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Many people in the Medicare program may find themselves lost in a maze of paperwork and unanswered questions. On occasion we post helpful information from Medicare’s website. The Medicare website provides a wealth of information to those that need help understanding the many facets of how Medicare works. Below you will find information about how Medicare works with other insurances. Recently we shared information from the Medicare website that explained the difference between primary and secondary payer. The following information is also from the Medicare website and explains what conditional payments are. We hope you find this information beneficial. To find more useful tools from Medicare, click here to visit their site.

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What’s a conditional payment?

How Medicare recovers conditional payments

Many people in the Medicare program may find themselves lost in a maze of paperwork and unanswered questions. On occasion we post helpful information from Medicare’s website. The Medicare website provides a wealth of information to those that need help understanding the many facets of how Medicare works. Below you will find information about how Medicare works with other insurances. Over the next couple of weeks we will share additional information from the Medicare website regarding conditional payments. We hope you find this information beneficial. To find more useful tools from Medicare, click here to visit their site.

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If you have Medicare and other health insurance or coverage, each type of coverage is called a “payer.” When there’s more than one payer, “coordination of benefits” rules decide which one pays first. The “primary payer” pays what it owes on your bills first, and then sends the rest to the “secondary payer” to pay. In some cases, there may also be a third payer.

What it means to pay primary/secondary

• The insurance that pays first (primary payer) pays up to the limits of its coverage.
• The one that pays second (secondary payer) only pays if there are costs the primary insurer didn’t cover.
• The secondary payer (which may be Medicare) may not pay all the uncovered costs.
• If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay.

Paying “first” means paying the whole bill up to the limits of the coverage. It doesn’t always mean the primary payer pays first in time. If the insurance company doesn’t pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should’ve made.

If you have questions about who pays first, or if your insurance changes, call the Medicare Coordination of Benefits Contractor.

Note: Tell your doctor and other health care providers if you have coverage in addition to Medicare. This will help them send your bills to the correct payer to avoid delays.

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The following information was released by the U.S. Department of Health and Human Services (HHS.gov) on October 25, 2012.

People with Medicare save $4.8 billion on prescription drugs because of the health care law

Over 20.7 million with Medicare also receive free preventive services in the first nine months of 2012  

As a result of the Affordable Care Act, 5.6 million seniors and people with disabilities have saved $4.8 billion on prescription drugs since the law was enacted, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today.  This year alone, 2.3 million people  in the Medicare prescription drug coverage gap known as the “donut hole” have saved an average of $657.  During the first nine months of 2012, over 20.7 million people with original Medicare got at least one preventive service at no cost to them.

This news comes after last month’s estimates that the health care law will save the typical person with original Medicare $5,000 from 2010 to 2022.

“I am pleased that the health care law is helping so many seniors save money on their prescription drug costs,” Secretary Sebelius said. “Medicare is stronger thanks to the health care law, offering new benefits at no cost to seniors.”

The health care law includes benefits to make Medicare prescription drug coverage more affordable. In 2010, anyone with Medicare who hit the prescription drug donut hole received a $250 rebate. In 2011, people with Medicare who hit the donut hole began receiving discounts on covered brand-name drugs and savings for generic drugs. For 2013, people with Medicare in the donut hole will receive about 53 percent on the cost of brand name drugs and a 21 percent savings for the cost of generic drugs. These savings and Medicare coverage will gradually increase until 2020, when the donut hole will be closed. (continue reading…)

The Medicare.gov website provides a wealth of information to those that need help understanding the many facets of how Medicare works. Often we post helpful information from Medicare’s website since many people have questions about their Medicare coverage. Below you will find a chart showing the Medicare Part D montly premiums based on your income. Recently we shared information from the Medicare website regarding Medicare Part A (hospital insurance) costs as well as Medicare Part B (medical insurance) costs in 2012. To find more useful tools from Medicare, click here to visit their site. We hope you find this information beneficial.

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The Medicare.gov website provides a wealth of information to those that need help understanding the many facets of how Medicare works. On occasion we post helpful information from Medicare’s website. Below you will find two charts – one that provides an overview of Medicare Part B monthly premiums and one that provides the costs of Medicare Part B (medical insurance) costs in 2012. Recently we shared information from the Medicare website regarding Medicare Part A (hospital insurance) costs and we will share information about Medicare prescription drug plans (Part D) premiums next week. We hope you find this information beneficial. To find more useful tools from Medicare, click here to visit their site.

Part B Monthly Premium
You pay a Part B premium each month. Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.

If you have questions about your Part B premium, contact Social Security.

