Presentation on theme: "Presented by Angela Free Associate Director, Benefits & Payroll May 7, 2014 CSRA Medicare Presentation."— Presentation transcript:
Presented by Angela Free Associate Director, Benefits & Payroll May 7, 2014 CSRA Medicare Presentation
Medicare Introduction Parts of Medicare What Medicare Covers Transitioning to Medicare Who Pays When? Pharmacy Benefits Medicare Appeals Answers to Submitted Questions New Questions? AGENDA
Medicare coverage is based on 3 main factors : Federal and state laws National coverage decisions made by Medicare about whether something is covered Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area MEDICARE INTRODUCTION
Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. PARTS OF MEDICARE
How to find out if Medicare covers what you need Talk to your doctor or other provider about why you need certain services or supplies, and ask if Medicare covers it. If you need something that's usually covered and your provider thinks that Medicare won't cover it, you'll have to sign a notice saying that you understand you have to pay for that item, service, or supply yourself. Go here to check for yourself. Enter all or part of the name of the procedure, item or supply in the search field: WHAT MEDICARE COVERS
Hospital care Skilled nursing facility care Nursing home care (as long as custodial care isn't the only care you need) Hospice Home health services WHAT DOES MEDICARE PART A COVER?
Part B covers 2 types of services: Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. You pay nothing for most preventive services if you get the services from a health care provider who accepts Medicare assignment. WHAT DOES PART B COVER?
Clinical research Ambulance services Durable medical equipment (DME) Mental health Inpatient care Outpatient care Partial hospitalization Getting a second opinion before surgery Limited outpatient prescription drugs PART B MEDICALLY NECESSARY:
Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests HIV screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time “Welcome to Medicare” preventive visit Prostate cancer screenings Sexually transmitted infections screening & counseling Shots: Flu, Hepatitis B, Pneumococcal Tobacco use cessation counseling Yearly "Wellness" visit PART B PREVENTATIVE & DIAGNOSTIC:
Medicare doesn't cover everything. If you need certain services that Medicare doesn't cover, you'll have to pay for them yourself unless you have other insurance or you're in a Medicare health plan that covers these services. Even if Medicare covers a service or item, you generally have to pay your deductible, coinsurance, and copayments. Some of the items and services that Medicare doesn't cover include: Long-term care, also called custodial care (remember Part A covers it as long as that’s not the only type of care you need at the time) Most dental care Eye examinations related to prescribing glasses Dentures Cosmetic surgery Acupuncture Hearing aids and exams for fitting them Routine foot care WHAT'S NOT COVERED BY PART A & PART B?
Part D adds prescription drug coverage to Original Medicare and other Plans, like our USG plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans, Like our Kaiser Senior Advantage Plan, may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. WHAT DOES PART D COVER?
The pharmacy benefits for Medicare Eligible Retirees enrolled in the BCBS plans are provided through Express Scripts (formerly Medco) Medicare Part D prescription drug plan for the University System of Georgia. This prescription drug plan generally provides retirees the same prescription drug coverage as for active employees with very few exceptions. USG RX COVERAGE
Kaiser Senior Advantage Pharmacy coverage If you enroll in the Kaiser Permanente Senior advantage plan, Kaiser Permanente will serve automatically as your Part D provider. If you are a new member selecting Kaiser Permanente Senior Advantage as your retiree option for 2014, your application will include Part D enrollment information. If you currently have an existing Part D Plan and enroll into Senior Advantage, your existing Part D Plan will automatically be cancelled by Medicare. KAISER RX
Medicare eligible retirees enrolled in the Open Access POS plan will be automatically enrolled in the Express Scripts Medicare Part D plan through the University System of Georgia as part of their pharmacy coverage If a retiree does not want to enroll in this Express Scripts Medicare Part D plan, the retiree may waive coverage under the plan; however, if the retiree waives coverage, he/she will no longer be eligible to participate in the Open Access POS plan. The retiree will have the option to enroll in the HSA Open Access POS plan or the Kaiser Sr. Advantage plan or cancel their retiree health coverage. If a retiree cancels their retiree health coverage through the University System of Georgia, they will not be allowed to re-enroll in coverage IMPORTANT INFORMATION MEDICARE-ELIGIBLE RETIREES NEED TO KNOW ABOUT THE OPEN ACCESS POS PHARMACY PLAN COVERAGE:
