MEDICARE

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HOME HEALTH BENEFIT

Medicare beneficiaries who are homebound are entitled to up to 35 hours per week of free skilled nursing and home health aide services as well as skilled therapy and services. If eligible, the are no premiums, no deductibles and no co-payments. However, there is a 20% co-payment for durable medical equipment. The benefit is available from any Medicare Certified Home Health Agency. You must be homebound and require skilled nursing services on an intermittent or part time basis. Part time is less than eight hours per day. Intermittent basis means fewer than five days per week or as little as once every 60 to 90 days. But once one has met eligibility criteria, it can cover for up to 35 hours per week. The skilled care of a registered nurse must be reasonable and necessary to the diagnosis and treatment of illness or injury. Your physician must certify care. A CHHA (Certified Home Health Agency) must draw up a plan of care specifying the nature, frequency and duration of care needed. While the level and extent of care is considerable, recognize that few ill qualify since they need SKILLED care- but very few actually qualify in this category.

MEDICARE BILLING

A patients can also tell if he is being overfilled when under Medicare since recent federal rule limit the amount doctors can charge Medicare patients. If your share of the bill is more than 31% of the total fees, you can conclude that you are being overfilled. And an interesting note from the Medicare Beneficiaries Defense Fund- it said that 78% of claims that are denied at first get fully or partly paid on the second try and 67% make it on the third try. Lastly some insurance policies may actually pay for services not identified in their policy if they believe that it will avoid more costly treatment later on. Apparently the illnesses such as outpatient psychotherapy and rehabilitative services may be paid since they could forestall more expensive treatment later on. The article also addressed that fact that when you need expensive treatment for cancer, for example, you can appeal to the Medical Care Ombudsman Program 301 657-0404. It enlists independent doctors to review patients cases and intervene on their behalf when appropriate.

MEDICARE: (1995) As I have commented on previously, Medicare allows so many days in the hospital for certain procedures. However, and what people do not specifically recognize is, if you are still sick, you have the right to medical care in a hospital no matter what the Diagnosis Related Groups say. If the hospital should decideo not to cover you and you have received a Notice of Noncoverage, you have the right to request a review of a Peer Review Organization (PRO). Recognize however that both your hospital and your doctor have to agree that Medicare is no longer responsible for paying your bills. Further, you are not required to pay any bills if you request a review if you file your appeal by noon of the first work day after you receive your Notice of Noncoverage and until the Peer committee makes a decision.

If the doctor and the hospital disagree, the hospital may agree to a PRO review. In such a case, the PRO must agree with the hospital in order to send out a Notice of Noncoverage.

If you do not request a review, the hospital may bill you for all the costs of your stay beginning with the third day after you receive the Notice of Noncoverage. The hospital however cannot charge you for care unless it provides you with a Notice of Noncoverage.

MEDICARE: (US News)
Family Income

(1990 Dollars)

 Percentage of all Families Receiving Benefits Average Benefits per Family
All families 24% 3,820
$1- $9,999 34 3,200
10,000- 19,999 30 3,830
20,000- 29,999 25 4,100
30,000- 39,999 21 4,270
40,000- 49,999 17 4,140
50,000- 74,999 15 4,170
75,000- 99,999 17 4,160
100,000- 149,999 18 4,290
150,000+ 20 4,380

More statistics

Percentage of Medicare beneficiaries by Income
Below $25,000 78%
$25,000- $50,000 18
More than 50,000 5


Percentage who are women ---57%

(Not surprising since there are more of them and they live longer)

Percentage of Medicare dollars spent in the last year of life----20%

Average annual expense on health care, age 65 and older $2,803

Biggest expense------Home care

Percentage who were satisfied with Medicare services------89%

Proportion of beneficiaries receiving home health services in

1982------------------40/1,000

1992------------------70/1,000

Percentage of Medicare population over 80-----------10

Percentage of same in managed care----------7

MEDICARE COVERAGE: (Answers 1995) Medicare will pay all costs for medically approved home health care services if the following conditions are met.

Elements that are not covered include:

One element in continuing Medicare treatment is a sympathetic doctor. If you have an "uncaring" doctor, it might be worthwhile to switch to one who understands the situation better.

MEDICARE COST INCREASES (1997): As indicated previously, overall costs have decreased but some areas- Home Health Care for example- have gone up almost exponentially and are the reasons why the Medicare budget is so precarious.

The number os Medicare beneficiaries has increased by 2% a year, but the number of home health visits have increased by 30% a year to 236 million in 1995 from just 63 million in 1990. The average number of visits for each user has doubled to 69 in 1995 from 34 in 1990. The number of Medicare patients who receive home health services reached 3.4 million in 1995 up from 1.9 million in 1990. Spending for such visits for nurses, home health aides and therapists has increased 31% year to $16.7 billion in 1996 from just $3.3 billion in 1990. Payments to skilled nursing home rose 26% to $11.1 billion in 1996 from $2.8 billion in 1990. How could such increases happen? Part is due to fraud (so what else is new?). The number of Home Health Care agencies that participate in Medicare increased 60% to 9,147 in 1995 from 5,718 in 1990. And most of these agencies are "for profit" organizations. The GAO said that such "proprietary agencies consistently provide more home health visits that nonprofit agencies," even for patients for the same illness. Health and Human Services Secretary Donna Shalala said that some of the spending was clearly appropriate but that "...investigations in several states show that 25% to 40% of home health visits paid for by Medicare were for services that were either never delivered or were provided to people who did not qualify for those services."

This activity is far more pronounced in the South and Midwest where home health care visits are being used as a substitute for full nursing home care- which is NOT covered by Medicare.

MEDICARE HOSPITAL DISCHARGE PLANNING: (HHS IG 1998) A study by June Gibbs Brown) found that "some hospitals which own nursing homes discharge patients sooner to their own facilities and those patients stay in the facilities longer, increasing Medicare reimbursement." With regard to hospital-owned home health agencies, no significant difference was found in the length of hospital stays; but the report documents beneficiaries referred to a hospital-owned home health agency "did get services for a longer period of time." Beneficiary satisfaction with care received at hospital-owned facilities, however, was high. Specifically, beneficiaries discharged to hospital-owned nursing homes were found to have average hospital stays of 6.8 days, a significantly shorter period as compared to the 8.9 days for beneficiaries discharged to a nursing home independent of the hospital. Similarly, the length of nursing home stays for seniors in hospital-owned facilities averaged 37 days, the IG says, while in independent entities the average stay was 29 days. "This supports the concern that hospitals are shifting patients from acute care reimbursed under a lump sum prospective payment, to post-acute care in nursing homes, which is reimbursed on a cost basis, thus maximizing Medicare reimbursement." Why all the hubbub, bub? Because Medicare is running out of money due to the efforts of hospitals and home health care agencies to increase revenue at the taxpayers expense.

MEDICARE AND MEDICAID APPROVED: (1998) About 11,000 facilities are certified for both Medicare and Medicaid, but some 1,100 homes are certified only for Medicare. If your relative needs continued nursing care, and Medicaid will at some point have to pay the bills, choose a facility that's certified for both.

MEDICARE HOME HEALTH REIMBURSEMENT: 1998 (Eldercare Journal) In October 1997, the Health Insurance Financing Administration changed its method of reimbursement to licensed Medicare certified agencies. Prior to this, agencies were paid on a fee per visit rate for all the visits they made to a patient, as long as the patient met the Medicare home health criteria.

Under the Prospective payment plan, agencies will be assigned a reduced per visit rate and be given a capitated rate of anywhere between $3,600 to $4,200 per patient per year depending on the region where the agency is located. (This article was written for the Phoenix, AZ area.) This is the maximum revenue per year that each Medicare resident will receive for the home health visits, which means a total of 40 to 52 visits per year for nursing, physical therapy, special therapy, occupational therapy, Medical social workers, and home health aides.

This reduction in overall services will mean that patients/residence will receive far fewer home health visits than they had received in past years.

