Medicare Advantage, Medicare costs

Draft Rules Would Help Protect Seniors When Medicare Advantage Plans Drop Doctors

By Susan Jaffe  March 24, 2014  KAISER HEALTH NEWS  in collaboration with wapo

Federal officials are considering new Medicare Advantage rules to help protect seniors when insurers make significant reductions to their networks of doctors and other health care providers. The proposals follow UnitedHealthcare’s decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.

The government’s response is part of the 148-page announcement of proposed rules and payment rates for next year’s Medicare Advantage plans released last month by the U.S. Centers for Medicare & Medicaid Services. Officials say that the terminations only a few weeks before Medicare’s Dec. 7 enrollment deadline may not have given seniors enough time to find new doctors, choose a different plan or rejoin traditional Medicare, which does not restrict beneficiaries to a limited network of providers.

…Although the announcement does not name any insurance companies, officials prefaced the proposals by writing, “Recent significant mid-year changes to MAOs’ [Medicare Advantage organizations’] provider networks have prompted CMS to reexamine its current guidance on these requirements and to consider augmenting such guidance in response to such changes.” [More from KHN] [More from Washington Post]

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By Susan Jaffe | March 7, 2014 | Kaiser Health News in collaboration with wapo
Federal efforts to strengthen inspections of the nation’s nursing homes are gaining momentum after a government probe uncovered instances of substandard care.
The March 3 report by the HHS Inspector General found that an estimated one-third of residents suffered harm because of substandard care and that the chances of nursing home inspectors discovering these “adverse events” are “slim to none,” said Ruth Ann Dorrill, a deputy regional director for the inspector general and the manager of the investigation.
Nearly 60 percent of these incidents were preventable — including injuries due to falls or medication errors — and more than half of residents were hospitalized as a result, costing Medicare an estimated $2.8 billion in 2011, according to investigators. In 6 percent of the cases, poor care contributed to residents’ deaths….
After reviewing a September draft of the IG report, Medicare officials became interested in using the IG’s investigative techniques, methods not normally used in measuring nursing home quality, Dorrill said. [More from KHN] [More from Washington Post]

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By Susan Jaffe  | February 28, 2014 |  Kaiser Health News produced in collaboration with 

It used to be difficult for Edith Couturier, an 85-year-old resident of the District of Columbia, to explain to her adult children on the West Coast all the details of her medical appointments. But now she doesn’t go alone — she takes along a volunteer “medical note taker.”

“There are four ears listening to what the doctor says,” said Couturier. That second set of ears belongs to Sharon Wolozin, who takes notes the old-fashioned way – with pen and paper – and then reads some of the main points aloud to confirm them with the doctor.

Wolozin is a volunteer for the Northwest Neighbors Village in Washington, D.C., one of the more than 200 “villages” across the United States. These neighborhood membership organizations provide volunteers and other resources to help with everything from transportation and snow shoveling to hanging curtains and solving computer glitches.

But as many of the Northwest Neighbors’ 210 dues-paying members “age in place” – the village movement’s top goal — some need more than just a ride to the doctor, said executive director Marianna Blagburn.
[More in KHN] [More in USA Today]

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By Susan Jaffe  Jan. 21, 2014  KAISER HEALTH NEWS  in collaboration with wapo

Medicare beneficiaries who have been waiting months and even years for a hearing on their appeals for coverage may soon get a break as their cases take top priority in an effort to remedy a massive backlog.

Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals (OMHA), announced in a memo sent last month to more than 900 appellants and health care associations that her office has a backlog of nearly 357,000 claims. In response, she said the agency has suspended acting on new requests for hearings filed by hospitals, doctors, nursing homes and other health care providers, which make up nearly 90 percent of the cases. But beneficiaries’ appeals will continue to be processed.

“We have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision,” said Judith Stein, executive director of the Center for Medicare Advocacy. [More from KHN] [More from Washington Post]

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By Susan Jaffe   |   January 10, 2014, 2:41 pm  

Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge. 