Retirees will receive a pre-enrollment letter from Express Scripts which will explain the plan in detail Upon enrollment, Retirees will receive a Welcome kit and a new pharmacy ID card with a new group number – it does not say Medicare, but the group number is a Medicare group Retirees will be able to get their prescriptions from the same retail pharmacies as before Retirees with questions may contact the University System of Georgia Shared Services Center toll-free at or For questions about the benefits or how the plan works, contact Express Scripts Medicare Customer Service at (CON’T) IMPORTANT INFORMATION MEDICARE- ELIGIBLE RETIREES NEED TO KNOW ABOUT THE OPEN ACCESS POS PHARMACY PLAN COVERAGE:
Generic copay $10 for 30 day supply Name brand $25 Mail order: Tier 1 $25 /Tier 2 $70 The HMO is subject to a formulary Some drugs are subject to pre-authorization or step-therapy HMO RX
85% of network cost of drug Not subject to formulary Some drugs are subject to pre-authorization or step-therapy Mail order is available OPEN ACCESS HSA POS Rx (HIGH DEDUCTIBLE)
Generic $10, Preferred brand-name $35 Non-preferred brand-name 20% of the drug’s cost/$45 minimum copay /$125 max co-pay Mail order: Days supply: Generic $25, Preferred $87.50 Non preferred $ minimum copay/$250 maximum copay Annual out of pocket max (Non-preferred brand-name does not count toward this) EE: $1000 EE + Ch or EE + Sp : $2000 Family (3 or more) $3000 This means the cost is waived for generic and preferred drugs after max is met in a year. OPEN ACCESS POS RX
Choosing Mail Order or Retail: A Message from the USG System Office In 2014, members enrolled in the OA POS plan using maintenance medications at retail must make a decision on how to receive maintenance prescription drugs – through home delivery or retail prior to the third refill. If a decision is not made by the third refill, members will be required to pay the full price of the prescription until a decision is made. We want all of our employees and their dependents to be aware of the savings and health benefits available to them through mail order! ACTIVE CHOICE
To make the decision about mail order, visit the Express Scripts website at Scripts.com/Decide or call Express Scripts at , Monday – Friday, 8:30 a.m. to 6 p.m., Eastern. Express Scripts will make the transition to mail order easy by contacting your doctor to get a new 90-day prescription on your behalf. Contact Express Scripts with your decision today! Thank you! University System of Georgia/Board of Regents Human Resources HOW TO CONTACT EXPRESS SCRIPTS
I’ll be 65 soon, what do I need to do? Sign up for Medicare Parts A & B (online at medicare.gov, by phone, or in person) Contact CSU Benefits Office or Shared Services with your Medicare Claim Number After you are enrolled, contact Medicare for coordination of benefits (more later) If you are already retired and turning 65, you need to make sure you are in an eligible health plan. If you are currently enrolled in the Blue Cross HMO – you must change plans because it is not Medicare compatible. You may choose High Deductible HSA POS Plan or Regular POS HSA Plan. You will receive a kit from the SSA days before your birthday. If you are still active and enrolled in a USG medical plan, it is considered credible coverage, and you can put off enrolling in Medicare parts B and D until you retire without paying a penalty. If you do choose to enroll while active, your USG plan will remain primary, and your Medicare B plan will be secondary. TRANSITIONING TO MEDICARE
MEDICARE CLAIM NUMBER
When you turn 65 - your Initial Enrollment Period During Medicare annual enrollment between January 1–March 31 each year When you lose employer sponsored group health coverage (8 months from end of employment or end of coverage, whichever occurs first) There is a penalty for signing up late – 10% for each full 12 month period past your initial enrollment deadline, but if you remain enrolled in your CSU plan as an active employee until you retire and then enroll, the penalty is waived. WHEN CAN I SIGN UP?
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. HOW MEDICARE WORKS WITH OTHER INSURANCE
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. 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 at PRIMARY PAYER
COORDINATION OF BENEFITS BETWEEN MEDICARE AND A SECOND PAYER Question: How does Medicare pay as a secondary payer?
