Medicare

The coronavirus legislation signed by President Donald Trump would let Medicare expand the use of telemedicine in outbreak areas, potentially reducing infection risks for vulnerable seniors.

By Associated Press, Wire Service Content March 6, 2020

BY RICARDO ALONSO-ZALDIVAR, Associated Press

WASHINGTON (AP) — The coronavirus legislation signed by President Donald Trump on Friday, March 6, 2020 lets Medicare expand the use of telemedicine in outbreak areas, potentially reducing infection risks for vulnerable seniors.

Coverage of telemedicine is now limited primarily to residents of rural areas facing long road trips for treatment from specialists. The law allows the government to waive those restrictions to help deal with the public health emergency created by the coronavirus outbreak.

It also could open the way for more lasting changes in Medicare’s coverage of virtual health care, including Skyping with the doctor or using devices that beam over measurements such as heart rate.

“Telehealth is really instrumental in containing and treating disease, particularly in a public health emergency,” said Megan O’Reilly, a lobbyist with AARP, the advocacy group for older people, which pushed for the telemedicine provisions. “For older Americans, this can help keep them safe.”

Scientists tracking the global respiratory disease outbreak have documented that coronavirus takes a higher toll on older people, on patients with multiple chronic conditions, and on those with compromised immune systems. Death rates are higher among older patients, while younger people are more likely to get a milder form of the illness.

To be clear, seniors who suspect they may have COVID-19 — the illness caused by the coronavirus — will still have to get tested physically, whether at a clinic or their doctor’s office.

Telemedicine cannot take the place of a swab of the throat to collect a sample for scientific testing. But it can help doctors make special arrangements to safely receive a patient who is sick and suspects the virus may be involved.

Perhaps even more important, telemedicine would offer a way for Medicare recipients in outbreak areas to take care of ongoing medical issues without having to go to the doctor’s office and risk coming into contact with someone who is sick. Many seniors have several doctors’ appointments every month.

Like the rest of the $8.3 billion coronavirus response bill, the telemedicine provisions were the result of a bipartisan effort by Democratic and Republican lawmakers in both chambers of Congress. “This will give seniors greater access to their health care providers without leaving home,” said Sen. Ron Wyden, D-Ore., a longtime telemedicine advocate who helped shoehorn the provisions into the coronavirus bill.

Seema Verma, head of the Centers for Medicare and Medicaid Services, has said she wants to find ways to focus government assistance on the people deemed most vulnerable. But her agency has not yet said how it would use its newly granted waiver authority.

To protect seniors from scams, the legislation requires that the doctor’s office billing for a telehealth visit have an established, ongoing relationship with the patient. And communication must take place through a two-way interactive video and voice link.

If telemedicine shows its worth in the coronavirus outbreak, that could lead to permanent changes making it more widely available to seniors. “While this law applies to the current public health emergency, we’ll continue to work on expanding the use of telehealth so that every American has access,” said Sen. Brian Schatz, D-Hawaii, who also worked on the provision.

Medicare is the government’s flagship health insurance program, covering about 60 million people age 65 and over, as well as younger people who qualify because of a disability. Medicare Advantage plans offered by private insurers have been allowed to offer telemedicine as a supplemental benefit like dental coverage or a gym membership for several years now, said Gretchen Jacobson, vice president for Medicare at the Commonwealth Fund think tank.

The new telemedicine waivers would most benefit the roughly two-thirds of Medicare recipients in the traditional program. Overall, telemedicine has grown steadily in recent years. Most mid-size or large employers now offer some way to connect patients and health care providers virtually. But researchers say patients have been relatively slow to try telemedicine, especially if they are used to in-person visits.

By Michelle Andrews – The New York Times – July 18, 2019

San Miguel de Allende. Mexico is home to the third-largest number of expatriate American retired workers, with 30,000.  CreditAlfredo Estrella/Agence France-Presse — Getty Images

When Karen Schirack, 67, slipped on her way into her house in January and broke her left femur in multiple places, she had a decision to make. Should she get surgery to repair the fractured thigh bone and replace her hip near Ajijic, Mexico, where she has lived for 20 years, or be airlifted back to her home state, Ohio, for surgery and rehabilitation?