…Medicare officials have urged hospital patients to find out if they’ve been admitted. But suppose the answer is no. Then what do you do?

Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation. ) MORE

Fighting ‘Observation’ Status

Affordable Care Act, The Lancet

The Affordable Care Act’s insurance programme takes effect

lancet cover 2

Volume 383, Issue 9912,  11 January 2014

 

WORLD REPORT Coverage kicked in for millions of Americans on Jan 1 under the Affordable Care Act while officials urged others to enrol before the 2014 sign-up deadline.Susan Jaffe reports from Washington, DC.

The Obama Administration faces what might be its most daunting challenge under the law: making sure an untested programme functions—will newly insured patients be able to get medical treatment or fill prescriptions?—while continuing to encourage people to sign up before the March 31 deadline for 2014 coverage, guaranteeing that the upgraded online sign up system keeps pace with demand, and fighting the latest lawsuit and political attack as the 2014 mid-term election campaign heats up. [MORE] [PDF]

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Judge’s Medicare Advantage Order Could Have National Impact

By Susan Jaffe | December 6, 2013 | Kaiser Health News produced in collaboration with  

In a decision that could have national implications, a federal judge in Connecticut temporarily blocked UnitedHealthcare late Thursday from dropping an estimated 2,200 physicians from its Medicare Advantage plan in that state. While the judge’s decision affects only the physicians in Fairfield and Hartford Counties who brought suit, several other medical groups are considering filing similar actions.

“This is very good news from Connecticut,” said Dr. Sam L. Unterricht, president of the Medical Society of the State of New York. “We will definitely seriously consider filing a suit in New York as well.” [Continued in Kaiser Health News and USA Today]

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By Susan Jaffe  | November 29, 2013 |  Kaiser Health News produced in collaboration with 

Dorathy Senay’s doctor had some bad news after her last checkup, but it wasn’t about her serious blood disorder called amyloidosis. Her Medicare Advantage managed care plan from UnitedHealthcare/AARP is terminating the doctor’s contract Feb. 1. She is also losing her oncologist at the prestigious Yale Medical Group — the entire 1,200 physician practice was axed. Senay, 71, of Canterbury, Conn., is among thousands of UnitedHealthcare Medicare members in 10 states whose doctors will be cut from their plan network.

The company is the largest Medicare Advantage insurer in the country, with nearly 3 million members. More than 14 million older or disabled Americans are enrolled in Medicare Advantage plans, an alternative to traditional Medicare that offers medical and usually drug coverage but members have to use the plan’s network of providers.

“I have a rare incurable disease and these doctors have saved my life,” said Senay. “I am in good hands and I will not change doctors.”

…Medicare officials review the private plans every year to make sure they comply with network adequacy and other requirements, but the agency did not approve the reconfigured networks resulting from the new provider cancelations. Spokesman Raymond Thorn said the agency “is currently reviewing UHC and other plans’ provider networks and closely monitoring all areas that have experienced disruptions to ensure that beneficiaries have full, transparent and timely information and access to needed care.” [More from KHN] [More in USA Today]

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By Susan Jaffe   |   November 1, 2013, 11:57 am 

Older adults and their caregivers have complained for years that Medicare, which now covers 52 million Americans, does not provide dental benefits.
For some adults with Medicare, the online insurance exchanges created by the Affordable Care Act may offer an alternative. MORE

Dental Coverage on the Insurance Exchanges

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By Susan Jaffe  | October 15, 2013 |  Kaiser Health News produced in collaboration with 

The seven-week enrollment period for next year’s Medicare prescription drug and managed-care plans begins Tuesday, but seniors shouldn’t simply renew their policies and assume the current coverage will stay the same. There’s a likely payoff for those who pay close attention to the details.[More in KHN] [More in USA Today]

Seniors Cautioned To Pay Close Attention To Details As Enrollment Begins In Medicare Plans

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By Susan Jaffe   |   October 11, 2013, 6:24 pm   

Shirley Mierzejewski was “very upset” when she found out her Medicare health insurance premiums will nearly double next year.