Answer: When Medicare is primary, Part A and B, the member has a Medicare deductible (which is usually met before BCBS) and BCBSGA deductible to meet before Blue Cross plan cover’s member’s Medicare’s 20% coinsurance. Also, if the member has not met their deductible for BCBS, the provider can bill the member for an amount that Medicare states is the patient's responsibility. *If the member uses an in network provider, the BCBS’s deductible is $300.00; once the deductible is met, BCBS will pick up the member’s Medicare coinsurance. *If the member uses an out of network provider, the BCBSGA’s deductible is $400.00; once the deductible is met, Blue Cross will pick up the member’s Medicare coinsurance. However, since the provider is not participating, the member will be subject to balance billing because out of network providers do not take provider’s write-offs because they are not contracted to. SECOND PAYER
The dollar amount charged by a provider that is in excess of the plan’s allowed amount for medical care or treatment. Amounts that are balance billed by a provider are the member's responsibility. Member costs incurred for balance billing will not apply toward the annual deductible or toward the annual maximum out-of-pocket limits. DEFINITION OF BALANCE BILLING:
HOW CLAIMS ARE PAID BY USG IF PROVIDERS OPT OUT OF MEDICARE As of 2014, members will pay a lower premium to USG when they have Medicare primary so they must find a provider who accepts both Medicare and Blue Cross OA POS. If a member uses a provider that has “opted-out” of Medicare, Blue Cross will not pay as primary, as they have done in the past. Blue Cross will process the claims as secondary and any amounts above the plan’s payment can be held as the patient’s liability. This means that Blue Cross will only cover the 20% of Medicare’s coinsurance.
HOW CLAIMS ARE PAID WHEN THE CLAIMANT HAS MEDICAID AND MEDICARE Blue Cross do not coordinate with Medicaid If the claimant has Medicare, Medicaid and Blue Cross, Medicare pays first, Blue Cross pays and if there is a balance of Medicaid allowable charges, Medicaid pays. If the claimant has Medicare and Medicaid only, Medicare pays first and Medicaid pays second.
Here are some basic steps for challenging Medicare coverage denials under Part A (including hospitalization, nursing homes and hospice services) and Part B (doctor visits, tests, home health care, durable medical equipment). In most cases, it is not necessary to hire a lawyer. Advocates say to be sure to write your Medicare or member number on all documents, and to keep copies. You have to be committed and tenacious. APPEALS
Level 1: Redetermination by the company that handles claims for Medicare Level 2: Reconsideration by a Qualified Independent Contractor (QIC) Level 3: Hearing before an Administrative Law Judge (ALJ) Level 4: Review by the Medicare Appeals Council (Appeals Council) Level 5: Judicial review by a Federal District Court FIVE LEVELS OF APPEALS
For the first appeal, called redetermination: Make the request within 120 days of receiving the denial Any dollar amount can be appealed Circle the questionable item on your quarterly Medicare statement, called the Medicare Summary Notice, and follow the mailing instructions on the form. You can also complete an appeals form found here: appeals/file-an-appeal/original-medicare/original-medicare-appeals.htmlwww.medicare.gov/claims-and- appeals/file-an-appeal/original-medicare/original-medicare-appeals.html FIRST APPEAL
If you get denied again, you can make a request for second appeal, called reconsideration: Make the request within 180 days of receiving notice that the first appeal was denied. In a letter, explain the services or items that you received and why payment is in dispute. Include a copy of the initial denial or fill out the reconsideration form available at medicare-appeals-level-2.html. medicare-appeals-level-2.html SECOND APPEAL
To request a hearing before an Administrative Law Judge, which usually is conducted via conference call with patients, doctors and others: Make the request within 60 days of receiving the denial of the second appeal. To be eligible for a hearing, the amount in dispute must be at least $140. In your letter, provide your name, address, Medicare number, document control number from previous denial, dates of services or items in dispute and why you are appealing. Include any other information to support your request, or complete a hearing request form available at 3.html.www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level- 3.html THIRD APPEAL
If you get denied again, you can make a request for consideration by the Medicare Appeals Council: Make this request within 60 days of receiving the hearing decision. In a letter, cite which parts of the decision you dispute and the date of the decision, or complete the hearing review request form available at FOURTH APPEAL
Beneficiaries who are still not satisfied can file an appeal in Federal Court, but the amount in dispute must be at least $1,350. FIFTH AND FINAL APPEAL
ANSWERS TO QUESTIONS
Question: My Medicare part B deductible for 2013 is $147. Is this something BCBS covers? OR am I responsible for the $300 BCBS annual deductible in addition to the Medicare Part B deductible? Answer: You must first meet your $300 deductible with us before we will consider any amounts for processing. For example, Medicare processes a claim with the $ of the total claim amount applying towards your Medicare deductible. You have not met your BCBS deductible. However, BCBS will apply that $ as a CREDIT towards your BCBS deductible. You will not be responsible for BCBS $ deductible plus the $ deductible from Medicare. Your responsibility would be your $147 which would be payable to the provider who rendered the service. Note: You will be responsible for paying the remainder $153 needed towards the deductible with BCBS before BCBS plan would pay.