As the number of American retirees living overseas grows, more of them are confronting choices like Ms. Schirack’s about medical care. If they were living in the United States, Medicare would generally be their coverage option. But Medicare doesn’t pay for care outside the country, except in limited circumstances.

Expatriate retirees might find private insurance policies and national health plans in other countries. But these may not provide the high-quality, comprehensive care at an affordable price that retirees expect through Medicare. Faced with imperfect choices, some retirees cobble together different types of insurance, a mix that includes Medicare.

That’s what Ms. Schirack has done. She pays about $3,700 annually for an insurance policy through Allianz that covered her surgery at a private hospital in Guadalajara, about an hour from Ajijic. She also has a medical evacuation policy that would have paid for her flight to the States, if she had opted for that. That policy costs roughly $3,000 for five years. And she pays for Medicare Part B, which she can use for care when she visits family in the United States. (The standard Part B premium is $135.50 monthly.)

Ms. Schirack has a scar running from her waist to the middle of her thigh, but she no longer needs home nursing care and wrapped up months of physical therapy in June. After five more months of healing, she hopes to be back to normal.  Her private plan paid the equivalent of about $20,000 for her surgery. Before she left the hospital, Ms. Schirack had to cover her portion of the total, about $2,400, and bills for other expenses, including blood transfusions.

After leaving the hospital, she was responsible for paying for other services — home nurses, physical therapy, medications — and submitting receipts to the insurer for reimbursement. She estimates she has spent $10,000 and has been reimbursed for about two-thirds of that so far.  If she had had surgery in the United States, she might have faced fewer paperwork hassles, Ms. Schirack said, “but all in all, I’m not going to complain.”

The quality of health care varies widely by country, as do the services available to foreign residents. And there are quite a few of these transplanted Americans.  Between 2012 and 2017, the number of retired workers living in foreign countries who were receiving Social Security benefits grew nearly 15 percent, to more than 413,000, according to the Social Security Administration. The largest numbers of expatriates were in Canada (nearly 70,000) and Japan (more than 45,000). Mexico was third, home to nearly 30,000 retired American workers.

Commercial health care policies for them may provide decent coverage, but people can generally be denied a policy or charged higher rates for medical reasons. The plans may refuse to cover some pre-existing conditions. Ms. Schirack’s policy, for example, doesn’t cover any services related to her allergies.  Private policies can be problematic for another reason: They may have age limits. The GeoBlue Xplorer Essential plan, for example, enrolls only people who are 74 or younger, and coverage expires when people turn 84. In contrast, Medicare eligibility generally begins at 65 and continues until a beneficiary dies.

And the policies aren’t cheap. A 70-year-old might pay $1,900 a month for an Xplorer Essential plan with a $1,000 deductible, said Todd Taylor, a sales director for GeoBlue. A plan with a $5,000 deductible might run $1,400 monthly. That doesn’t include coverage for services in the United States.  Rates may also vary by country. A 67-year-old American living in Costa Rica who buys a midlevel Cigna plan with a deductible of $750 for hospital care and $150 for outpatient care might pay $1,164 a month, said David Tompkins, president of TFG Global Insurance Solutions. The same policy might cost $913 in France. If the person wanted to add coverage for treatment in the United States, the monthly premium would increase to $1,440 in Costa Rica and $1,138 in France, Tompkins said.

Since medical care is sometimes much less expensive overseas, some retirees opt to pay out of pocket for minor or routine services.

Claudia Peresman, who will turn 63 on Sunday, moved from Stonington, Conn., to San Miguel de Allende in central Mexico in November. On her first night there, she tripped in the bathroom, hit her face on a wall and split her lip. Her neighbors helped her get a cab to a 24-hour emergency room at a hospital about five minutes away, where staff cleaned up the cut and sent her home. She paid the roughly $25 fee in cash.