“I cannot afford that, I cannot,” said Ms. Mierzejewski, 77, who lives in Euclid, Ohio, and works part time as a receptionist at a local college. She has a private Medicare  Advantage policy from Anthem, which provides drug and medical coverage.

“So I started thinking about the marketplaces,” she said, referring to the online insurance exchanges created by the Affordable Care Act. “Maybe I could find something cheaper there.”

While thousands of Americans are trying to sign up for insurance on the exchanges, Medicare counselors like Semanthie

Brooks, who spoke at the meeting Monday in Euclid, are trying to steer seniors away. They worry that Ms. Mierzejewski  and other older adults may not realize that Medicare is a pretty good deal compared to exchange policies and may try to buy one anyway.

…To clear up confusion in Montgomery County, Md., officials held meetings at six centers for the elderly. “They want to know if they are better off in the exchange than in Medicare,” said Leta Blank, director of the Montgomery County State Health Insurance Assistance Program. “Everyone is looking for a less expensive way to get health care.”

So in a year in which the insurance market is being turned upside down, here are some shopping tips for people with Medicare and caregivers. MORE

Q & A: Medicare and the Insurance Exchanges

Appeals, Observation care

Judge Dismisses Hospital ‘Observation Care’ Lawsuit

By Susan Jaffe  | Connecticut Health Investigative Team Writer | Sept. 23, 2013

Today, A lawsuit filed by fourteen seniors, including seven from Connecticut, seeking Medicare nursing home coverage was dismissed Monday by a federal court judge in Hartford.

The seniors were among more than a million Medicare beneficiaries who enter the hospital for observation every year. Because they did not spend at least three consecutive hospital days as admitted patients, Medicare will not pay for their nursing home care.

In their lawsuit, they argued that there is little difference between observation and admitted patients, except when it comes to paying tens of thousands of dollars in nursing home bills. They asked the judge to eliminate the ‘observation care’ designation or at least set up an expedited appeals process so that their observation status would be reviewed. They also wanted the judge to order Medicare officials to require hospitals to tell patients if they are receiving ‘observation care’ and have not been admitted.MORE

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By Susan Jaffe | Sept. 17, 2013 | KAISER HEALTH NEWS  in collaboration with washingtonpost logo
The U. S. Department of Labor issued new rules Tuesday that mandate home health care agencies pay their workers the minimum wage and receive overtime pay starting in 2015.
“Almost 2 million home care workers are doing critical work, providing services to people with disabilities and senior citizens who want to live in community settings and age in place in their familiar surroundings,” said Secretary of Labor Thomas Perez.
But when it comes to getting paid, they are “lumped into the same category as teenage babysitters,” he said. “This is wrong and this is unfair.”
For nearly 40 years, home care workers had been exempted from the pay rules because their services were considered “companionship.” But advocates, including organized labor organizations, had argued that these workers were often doing much more, providing assistance with dressing, eating and other daily activities. [More from KHN or Washington Post]

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By Susan Jaffe | Sept.13, 2013 | KAISER HEALTH NEWS  in collaboration with washingtonpost logo
After reassuring seniors that Medicare is not part of the new health insurance marketplaces, administration officials have a warning for anyone who may have other ideas: selling marketplace coverage to people who have Medicare is illegal.
Federal officials are eager to get the word out that seniors and disabled individuals enrolled in Medicare Part A — which covers hospitalization and limited nursing home care and is free for most beneficiaries – do not need to buy a marketplace plan, because they are already meeting the insurance requirements.
And no one needs to sell them one, either, according to information on a new “Medicare & the Marketplace” government webpage and in a “frequently asked questions” flyer officials recently distributed to Medicare counselors and other seniors advocates. MORE