Medicare

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.

___________

‘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.

Because of general confusion about the rules regarding enrollment in Medicare Part B, nearly 700,000 Medicare beneficiaries are now paying late Part B enrollment penalties according to the Center for Medicare and Medicaid Services.

This is the most common question I get from people approaching 65 who are still working, “Do I have to sign up for Medicare Part B?”  They ask that question because they intend to remain enrolled in their employer’s group health insurance plan after turning 65.  For most people in 2019, the monthly premium for Part B coverage is $135.50.  The premium goes up for individuals with adjusted gross incomes above $85,000 if filing an individual tax return and $170,000 if filing a joint tax return.  In fact, there are five additional premium rates depending on one’s AGI.

So the question is why pay the Part B premium if you’re covered by a group plan at work and for which you’re probably paying a portion of the premium through payroll deductions.  In such cases, it’s possible to delay your Part B enrollment without a penalty being assessed later when you do enroll in Part B and that’s exactly what many people do. However, for those who have remained in a group plan after their employment ended through COBRA, it’s important to understand that CMS does not consider COBRA to be “creditable coverage”.  This means that you would be subject to a late enrollment penalty if you don’t enroll in Medicare Part B within eight months following the termination of your group plan enrollment even if you continued with the group plan enrollment under COBRA.

As people work later in life and delay receiving Social Security, they may not be aware that such a delay means that they won’t be automatically enrolled in Part B when they turn 65. Another misunderstood part of the Medicare enrollment process is the fact that Social Security does not automatically enroll you in Medicare Part B if you aren’t yet receiving your monthly Social Security retirement benefit.  Rather, you must make a proactive Medicare Part B enrollment choice as you approach age 65.  If you are receiving your monthly Social Security retirement benefit before turning 65, Social Security assumes that you want to be enrolled in both Medicare Part A and B and will deduct the Part B premium from your monthly Social Security retirement benefit.  If that’s your situation, and you want to delay your Part B enrollment, you’ll need to proactively inform Social Security that you want to delay your Part B enrollment.

Some in Congress want to make all of this more transparent through legislation called the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act. The BENES act has not gained much traction in Congress yet but perhaps this will be one thing on which the new House and existing Senate can agree.  Social Security would send out notices to people approaching age 65 explaining Part B enrollment including how the specific enrollment periods work. This should eliminate some of the circumstances where the transition to Part B is mismanaged resulting in lifetime late enrollment penalties.

The rules are complicated and not well understood by most human resource experts in employer benefits departments.  They typically lack the Medicare knowledge to guide their employees and retirees on Medicare enrollment.  Further, the federal government provides virtually no notification to people who are nearing Medicare eligibility about when and how to do so.  As a result, people with employer-sponsored group coverage often bear the full burden of understanding and navigating Medicare’s complex enrollment rules which can lead to costly mistakes.  The following are the rules regarding the enrollment periods for Medicare Part B:

1)   Initial Enrollment Period–The seven-month period beginning with three months before the 65^thbirth month, the birth month, and three months after the birth month.

2)   Special Enrollment Period– Available to those who have continued to stay on their own (or their spouse’s) group health plan. Upon termination of their enrollment in the group health plan, they have an eight-month period during which to sign up for Part B in order to avoid the late enrollment penalty.

3)   General Enrollment Period– Here’s the nasty one.  Using the General Enrollment Period means that the individual has missed their Initial Enrollment Period, or the Special Enrollment Period, and wishes to sign up for Medicare Part B. They fall into the General Enrollment Period, which they can only utilize from January 1 to March 31, but with coverage not beginning until July 1of that year.  Depending on when a person chooses to sign up from Jan. 1 to March 31, they may have encountered a “Blackout Period”, which can run up to ten months, or in some cases, even over a year, depending on the sign up time.  And that’s where they create the 10% penalty per year for each year, which lasts forever.