Ms. Peresman recently bought a private insurance plan with a $2,500 deductible, for which she pays about $100 a month.  “What I wanted was catastrophic coverage,” she said. “Things are so affordable here that, outside of being admitted to the hospital, I can probably afford it.”

By Sarah O’Brien – PERSONAL FINANCE – July 19, 2019

If you’re among the growing contingent of Americans who plan to continue to work after age 65, be sure to review your Medicare options before you do eventually decide to finally say farewell to your coworkers.  While it’s common for people working past that age to stick with a company-sponsored health plan and delay enrolling in Medicare, impending retirement means you should be planning ahead to avoid a coverage gap or costly missed deadlines.

“It’s important to do everything you need to do before you set your retirement date,” said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans. “I’d start planning at least a few months before then to make sure all your ducks are in a row.”

Most people sign up for Medicare when first eligible at age 65 either because they no longer are working or don’t have qualifying coverage through a job. For a small but growing number of older Americans who continue to work past that age, however, having workplace coverage means having options.

Regardless of when you sign up, Medicare Part A (hospital coverage) costs nothing as long as you have at least a 10-year work history. Part B, which covers outpatient care and medical equipment, has a standard monthly premium of $135.50 for 2019. Part D prescription coverage also comes with monthly premiums averaging $32.50. For both Parts B and D premiums, higher-income enrollees will pay more.

For those in the age-65-and-older crowd who work for a large company and get qualifying health-care coverage through their job (the rules are different for small firms), it can sometimes make sense to delay signing up for the Medicare parts that come with a cost.

“They tend to enroll in just Part A because it’s free and then delay Part B and Part D because they’d have to pay premiums,” said Danielle Roberts, co-founder of insurance firm Boomer Benefits in Fort Worth, Texas.

However, be aware that if you also have a health savings account through work, you cannot continue to make contributions once you enroll in Medicare, even if only Part A.

Once you’re planning to retire from your job and will lose workplace coverage, you need to be aware of various Medicare deadlines and rules to avoid shelling out more for premiums than necessary.  As long as your employer-sponsored health care is considered qualifying coverage (called “creditable”), you can avoid paying a penalty for having delayed Part B signup — although you must enroll within eight months of stopping work.

Ideally, however, you should coordinate the end of your work-sponsored coverage with your Medicare effective date so you don’t find yourself without insurance.  If you were to be subject to the late-enrollment penalty for Part B, it would be 10% per year that you should have been signed up but were not. The amount would be life-lasting and tacked on to your premium.

Be aware that when you retire, if for some reason you end up continuing your workplace health plan under COBRA — a law that allows you to continue the coverage for a set time if you pay the full premiums — Medicare does notconsider that coverage creditable. The same goes for insurance through your ex-employer after you retire.

For Part D prescription coverage, the late-enrollment penalty is 1% for every month that you could have been signed up. People with qualifying coverage through an employer plan don’t face that life-lasting penalty as long as they secure coverage within two months of their other plan ending.  However, once you do enroll, you’ll get a form from the insurance company that needs to be filled out and returned to confirm you were permitted to delay enrollment, Roberts said.  “If you miss that letter and fail to send it back, you’ll get charged the penalty,” Roberts said. “We’ve seen where someone misses it because they get so much mail and accidentally throw it out and it can take months to appeal that late penalty,” she said.

Meanwhile, if you want to sign up for a Medicare Advantage Plan, you also get two months from when your workplace coverage ends to do so without having to wait until the fall general enrollment period.  If you go this route, your Parts A and B coverage — and typically Part D — will be delivered through the insurer offering the plan. The cost of an Advantage Plan (on top of your Part B premium) depends on the level of coverage you choose and availability of options in your area.

For some Medicare recipients, however, an Advantage Plan isn’t a good fit. Those folks often pair a so-called Medigap policy with their Parts A, B and D coverage (you cannot have both Medigap and an Advantage Plan). Those policies provide help with things such as deductibles, copays and coinsurance.

If you plan to go this route: Once you sign up for Part B, you have six months to get a Medigap policy without the insurer being allowed to nose through your health history. After that window, you could face that underwriting process and possibly be charged more for coverage or rejected altogether.