Part B Services

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The Medicare.gov website provides a wealth of information to those that need help understanding the many facets of how Medicare works. On occasion we post helpful information from Medicare’s website. Below you will find two charts – one that provides an overview of Medicare monthly premiums and one that provides the costs of Medicare Part A costs in 2012. Over the next couple of weeks we will share information from the Medicare website regarding Medicare Part B (medical insurance) costs as well as Medicare prescription drug plans (Part D) premiums. We hope you find this information beneficial. To find more useful tools from Medicare, click here to visit their site.

Note: If you’re in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those noted above.  Review the Evidence of Coverage from your plan.

The following information can be found at the Medicare.gov.

If your Medicare card is lost, stolen or damaged, you can ask for a new by visiting the Medicare.gov website.

What is a Medicare Card?

• The Medicare card looks like the red, white and blue card shown here.
• Your Medicare card is your proof that you have Medicare health insurance.
• You can use this application only to request a Medicare card. If you need a Medicaid card, please contact your state Medicaid office.

What You Should Know

• Your Medicare card will arrive in the mail in about 30 days.
• It will be mailed to the address Social Security has on file for you.
• If you need proof that you have Medicare sooner than 30 days, you also can request a letter which you will receive in about 10 days.
• If you need proof immediately for your doctor or for a prescription, visit your nearest Social Security office.
• For security reasons, there is a 30 minute time limit to complete each page. You will be given notice when you are about to time out and can get more time to finish.
• You can read more about Social Security’s Internet policy here.

If You Have Moved

• If you have moved and have not reported this to us, you will need to report this change to us before we can process your request.
• If you have moved and have reported this to us recently, you will need to contact us before we can process your request.

Block access to your personal information

If you want to prevent online and automated telephone access to your personal information, you can block access to your personal information.

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The Department of Health and Human Services (HHS) released proposed new rules late last week to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). An ACO is a network of doctors and other health care providers and suppliers that shares responsibility for providing care to patients.

The latest release from the HHS states that,

ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary.

You or someone you know, may have a serious illness and have more than one doctor and taking more than one medication. If so, you have more than likely witnessed how disorganized your doctor’s office is when it comes to your medical information. No one likes to have to repeat the same information at each visit or watching doctors fumble through unsystematic files. It shows just how much our health care system needs to form accurate coordination of information and better communication between health care providers.

Medicare beneficiaries who have five or more chronic conditions suffer the most – and more than have of the Medicare beneficiaries fall into this category. With such serious conditions as diabetes, heart disease and kidney disease, these beneficiaries are very likely to have multiple physicians. These patients are at risk when doctors have failed to coordinate information in their files – so each physician is not sure what the last doctor did or they may not know which medication or dosage was prescribed. This can inevitably lead to the patient not getting the right care they need and there is an increased risk of being prescribed a medication that should not be taken with a medication prescribed by another doctor. It can also lead to complications that require hospitalization – which could have  easily been prevented. A study was conducted on nearly 12 million Medicare beneficiaries which showed that 1 in 5 patients discharged from the hospital was readmitted within 30 days which means if hospitals and doctors were better organized and coordinated with files and communication ”across care settings” , readmission may have been avoided. (continue reading…)

The following information is from Medicare.gov and it covers what Medicare Part D (Medicare Prescription Drug Coverage) is and it provides valuable resources that may answer questions that you have about this complex topic.

Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. There are two ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
2. Medicare Advantage Plans (like an HMO or PPO) are other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”

If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other credible prescription drug coverage, you will likely pay a late enrollment penalty.

How Much Does Medicare Prescription Drug Coverage Cost?

Each plan can vary in cost and drugs covered. The Medicare Drug Plan Finder can help you find and compare plans in your area.

Your Part D monthly premium could be higher based on your income. This includes Part D coverage you get from a Medicare Prescription Drug Plan, or a Medicare Advantage Plan or Medicare Cost Plan that includes Medicare prescription drug coverage. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain amount, you will pay a higher monthly premium.  For more information, visit Social Security’s website.

Many people qualify to get Extra Help paying their Medicare prescription drug costs but don’t know it. Most who qualify and join a Medicare drug plan will get 95% of their costs covered. Don’t miss out on a chance to save. Extra Help and other programs (like Medicare Savings Programs) may help make your health care and prescription drug costs more affordable. (continue reading…)

Banyan Administrators have been providing us with beneficial information about several different aspects of the Health Care Reform and how it affects us. Over the next months and years, employers will be faced with numerous changes, many of which require regulatory clarification. Banyan will continue to keep us up to date and on target with decisions that affect our plans.  Over the past few weeks, Banyan has provided answers to many questions regarding Medicare and how the reform affects you. If you missed the first two articles in this series, make sure to check them out – Article #1 and Article #2. We are sure you will find the information valuable.