"In the past, nurses and therapists provided care and treatments; now they will be educating adult home care staff and expecting that caregivers to take a more active role in providing treatment and follow through as decreased funding reduces their number of visits."

The author noted that they expected patients to receive visits for shorter overall periods of time and that some residents will be sent to nursing homes for transitional care because the level of care needed in the home will be more than the agency can afford to provide.

MEDICARE: (1998) Elderly people spend about one-fifth of their income (approximately $2,149) on medical care and prescription drugs. Poor Medicare beneficiaries-those who do not qualify for Medicaid- spend about half their income on health care. A recent study showed that 60% of elderly people under the official poverty level are not on Medicaid since, in many states, the income ceiling for Medicaid recipients is far below the states poverty level.

MEDICARE: 1998 Elderly people spend about one-fifth of their income (approximately $2,149) on medical care and prescription drugs. Poor Medicare beneficiaries-those who do not qualify for Medicaid- spend about half their income on health care. A recent study showed that 60% of elderly people under the official poverty level are not on Medicaid since, in many states, the income ceiling for Medicaid recipients is far below the states poverty level.

Medicare provide health insurance for about 33 million people age 65 and older and five million people under 65 who have long-term disabilities. The most affluent beneficiaries- those with incomes four times the poverty level-spend an average of 10 percent of their income for health-care

60% of Medicare beneficiaries are women. Women live about 7 years longer than men with more complex, chronic diseases. 83% of women on Medicare have less than $25,000 income per year. The typical Medicare beneficiary requiring home health care is 75 years old and has a median income of $8,365. She requires an average of 3 home health visits per week.

MORE MEDICARE: An AARP study in 1997 found that Medicare Enrollees spent in average of 2,149 or 19% of their income for out-of-pocket health care costs, excluding the cost of home health care and nursing home care. Medicare paid, on average, just over five thousand dollars in benefits per beneficiary last year.

Medicare Enrollees living below the poverty line-7,775 for individuals and 9,780 for couples in 1997-spent 35 % of their income out-of-pocket on health bills.

About 3.8 million Medicare Enrollees get some form of home health care.

MEDICARE: (1999) Medicare Part A or Hospital Insurance is financed by a 2.9% payroll tax. If you have sufficient number of working quarters, it costs nothing. Medicare Part B or the Supplemental Medical Insurance will cost $45.50 in 1999 but represent only about 25% of the total cost of care. In fiscal 1998, Federal outlays for Part A was about $135 billion and for Part B about $75 billion. The total was about 1/8 of the entire Federal budget and about $5,500 per enrollee.

And per the American Institute for Economic Research, the sickest 5% of beneficiaries account for half the total benefits paid. And a similar proportion of the benefits goes to the care of those in the last six months of life.

The Balanced Budget amendment of 1977 switched home health care over to Part B in a effort to forestall the deficit of Part A. This will only work for awhile and once the deficit finally  hits, more tax is mandatory.

The Health Care Financing Administration estimates that in order to meet hospitalization costs under current law, it will have to increase payroll tax to 3.7% by 2010, to 4.9% by 2020 and 6.2% by 2030 using intermediate assumptions of the future trends of payrolls, hospital use and costs. Under the most pessimistic assumptions, the tax increases are to 4.6% in 2010, 7.2% in 2020 and 10.9% in 2030.

Under intermediate assumptions, payments for Part B (in 1997 dollars) would be $126 billion in 2010, $189 billion in 29020 and $267 billion in 2030. The pessimistic assumptions call for $331 by 2030.

Women and aging : (1999) (NY Times) As women get older, they have a greater need to Medicare coverage. They are also much poorer than men. And they live longer.

Percentage of Medicare
Age Men Women
65- 74 46% 54%
75- 84 39 61
85+ 29 71

CPI: (1999) Once the FED reduced the amount of the CPI (Cost of Living increases) that HMO's would receive, HMO's have been dropping Medicare service left and right because they are no longer profitable. While the law does require HMO's to find substitute medical coverage for the elderly (about 440,000 beneficiaries may be affected), it is almost universally at a higher price. Federal officials say that a person dropped from a Medicare HMO has a right to buy certain types of Medigap insurance. "Disabled people who choose to buy Medigap policies are likely to have higher health costs than the average senior covered by Medicare and Medigap. Requiring insurance companies to sell Medigap policies to the disabled, at standard rates regardless of their claims experience, will lead inevitably to higher Medigap premiums for the elderly." But only the first 4 out of 10 allowed Medigap policies are apparently required. The other 6 groupings DO allow a decline because of prior health conditions- and these are the ones that include prescriptions and other elements many seniors would like.

Premiums were already rising rapidly, with many Medigap insurers reporting a cumulative increase of more than 45 percent over the last three years.

Americans have the highest paid doctors in the industrialized world. American patients report that their last visit to a doctor lasted longer than 20 minutes- yet are the most likely to complain that the visits are to short.

This whole scenario seems to be going back to the 70's where medical care for the elderly was scarce- and expensive. This is gong to be a major debacle- nobody should get much back out the budget "surplus". It should be used to fund more care- or at least more research to fix what will be a monstrous problem.

And more- Clinton said he wanted to include prescription drugs. But the Congressional Budget Office noted that he had "grossly underestimated" the cost. Clinton indicate a cost of $118 billion over 10 years. The study indicated it would be $168 billion- $50 billion more- a 42% increase.

And even more- Medicare also helps train doctors. But certain hospital in New York are getting three times the amount for each trainee than in LA or Cleveland and 7 times more than in Houston. New York hospitals get as high as $55,000 annually for each trainee while a major teaching hospital in Houston gets only $7,000.

MEDICARE AND MEDICAID BUDGETS: (1999) The New England Journal of Medicine, February 1999, Volume 340, Number 5 The American Health Care System -- Medicaid, John K. Iglehart. He notes, in part, "In recent years, Medicaid has changed in important ways. The change that has affected the greatest number of people is the expansion of the population eligible for Medicaid, from 28.3 million in 1993 41.3 million today." That in itself explains why the Medicaid budget exploded- so has Medicare.

MEDICARE AND DRUGS: (2000) (National Bipartisan Commission on the Future of Medicare) 12% of the population is elderly but they account for about 33% of all prescription drug costs. Per capita spending by the elderly is 3 times more than other adults and 10 times more than children. Average cost is $600 annually with 10% spending $2,000+. Drug spending is indicated to increase by 8% annually- which you will not is many times the rate of inflation. (That's one reason why there is a special Elderly CPI- higher than the "regular" CPI).

Indicator 29 Use of Health Care Services
TABLE 29A:  RATES OF HEALTH CARE SERVICE USAGE BY MEDICARE BENEFICIARIES AGE 65 OR OLDER, 1990 TO 1998 (PER 1,000)
USE OF SERVICES
TYPE OF SERVICE 1990 1991 1992 1993 1994 1995 1996 1997 1998
HOSPITALIZATION 307 311 311 306 337 344 352 364 365
HOME HEALTH VISITS 2,141 - 3,822 4,648 6,352 7,608 8,376 8,227 5,058
SKILLED NURSING FACILITY ADMISSIONS 23 - 28 33 43 50 59 67 69
PHYSICIAN VISITS AND CONSULTATIONS 10,800 11,800 11,800 12,100 12,500 12,900 13,000 13,000 13,100
AVERAGE LENGTH OF HOSPITAL STAY (DAYS) 8.8 8.6 8.3 7.9 7.4 6.9 6.5 6.2 6.1
- = NOT AVAILABLE

Note: Data for 1998 should be considered preliminary. Some data for 1991 are not available (—). For hospitalizations, home health visits, and skilled nursing facility admissions, utilization rates for 1994–1998 exclude HMO enrollees from the numerator and denominator because utilization data are not available for this group. Prior to 1994, HMO enrollees were included in the denominators causing utilization rates to be understated. Prior to 1994, HMO enrollees represented 7 percent or less of the Medicare population; in 1998 they represented about 18 percent.  For physician visits, data on HMO enrollees are excluded for all years.
Reference population: These data refer to Medicare beneficiaries in fee-for-service only.
Source: Medicare claims and enrollment data.

