Some important changes in appeal rights for Medicare beneficiaries who are in Medicare Advantage (managed care) or in Part D of Medicare go into effect on January 1, 2011. (Because Medicare's contracts with Part C and Part D companies are on a calendar year basis, changes typically occur at the begining of each year.) These changes are:
Part C
2011 brings a substantial expansion in the appeal rights of beneficiaries enrolled in managed care. Specifically, whenever any written plan of care, course of treatment, or arrangement for medical services is drawn up for you, your Plan must give you a written notice before it discontinues the services, or reduces their number, or lowers the intensity of the treatment, or changes the mix or range of sessions or services. You can then make a request for an organization determination to reverse this. This, of course, does not in any way affect your right to request such a determination at any time, it just puts the burden of a prior, written notice on the Plan in these cases and reinforces your right to appeal. Previously, beneficiaries had this right only in four specific provider settings (see page 200 of Managing Your Medicare).
Another expansion is that beneficiaries now have the right to make a request for an organization determination orally, and Plans must have a method to properly record and control these. (This does not apply to request for payment for a service already rendered.)
Part D
Beneficiaries now have the right to make a request for a coverage determination orally, and drug plans must have a method to properly record and control these. (This does not apply to request for payment for a drug already received by the beneficiary.)
If a request for a coverage determination for payment for a drug already received is made, the plan must make a decision in 14 (not three) days, and actually make payment, if any is due, within those 14 days.
In Part D, a plan may now give their response to either a fully favorable or to an adverse expedited coverage determination orally, as long as they follow up with a written notice in three days. And the appeals clock starts from the date of the written notice. This also applies to expedited redetermination requests. In either case, if there are conditions which attach to a fully favorable expedited determination or redetermination, the notice must state them in a “readable and understandable form.”
Saturday, December 25, 2010
Saturday, December 4, 2010
Medicare Changes Beginning January 1, 2011
Here is a summary of how Medicare beneficiaries will be directly affected by legislation (principally the Health Care Reform bills) and by regulations that go into effect on January 1, 2011. Many other changes will also kick in on that date, but these are the items that directly affect beneficiaries, broken down by the four parts of Medicare. Note that some other changes will come in 2011, but not until later, and I’ll blog about them at the appropriate time. And this posting doesn’t go into the routine changes, such as the change (usually increases) in deductibles, premiums and limits, which typically occur every calendar year.
PART A
No changes in Part A.
PART B
Preventive Services: A New Service and Changes in Cost Sharing
The most significant change in Part B will be the introduction of an annual “wellness exam” and the elimination of applying the annual deductible or paying coinsurance for many preventive services. If your provider accepts assignment for these services, you will pay nothing for them. But not all preventive services are included.
The new Annual Wellness Exam, also called the Annual Wellness Visit (AWV), is a physical exam which includes a “comprehensive health risk assessment” and a “personalized prevention plan.” The personalized prevention plan (also called Personal Prevention Plan Services or PPPS) takes into account the findings of the health risk assessment and include elements such as: a five- to ten-year screening schedule; a list of identified risk factors and conditions and a strategy to address them; health advice and referral to education and preventive counseling community-based interventions to address modifiable risk factors such as physical activity, smoking, and nutrition.
The exam also includes establishing your medical / family history, routine measurements such as weight, height, blood pressure, and body mass index (BMI), detection of any cognitive impairment, screening for depression, a review of your functional ability, and voluntary advanced care planning, that is, giving you information about advanced directives.
No coinsurance or deductible will apply to this newly covered service.
You can get this exam once every 12 months, but not within first 12 months of Part B enrollment (which is the timeframe in which you can get the “Welcome to Medicare” physical exam). And, because is it very similar, you can‘t get it within 12 months of a “Welcome to Medicare” exam.
Most beneficiaries should immediately schedule one of these exams for 2011 with their physician, as, unless they meet either of the two exceptions above, the sooner they get it, the sooner they can get it in subsequent years. Plus my experience is that it often takes a good deal of time to schedule a physical, so call now for your first date in 2011.