‘Greg Says’….The best advice I can offer with regard to the Part B enrollment question is to seek the free counsel of a licensed health insurance agent. Relying on the advice of your company’s HR department, well-intentioned friends, or trying to figure it out on your own, could result in a costly mistake from which there is no recovery.

Christina Farr | CNBC.com

Jan 16, 2019

Apple is in talks with private Medicare plans about getting Apple Watches into the hands — or on the wrists — of millions of people over the age of 65.

It makes a lot of sense for Apple to do that, health experts tell CNBC, since it could prevent pricey doctor or hospital visits.

Apple has previously signed a deal with insurance giants Aetna and United Healthcare about subsidizing the cost of the watch.

Apple has been in talks with at least three private Medicare plans about subsidizing the Apple Watch for people over 65 to use as a health tracker, according to people familiar with the discussions.

The insurers are exploring ways to subsidize the cost of the device for those who can’t afford the $279 price tag, which is the starting cost of an older model. The latest version of the device, which includes the most extensive health features including fall detection and an electrocardiogram to measure the heart’s rhythm, retails for a minimum of $399, which many seniors could benefit from but can’t afford.

The talks have not resulted in any official deals just yet, the people said. Apple has paid a visit to several of the largest insurers in the market, as well as some smaller, venture-backed Medicare Advantage plans. The people involved declined to be named as the discussions are still private.

Health experts say that seniors are an ideal market for the Apple Watch, which has introduced features that can be used by anyone, but are most beneficial to seniors, including fall detection and cardiac arrhythmia monitoring. It also makes sense as a business model for insurers, as seniors are a particularly lucrative market.

“It’s the segment of health insurance with the highest dollar revenue and margin per member,” explains Augustin Ruta, a health insurance consultant at A2 Strategy Group. Ruta also noted that Medicare members enrolled in these private plans tend to have lower churn rates, which gives insurers more of an incentive to invest in members’ long-term health outcomes.

About 22 million seniors, and growing, are now enrolled in a Medicare Advantage plan, which are private health plans that receive government payouts for providing services to seniors — about $10,000 per member, on average. Consulting firm PricewaterhouseCoopers, expects the Medicare Advantage market to generate more than $350 billion in annual revenue by 2020, although the market is regulated to limit insurers’ profits.

The government payments provide more flexibility for insurers running Medicare Advantage plans to invest in new technologies, like the Apple Watch, if they have a demonstrated benefit.

Apple Watch might be pricier than other trackers, such as the Fitbit, but insurance executives say they’d work with Apple if the company can show that it helps its members detect potentially serious health problems before they require an expensive intervention.

“Avoiding one emergency room visit would more than pay for the device,” said Bob Sheehy, CEO of Bright Health, an insurance start-up with a Medicare Advantage plan, and the former CEO of United Healthcare.

Apple is increasingly invested in this kind of research, such as its heart study with Stanford University and its partnership with Zimmer Biomet to better understand through the Apple Watch how patients can more quickly recover from knee and hip replacement procedures.

The latest Apple Watch now includes an electrocardiogram, which is designed to pick up on atrial fibrillation, a condition that impacts far more people over the age of 65 than their younger counterparts, and puts them at a higher risk for stroke and other potentially fatal health outcomes. While Apple Watch doesn’t diagnose disease or replace a doctor, the company is positioning it as an “intelligent health guardian.”

Apple CEO Tim Cook told CNBC in an interview last week that health technology would be a major initiative for the company in the future.

“We are taking what has been with the institution and empowering the individual to manage their health. And we’re just at the front end of this,” Cook said. “But I do think, looking back, in the future, you will answer that question: Apple’s most important contribution to mankind has been in health.”

Apple’s health team is also looking to work with other large insurers outside of Medicare. It signed a deal with Aetna in August of last year; and in November 2018, it integrated with United Healthcare for a program that rewards those who walk at least 10,000 steps per day to subsidize the cost of a watch. It is also working with life insurer John Hancock to offer a steeply discounted watch to those who live healthy lifestyles.