 
TABLE 29B:  USE OF HOME HEALTH AND SKILLED NURSING FACILITY SERVICES BY MEDICARE BENEFICIARIES AGE 65 OR OLDER, BY AGE GROUP, 1998
65 TO 74 75 TO 84 85 OR OLDER
HOME HEALTH VISITS PER 1,000 ENROLLEES 2,350 6,262 12,709
SKILLED NURSING FACILITY ADMISSIONS PER 1,000 ENROLLEES 27 83 200
Note: Data for 1998 should be considered preliminary.
Reference population: These data refer to Medicare beneficiaries in fee-for-service only.
Source: Medicare claims and enrollment data.

2000 Guide to Health Insurance for People with Medicare )The U.S. Health Care Financing Administration) The "Guide helps consumers understand and purchase Medicare Supplement (Medigap) policies and provides information about other types of health insurance available. The Guide is available in English and Spanish editions, as well as audiotape, large type and Braille editions. A copy of the Guide may be obtained by calling 1-800-MEDICARE or TTY/TDD 1-877-486-2048 or by downloading the PDF file

Medicaid/Care Home Health Care (Clarence J. Sundram article "Abuse and Neglect in Community Settings," in the September/October 2000 issue (Vol. 3, No. 3) of "Victimization of the Elderly and Disabled". HCFA has been conducting in-depth reviews of the Home and Community Based Waiver programs in several states and its findings strongly suggest that the problems of abuse and neglect that once plagued institutions, like the institutional residents, have migrated to the community programs in which they now reside."

"In California, HCFA found residential facilities and day programs to be unsanitary, unsafe and inadequately supervised. Medications were improperly prescribed and administered. It found the State had failed to fulfill its obligation to safeguard the health and safety of the service recipients. The licensure system was not effective in protecting the health and safely of consumers."

"Just as the conditions in institutions were a visible manifestation of an abdication by government of its responsibility to be a competent service provider, the emerging problems in the community signal an equally profound failure of government to fulfill its responsibility to be a competent funder and regulator."

"Just as the conditions in institutions were a visible manifestation of an abdication by government of its responsibility to be a competent service provider, the emerging problems in the community signal an equally profound failure of government to fulfill its responsibility to be a competent funder and regulator."

"As states implement the Medicaid Home and Community Based Waiver and policies on self-determination, they are expanding rapidly to non-traditional providers where there is even less scrutiny of competence and fiscal accountability."

"[T]he Medicaid waiver is an engine for reform and offers access to public money and freedom from regulation. But its chief virtue is also its principal vice. The complete absence of standards and regulations continues to expose vulnerable people to unreasonable risks. We have to be more careful to ensure that the Medicaid waiver does not aid and abet a waiver of responsibility."

  Quality of Medical Care Delivered to Medicare Beneficiaries (JAMA. 2000;284:1670-1676)
Medicare HMO's (WEISS) By year-end 2000, nearly 934,000 seniors on Medicare will be dropped from their HMOs, on top of the 700,000 that were dropped in 1998 and 1999. But unlike the experience of previous years, when most seniors could still find alternative HMOs that might accept them, next year they will have few remaining options, according to a study by Weiss Ratings, Inc. Among the 237 HMOs reviewed by Weiss that opened their doors to Medicare beneficiaries in recent years, 147 will have fully or partially abandoned the business by December 31. This leaves only 90 HMOs (17% of the HMOs rated by Weiss) that are continuing to maintain their current Medicare business, for now. Among these remaining 90 HMOs, 37 are losing money. They lost a total of $645 million in 1999, plus another $82 million in the first quarter of 2000. At the same time, 34 have earned a Weiss Safety Rating of D+ ("weak") or lower. Only 22 have earned a  Weiss rating of B- ("good") or better.

Medicare HMO's (WEISS 2000) By year-end 2000, nearly 934,000 seniors on Medicare will be dropped from their HMOs, on top of the 700,000 that were dropped in 1998 and 1999. But unlike the experience of previous years, when most seniors could still find alternative HMOs that might accept them, next year they will have few remaining options, according to a study by Weiss Ratings, Inc. Among the 237 HMOs reviewed by Weiss that opened their doors to Medicare beneficiaries in recent years, 147 will have fully or partially abandoned the business by December 31. This leaves only 90 HMOs (17% of the HMOs rated by Weiss) that are continuing to maintain their current Medicare business, for now. Among these remaining 90 HMOs, 37 are losing money. They lost a total of $645 million in 1999, plus another $82 million in the first quarter of 2000. At the same time, 34 have earned a Weiss Safety Rating of D+ ("weak") or lower. Only 22 have earned a  Weiss rating of B- ("good") or better.

Growth in Medicare and Out-Of-Pocket Spending: Impact on Vulnerable Beneficiaries Assuming no change in the eligibility rules, the number of beneficiaries will increase 77 percent over the next 25 years, from about 40 million to an estimated 70 million

Table ES-1
Selected Medicare Projections, 2000 and 2025
(in 2000 dollars)

  2000 2025
Number of Beneficiaries
In thousands 39,484 69,728
As a share of the U.S. population 13.8% 20.6%
Number of beneficiaries per 100 workers 29 44
Medicare Expenditures
In billions $239.5 $599.1
Per capita $6,213 $8,987
As a share of GDP 2.61% 4.43%
Taxpayer portion of Medicare as a share of GDP 2.35% 3.89%
Per Capita Medicare Beneficiary Liability
Part B premium $631 $1,151
Cost-sharing $1,005 $1,509
Total $1,636 $2,660
As a share of total Medicare expenditures 22.7% 25.3%
Out-of-Pocket Spending
Elderly beneficiaries $3,142 $5,248
Elderly with poor health and no additional insurance $4,478 $7,263
Low-income single women over age 85 in poor health $5,969 $9,378
Out-of-Pocket Spending as a Share of Income
Elderly beneficiaries 21.7% 29.9%
Elderly with poor health and no additional insurance 44.0% 63.3%
Low-income single women over age 85 in poor health 51.6% 71.8%
Notes: GDP is gross domestic product. Taxpayer portion of Medicare is total spending minus beneficiary liability.
Source: The 1999 Trustees Reports and The Urban Institute’s 1999 Medicare Projections Model.

Figure 4 illustrates the historical and projected rates of growth in Medicare spending, in aggregate and per capita terms. The projections indicate a slowdown in the growth of real per capita spending, eventually approaching the rate of growth of spending on GDP. (While some may criticize that projection as too optimistic, allowing Medicare spending to grow at a rate substantially above GDP for a long period of time would result in untenable figures.) The effect of the expanding number of beneficiaries over time is also shown in Figure 4. The shaded area between the per capita and aggregate growth lines very clearly captures the bulging demographic impact.

Beneficiary Expenditures and Characteristics

Based on these projections, real per capita spending (expressed in 2000 dollars) on Medicare is projected to shoot up 44 percent between 2000 and 2025, from $6,213 to an estimated $8,987. Some beneficiaries will face substantially higher levels of expenditures (Table 2). Current Medicare spending across our six cohorts ranges from a low of $3,734 per year (among younger, high-income beneficiaries) to a high of $13,585 (among older, low-income women in poor health). By 2025, spending is projected to reach $5,700 and $18,338 for these two cohorts, respectively

Table 2
Selected Characteristics and Medicare Expenditures of Beneficiary Cohorts

Cohort Total Medicare Spending Projected Medicare Spending, 2025 Percent Medicare Spending on Home Health Median Individual Income Percent with Employer-Sponsored Insurance Percent Female
Elderly Beneficiaries $5,451 $7,863 10% $14,494 42% 56%
Elderly Beneficiaries in Poor Healtha 9,740 13,251 19 10,029 n/ab 47
Older Low-Income Women in Poor Health 13,585 18,338 23 11,570 30 n/ac
Younger, High-Income Beneficiaries 3,734 5,700 2 45,756 n/ad 47
Women with QMB Protection 7,914 11,213 16 7,871 n/a n/ae
Older Disabled Beneficiaries 6,306 8,217 14 13,285 18 40
üˆ

Notes: Data are from the 1995 Medicare Current Beneficiary Survey. All dollars are in 2000 terms. QMB is Qualified Medicare Beneficiary. N/A is not applicable. Each of the cohorts excludes beneficiaries in Medicare managed care plans, residing in nursing homes, and those with end-stage renal disease.
Source: The Urban Institute’s 1999 Medicare Projections Model.