These are the preventive services which, beginning in 2011, will not be subject to the Part B deductible or coinsurance:
“Welcome to Medicare” Physical Exam
Annual Wellness Exam
Abdominal Aortic Screening
Bone Mass Measurement
Flexible Sigmoidoscopy
Colonoscopy
Pelvic Exam and Clinical Breast Exam
Screening Mammogram
Hepatitis B Shot
If you have not gotten these and you are otherwise eligible (the criteria are spelled out in Chapter 4 of Managing Your Medicare) you should take this opportunity to make an appointment in 2011 to get the service.
Note that these preventive services already had no cost sharing, and if you need them, get them right way, don’t wait ‘til 2011:
Cardiovascular Disease Screening (lab test)
Fecal Occult Blood Test (lab test)
Diabetes Screening (lab test)
HIV Screening (lab test)
Pap Smear (lab test)
PSA (lab test)
Flu Shot (including the “swine” flu (H1N1) shot)
Pneumococcal Pneumonia Shot
(Note that lab tests have to be assigned and are not subject to the deductible or coinsurance, but you may have to pay part of the cost of the visit to take the specimen or have the results interpreted.)
These preventive services will continue, in 2011 and beyond, to have the deductible and coinsurance apply, as before, so there is no sense in waiting to avail yourself of them:
Barium Enema
Glaucoma Screening
Diabetic Retinopathy Exam
Digital Rectal Exam
And finally, these “preventive” services, which are counseling and educational services, will continue to be available. Again, you should avail yourself of each that apply to you as soon as possible, both for the sake of your health and so that you can repeat them in the future as permitted:
Beginning with January 1, 2011, neither the deductible not the coinsurance wil apply to these two services:
Tobacco Cessation Services
Medical Nutrition Therapy Services
You will continue to be responsible for the deductible and coinsurance for these two services:
Kidney Disease Education (KDE) Services
Diabetes Self-management Training
[The following applies only to beneficiaries in Medicare Advantage Plans, although all other Part C items are covered in the next section.]
Finally, although there is a general rule in Medicare that whatever benefits must be provided under Original Medicare must also be provided by any Medicare Advantage Plan, it, like all Medicare rules, has exceptions. And the new Annual Wellness Exam and the eliminations of co-payments and deductibles from the nine specific services noted above are exceptions. Medicare Advantage Plans, in 2011, do not have to provide the exam or eliminate the co-payments and deductibles. (This is because their payment rates from Medicare were set before the new Health Care Reform law mandated these changes.) So be sure to check with your Plan or your Evidence of Coverage booklet before you get an exam or use one of these services to find out (1), if your plan covers an annual exam, and (2), for all these services, exactly what your liability will be. Many Medicare Advantage Plans have had more generous preventive benefits that Original Medicare, so your liability may be zero or at least reasonable.
Therapy Cap Exception Process – The “therapy cap exception process,” which generally allows beneficiaries to exceed the dollar amount caps or limits on (1) physical and speech therapy and on (2) occupational therapy will no longer be in effect in 2011. The caps in 2011 will each be $1,870.
Power-Driven Wheelchairs - Power-driven wheelchairs will no longer have the purchase with a lump-sum payment option – rental is mandatory for this piece of durable medical equipment. Medicare will pay for these over a 13-month period. Complex rehabilitative wheelchairs are excluded from this mandate – they continue to have the purchase option.
Medicare Competitive Bidding Program on Durable Medical Equipment Because of a special program Medicare will begin in 2011 to get better prices on durable medical equipment and allied supplies, a number of beneficiares will see significant changes in who can supply these items and how much they will cost. This program will apply only to certain parts of California, Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio, Pennsylvania, South Carolina, and Texas, and then only to certain items of equipment and supplies. So be sure to see my blog posting of 10/11/10 for complete details.
Two cautions: If you don’t reside in the affected areas but visit there and get any of the affected DME items while there, you are subject to this program. And, while this technically involves only those of you in Original Medicare, those of you in Medicare Advantage (Part C) may be affected and you need to carefully check with your Plan before you purchase or rent any of the involved items, but, of course, it’s always wise to do that when you are in Medicare Advantage.)