The following information is provided by Banyan Administrators:

Arguably the greatest volume of reforms through the Patient Protection and Affordable Care Act (“Affordable Care Act”) signed into law on 03/23/2010 involve Medicare. Some of the provisions are direct reforms to Medicare while other provisions of the Affordable Care Act may have an indirect, but intentional, impact on the program. The following Q&A will give you an overview of the reforms to the Medicare program and how they are all intended to work together.

1.  What are the Medicare Part D reforms?

The first Medicare Part D reform is the closing of the “donut hole”. For Medicare Part D enrollees in 2010, coverage breakdowns as follows: 

• $2,830 – After the enrollee pays the first $310 in drug costs (the deductible), the plan pays 75% of the drug cost up to $2,830 with the enrollee paying the other 25%, then
• $2,831-$4,550 – The “donut hole” – The enrollee pays 100% of their drug costs up to $4,550, then
• $4,551+ – “catastrophic coverage” – The enrollee pays a $2.40 copay for generic drugs. For other drugs the enrollee pays either $6.00 or 5% of the drug cost, whichever is greater.

Beginning in 2010, the reforms going into effect to address the donut hole are: 

• 2010 – Enrollees in the “donut hole” received $250 rebate checks from Medicare
• 2011 – If an enrollee reaches the donut hole, they will be given a 50% discount on the total cost of the brand name drugs while in the gap. Medicare also will phase in additional discounts on the cost of both brand name and generic drugs.
• By 2020 – Effectively close the donut hole so that the plan pays 75% of the drug cost with the enrollee paying the remaining 25%.

The second Medicare Part D reform is the elimination of the Medicare Part D Subsidy paid to employers who sponsor a retiree drug plan.  (continue reading…)

The following information is from www.healthcare.gov and is by Donald Berwick, MD, Administrator of the Centers for Medicare and Medicaid Services.

Today, November 15, Medicare’s Open Enrollment period begins, and runs it runs through December 31. Open Enrollment offers people with Medicare—-including those with Original Medicare—an opportunity to review their current health and prescription drug coverage; compare health and drug plan options available in their area, and choose coverage that best meets their needs.

Although this is an annual event, this year is an especially important time for people with Medicare to take advantage of the Open Enrollment period. The Affordable Care Act provides new benefits to most people with Medicare in 2011, including:

• A 50% discount on covered brand name drugs if you hit the prescription drug ‘donut hole,’
• A free annual wellness visit, and
• No co-pays for recommended preventive services

If you or someone you love has Medicare, checking out some options during Open Enrollment may result greater savings or even better coverage than you have this year.

For assistance during Open Enrollment, visit www.medicare.gov, consult your 2011 Medicare & You Handbook, or call 1-800-MEDICARE. You can also get one-on-one counseling assistance from your local State Health Insurance Assistance Program (SHIP).

Here at the Centers for Medicare and Medicaid Services (CMS), we are working hard each and every day to ensure that Medicare stays strong, and that people with Medicare have access to quality, affordable care. We encourage all seniors and people with disabilities in the program, to look at their current coverage, compare it to the options available, and decide which coverage best meets their needs during this Open Enrollment period.

Note: Remember—protect your personal information—don’t give out your Medicare number to anyone who arrives at your home uninvited, calls you and asks for it, or offers you free equipment or services in exchange for your Medicare number. Guard your Social Security and Medicare numbers like you would your credit cards. (Visit stopmedicarefraud.gov for more information.)

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Banyan Administrators have been providing us with beneficial information about several different aspects of the Health Care Reform and how it affects us. Over the next months and years, employers will be faced with numerous changes, many of which require regulatory clarification. Banyan will continue to keep us up to date and on target with decisions that affect our plans.  Over the next few weeks, Banyan will be providing answers to many questions regarding Medicare and how the reform will affect you. We are sure you will find the information valuable.

If you missed the first article in this series that was posted last week, click here.

The following information is provided by Banyan Administrators:

Arguably the greatest volume of reforms through the Patient Protection and Affordable Care Act (“Affordable Care Act”) signed into law on 03/23/2010 involve Medicare. Some of the provisions are direct reforms to Medicare while other provisions of the Affordable Care Act may have an indirect, but intentional, impact on the program. The following Q&A will give you an overview of the reforms to the Medicare program and how they are all intended to work together.