---

At ‘Greg Says’ we believe this is a trend that has legs because everybody wins – Apple, the insurer, and the consumer.

 

Planning to travel abroad soon?  Before you go, remember to look into how your Medicare coverage works outside the United States.

If you have Medicare Part A (Hospital Insurance) and Part B (Medical Insurance), your health care services and supplies are covered when you’re in the U.S.  The 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa are considered part of the U.S.  In general however, health care you get while traveling outside the U.S. isn’t covered.

Medicare may pay for inpatient hospital, doctor, ambulance services, or dialysis services that you get in a foreign country in the following rare cases:

• You’re in the U.S. when a medical emergency occurs, and a foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition.
• You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and a Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency.
• You live in the U.S. and a foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.

In some cases, Medicare may cover medically necessary health care services you get on board a ship within the territorial waters adjoining the land areas of the U.S. However, Medicare will not pay for health care services you get when a ship is more than 6 hours away from a U.S. port.

Medicare drug plans do not cover prescription drugs you buy outside the U.S.

So, what is your out-of-pocket exposure for health care when travelling outside the U.S. if you have Original Medicare only?

You pay 100% of the costs, in most cases.  In the rare situations described above, you pay 20% of the approved amount, and the Part B deductible applies.

• Medicare Part A (Hospital Insurance)covers hospital care (care you get when you’ve been formally admitted with a doctor’s order to a foreign hospital as an inpatient).
• Part B covers emergency and non-emergency ambulance and doctor services you get immediately before and during your covered foreign inpatient hospital stay.
• You pay the part of the charge you would normally pay for covered services. This includes any medically necessary doctor and ambulance services you get in a foreign country as part of a covered inpatient hospital stay. You also pay the coinsurance, copayments, and deductibles you’d normally pay if you got these same services or supplies inside the U.S.
• Medicare generally will not pay for services, like ambulance trips to return home, in either of these cases:
  • Medicare didn’t cover your hospital stay.
  • You got ambulance and doctor services outside the hospital after your covered hospital stay ended.

What if, in addition to Original Medicare, you have a Medicare supplement (Medigap) plan?

If you have a Medicare supplement (Medigap) policy, you may have some additional coverage, beyond what Original Medicare provides, for health care services or supplies that you get outside the U.S.  Standard Medigap Plans C, D, F, G, M, and N provide foreign travel emergency health care coverage when you travel outside the U.S. Plans E, H, I, and J are no longer for sale, but if you bought one before June 1, 2010 you may keep it.  All of these plans also provide foreign travel emergency health care coverage when you travel outside the U.S.

If you have a Medigap Plan C, D, E, F, G, H, I, J, M or N, your plan:

• Covers foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn’t otherwise cover the care.
• Pays 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year.
• Foreign travel emergency coverage with Medigap policies has a lifetime limit of $50,000.

Before you travel outside the U.S., talk with your Medigap plan or insurance agent to get more information about your Medigap coverage while traveling.

Who files Medicare claims when you receive health care services outside the U.S.?

Foreign hospitals are not required to file Medicare claims.  You may need to submit an itemized bill to Medicare for your doctor, inpatient, and ambulance services if both of the following apply:

• You are admitted to a foreign hospital under one of the situations noted previously.
• The foreign hospital doesn’t submit a Medicare claim for you.

How can you minimize your out-of-pocket exposure to health care costs when travelling outside of the U.S.?

Because Medicare has limited coverage of health care services received outside the U.S., you may want to consider purchasing a travel insurance policy.  An insurance agent or travel agent can give you more information about travel insurance.  Remember that travel insurance does not necessarily include health care coverage, so it’s important to read the conditions and restrictions of the policy carefully.

Some Medicare Advantage plans include limited health care coverage while travelling out of the U.S. If you have such a plan, check with the company or with your agent for the extent of the coverage as each company’s provisions can be quite different.

The following link will take you to a useful CMS-produced video on the subject of this newsletter: https://www.youtube.com/watch?v=yq2WbpPK-9c