Renal Dialysis Prospective Payment System – Beginning in 2011 renal dialysis will be paid for under a new payment methodology called a “prospective payment system.” This basically bundles the payment Medicare makes for dialysis into a comprehensive rate. I do not know at this point exactly the effect on beneficiaries, but it appears that some drugs they use will now be paid for under Part B rather than Part D. This may shift some costs to beneficiaries as this service will, of course, be subject to a 20 percent coinsurance, which may be more than what a beneficiary is responsible for under Part D.
Part B Premium Surcharge Incomes Frozen at 2010 Levels – In previous years the income level which subjects a beneficiary to the high income premium surcharge in Part B would automatically rise, but the income levels in effect in 2010 are now frozen for 2011 and future years. Currently about 5 percent of beneficiaries must pay a surcharge, but this will tend to increase as time goes on. Details about the 2010 Part B premium surcharges are in my post of 11/15/10.
PART C
Elimination of the Open Enrollment Period and Inauguration of the Annual Disenrollment Period
In 2011 the Medicare Advantage Open Enrollment Period, which has run from January 1 to March 31 and which allowed you to make a variety of changes to how you got your Medicare, and which Plan you were in, is eliminated. It will no longer be in effect.
In its place is a new Annual Disenrollment Period, which will run only from January 1 to February 14 of 2011 and every year thereafter. During this 45-day period you can make these changes:
You may leave Medicare Advantage (Part C) and go to Original (fee-for-service) Medicare. The change will be effective first day of month following the date you disenroll from your Medicare Advantage Plan.
And, if you do so, you may join a stand-alone Part D drug plan. You will join this drug plan on first day of month following the date the plan gets your enrollment request. Note that you may enroll in a Part D plan whether or not the Medicare Advantage Plan you were in did or did not have Part D drug coverage.
Full information about this change is in my post of 11/28/10.
Establishment of a Maximum Out-of-Pocket Limit While many Medicare Advantage Plans have had a cap on how much a Medicare Advantage enrollee has to pay out-of-pocket each year for Part A and B services, Medicare has now imposed such a limit on most types of Plans. For example, for 2011, this “maximum out-of-pocket” (MOOP) limit is $6,700 for Private Fee for Service (PFFS) Plans. This limit will change each year. As this rule is more than a little complicated, a particular Plan may have a much lower limit, a higher one, or none. And certain Plans may have one limit for in-network services, and another, higher one for in- and out-of-network services combined. But you should consider a Plan with a reasonable limit, as this is a valuable protection you do not have in Original Medicare. These limits can be seen in the Medicare Plan Finder (also called Medicare Compare) on Medicare.gov both in summary and in detail.
If you get your Part D prescription drug coverage through your Medicare Advantage Plan, the cost of your drugs do not count toward this limit, just Part A and B services.
Charge Limitations on Three Specific Types of Services – Beginning in 2011, Medicare Advantage Plans can’t charge a beneficiary more than Original Medicare for three specific types of services:
Chemotherapy
Renal Dialysis
Skilled Nursing Facility (SNF) Care
Be advised that as with everything in Medicare this is more complicated than it looks. For example, a Plan may charge you a Skilled Nursing Facility (SNF) co-payment in the first 20 days of your stay (which Original Medicare does not) as long as actuarially their charges for SNF stays don’t exceed those in Original Medicare.
Clinical Trials and Medicare Advantage – New Rules in 2011
For 2011, the Center for Medicare & Medicaid Services has given Medicare Advantage Plans additional direction on the issue of what they must pay when an enrolled beneficiary receives services in an approved clinical trial, specifically:
1. Plans will be required to reimburse enrollees for the difference between fee-for-service cost sharing incurred for covered clinical trial items and services and the Medicare Advantage Plan’s in-network cost sharing for the same category of service. So if the clinical trial people charge you as if you were in fee-for-service Medicare, you are responsible only for what you would pay under the terms of your Plan’s benefit structure.