1.  What is the future of Medicare?

What could not have been foreseen in 1965 when Medicare was created was that the United States was coming to the end of the post-World War II “Baby Boom”. More “Baby Boomers” are reaching Medicare eligibility than are being replaced in the work force by younger workers.  With Medicare being funded by FICA taxes, at some point, it mathematically becomes impossible to fund all the benefits for all the Medicare enrollees. (continue reading…)

Banyan Administrators have been providing us with beneficial information about several different aspects of the Health Care Reform and how it affects us. Over the next months and years, employers will be faced with numerous changes, many of which require regulatory clarification. Banyan will continue to keep us up to date and on target with decisions that affect our plans.  Over the next few weeks, Banyan will be providing answers to many questions regarding Medicare and how the reform will affect you. We are sure you will find the information valuable.

The following information is provided by Banyan Administrators:

Health Care Reform – Medicare

What You Need to Know Now About: Medicare

Arguably the greatest volume of reforms through the Patient Protection and Affordable Care Act (“Affordable Care Act”) signed into law on 03/23/2010 involve Medicare. Some of the provisions are direct reforms to Medicare while other provisions of the Affordable Care Act may have an indirect, but intentional, impact on the program. The following Q&A will give you an overview of the reforms to the Medicare program and how they are all intended to work together.

1.  What is the history of Medicare?

As early as 1945, President Harry S. Truman proposed a government administered national social insurance program. It was not until the Social Security Act of 1965 signed into law by President Lyndon B. Johnson that the Medicare program was created. The first senior enrolled into the Medicare program was former President Harry S. Truman. Former First Lady Bess Truman was the second senior enrolled.

The first two programs created in 1965 were Medicare Part A and Medicare Part B. Since that time, Medicare Part C (1997) and Medicare Part D (2006) have been added.

Medicare Part A is hospitalization insurance providing coverage to the Medicare enrollee for inpatient hospital stays. Medicare Part A also pays for other facility-based skilled services such as care at a skilled nursing facility, but, on a limited basis. Most Medicare enrollees do not pay a premium for Medicare Part A coverage because they (or a spouse) have paid enough into the program through payroll taxes prior to retirement. Medicare enrollees do have to meet a Medicare Part A deductible before any benefits are paid. In 2010, the Medicare Part A deductible is $1,100 for an inpatient stay up to 60 days.

Medicare Part B is medical insurance providing coverage to the Medicare enrollee for outpatient services provided by a physician. Services include physician services, nursing services, x-ray, laboratory and diagnostic tests, vaccinations, renal dialysis, outpatient hospital procedures, etc. No benefit is provided for prescription drugs unless the drug is administered by a physician. Participation in Medicare Part B is voluntary if an eligible retiree wishes to participate; the premium amount will be deducted from his social security benefit. In 2010, Medicare Part B monthly premium, on average, is $100.50. The Medicare Part Benrollee also has to meet a $155 deductible and then pay 20% coinsurance.

In 2008, there were 45 million enrollees in Medicare making it the nation’s largest single health care payer in the nation. By 2030, it is expected that enrollment will reach 78 million. In 2008, Medicare spending reached $599 billion which was 20% of the total federal government spending. At $599 billion, Medicare is only surpassed by Social Security and defense spending. (continue reading…)

The following information is from Medicare.gov and is beneficial to those who are new to Medicare. This article will guide them through the actions they need to take in order to get the most from their Medicare benefits. 

New to Medicare? 6 Things You Need to Do

Use this checklist to get the most from your Medicare benefits and make sure your claims get paid quickly and correctly.

1. Fill out an Initial Enrollment Questionnaire
The Initial Enrollment Questionnaire (IEQ) should come in the mail about 3 months before you qualify for Medicare. It asks about other health insurance you have that might pay before Medicare does, like group coverage you have from your employer or through a family member, treatments covered under liability insurance, or workers’ compensation you get.

You must fill out and return this questionnaire to make sure your medical bills get paid correctly and on time. You can:
• Mail back the paper copy you got in the mail.
• Complete the questionnaire online at MyMedicare.gov
• Complete the questionnaire over the phone by calling the Coordination of Benefits Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782.