Medicare recipients will pay substantially more for health care in future years if no changes are made to the system, and those who are poorer, sicker and older will disproportionately absorb the rising costs, according to a study by the Urban Institute released January 2, 2001. The average annual out-of-pocket cost for services not covered by Medicare is $3,142. That is expected to increase to $5,248 in 2000 dollars by 2025, according to the report. By 2025, all americans over 65 will spend 29.9% of their incomes on out-of-pocket health care costs, a roughly 10% increase from 2000. Costs are anticipated to increase faster than the incomes of Medicare beneficiaries.

 It will only get worse: (USA Today 2001)  Medicare patients who buy supplemental insurance to cover prescription drugs are paying an average of 37% more for those policies than they did just 3 years ago. The Health Care Financing Administration said prescription drug expenses would rise from 9.4% of personal health spending to 16% by 2010, the fastest rise of any medical category.

Of the 10 Medigap policies reviewed by Weiss research, seven of the plans do not offer a drug benefit. For those, premiums rose an average of 15.5% from 1998 to 2000. But for the three plans that offer from $1,250 to $3,000 worth of drug coverage, premiums rose an average of 37.2% during that same period.

Average cost nationally in 2000 for the plans that provide drug coverage ranged from $2,347 to $3,065, based on quotes given for a 65-year-old male.

More Medicare and drugs: (2001) the Congressional Budget Office estimated that Medicare will spend $237 billion on benefits for 40 million elderly and disabled people in fiscal year 2001. Despite the recent slowdown in spending growth, that a mount is almost 25 percent more than Medicare spent five years ago. CBO is projecting faster Medicare growth over the next decade, to more than double, to $491 billion, by fiscal year 2011. CBO expects prescription drug costs for Medicare enrollees to grow at a rapid pace over the next decade. At an average annual rate of 10.3 percent per beneficiary, drug costs would rise at nearly twice the pace of combined costs for Medicare's Part A and Part B programs, and much faster than growth in the nation's economy.

And more Medicare: (Urban Institute's Marilyn Moon  2001) "Ultimately, none of the reforms now under consideration are likely to solve the problem of how to finance Medicare after the next decade. The question, then, is who will pay for the health care of older  Americans and those who are disabled -- beneficiaries or taxpayers? Even with higher contributions from beneficiaries and successful cost containment, in the long run, Medicare will require additional public funds. Reducing the number of beneficiaries or the scope of coverage would shrink the federal liability but do little to reduce the societal costs of financing health care. The basic issue will be how to share that burden."

I have said for years that there is NO budget surplus once you include the clear increases for Medicaid and Medicare.

New Medicare Managed Care Manual Released: (pdf 2001) The Centers for Medicare and Medicaid Services has released the first three chapters of the new Medicare Managed Care Manual, a vehicle for instructions to Medicare+Choice managed care organizations. Key portions of the new release include an overall table of contents and Chapter 14, which provides procedures for making and reviewing contract determinations and the appeals process.

What a ripoff: (USA Today 2001) "At issue is a practice in which drug companies report average wholesale prices for drugs that are higher than what they actually charge for the products. Because of the way Medicare reimburses, doctors are able to keep the difference. As a result, some drug companies promote products to doctors based on artificially high wholesale prices.

That practice cost Medicare $887 million last year for just 24 drugs."

Currently, Medicare reimburses doctors 95% of a drug's average wholesale price. Yet a General Accounting Office report out today says that the respiratory drugs albuterol and ipratropium bromide were available at prices that averaged, respectively, 85% and 78% less than average wholesale.

Another example: Doctors can charge Medicare $18.02 for a dose of leucovorin, a cancer treatment that costs them $2.94.

Medicare HMO withdrawals in 2001: A state-by-state list of pullouts. More than 500,000 elderly and disabled Americans will be dropped from their Medicare HMO plans on Dec. 31.

Wasted Medications May Cost More Than $1 Billion a Year - Unused pills may account for more than $1 billion in drug costs among elderly Americans each year, new research suggests.

Shortage of Anesthesiologists Documented in US There is a shortage of anesthesiologists in the US that will continue for years unless more people are attracted to the field, according to a report in the October issue of the Mayo Clinic Proceedings.

Seniors face Medicare health insurance dilemma

Medicaid care in a nursing home. (2001) "Maybe the care in nursing homes appears the same regardless of payment status, but the overall experience may be quite different. We actually do have a nursing home here in Spokane that has a Medicaid Wing. I told them that Washington State has a statute prohibiting Medicaid discrimination. I don't think it stopped them. This same facility has some rooms that are much less desirable than others. One of our Medicaid clients was in a room where the air conditioner blew cold air on him constantly. (He developed pneumonia and died at that facility. No, the family did not sue, but they really would have liked to have him around longer.) The nursing home told me, We give Medicaid patients the least desirable rooms.The best rooms go to those who can pay for them."

"Even if you get the same care, it can be the little things that make a real difference in the quality of care. For example, having a telephone in one's room matters a great deal to most residents. Have your ever seen the line at the public phone in a SNF [skilled nursing facility]?  Besides that, there's no privacy. The ability to have some spending money for the beverage cart that comes around in the afternoons is a big plus. There are lots of examples of the little extras that make life so enjoyable, I need not say more. "

Medicare: The Department of Health and Human Services announced legally mandated increases in the Medicare premium, deductible and coinsurance amounts to be paid by beneficiaries in 2002. For Medicare Part A, which pays for hospital, skilled nursing, hospice care and some home health care, the beneficiary deductible will increase to $812, up 2.5 percent from $792 in 2001. The premium for Medicare Part B, which helps pay for physician services, ambulatory care and other services, will rise to $54 per month, up 8 percent from $50 per month in 2001.

The Part A deductible is a beneficiary's only cost for up to 60 days of Medicare-covered inpatient hospital care. However, for extended Medicare-covered hospital stays, beneficiaries must pay an additional $203 per day for days 61 through 90 and $406 per day for hospital stays beyond the 90th day in a benefit period -- up from $198 per day and $396 per day, respectively. For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 will be $101.50, up from $99 in 2001.

The Part A premium, paid by only a small percentage of beneficiaries, also is increasing in 2002. For the estimated 392,000 beneficiaries who pay a premium for Medicare Part A coverage, premiums will increase by $19, to $319. This amount is paid by Medicare beneficiaries with less than 30 quarters of Medicare- covered employment (and by certain people with disabilities who are under age 65, have lost disability benefits because of work and earnings and have less than 30 quarters of Medicare-covered employment). Seniors with 30 to 39 quarters of Medicare-covered employment (and certain people with disabilities who are under age 65, have lost disability benefits because of work and earnings, and have at least 30 quarters of Medicare-covered employment) are entitled to a reduced monthly premium, which is increasing by $10, to $175.

Medicare coverage: (BW HealthWire 2001) By year-end 2001, more than 536,000 seniors on Medicare will be dropped from their HMOs, on top of the 1.6 million that have already been dropped since 1998. The affected enrollees, living in 28 states, will be forced to find alternative coverage before December 31, 2001.

