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Posted 8 months ago
By Jennah Mitchell
Table of Contents
Some of these commonly used terms are as follows:
Advance Beneficiary Notice: A notice that is given to a Medicare beneficiary by a hospital, doctor, or other provider prior to providing a particular item or service that the provider believes Medicare may not cover. If a beneficiary is not given an ABN prior to receiving the service or item and Medicare does deny payment, the beneficiary may not be required to pay for it. If, however, the beneficiary is given the notice and signs it before Medicare denies payment, that beneficiary will likely have to pay for that item or service.
Advance Directive: A written document prepared by a beneficiary stating how he or she wishes medical decisions to be made in the event that he or she loses the ability to make those decisions. It often includes a living will and a durable power of attorney for health care.
Appeal: This is action that can be taken if a beneficiary disagrees with a decision regarding coverage or payment that has been made by Medicare or any related Medicare plan. An appeal can be filed if Medicare or a Medicare plan denies one of the following:
Medical Insurance Protection: Often referred to as Medicare Part B, this is a voluntary program that is designed to cover the health-care expenses not covered by Part A, including outpatient care, medical equipment, ambulance costs, doctor’s services, and physical therapy. This program is financed by both federal contribution and premiums paid by beneficiaries.
Medicare Advantage: Often referred to as Medicare Part C, this coverage plan allows beneficiaries to choose between benefits offered by the Medicare Program or the Medicare Advantage Plan, which includes PPOs or HMOs.
Open Enrollment Period: The specific date range during which applications are accepted from applicants aged 65 years or older. During this period, the applicants are also able to select the Medicare supplement insurance they wish to have in addition to their primary Medicare coverage.
Part D Coverage Determination: The initial decision made by a beneficiary’s Medicare drug plan regarding his or her eligibility, which includes:
Custodial Care: Non-skilled personal care that is provided to an individual. Includes help with daily activities such as eating, dressing, bathing, mobility concerns, and basic health-care tasks such as the use of eye drops. In most situations, Medicare will not pay for custodial care.
Exception: A specific type of Medicare decision regarding prescription drug coverage. It is usually a ruling on whether or not Medicare will cover a medication that is not on its current list of covered drugs, but sometimes an exception will be used to overrule a specific Medicare policy or rule. Requests for an exception must be accompanied by a note from a doctor or from another eligible health-care provider; the note must outline the medical reasons behind the exception request.
Guaranteed Issue Rights: Also referred to as Medigap protections, these are rights that apply to situations requiring insurance companies to offer beneficiaries a Medigap policy that is not restricted by a past or present health condition. In other words, it prevents insurance companies from denying coverage based on preexisting health conditions.
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| Posted 8 months ago
Medicare and the Affordable Care Law
Closing the Doughnut Hole
One aspect of the Medicare program is Part D coverage, also known as Prescription Coverage. Prior to the changes enacted by the Affordable Care Act, Part D coverage worked essentially as follows:
Cracking Down on Health-Care Fraud
According to Healthcare.gov, billions of dollars have been lost to health-care fraud. This results in the sharp increase of health-care costs to the public. An important feature of the Affordable Care Law is efforts to fight this fraud. The law allows for new resources to be invested into the detection and diffusion of health-care fraud, as well as the establishment of new screening procedures to be used by health-care providers in order to reduce the risk of fraud. The Medicare Trust fund is utilized to protect the program and work to provide additional savings on premiums and coinsurance into the future.
Protection of Coverage
The Affordable Care Act establishes protections to Medicare benefits, ensuring that these benefits cannot be reduced or taken away so long as eligibility continues. This element of the Act also ensures that beneficiaries will continue to have the ability to choose their own doctors to provide needed services and treatments.
Regulation Effective Dates
When the Affordable Care Act was signed into law, it was done with the goal of implementing the various program modifications and regulations progressively over the course of several years. Some of the key dates at which program elements are considered in effect include:
September 23, 2010—Medicare coverage is expanded to cover small, rural facilities and hospitals, and Medicare patients coping with chronic illnesses will be evaluated every three months in order for coverage of medications and treatments to continue.
January 1, 2011—Centers for Medicare and Medicaid Services are responsible for the development of innovative delivery and payment models for applicable services.
January 1, 2013—An additional 3.8 percent Medicare tax will apply to unearned income.
January 1, 2015—Payments made to physicians from Medicare will be modified so that they will be based not on the volume of care provided, but on the quality of such care.
January 1, 2017—States will have the option of applying for a waiver for state innovation from the Secretary of Health and Human Services. This option will be available only if the state also passes legislation intended to implement an alternative health-care plan.
2018—Approved preventive care, including regular checkups, must be covered by all existing health insurance plans and be provided without a co-payment. A 40 percent excise tax will also be applied to health insurance policies with high-cost premiums. The premium thresholds, including higher thresholds that are imposed on retirees and those that are employed in professions considered high risk, will be modified in accordance with inflation.
2020—The Medicare Part D doughnut hole, or coverage gap, will be eradicated, providing Medicare beneficiaries with more consistent drug coverage.