2. Fill out an Authorization Form
Medicare can’t give personal health information about you to anyone unless you give permission in writing first. If you want your loved ones to be able to get information about your care, it’s a good idea to provide authorization in advance. You can do this in several ways:

• Fill out and submit an e-Authorization Form online: Medicare Online Forms.
• Download and complete a .PDF version of the Standard Authorization form: Medicare Online Forms. Mail the completed, signed form to Medicare BCC, Written Authorization Department, P.O. Box 1270, Lawrence, KS 66044.
• Call 1-800-MEDICARE (1-800-633-4227) and ask for the Standard Authorization form to complete and mail in. Or, the CSR can help you complete the form over the phone, then mail the form to you to sign and return. (continue reading…)

The following information is from Healthcare.gov:

How the Affordable Care Act will make Medicare stronger into the future

• The life of the Medicare Trust fund will be extended to at least 2029, a 12-year extension as a result of reducing waste, fraud and abuse, and slowing cost growth in Medicare. This will provide you with future cost savings on your premiums and coinsurance.
• Medicare will take strong action to reduce payment errors, waste, fraud, and abuse in Medicare. The President has made a commitment to reduce Medicare fraud 50 percent by 2012. The Affordable Care Act makes an historic, ten-year, $350 million investment to prevent, detect and fight fraud in Medicare, Medicaid and the Children’s Health Insurance Program—including criminal efforts to exploit the new law. Visit Stop Medicare Fraud for more information.
• In 2011, if you hit the prescription drug donut hole, you will get a 50% discount on brand-name drugs. Every year after, you will pay less for your prescription drugs in the donut hole until there’s complete coverage of the donut hole in 2020. Between now and then, you will get continuous Medicare coverage for your prescription drugs.
• The coordination of care between doctors and the overall quality of care will improve so that you will be less likely to experience preventable and harmful re-admissions to the hospital for the same condition.
• Hospitals will have new, strong incentives to improve your quality of care.
• Starting in 2014, the Affordable Care Act offers additional protections for Medicare Advantage Plan members by taking strong steps that limit the amount these plans spend on administrative costs, insurance company profits, and things other than health care.

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Our group plans require that you work a minimum of 20 hours per week in order to maintain your coverage. If you plan to retire before your 65th birthday (Medicare eligible age) you will not be eligible for coverage. You may be eligible for COBRA and/or CalCOBRA coverage depending on the size of your firm. Please contact Banyan Administrators, LLC at 877-480-7923 to discuss your options.

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The following information is from Medicare.gov.

Question: 2010 Part B Premium Amounts for Persons with Higher Income Levels

Answer:  Most Medicare beneficiaries will continue to pay the same $96.40 Part B premium amount in 2010. Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less ($170,000 or less for joint filers) will not have an increase in their Part B premium for 2010.

For all others, the standard Medicare Part B monthly premium will be $110.50 in 2010, which is a 15% increase over the 2009 premium. The Medicare Part B premium is increasing in 2010 due to possible increases in Part B costs.  If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $110.50 per month.

Social Security will use the income reported two years ago on your IRS income tax return to determine your premium (if unavailable, SSA will use income from three years ago).  For example, the income reported on your 2008 tax return will be used to determine your monthly Part B premium in 2010. If your income has decreased since 2008, you can ask that the income from a more recent tax year be used to determine your premium, but you must meet certain criteria.

The chart below shows the Part B monthly premium amounts based on income. These amounts change each year. There may be a late-enrollment penalty.

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The following information is from the Department of Labor’s website and is full of valuable information for all of us!

The Department of Labor’s Employee Benefits Security Administration (EBSA) administers several important health benefit laws covering employer-based health plans. They govern your basic rights to information about how your health plan works, how to qualify for benefits, and how to make claims for benefits. In addition, there are specific laws protecting your right to health benefits when you lose coverage or change jobs. EBSA oversees health care laws covering special medical conditions. For more information on the laws that protect your benefits, see EBSA’s Web site at www.dol.gov/ebsa. Or, call the agency’s toll-free help line at 1.866.444.3272 to reach a regional office near you. These 10 tips can help make your health benefits work better for you.

Realize that Your Options are Important

There are many different types of health benefit plans. Find out which one your employer offers, then check out the plan, or plans, offered. Your employer’s human resource office, the health plan administrator, or your union can provide information to help you match your needs and preferences with the available plans. If your employer offers a high deductible health plan, look into setting up a Health Savings Account to save money for future medical expenses on a tax-free basis. The more information you have, the better your health care decisions will be.

Review the Benefits Available

Do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Answers to these questions can help determine the out-of-pocket expenses you may face. Matching your needs and those of your family members will result in the best possible benefits. Cheapest may not always be best. Your goal is high quality health benefits.

Read Your Plan’s Summary Plan Description (SPD) for the Wealth of Information It Provides

Your health plan administrator should provide a copy. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services will require a co-pay, and the circumstances under which your employer can change or terminate a health benefits plan. Save the SPD and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits. (continue reading…)