Fifty-four HMOs are either withdrawing from Medicare completely or reducing their service areas, with eight individual HMOs dropping more than 20,000 enrollees each CA - 83,634, FL - 59,348, PA - 54,561, NJ - 53,144, TX - 45,977, IL - 40,539, CN - 38,785, MI - 31,446, AR - 16,841, NY - 15,590

You have 63 days from the date you leave your current HMO to take advantage of a guaranteed Medigap plan. But this ads a LOT of additional expense over the HMO

Medicare Home Health Care (pdf 2001) : This inspection report looks at Medicare home health beneficiaries who begin receiving these services without having first been discharged from a hospital. These are known as ''community'' home health beneficiaries. OIG found that about 40 percent of Medicare home health beneficiaries do not have a prior hospital or nursing home stay.

Medication toxicity and drug-related problems can have profound health, safety, and economic consequences for older adults and have been implicated in up to 30% of hospital admissions in the elderly.

Medicare Home Health Care: (pdf 2001) OIG found that about 40 percent of Medicare home health beneficiaries do not have a prior hospital or nursing home stay. There is some evidence that they have more chronic conditions than hospital-discharge patients. Their characteristics, including the most common diagnoses, have generally remained the same over the course of the last few years, during which the Medicare interim and prospective payment systems were implemented. Through reliance on their physicians, family, and the aging network, they appear to be getting access to Medicare home health care. However, some concerns emerged, such as barriers for Medicare patients with certain medical conditions, confusion regarding Medicare eligibility and coverage, and home health agency staffing shortages. In most instances, OIG found the reported experiences of "community" beneficiaries to be similar to those discharged from the hospital into home health services.

Influence of Age on Medicare Expenditures and Medical Care in the Last Year of Life (JAMA 2001) Results For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admission.

Conclusions Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Medicare: (2001) Expenditures for Medicare beneficiaries in the last year of life have been shown in several previous studies to decrease with increasing age. In this analysis of Medicare data for beneficiaries aged 65 years or older from Massachusetts and California who died in 1996, researchers found a similar pattern of decreasing expenditures with increasing age for medical care of the elderly in the last year of life. This pattern appears to result largely from a decrease in the use of aggressive care with increasing age.

Medicare NO Choice: The General Accounting Office said on Dec. 3 that increased reimbursements for health plans that participate in Medicare+Choice have not stopped the withdrawal of HMOs from the program.

"Medical inflation has outstripped the increases in Medicare reimbursement. "Costs are rising 8% to 12% a year. Some hospitals are demanding increases of 30% in the payments they receive from health plans. But for many plans, Medicare reimbursement has been rising only 2% or 3% a year." About 5.6 million seniors, or 14% of the 40 million Medicare beneficiaries, participate in Medicare+Choice. A number of HMOs plan to withdraw from the program on Jan. 1, which will affect about 536,000 seniors nationwide.

Medicare: Out-of-pocket costs for Medicare+Choice beneficiaries increased almost 50% from 1999 to 2001, while average monthly premiums rose and prescription drug coverage declined during the same period. Out-of-pocket prescription drug costs for those in poor health increased 56% from 1999 to 2001, while drug costs for those in good health increased 47%. The average monthly premiums for Medicare+Choice beneficiaries increased from $14.43 in 2000 to $22.94 in 2001, while the percentage of beneficiaries with prescription drug coverage decreased from 78% to 70% over the same period

MEDICARE HMOS SAY PAYMENT RATES FALL SHORT OF COSTS (2002) Federal payments to Medicare HMOs will be insufficient to meet costs unless Congress acts quickly to salvage the program, the American Association of Health Plans (AAHP) warned.

Thought it would be the other way. (Health Affairs Web 2002)  The number of Medicare beneficiaries enrolled in MediGap policies decreased from 9.9 million in 1996 to 8.4 million in 1999, while enrollment in Medicare+Choice increased from 4.1 million in 1996 to six million in 1999, which contributed to an overall increase in the number of beneficiaries with prescription drug coverage.

nearly 90% of Medicare beneficiaries had supplemental insurance coverage between 1996 and 1999. One-third of beneficiaries had supplemental coverage through an employer in 1999, one-fourth had a MediGap policy and one-sixth had coverage through Medicare+Choice. An additional 11% had coverage through Medicaid in 1999, and 2% had coverage through other public programs, the study found. The study found that 12.5% of Medicare beneficiaries, about 4.3 million people, who lacked supplemental insurance coverage in 1999, a "disproportionately large share" were African-American beneficiaries and beneficiaries younger than age 65. Over the four-year period, Medicare HMO enrollment increased by 5.1%, while the number of beneficiaries enrolled in a MediGap policy dropped by 5.1%. The number of beneficiaries who received supplemental insurance coverage from other sources or had no supplemental insurance coverage "remained generally constant" over the four-year period. According to the study, beneficiaries in the highest income group -- those with annual incomes more than $30,000 -- and rural beneficiaries "experienced modest net declines" in supplemental insurance coverage, while beneficiaries in the lower income groups "made gains."

Medicare overspending (Department of Health and Human Resources 2002) Among the findings:

Medicare could have saved $1.9 billion on 24 drugs in 2000 if it were able to pay the same prices paid by the Veteran's Administration (VA), which gets the deepest discounts from manufacturers.

Despite falling prices for the asthma drug albuterol, Medicare pays three to five times more than the drug's wholesale cost as reported by manufacturers.

Medicare and its patients could save $279 million a year if a drug used to treat bronchitis and emphysema — ipratropium bromide — were reimbursed at the median price paid by the VA.

States are overspending on generic drugs through the Medicaid programs. Up to $470 million could be saved annually if states readjusted their generic drug payment policies.

Medicare (2002) Medicare+Choice beneficiaries will face increased out-of-pocket costs under their health plans in 2002, and sicker beneficiaries will "bear the brunt of big changes" as more Medicare HMOs restrict prescription drug coverage and increase cost-sharing requirements.

*Monthly premiums for Medicare+Choice beneficiaries will increase "significantly" this year, from about $22.94 in 2001 to $32.38 in 2002.

*The number of Medicare+Choice beneficiaries in plans with a monthly premium higher than $50 will increase from 19% in 2001 to 33% in 2002.

*The percentage of Medicare+Choice beneficiaries in a basic plan that provides prescription drug coverage will increase from 70% in 2001 to 71% in 2002, but 51% of the plans will only cover generic drugs, compared with 18% in 2001.

*About 80% of Medicare+Choice beneficiaries will have a cost-sharing requirement for inpatient hospital care in 2002, compared with only 33% in 2001, a trend that will "particularly affect" sicker beneficiaries.

*Medicare+Choice beneficiaries in urban areas will face the largest reductions in benefits in 2002 (Achman/Gold, "Medicare+Choice: Beneficiaries Will Face Higher Cost-Sharing in 2002," March 2002). 

So you think the government will provide good LTC?: (2002) A scheduled 17% reduction in Medicare reimbursement rates for nursing homes could have a "significant" impact on quality of care at those facilities, according to a new study released March 25 by the American Health Care Association and the Alliance for Quality Nursing Home Care (Wheeler, Gannett News Service/Asbury Park Press, 3/24). The study, a state-by-state analysis conducted by the health policy research company Muse & Associates, ranked states based on which would face the "steepest" loss of Medicare nursing home funds and the "greatest possibility of dislocation and quality care and access problems" as a result of the scheduled reduction, mandated under the 1997 Balanced Budget Act and set to take effect on Oct. 1. The study found that Medicare reimbursements for nursing homes in California, which would see the most serious loss, would decrease from $418.75 per patient per day in fiscal year 2002 to $347.99 per patient per day in FY 200hB

"Trends in Medicare Supplemental Insurance and Prescription Drug Coverage, 1996-1999," released in the online issue of the journal Health Affairs examines trends in Medicare supplemental insurance and prescription drug coverage. The article reports that the overall share of people on Medicare who have supplemental coverage remained fairly constant during the four-year period ending in 1999, with a 5.1 percentage point gain in Medicare+Choice enrollment offsetting a comparable decline in Medigap enrollment. During this time period, there was an increase in prescription drug coverage, from 57% to 62%, which the authors attribute to the increase in Medicare HMO coverage. The number of Medicare beneficiaries enrolled in Medicare supplemental plans decreased from 9.9 million in 1996 to 8.4 million.