Question: What are the planned changes to the BOR/USG Health Benefit Plan and the impact on retirees? Answer: I am not aware of any. I posed the question to the system office and they indicated they had nothing to share at this time that would have an impact on retirees.
Question: Does Medicare cover Pap tests? If so, how often is the test covered? Answer: Yes. Once every 24 months for all women Once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of childbearing age and have had an abnormal Pap test in the past 36 months
Question: What are the procedures now covered by Medicare not covered by University System Health Insurance (now BCBS)? Answer: Acupuncture (discounts provided through BCBSGa’s Special Offers Program) Air-fluidized beds (discounts provided through BCBSGa’s Special Offers Program) Bariatric surgery Canes (discounts provided through BCBSGa’s Special Offers Program) Cosmetic Surgery Gym membership and fitness programs (discounts provided through BCBSGa’s Special Offers Program) Hearing Aids Hospital Beds Adult diapers (discounts provided through BCBSGa’s Special Offers Program)
Question: If Medicare denies a procedure or test, at present, when will University System Health Insurance pick up coverage? Answer: If Medicare does not cover the services and the services are covered by Blue Cross, a denial EOB from Medicare must be submitted to Blue Cross to show it is non-covered under the primary provider. At that point, Blue Cross would pay.
Question: In the future, if Medicare cuts kick in and coverage is denied for tests and procedures now covered, does the University System plan to cover these tests and procedures? Probably would require an increase in premium. Answer: The intent of the USG plan is to cover the Medicare 20% coinsurance once deductibles have been met. At this time there is not a plan to change the structure and provide additional or different coverage.
Question: It is constant guesswork what they have covered following a procedure? Is there a way a covered individual can electronically access his or her records--hopefully, not just a telephone number? Answer: Yes! “Blue Button” allows you to download your health data. Here is the link to an online demonstration of registration: https://mymedicare.gov/Help/VirtualTour/WBT_Register_V2.aspx Another useful like with how to demos for several other functions: https://mymedicare.gov/help/virtualtour.aspx#
Question: My physical therapist advised me that there was a federal bill in motion--don't know if it is house or senate--to cover additional services, including a) therapeutic massages, b) personalized gym training, c) acupuncture and dry needle therapy. What is the status of that bill? Answer: We could not find evidence that it ever existed. The system office, our Blue Cross Account Manager and a couple of researchers in the HR office tried to help find it but could not.
Question: One healthcare provider I see is registered dietitian/nutritionist. She does not accept insurance or Medicare, but will provide diagnosis code sheet. I filed her sheet with BCBS and they paid 100%. Should I have also submitted to Medicare--if so, how, since they don't seem to have a system of direct patient input? Answer: Submit via the claim form, The Patient’s Request for Medical Payment Found here:
Question: Medicare so far has proven to be a retirement penalty costing $ per month. Having retired July 1, 2013, spouse and I are now paying $ each per month for part B which we had never paid before. We had been under BCBS high deductible family plan of $132/month and continue with that plan in retirement. So far Medicare has paid $0. At this rate, it appears we will be out of pocket rest of our lives $ per month (plus any Medicare Part B increases). Please provide numeric illustrations of what CMS/Medicare will provide. We realize that BCBS will help with some of the drug/pharmacy since we don't have Part D, but to get any other benefits from CMS/Medicare it appears we may have to drop BCBS to get those. Are we over-insured and under-benefitting?