At ‘Greg Says’ we’re ready to help those who have delayed their enrollment in Medicare Parts B and D adhere to the rules in order to avoid the penalties and possible coverage gaps.

By Ricardo Alonzo-Zaldivar – The Associaed Press

WASHINGTON (AP) — Medicare wants to change how it pays for emergency ambulance services to give seniors more options besides going to a hospital emergency department, officials said recently.

Other options could include going to an urgent care center, a doctor’s office, or even treatment at home under supervision of a doctor via telehealth links.

It’s just a pilot project for now, but if adopted nationwide the idea could save Medicare more than $500 million a year and allow local fire departments and ambulance services to focus the time and energy of first responders on the most serious emergencies.

Some advocates for patients welcomed the plan, but said it needs careful review and supervision.

“We definitely think this is intriguing and exciting, but it really does need to be monitored very closely,” said Julie Carter, a federal policy expert with the Medicare Rights Center, which advocates on behalf of beneficiaries. “We see this as a potential opportunity to keep people out of the ER when they don’t need to be there.”

Medicare officials said nothing’s going to change overnight, and they pledged the pilot program would be closely evaluated. Patients will retain the option of going to a hospital emergency room if that’s their wish.

Later this year, Medicare will announce up to 40 grants available to local governments or agencies that operate 911 dispatch centers. The pilot program would start early next year and run for two years. If successful, it could be adopted nationwide. Medicare says it also wants to get state Medicaid programs and private insurance companies interested in the approach.

The idea came out of the Center for Medicare and Medicaid Innovation, created under the Obama health care law to improve quality and reduce wasteful spending in the two giant health care programs. Although President Donald Trump tried to repeal the Affordable Care Act, his administration has now tapped the center in its own efforts to cut costs and help patients become more knowledgeable consumers of services.

Unveiling the ambulance proposal at a Washington, D.C., fire station, Adam Boehler, the innovation center director, said he was astounded to learn that under current rules Medicare will only pay for emergency ambulance services if the patient is going to a hospital, in most cases. Transportation to rehab centers or nursing homes, as well as dialysis facilities, is also allowed.

“I thought that was a joke,” said Boehler, a former health care entrepreneur who ran a company providing in-home medical care to seriously ill patients. He called Medicare’s current policy a “ridiculous incentive” to funnel patients to the most high-cost setting. Most private insurance plans discourage emergency room use by imposing higher copays, and some state Medicaid plans are trying similar tactics.

Appearing at the same event, the chief medical officer for the New York City fire department endorsed Medicare’s experiment. Dr. David Prezant said his agency is overwhelmed with non-emergency calls and transporting patients to a hospital is a time-consuming process that keeps ambulance crews needlessly tied up.

“If only 20 percent of our calls no longer required transport to an ED (emergency department), we would save lives in cases when every second counts,” Prezant said.

‘Greg Says‘ thinks this proposal is worth evaluating as a way to lower the overall cost of emergency services for Medicare, the emergency service providers, and the patient.

Forthcoming policies from CMS will open up the home as a covered site of care in which hospitals can earn payment. 

Dec. 14, 2018 – By Susan Morse,Senior Editor, Healthcare Finance

This past October, the Centers for Medicare and Medicaid Services came out with an eagerly-anticipated new rule expanding the ways providers can use telehealth and get paid by Medicare Advantage plans. 

The biggest way the rule changes the status quo, once it goes into effect in 2020, is that providers will be able to keep track of a patient’s health through remote monitoring and consumers will be able to connect to their physicians through telehealth from their homes.

IMPROVING CARE FOR CHRONIC CONDITIONS

Remote monitoring is especially important in controlling chronic conditions, diseases which affect seniors in particular.  Previously, consumers had to be in a provider’s office or another designated place, or live in a rural area, to use telehealth, at least from the standpoint of reimbursement.

Days after the new MA rule was announced, traditional Medicare also got a boost to allow for more codes for telehealth in the home, for a broader range of conditions.  Remote patient monitoring is expected to be the biggest use.