2. Starting in 2011, your Medicare Advantage Plan, in adding up all the medical costs which count toward your annual out-of-pocket maximum amount, must include in these medical costs not only what you pay out-of-pocket, but also what it must pay under the new rule above.
And be aware that you do not have to get any pre-authorization or permission from your Plan to join a clinical trial.
These new rules are more fully discussed in my posting of 10/16/10, which also gives information about some billing issues that may arise in clinical trials.
Prohibition on Certain Prior Notification Requirements – “Prior Notification,” the requirement that an enrollee tell their Plan that they will receive a particular service in return for getting a lower co-payment or coinsurance rate, is a form of utilization control in the managed care setting. However, beginning in 2011, this practice will no longer be allowable for Private Fee for Service Plans (PFFS), Medicare Savings Account (MSA) Plans and, for out-of-network services only, for Preferred Provider Organization (PPO) Plans. Prior authorization continues to be unallowable.
PART D
Dramatic Narrowing of the Donut Hole The “donut hole” has been the 100% coinsurance band where you pay all of the cost of your prescription drugs, but it is being narrowed rather substantially. In 2011, once you have satisfied your deductible (Never more than $310.) and have gone through the 25% Coinsurance Band, where you pay 25% and Medicare pays 75% of the next $2,240 in drug costs, you hit the donut hole. In this band you are responsible for an additional $3,607.50, while Medicare’s dollar responsibility varies. However, in 2011:
For brand name drugs, the manufacturer has to give a discount of 50% off the price of the drug itself, and you have to pay the remaining 50%, plus any dispensing fee.
For generic drugs, the government will pay 7% of the cost of the drug itself. You pay the other 93%, plus the dispensing fee.
You will remain in the donut hole until all your drug expenses total $4,550. This includes your deductible, anything you 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 you on brand name drugs while you 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 typical 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 drug spending.
And once you have reached $4,550 drug expense total (this is called the "out-of-pocket threshold") you go into the catastrophic band. Here you are responsible for 5% of you drug costs, and Medicare, 95%, without any upper limit to the total spending on your drugs. The minimum dollar amount you must pay in the catastrophic phase for a [prescription remains the same as 2010: $2.50 for generics and $6.30 for brand name drugs.
Part D Premium Surcharge Begins – Starting with January 2011 and beyond, high-income beneficiaries will be subject to a Part D premium surcharge of from $12.00 to $69.10 per month. The income thresholds are the same as apply to the Part B premium surcharge. My blog of 10/04/10 explains this in detail.
Widened Definition of “True Out-of-Pocket Costs” (TrOOP) Beginning January 1, 2011, drug costs reimbursed by the Indian Health Service (HIS) and by AIDS Drug Assistance Programs (ADAPs, these are funded under the Ryan White Care Act) WILL count toward the TrOOP threshold.
Mandated Coverage of Certain Types of Drugs Part D must cover, not substantially all, but all drugs in these six categories, called “protected classes:”
Anti-Cancer / Antineoplastics
Anticonvulsants
Antidepressants
Antipsychotics
Antiretrovirals (usually used in HIV/AIDS therapy)
Immunosuppressants used following an organ transplant
CMS can allow exceptions only on a case-to-case basis.
PART A
No changes in Part A.
PART B
Preventive Services: A New Service and Changes in Cost Sharing
The most significant change in Part B will be the introduction of an annual “wellness exam” and the elimination of applying the annual deductible or paying coinsurance for many preventive services. If your provider accepts assignment for these services, you will pay nothing for them. But not all preventive services are included.
The new Annual Wellness Exam, also called the Annual Wellness Visit (AWV), is a physical exam which includes a “comprehensive health risk assessment” and a “personalized prevention plan.” The personalized prevention plan (also called Personal Prevention Plan Services or PPPS) takes into account the findings of the health risk assessment and include elements such as: a five- to ten-year screening schedule; a list of identified risk factors and conditions and a strategy to address them; health advice and referral to education and preventive counseling community-based interventions to address modifiable risk factors such as physical activity, smoking, and nutrition.