Medicare: (2002)Medicare will not go broke until 2030, a year later than previously predicted, but its future viability is still very much at risk.

Nursing homes: (2002) For-profit nursing facilities could face a staggering round of bankruptcies next year if the US Congress does not prevent cuts in their Medicare payment

Hospitals: (American Hospital Association 2002) At least 90 percent of large U.S. hospitals with more than 300 beds operate at or over capacity for treating patients, and often have to divert incoming ambulances to other hospitals. The finding suggests many hospital emergency rooms are unable to handle even the day-to-day stresses, let alone any big emergencies.

A survey done by the Lewin Group on behalf of the association found that six out of 10 hospitals nationwide are filled to capacity. The larger the hospital, the worse the problem seems to be.

At the same time when patients' needs are increasing, the nation's hospitals are facing a severe shortage of key hospital workers and soaring costs of the goods and services they need to do their jobs for their communities," he said. The group did not blame the for-profit health-care system and the growing dominance of managed care. "Only 14 percent of the nation's hospitals are for profit."

"The Medicare program pays less than the cost of caring for a patient on Medicaid," she said, adding that the same is true for Medicare. Hospitals also cannot keep enough staff on the payroll. "There are more than 168,000 unfilled positions, of which 75 percent are for registered nurses." 

"Medical Care at the End of Life: Diseases, Treatment Patterns, and Costs" ( ALAN GARBER, THOMAS MACURDY, MARK MCCLELLAN) ABSTRACT 2002:

In recent years, the use of Medicare-covered home health care and hospice services has grown dramatically. Hospice care, like much home health and nonacute hospital care, is designed to meet the needs of dying patients, who are known to generate disproportionately large costs of care. How has use of these services by dying Medicare beneficiaries changed over time? How has it varied by disease? Does recent experience suggest that these services have helped save the Medicare program money by displacing hospital care and other costly services? To address these questions, we examined linked Medicare claims files from 1988 to 1995, determining the location of death, days of use of services, and expenditures for the care of beneficiaries in the final months of life.

We found that use of hospice and home health services by decedents grew rapidly over the eight-year study period, and especially rapidly among patients who died with a predictably terminal illness such as lung cancer. Among the elderly who have such illnesses, these alternatives to acute hospital care have reduced the use of hospital care near the very end of life. Most of the growth in these services in the year or two before death, however, appears to involve additional Medicare-covered services. As a result, utilization of Medicare-covered home health and hospice care by dying beneficiaries has increased over time, with an associated reduction in the proportion of deaths occurring in acute-care hospitals. But as the use of non-hospital services has grown, the growth in Medicare expenditures for hospital services at the end of life has not slowed appreciably, nor has there been a marked change in the intensity of end-of-life treatment for Medicare beneficiaries dying of more acute illnesses or requiring substantial supportive care.

Nursing Homes:  (2002) MEDICARE CUTS THREATEN QUALITY OF NURSING HOME CARE

Impending fee reductions for nursing home care under the Medicare program threaten both the quality of care for residents and the overall economic stability of the industry.

Medicare: (US News 2002) While Medicare provides nursing home care in the amount of 10 to 15%, the cost is 25% of nursing home revenue. That's due to the more extensive care under Medicare. It is also more than necessary and can provide a big cushion to the nursing homes since there is a margin of about 20%. However they "need" that since the coverage for their other Medicaid patients in woefully inadequate. Nursing homes state that they lose money on 75% of their patients. Medicare might pay $300 per day of coverage per patient while Medicaid pays $128- and that is $9 below its costs.

Medicare Home Health Spending to Increase 12% in 2003 Medicare payments for home health services will grow to an estimated $14.9 billion next year from an estimated $13.2 billion in 2002, one of the largest increases in the Medicare program, according to the Centers for Medicare & Medicaid Services. In its latest Health Care Industry Market Update, the CMS said home health care spending is expected to grow by about 12% in 2003. The figure would be even higher without new the prospective payment rates that become effective October 1, 2002.

This should ring a bell from the activities of the 80's: (2002) Health Care for Thousands of Seniors at Risk- A new study indicates that the number of family physicians who are no longer taking new Medicare patients is 28 percent higher than one year ago. The annual survey of its members by the American Academy of Family Physicians finds that 21.7 percent of physicians surveyed in June, 2002, report that they can no longer take new Medicare patients, a significant increase from last year's figure of 17 percent.

The formula used to calculate the Medicare physician fee schedule updates is seriously flawed, resulting in a 5.4 percent reduction in the reimbursement rate for physicians and other health providers in January, 2002.

GAO Finds Serious Quality of Care Issues in Medicare Home Health Agencies (2002) The General Accounting Office was requested by Congress to survey and report on quality of care provided to beneficiaries by Medicare home health agencies (HHAs). Although HHA surveys conducted nationwide since 1998 identified a small proportion of HHAs with serious, COP-level deficiencies, there is evidence suggesting that the extent of serious care problems may be understated and that situations endangering the health and well-being of home health patients may occur more often than documented.

Medicare's Problem in Treating Mental Illness in Elderly (2002) Myriad obstacles to mental health care services face Medicare beneficiaries. Physicians cite traditional Medicare's unequal coverage policies, the lack of outpatient drug coverage, a persistent stigma associated with mental illness, and health system weaknesses as barriers.

Medicare and Medicaid Spending Increasing at Higher Rate: (2002) Federal spending on Medicare and Medicaid continues to grow at a higher rate compared to just a few years ago, with Medicare outlays up 9.5 percent in the first 10 months of fiscal 2002 compared with the previous year, while Medicaid spending has risen 13.5 percent, according to the Congressional Budget Office. In its August 2002 Monthly Budget Review, CBO said Medicare outlays were $212 billion from October 2001 to July 2002, compared with $197 billion for the first 10 months of fiscal 2001. Medicaid outlays were $123 billion during these months, up from $108 billion in the same period of fiscal 2001

HMO's: Medicare health plans have dropped about 2.4 million Medicare beneficiaries since 1998.

With more HMOs expected to drop out of the Medicare program for 2003, a new wave of Medicare beneficiaries will be forced to shop for alternative health insurance coverage, but the fallout will likely vary depending on where enrollees live, says a new study by Marsha Gold, a senior fellow at Mathematica Policy Research Inc. and co-author of a new report that examines trends in the Medicare+Choice program. The report identifies the metropolitan areas hardest hit by withdrawals from the Medicare+Choice program between 1999 and 2002. Long Island, New York's Nassau/Suffolk area, topped the list, with 87,698 enrollees affected by health plan pullouts over the four-year period studied. Houston, Chicago, Dallas and Baltimore rounded out the top five markets for withdrawals. Overall, health plan pullouts from the Medicare program affected about 2.2 million Medicare beneficiaries between 1999 and 2002.

HMO (American Association of Health Plans) An estimated 200,000 elderly and disabled Americans will be dropped from their Medicare HMO plans on Dec. 31, 2002,

Since 1999, approximately 2.2 million Medicare beneficiaries have been dropped from their health plans. Although far fewer beneficiaries are losing their coverage in 2002 than in previous years, the number is still significant. Since 1999, approximately 2.2 million Medicare beneficiaries have been dropped from their health plans by insurers who say they were forced to withdraw from the Medicare+Choice program due to inadequate government funding. Of the 40 million people with Medicare, only about 5 million have chosen the Medicare HMO option.

Medicare beneficiaries will be able to begin enrollment in the new PPO option in November 2002. The PPO plans, which go into effect on Jan. 1, 2003, will be available to more than 11 million Medicare beneficiaries in parts or all of 23 states: Alabama, Arizona, California, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Missouri, North Carolina, Nevada, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Virginia, West Virginia, and Washington.