Medicare Covers… Abdominal aortic aneurysm screening Acupuncture Air-fluidized beds Alcohol misuse screening & counseling Ambulance services Ambulatory surgical centers Anesthesia Artificial eyes & limbs Bariatric surgery Blood Blood processing & handling Blood sugar (glucose) test strips Blood sugar monitors Bone mass measurement (bone density) Braces (arm, leg, back, and neck) Breast prostheses Canes Cardiac rehabilitation programs Cardiovascular disease (behavioral therapy) Cardiovascular disease (behavioral therapy) Cardiovascular disease screenings Cataract surgery Cervical & vaginal cancer screenings Chemotherapy Chiropractic services Clinical research studies Colorectal cancer screenings Commode chairs Continuous passive motion (CPM) machine Continuous passive motion (CPM) machine Cosmetic surgery Crutches Custodial care Defibrillator (implantable automatic) Dental services Depression screenings Diabetes screenings Diabetes self-management training Diabetes supplies & services Diagnostic tests, X-rays, and clinical laboratory services Diagnostic tests, X-rays, and clinical laboratory services Dialysis (children) Dialysis (kidney) services & supplies Doctor & other health care provider services Doctor & other health care provider services Drugs Durable medical equipment (DME) coverage Durable medical equipment (DME) coverage
Medicare Covers… Diabetes screenings Diabetes self-management training Diabetes supplies & services Diagnostic tests, X-rays, and clinical laboratory services Diagnostic tests, X-rays, and clinical laboratory services Dialysis (children) Dialysis (kidney) services & supplies Doctor & other health care provider services Doctor & other health care provider services Drugs Durable medical equipment (DME) coverage Durable medical equipment (DME) coverage EKG (electrocardiogram) screening Emergency department services Enteral nutrition supplies & equipment (feeding pump) Enteral nutrition supplies & equipment (feeding pump) Eye exams Eyeglasses/contact lenses Flu shots Foot care Foot exam Glaucoma tests Glucose control solutions Gym membership & fitness programs Health education & wellness programs Hearing and balance exams & hearing aids Hearing and balance exams & hearing aids Hepatitis B shots HIV screening Home health services Home oxygen equipment & supplies Hospice & respite care Hospital beds Hospital care (outpatient) Humidifiers Incontinence supplies & adult diapers Infusion pumps Inpatient hospital care Insulin Kidney disease education Kidney transplants (adults) Kidney transplants (children) Laboratory services (clinical) Lancet devices & lancets Long-term care hospitals Macular degeneration Mammograms Massage therapy Mental health care (inpatient) Mental health care (outpatient) Mental health care (partial hospitalization) Mental health care (partial hospitalization) Nebulizers & nebulizer medications Nursing home care Nutrition therapy services (medical) Obesity screening & counseling
Medicare Covers… Orthotics & artificial limbs Osteoporosis drugs for women Ostomy supplies Outpatient hospital services Oxygen therapy Pancreas transplants (adults) Patient lifts Physical therapy/occupational therapy/speech-language pathology services Physical therapy/occupational therapy/speech-language pathology services Pneumococcal shots Prescription drugs (outpatient) Preventive & screening services Preventive visit & yearly wellness exams Preventive visit & yearly wellness exams Prostate cancer screenings Prosthetic devices Pulmonary rehabilitation program Radiation therapy Religious non-medical health care institution (RNHCI) Religious non-medical health care institution (RNHCI) Rural health clinic & federally qualified health center services Rural health clinic & federally qualified health center services Second surgical opinions Sexually transmitted infections (STI) screening & counseling Sexually transmitted infections (STI) screening & counseling Shingles shot Shots (vaccinations) Skilled nursing facility (SNF) care Sleep apnea & Continuous Positive Airway Pressure (CPAP) therapy Sleep apnea & Continuous Positive Airway Pressure (CPAP) therapy Sleep study Smoking & tobacco use cessation (counseling to stop smoking or using tobacco products) Smoking & tobacco use cessation (counseling to stop smoking or using tobacco products) Substance-related disorders Suction pumps Supplies (you use at home) Surgery (estimating costs) Surgical dressing services Tdap shot (tetanus, diphtheria, & pertussis shot) Tdap shot (tetanus, diphtheria, & pertussis shot) Telehealth Therapeutic shoes or inserts Traction equipment Transplants (adults) Transportation Travel (when you need health care outside the U.S.) Travel (when you need health care outside the U.S.) Urgently needed care Walkers Wheelchairs & power mobility devices Wheelchairs & power mobility devices X-rays Yearly eye exam