each drug they receive, and Medicare, 95%, without any upper limit to the total spending on their drugs. In addition, the minimum amount a beneficiary must pay in catastrophic phase remains the same as 2010: $2.50 for generics and $6.30for brand name drugs.
And you may note that the deductible and the “out-of-pocket” threshold are the same as they were in 2010, and the initial coverage limit is only $10 more. Finally, the "base beneficiary premium" will be $32.34 in 2011 (compared to $31.94 in 2010); this means that the monthly penalty amount will stay at $0.32. That is, you will have to pay a penalty of 32 cents for each month you were not in Part D that you could have been.
Recommended Part D Benefit Structure for 2011
Annual Deductible Band (from $0 to $310) The beneficiary pays $310.00 and Medicare, nothing. Many plans have no or a lower deductible
25% Coinsurance Band (from the deductible to $2,240 add’l) The beneficiary pays $632.50 (25%) and Medicare pays $1,897.50 (75%) of the next $2,240.
Total Spending to this point is $2,840.00, of which the beneficiary has paid $942.50 and Medicare, $1,897.50. This $2,840 is called the "initial coverage limit”
Donut Hole – the beneficiary is responsible for an additional $3,607.50, while the Medicare responsibility varies.
At this point, the beneficiary goes into the “donut hole,” but it is very different from 2010 and previous years. Once a total of $2,840 has been spent on drugs, Health Care Reform legislation provides that:
For brand name drugs, the manufacturer has to give a discount of 50% off the price of the drug itself, and the beneficiary has to pay the remaining 50%, plus any dispensing fee.
For generic drugs, the government will pay 7 percent of the cost of the drug itself. The beneficiary pays the other 93 percent, plus the dispensing fee.
The beneficiary will remain in the donut hole until all their drug expenses total $4,550. This includes their deductible, anything they spent in the 25% coinsurance band and in the donut hole, plus whatever the dollar amount of the discounts that drug manufacturers had to give them on brand name drugs while they were in the donut hole. (But not the amount the government paid for generics in the donut hole.)
While it will be different for every beneficiary, it is likely that a beneficiary will actually have to spend perhaps $1,900 or $2,000 out-of-pocket while in the donut hole to get out of it, as the 50% manufacturers' discount will count toward their spending.
And once the beneficiary has reached their $4,550 drug expense total (this is called the "out-of-pocket threshold") the beneficiary goes into the:
Catastrophic Band and is responsible for 5% of their drug costs, and Medicare, 95%.
That is, in the catastrophic band, the beneficiary will be responsible for 5% for the total cost of each drug they receive, and Medicare, 95%, without any upper limit to the total spending on their drugs. In addition, the minimum amount a beneficiary must pay in catastrophic phase remains the same as 2010: $2.50 for generics and $6.30for brand name drugs.
And you may note that the deductible and the “out-of-pocket” threshold are the same as they were in 2010, and the initial coverage limit is only $10 more. Finally, the "base beneficiary premium" will be $32.34 in 2011 (compared to $31.94 in 2010); this means that the monthly penalty amount will stay at $0.32. That is, you will have to pay a penalty of 32 cents for each month you were not in Part D that you could have been.
Thursday, August 19, 2010
$250 Rebate Checks
Back in May, I blogged about the $250 rebate check that Part D Medicare beneficiaries will get when they hit the “donut hole” (the Part D “coverage gap”) with their prescription drug expenses this year, 2010. This is the first step in plugging the donut hole, which will eventually be fully accomplished in 2020 by the Health Care Reform legislation.
The Centers for Medicare & Medicaid has just released some information on how this rebate program is going. As of the end of July, almost 400,000 of these checks have gone out, and they project about 670,000 more will go out in August. Up ‘til now they have released checks on a monthly basis, but this will be stepped up to a twice-a-month basis this month, August, and be kept at this level until the end of the year. And don’t worry, if you don’t hit the donut hole until late this year, or you check was delayed for some reason, they will still be mailing the checks out next year for those who hit the donut hole in 2010.
The Centers has further indicated that if you expected this check but haven’t received it, you should call your Part D Drug Plan (or your Medicare Advantage Plan, if you get your Part D prescriptions through it) as most issues can be resolved at this level. For example, you may have thought you reached the donut hole, but have not actually done so as of yet. It further advises that if you are in fact due the check, and your Plan has told you that they have transmitted this information to Medicare, and your correct mailing address is on file with the Social Security Administration, that you should wait four months after you actually hit the donut hole to contact 1-800-MEDICARE to resolve the problem. However, Medicare indicates that the program seems to be working pretty smoothly; you just may need to be a bit patient.
And, as was inevitable, scamsters and con artists have gotten into the act, and have been calling Medicare beneficiaries promising to get them their rebate check if they give them their bank account, Social Security, Medicare and other personal information. Do not do this under any circumstances; if someone calls you telling you they can get you your rebate check, slam your phone down and report this immediately to 1-800-MEDICARE.
Again, I would appreciate hearing from anyone about their experiences getting their rebate. I will soon blog about the next step in plugging the donut hole, which will take place in 2011.