The exam also includes establishing your medical / family history, routine measurements such as weight, height, blood pressure, and body mass index (BMI), detection of any cognitive impairment, screening for depression, a review of your functional ability, and voluntary advanced care planning, that is, giving you information about advanced directives.
No coinsurance or deductible will apply to this newly covered service.
You can get this exam once every 12 months, but not within first 12 months of Part B enrollment (which is the timeframe in which you can get the “Welcome to Medicare” physical exam). And, because is it very similar, you can‘t get it within 12 months of a “Welcome to Medicare” exam.
Most beneficiaries should immediately schedule one of these exams for 2011 with their physician, as, unless they meet either of the two exceptions above, the sooner they get it, the sooner they can get it in subsequent years. Plus my experience is that it often takes a good deal of time to schedule a physical, so call now for your first date in 2011.
These are the preventive services which, beginning in 2011, will not be subject to the Part B deductible or coinsurance:
“Welcome to Medicare” Physical Exam
Annual Wellness Exam
Abdominal Aortic Screening
Bone Mass Measurement
Flexible Sigmoidoscopy
Colonoscopy
Pelvic Exam and Clinical Breast Exam
Screening Mammogram
Hepatitis B Shot
If you have not gotten these and you are otherwise eligible (the criteria are spelled out in Chapter 4 of Managing Your Medicare) you should take this opportunity to make an appointment in 2011 to get the service.
Note that these preventive services already had no cost sharing, and if you need them, get them right way, don’t wait ‘til 2011:
Cardiovascular Disease Screening (lab test)
Fecal Occult Blood Test (lab test)
Diabetes Screening (lab test)
HIV Screening (lab test)
Pap Smear (lab test)
PSA (lab test)
Flu Shot (including the “swine” flu (H1N1) shot)
Pneumococcal Pneumonia Shot
(Note that lab tests have to be assigned and are not subject to the deductible or coinsurance, but you may have to pay part of the cost of the visit to take the specimen or have the results interpreted.)
These preventive services will continue, in 2011 and beyond, to have the deductible and coinsurance apply, as before, so there is no sense in waiting to avail yourself of them:
Barium Enema
Glaucoma Screening
Diabetic Retinopathy Exam
Digital Rectal Exam
And finally, these “preventive” services, which are counseling and educational services, will continue to be available. Again, you should avail yourself of each that apply to you as soon as possible, both for the sake of your health and so that you can repeat them in the future as permitted:
Beginning with January 1, 2011, neither the deductible not the coinsurance wil apply to these two services:
Tobacco Cessation Services
Medical Nutrition Therapy Services
You will continue to be responsible for the deductible and coinsurance for these two services:
Kidney Disease Education (KDE) Services
Diabetes Self-management Training
[The following applies only to beneficiaries in Medicare Advantage Plans, although all other Part C items are covered in the next section.]
Finally, although there is a general rule in Medicare that whatever benefits must be provided under Original Medicare must also be provided by any Medicare Advantage Plan, it, like all Medicare rules, has exceptions. And the new Annual Wellness Exam and the eliminations of co-payments and deductibles from the nine specific services noted above are exceptions. Medicare Advantage Plans, in 2011, do not have to provide the exam or eliminate the co-payments and deductibles. (This is because their payment rates from Medicare were set before the new Health Care Reform law mandated these changes.) So be sure to check with your Plan or your Evidence of Coverage booklet before you get an exam or use one of these services to find out (1), if your plan covers an annual exam, and (2), for all these services, exactly what your liability will be. Many Medicare Advantage Plans have had more generous preventive benefits that Original Medicare, so your liability may be zero or at least reasonable.
Therapy Cap Exception Process – The “therapy cap exception process,” which generally allows beneficiaries to exceed the dollar amount caps or limits on (1) physical and speech therapy and on (2) occupational therapy will no longer be in effect in 2011. The caps in 2011 will each be $1,870.