Beneficiaries will pay between $60 and $80 in monthly PPO premiums, compared with an average of $54 monthly for HMO premiums. Fee-for-service Medicare costs $54 a month and patients pay 20 percent of their medical bills.

Medicare's Disabled Beneficiaries: The Forgotten Population in the Debate Over Drug Benefits  (2002) About 5 million Americans under age 65 qualify for Medicare coverage because they are totally and permanently disabled. They are more likely than the elderly to live in poverty, to be in poor health, and to experience difficulties living independently and performing basic daily tasks. A new study from The Commonwealth Fund and the Henry J. Kaiser Family Foundation reports that the disabled have few options other than Medicaid for obtaining prescription coverage.

Always going up: Medicare's 40 million beneficiaries will pay higher premiums and deductibles next year, on top of a slim cost-of-living adjustment for 2003. Seniors' monthly premium for physician services will jump 8.7% to $58.70 in 2003, the federal government said on Friday. The deductible for hospital inpatient services will rise 3.5% to $840,

The Part A deductible that seniors pay covers up to 60 days of inpatient care. For longer stays, beneficiaries must pay an additional $210 per day through day 90 and $420 a day after that. Those amounts are 3.4% higher than this year's rates. Seniors also can expect to pay more out-of-pocket for care they receive in nursing homes. The daily co-insurance rate will rise more than 3.4% to $105 for services received from days 21 through 100. Only beneficiaries enrolled in traditional Medicare pay the Part A deductible.

Medicare Premiums for 2004:

Part A: (Hospital Insurance) Premium

Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.

The Part A premium is $189.00 for people having 30-39 quarters of Medicare-covered employment.

The Part A premium is $343.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

Part B: (Medical Insurance) Premium

$66.60 per month.

Medicare Deductible and Coinsurance Amounts for 2004:

Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2004 = $876) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.

For each benefit period you pay:

· A total of $876 for a hospital stay of 1-60 days.

· $219 per day for days 61-90 of a hospital stay.

· $438 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).

· All costs for each day beyond 150 days

Skilled Nursing Facility Coinsurance

$109.50 per day for days 21 through 100 each benefit period.

Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)

· $100.00 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $100.00 deductible.)

About 95 percent of Medicare's 41.7 million beneficiaries are enrolled in the optional Part B, which helps pay for physician services, hospital outpatient care, durable medical equipment and other services, including some home health care. Nearly 90 percent also have some form of supplemental coverage (such as Medigap, Medicaid, or Medicare+Choice) to help reduce out-of-pocket medical costs.

Medicaid: (AARP) Medicaid is the single largest public source of funding for long-term care (LTC) in the United States, accounting for more than 38 percent of total long-term care expenditures in fiscal 1996. Medicaid spending for LTC more than doubled from fiscal 1987 through fiscal 1997, rising from $21.1 billion in fiscal 1987 to $56.1 billion in fiscal 1997. The bulk of Medicaid spending has gone to nursing home care over the years, but recent expenditure reports show states allocating an increasing share of that spending to home care services.

Medicare: Lower Medicare reimbursements are causing a worsening problem for the elderly, as they scramble to find physicians. Because the Medicare program has reduced the amount it reimburses doctors, many Medicare beneficiaries now have to make as many as a dozen phone calls just to find a physician who is still accepting new Medicare patients. Although the federal government recently increased the amount it pays to hospitals, a 4.4% cut for next year in Medicare payments to doctors is likely to make a bad situation get even worse.

Medicare Premiums for 2004:

Part A: (Hospital Insurance) Premium

Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.

The Part A premium is $189.00 for people having 30-39 quarters of Medicare-covered employment.

The Part A premium is $343.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

Part B: (Medical Insurance) Premium

$66.60 per month.

Medicare Deductible and Coinsurance Amounts for 2004:

Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2004 = $876) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.

For each benefit period you pay:

· A total of $876 for a hospital stay of 1-60 days.

· $219 per day for days 61-90 of a hospital stay.

· $438 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).

· All costs for each day beyond 150 days

Skilled Nursing Facility Coinsurance

$109.50 per day for days 21 through 100 each benefit period.

Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)

· $100.00 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $100.00 deductible.)

About 95 percent of Medicare's 41.7 million beneficiaries are enrolled in the optional Part B, which helps pay for physician services, hospital outpatient care, durable medical equipment and other services, including some home health care. Nearly 90 percent also have some form of supplemental coverage (such as Medigap, Medicaid, or Medicare+Choice) to help reduce out-of-pocket medical costs.

SS and Medicare:  (2003) trustees of the two programs projected that Medicare would run out of money to pay benefits in 2026 -- four years earlier than predicted last year -- while Social Security gained a year on its expected life span, to 2042. The reasons include more-pessimistic assumptions about wages, which could erode Medicare payroll-tax revenues, as well as more-optimistic assumptions about future immigration trends, which could help Social Security.

"What are Social Security's total cash deficits? Social Security's net cash shortfall over the next 75 years totals $25.33 trillion in 2003 dollars, a $1.46 trillion increase from the 2002 report. That figure assumes today's surpluses are saved; if surpluses are not saved, then from 2018 through 2077 Social Security faces gross cash deficits of $26.40 trillion (in $2003), an increase of $1.37 trillion from the 2002 report.

Health Care: Next year Medicare premiums would rise to $66 a month, an increase of $7.30, or 12.4 percent, the largest increase in 11 years.

Medicare officials said they now estimated that the fees paid to doctors for treating Medicare patients would be cut 4.2 percent next year.

Medicare provides health care for 40 million elderly and disabled people. When spending on doctors' services increases, beneficiaries' premiums normally rise as well because the premiums are supposed to cover about one-fourth of the costs of the Medicare trust fund that pays doctors.

Even when Medicare reduces the payment for each service, total Medicare spending for physician services can still rise if doctors perform more services, or more complex services for which the government pays more. That is what happened last year.

Medicare spent $45 billion on doctors' services last year, an increase of $3 billion, or 7 percent, from 2001, even though the average fee for each service was reduced.

The government previously said that doctors could expect increases in Medicare fees in 2004 and later years. But we now estimate physician fee schedule updates will be negative for 2004 to 2007," because spending for doctors' services grew more and the economy grew less than expected last year.

¶Inpatient hospital care, up 10 percent, to $104.9 billion.

¶Outpatient hospital services, up 10 percent, to $15.4 billion.

¶Skilled nursing homes, up 9 percent, to $14.6 billion.

¶Home health care, up 14 percent, to $10.5 billion.

¶Durable medical equipment, including wheelchairs, up 20 percent, to $6.5 billion.

¶Hospice, up 24 percent

As many as 1.7 million low-income Americans could lose publicly-funded health coverage because of worsening budget crises in the states, to $4.6 billion.

Medicare (2003) trustees of the two programs projected that Medicare would run out of money to pay benefits in 2026 -- four years earlier than predicted last year -- while Social Security gained a year on its expected life span, to 2042. The reasons include more-pessimistic assumptions about wages, which could erode Medicare payroll-tax revenues, as well as more-optimistic assumptions about future immigration trends, which could help Social Security.

Medicare Beneficiaries and Prescription Drugs: Costs and Coverage On average, total prescription drug spending in the U.S. grew by 13% per year between 1993 and 2000. It is expected to grow by 12% per year through 2011.

Medicare- (2003) The quality of care improved in 20 of 22 measures of quality from 1998- 1999 to 2000- 2001 but still only 73.4% of Medicare patients received appropriate care. A report however showed wide variations in the quality of care across states and regions.

Medicare+Choice Beneficiaries More Likely To Enter Hospice Care Than Fee-For-Service Beneficiaries

Medicaid: Half of California's doctors no longer treat Medicaid patients. . Only about 20%  of doctors care for 80% of Medicaid patients. The percentage of urban surgery specialists who refuse new Medicaid patents have doubled from 1988 to about 40%.