The Centers for Medicare & Medicaid has just released some information on how this rebate program is going. As of the end of July, almost 400,000 of these checks have gone out, and they project about 670,000 more will go out in August. Up ‘til now they have released checks on a monthly basis, but this will be stepped up to a twice-a-month basis this month, August, and be kept at this level until the end of the year. And don’t worry, if you don’t hit the donut hole until late this year, or you check was delayed for some reason, they will still be mailing the checks out next year for those who hit the donut hole in 2010.
The Centers has further indicated that if you expected this check but haven’t received it, you should call your Part D Drug Plan (or your Medicare Advantage Plan, if you get your Part D prescriptions through it) as most issues can be resolved at this level. For example, you may have thought you reached the donut hole, but have not actually done so as of yet. It further advises that if you are in fact due the check, and your Plan has told you that they have transmitted this information to Medicare, and your correct mailing address is on file with the Social Security Administration, that you should wait four months after you actually hit the donut hole to contact 1-800-MEDICARE to resolve the problem. However, Medicare indicates that the program seems to be working pretty smoothly; you just may need to be a bit patient.
And, as was inevitable, scamsters and con artists have gotten into the act, and have been calling Medicare beneficiaries promising to get them their rebate check if they give them their bank account, Social Security, Medicare and other personal information. Do not do this under any circumstances; if someone calls you telling you they can get you your rebate check, slam your phone down and report this immediately to 1-800-MEDICARE.
Again, I would appreciate hearing from anyone about their experiences getting their rebate. I will soon blog about the next step in plugging the donut hole, which will take place in 2011.
Monday, August 9, 2010
Changes to the January - March Open Enrollment
I was recently talking with some SHIP counselors where I do volunteer counseling for Medicare, and learned that a significant change will take place early next year, 2011, to the so-called “Open Enrollment Period.” (See page 121, section 2.5.) The current rule allows a beneficiary, in the first three calendar months of a year, to go from Original Medicare into Medicare Advantage, or vice-versa, or even change their Medicare Advantage Plan, AS LONG AS THEY DO NOT CHANGE THEIR PART D STATUS. (It’s a little complicated, but Table 14 on page 122 simplifies all the details. And don’t confuse it with the Annual Coordinated Election Period (also called the Annual Coordinated Enrollment Period), which runs from November 15 to December 31 of each year.)
I understand that beginning in 2011, the only changes which beneficiaries will be allowed to make are to go from a Medicare Advantage Plan to Original Medicare. And if a beneficiary does this, they may also join a Part D stand-alone prescription drug plan, and they can do this even if the Medicare Advantage plan they left did not have Part D coverage.
On the one hand, this takes away some of the complexity of the Open Enrollment Period. But also negates a beneficiary’s ability, if they quickly find out that they do not like their Medicare Advantage Plan, to switch to another. For example, they may have been in a Plan, but used the Annual Election Period to go to a new Plan. Maybe to help avoid a big premium hike. But in January they found their new Plan very much not to their liking. Their only choice is to go back to Original Medicare, not back to their old Plan.
But at least they will have the opporunity to enroll in Part D if they had not done so.
What’s worse is that the new Open Enrollment Period will last only until February 14, 2011. You won’t have three months to make a change, only six weeks or so. And so your opportunity to decide if you like your new situation is extremely limited. In fact, it will no longer be called the “Open Enrollment Period,” but the “Annual Disenrollment Period.”
Stay tuned on this as the details are announced. But it seems to me that the clear implication is, that when beneficiaries do their yearly Medicare plan review toward the end of the calendar year, they will have to take extra care in choosing a new Medicare Advantage Plan, and perhaps pay more attention to the quality ratings shown on the Medicare website
I understand that beginning in 2011, the only changes which beneficiaries will be allowed to make are to go from a Medicare Advantage Plan to Original Medicare. And if a beneficiary does this, they may also join a Part D stand-alone prescription drug plan, and they can do this even if the Medicare Advantage plan they left did not have Part D coverage.
On the one hand, this takes away some of the complexity of the Open Enrollment Period. But also negates a beneficiary’s ability, if they quickly find out that they do not like their Medicare Advantage Plan, to switch to another. For example, they may have been in a Plan, but used the Annual Election Period to go to a new Plan. Maybe to help avoid a big premium hike. But in January they found their new Plan very much not to their liking. Their only choice is to go back to Original Medicare, not back to their old Plan.
But at least they will have the opporunity to enroll in Part D if they had not done so.
What’s worse is that the new Open Enrollment Period will last only until February 14, 2011. You won’t have three months to make a change, only six weeks or so. And so your opportunity to decide if you like your new situation is extremely limited. In fact, it will no longer be called the “Open Enrollment Period,” but the “Annual Disenrollment Period.”
Stay tuned on this as the details are announced. But it seems to me that the clear implication is, that when beneficiaries do their yearly Medicare plan review toward the end of the calendar year, they will have to take extra care in choosing a new Medicare Advantage Plan, and perhaps pay more attention to the quality ratings shown on the Medicare website
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