Power-Driven Wheelchairs - Power-driven wheelchairs will no longer have the purchase with a lump-sum payment option – rental is mandatory for this piece of durable medical equipment. Medicare will pay for these over a 13-month period. Complex rehabilitative wheelchairs are excluded from this mandate – they continue to have the purchase option.
Medicare Competitive Bidding Program on Durable Medical Equipment Because of a special program Medicare will begin in 2011 to get better prices on durable medical equipment and allied supplies, a number of beneficiares will see significant changes in who can supply these items and how much they will cost. This program will apply only to certain parts of California, Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio, Pennsylvania, South Carolina, and Texas, and then only to certain items of equipment and supplies. So be sure to see my blog posting of 10/11/10 for complete details.
Two cautions: If you don’t reside in the affected areas but visit there and get any of the affected DME items while there, you are subject to this program. And, while this technically involves only those of you in Original Medicare, those of you in Medicare Advantage (Part C) may be affected and you need to carefully check with your Plan before you purchase or rent any of the involved items, but, of course, it’s always wise to do that when you are in Medicare Advantage.)
Renal Dialysis Prospective Payment System – Beginning in 2011 renal dialysis will be paid for under a new payment methodology called a “prospective payment system.” This basically bundles the payment Medicare makes for dialysis into a comprehensive rate. I do not know at this point exactly the effect on beneficiaries, but it appears that some drugs they use will now be paid for under Part B rather than Part D. This may shift some costs to beneficiaries as this service will, of course, be subject to a 20 percent coinsurance, which may be more than what a beneficiary is responsible for under Part D.
Part B Premium Surcharge Incomes Frozen at 2010 Levels – In previous years the income level which subjects a beneficiary to the high income premium surcharge in Part B would automatically rise, but the income levels in effect in 2010 are now frozen for 2011 and future years. Currently about 5 percent of beneficiaries must pay a surcharge, but this will tend to increase as time goes on. Details about the 2010 Part B premium surcharges are in my post of 11/15/10.
PART C
Elimination of the Open Enrollment Period and Inauguration of the Annual Disenrollment Period
In 2011 the Medicare Advantage Open Enrollment Period, which has run from January 1 to March 31 and which allowed you to make a variety of changes to how you got your Medicare, and which Plan you were in, is eliminated. It will no longer be in effect.
In its place is a new Annual Disenrollment Period, which will run only from January 1 to February 14 of 2011 and every year thereafter. During this 45-day period you can make these changes:
You may leave Medicare Advantage (Part C) and go to Original (fee-for-service) Medicare. The change will be effective first day of month following the date you disenroll from your Medicare Advantage Plan.
And, if you do so, you may join a stand-alone Part D drug plan. You will join this drug plan on first day of month following the date the plan gets your enrollment request. Note that you may enroll in a Part D plan whether or not the Medicare Advantage Plan you were in did or did not have Part D drug coverage.
Full information about this change is in my post of 11/28/10.
Establishment of a Maximum Out-of-Pocket Limit While many Medicare Advantage Plans have had a cap on how much a Medicare Advantage enrollee has to pay out-of-pocket each year for Part A and B services, Medicare has now imposed such a limit on most types of Plans. For example, for 2011, this “maximum out-of-pocket” (MOOP) limit is $6,700 for Private Fee for Service (PFFS) Plans. This limit will change each year. As this rule is more than a little complicated, a particular Plan may have a much lower limit, a higher one, or none. And certain Plans may have one limit for in-network services, and another, higher one for in- and out-of-network services combined. But you should consider a Plan with a reasonable limit, as this is a valuable protection you do not have in Original Medicare. These limits can be seen in the Medicare Plan Finder (also called Medicare Compare) on Medicare.gov both in summary and in detail.
If you get your Part D prescription drug coverage through your Medicare Advantage Plan, the cost of your drugs do not count toward this limit, just Part A and B services.
Charge Limitations on Three Specific Types of Services – Beginning in 2011, Medicare Advantage Plans can’t charge a beneficiary more than Original Medicare for three specific types of services:
Chemotherapy
Renal Dialysis
Skilled Nursing Facility (SNF) Care
Be advised that as with everything in Medicare this is more complicated than it looks. For example, a Plan may charge you a Skilled Nursing Facility (SNF) co-payment in the first 20 days of your stay (which Original Medicare does not) as long as actuarially their charges for SNF stays don’t exceed those in Original Medicare.