This will cut down on the amount of visits by high users of the ER and improve the management of patients’ conditions, said Dr. David McSwain, CMIO at Medical Univ. of SC.

“There’s a huge amount of investment from insurance companies,” said McSwain, who chairs the American Telemedicine Association Pediatric Telemedicine Guidelines Committee. 

The rule makes it more likely that MA plans will offer the benefits and that more enrollees will be able to use the benefits, CMS said.  What’s more, private commercial insurers and state Medicaid agencies tend to follow Medicare’s lead, McSwain said. 

CMS promoted Medicare Advantage plans ahead of open enrollment this year, and adding flexibility to telehealth only added to their attraction for insurers and consumers.  Insurers, as shown most recently by their third quarter earnings, are doing well with Medicare Advantage plans. Next year, enrollment in Medicare Advantage is projected to increase by 11.5 percent, and the number of plans to increase by 600. About a third of all Medicare beneficiaries are in a Medicare Advantage plan as compared to fee-for-serviceMedicare, and that number is projected to grow.

Adding telehealth to MA benefits increases plans’ ability to take cost out of the healthcare system.  If telehealth can do so without sacrificing quality, that’s the basis of value-based care. 

HOW PROVIDERS ARE ALREADY USING TELEHEALTH

Because of the convenience there is the potential for over-utilization, and there’s the risk of fragmented care according to McSwain.  But telehealth can have dramatic impacts on healthcare outcomes and healthcare costs, he said. 

Telehealth is driving value, CMS Administrator Seema Verma said on November 15, addressing the Alliance for Connected Care. 

Telehealth includes remote monitoring, such as for glucose and vital signs, tracking weight and blood pressure.  It spans a wide array of communication, from video visits to text messaging and phone calls. 

Medicare-age patients often have numerous doctors’ appointments. Consumers welcome the ability to connect from their homes rather than travelling to the office.  Patients with restricted mobility will often miss appointments. 

The Cleveland Clinicuses remote patient monitoring that sends live-time data back to clinicians, Verma said during the Alliance for Connected Care conference.  A mission control center at the hospital assimilates the data and if needed, triggers an intervention. 

About five years ago, Dallas Children’s Health wanted to look at telemedicine as a strategy for population health, said Julie Hall-Barrow, former vice president of Virtual Health and now the senior vice president of Network Development and Innovation. 

Telehealth is being used in the children’s hospital for remote patient monitoring programs, such as digital sensors that measure medication compliance.  “We set the stage knowing it’s covered,” Hall-Barrow said of reimbursement. “I think anytime we reduce barriers for how to deliver care, it’s a win for everybody,” she said. It offers, “the ability for us to provide high quality care at any delivery point.” 

The big picture for telehealth is how to design programs in a way that lead to improved outcomes that have the biggest impact on cost of care access and quality, McSwain said. 

The Medical University of South Carolina is one of only two national Telehealth Centers of Excellence in the United States. The system is currently awaiting word on a National Institutes of Healthgrant that would allow it to leverage a network of healthcare institutions across the country to facilitate the design and completion of telehealth studies, such as what is being taught at MUSC. 

Bryan Adams, chief commercial officer at digital health company GreatCall, said of telehealth, “Everyone is interested. Everyone is trying to find out the right entry point.”  GreatCall provides cell phones, medical alert devices and sensors for independent living at home. Sensors can monitor for risk, such as for falls from a bed or chair, or even be put in the tank of a toilet to detect toilet flushes.  The use of the sensor has resulted in the reduction in the use of long-term care and acute hospitalization, Adams said. 

“This is truly a whole new world of healthcare innovation,” Verma said of telehealth. 

McSwain added that CMS’s new flexibilities “sent a serious wave of excitement around the country.  We’ve been fighting the battle for telehealth in the home, it’s been such a barrier. Those restrictions coming down is like the fall of the Berlin Wall.

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‘Greg Says’believes that telehealth and telemedicine have a big role to play in reducing the overall cost of healthcare in the USA.  Now that there are additional financial incentives for healthcare providers to adopt these tools to remotely serve patients, the door is opening to increased use.