Clinical Trials and Medicare Advantage – New Rules in 2011
For 2011, the Center for Medicare & Medicaid Services has given Medicare Advantage Plans additional direction on the issue of what they must pay when an enrolled beneficiary receives services in an approved clinical trial, specifically:
1. Plans will be required to reimburse enrollees for the difference between fee-for-service cost sharing incurred for covered clinical trial items and services and the Medicare Advantage Plan’s in-network cost sharing for the same category of service. So if the clinical trial people charge you as if you were in fee-for-service Medicare, you are responsible only for what you would pay under the terms of your Plan’s benefit structure.
2. Starting in 2011, your Medicare Advantage Plan, in adding up all the medical costs which count toward your annual out-of-pocket maximum amount, must include in these medical costs not only what you pay out-of-pocket, but also what it must pay under the new rule above.
And be aware that you do not have to get any pre-authorization or permission from your Plan to join a clinical trial.
These new rules are more fully discussed in my posting of 10/16/10, which also gives information about some billing issues that may arise in clinical trials.
Prohibition on Certain Prior Notification Requirements – “Prior Notification,” the requirement that an enrollee tell their Plan that they will receive a particular service in return for getting a lower co-payment or coinsurance rate, is a form of utilization control in the managed care setting. However, beginning in 2011, this practice will no longer be allowable for Private Fee for Service Plans (PFFS), Medicare Savings Account (MSA) Plans and, for out-of-network services only, for Preferred Provider Organization (PPO) Plans. Prior authorization continues to be unallowable.
PART D
Dramatic Narrowing of the Donut Hole The “donut hole” has been the 100% coinsurance band where you pay all of the cost of your prescription drugs, but it is being narrowed rather substantially. In 2011, once you have satisfied your deductible (Never more than $310.) and have gone through the 25% Coinsurance Band, where you pay 25% and Medicare pays 75% of the next $2,240 in drug costs, you hit the donut hole. In this band you are responsible for an additional $3,607.50, while Medicare’s dollar responsibility varies. However, in 2011:
For brand name drugs, the manufacturer has to give a discount of 50% off the price of the drug itself, and you have to pay the remaining 50%, plus any dispensing fee.
For generic drugs, the government will pay 7% of the cost of the drug itself. You pay the other 93%, plus the dispensing fee.
You will remain in the donut hole until all your drug expenses total $4,550. This includes your deductible, anything you 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 you on brand name drugs while you 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 typical 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 drug spending.
And once you have reached $4,550 drug expense total (this is called the "out-of-pocket threshold") you go into the catastrophic band. Here you are responsible for 5% of you drug costs, and Medicare, 95%, without any upper limit to the total spending on your drugs. The minimum dollar amount you must pay in the catastrophic phase for a [prescription remains the same as 2010: $2.50 for generics and $6.30 for brand name drugs.
Part D Premium Surcharge Begins – Starting with January 2011 and beyond, high-income beneficiaries will be subject to a Part D premium surcharge of from $12.00 to $69.10 per month. The income thresholds are the same as apply to the Part B premium surcharge. My blog of 10/04/10 explains this in detail.
Widened Definition of “True Out-of-Pocket Costs” (TrOOP) Beginning January 1, 2011, drug costs reimbursed by the Indian Health Service (HIS) and by AIDS Drug Assistance Programs (ADAPs, these are funded under the Ryan White Care Act) WILL count toward the TrOOP threshold.
Mandated Coverage of Certain Types of Drugs Part D must cover, not substantially all, but all drugs in these six categories, called “protected classes:”
Anti-Cancer / Antineoplastics
Anticonvulsants
Antidepressants
Antipsychotics
Antiretrovirals (usually used in HIV/AIDS therapy)
Immunosuppressants used following an organ transplant
CMS can allow exceptions only on a case-to-case basis.
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