It reinforces the reason why you never want to use Medicaid as the resource for long term care

The average premium and other out-of-pocket costs rose again in 2003 for people enrolled in the Medicare+Choice managed care plan, (2003)

Medicare going broke? (NY Times 2004) The Medicare trustees said that by 2019 - seven years sooner than was expected last year - the hospital insurance trust fund is projected to exhaust its surplus. But because the fund gets its money from the Medicare payroll tax, which would continue, the fund would still be able to pay 80 percent of its bills. This hospital fund, known as Part A, accounts for 56 percent of the Medicare program's spending. Part B, which pays for doctor bills and other outpatient services, gets 25 percent of its money from premiums paid by beneficiaries and 75 percent from general tax revenue. It would not be affected by depletion of the hospital fund surplus.

It all boils down to this: in 15 years, Medicare may not be able to pay 20 percent of a 56 percent chunk of its bills without some extra money from somewhere. That means an overall shortfall for all Medicare spending of about 11 percent.

The article went on to note that projected costs are difficult to determine since there are new technologies being invented every day that can reduce the overall cost of care. True enough. But with every bit of new technology comes other very expensive methods to treat all types of diseases. And once they become known, consumers want more and more of them. If there is an advancement for Alzheimers, can you imagine the costs for treatment?

Reported And Predicted Percentages Of Medicare Beneficiaries 65 And Older Not Purchasing At Least One Prescription Drug In 2001 Because Of Cost  (2004)

Medicare: Hospitals discharge their Medicare patients quicker and sicker that ever before. In 1968, patients age 65 and older stayed in the hospital an average of 14.2 days. By 1982, that was down to 10.1 days. Now it only 6.4 days.

According to The Wall Street Journal, "Nearly one in five people admitted to hospitals with broken hips are discharged before all of their vital signs are stable ... . Those patients are far more likely to die or be readmitted to the hospital within two months."

Drugs: (2004) The new Medicare drug benefit would pick up only one-third of drug costs for people with average drug expenses. In 2006, average annual drug costs for people with Medicare are projected at $3,167. A person with such expenses would have to pay

$420 (at least) for the premium

$250 for the deductible

$1,417 for remaining drug expenses

Table: How The Rx Drug Benefit Will Affect You

A Guide to the New Medicare Prescription Drug Benefit 2004

Playing Cards: Do you know someone who is home, recovering from an injury or illness? Rather than the standard flowers or chocolates, why not have the gift be a deck of playing cards from the Medicare Rights Center. Each card has important information and resources about health care benefits, rights and options and can be used for playing all the favorite standard-deck card games.

"Medicare Demonstration PPOs: Financial and Other Advantages for Plans, Few Advantages for Beneficiaries,"  2004

Primary Care Experiences of Medicare Beneficiaries,:  (2004) Jana E. Montgomery, ScM; Julie T. Irish, PhD; Ira B. Wilson, MD, MS; Hong Chang, PhD; Angela C. Li, BS; William H. Rogers, PhD; Dana Gelb Safran, ScD. Over a 2-year period, the quality of seniors' interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation's portfolio of quality indicators

Quicker but sicker: (2005) Hospitals discharge their Medicare patients quicker and sicker that ever before. In 1968, patients age 65 and older stayed in the hospital an average of 14.2 days. By 1982, that was down to 10.1 days. Now it only 6.4 days.

Preventative care: (Medicare Payment Advisory Commission (MedPAC 2005). People without supplemental Medicare coverage tend to use fewer clinically necessary preventive services: 91.7 percent of men and women with Medicare who have some form of supplemental coverage use necessary preventive services every year, while only 72.8 percent of those without coverage use these annual services.

Medicare Discount Card info

Home Health Compare From Medicare

Medicare pays for immunosuppressive drugs for people with Medicare under the following conditions:

* The kidney transplant must be conducted in a Medicare-certified facility;

* The transplant must be paid for either by Medicare or private insurance that paid as primary payer to your Medicare Part A coverage;

* You must administer the immunosuppressive drugs yourself;

* The medication is medically necessary to prevent or treat rejection of the transplanted organ.

Medicare will not pay for immunosuppressive drugs for people with end-stage renal disease who enrolled in Medicare after they received a kidney transplant.

Care at home: Here are the conditions for Medicare to cover your mother’s care at home:

1. She must be homebound, meaning it takes a considerable and taxing effort to leave home; and

2. She must need skilled therapy or skilled nursing care on an intermittent (less than seven days a week) or part-time (less than eight hours a day) basis. If she only requires skilled nursing, she must either need it less than seven days a week (even as little as once every 60 to 90 days) or daily (seven days a week) for a finite and predictable period of time (usually two to three weeks but possibly longer); and

3. A doctor must certify her need for home care; and

4. She must receive this care from a Medicare-certified home health agency (CHHA).

If your mother qualifies for the home health benefit, Medicare covers the full cost of skilled care, home health aide services and medical social services she receives.

(The "trick" above is skilled care. Not simple care. Skilled)

Medications: Here are 10 questions to ask your doctor:

1. What is the name of the medicine, and what is it supposed to do?

2. Is this the brand or generic name? (Is a generic version available?)

3. When do I take the medicine and for how long?

4. Should I take this medicine on an empty stomach or with food?

5. What should I do if I forget a dose?

6. What foods, drinks, medicines, dietary supplements or activities should I avoid while taking this medicine?

7. Will this new prescription work safely with the other prescription and nonprescription medicines I am taking?

8. What are the possible side effects, and what do I do if they occur?

9. When should I expect the medicine to begin to work, and how will I know if it is working?

10. How should I store this medicine?

No! NO! NO! (2006) Social Security, Medicare and Medicaid account for about a third of all federal spending. That's about $1 trillion out of $2.2 trillion.

One third of all federal spending went to five states in 2004: California; New York; Texas; Florida; and Pennsylvania.

- California led all states with $232 billion.

— Wyoming received the least money, $4.4 billion.

— Alaska received only $8.4 billion. But with its relatively small population, it led the nation in per capita federal spending, at $12,885 a person.

— Nevada received the lowest per capita amount, $5,469 a person.

— Defense Department spending was highest in California, Virginia, Texas, Florida and Maryland.

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Medicare coverage under age 65- (2006)  you can get Medicare coverage if you are under 65 years of age and meet the following three criteria:

You are disabled and have received Social Security Disability Insurance (SSDI) for more than 24 months (two years);

You are a U.S. citizen (or have your resident visa); and

You have lived in the United States for five years in a row.

If so, your eligibility begins during the month you receive your 25th SSDI check. You do not need to contact anyone. Social Security should automatically mail you your Medicare card three months before you become eligible.

Because you have health insurance through your wife’s employer, you may not need Medicare Part B , which covers 80 percent of doctors’ services, durable medical equipment and most other outpatient medical care. (This year Part B has a monthly premium of $88.50 and an annual deductible of $124.)

If your wife’s employer has 100 employees or more, your wife’s employer health plan is your primary insurance. You don’t need to enroll in Medicare Part B if you are satisfied with this group coverage. But if you are having a hard time covering your medical expenses, Medicare might help. You can enroll in Medicare Part B, and it will help pay the costs left over after your wife’s employer coverage pays (this is called secondary insurance).

Note: If you initially decline Part B, you can enroll in it later without penalty during your Special Enrollment Period (SEP). Your SEP lasts throughout the entire time you have your wife’s coverage and for up to eight months after you lose this group coverage or your wife stops working, whichever comes first.

If your wife’s employer has fewer than 100 employees, Medicare is your primary insurer. If you decline Part B, neither Medicare nor your wife’s job coverage will pay for your doctors’ services and other medical care (with limited exceptions).

Convoluted rules on Medicare:  (2006) My doctor referred me to a specialist who doesn’t take assignment, and the specialist made me pay up front. He said he would bill Medicare and I would be reimbursed, but when I got my paperwork from Medicare, it didn’t include this appointment. Is the specialist required to file a Medicare claim? Do you think it was a scam?

Reply- Most likely it is not a scam, but it is a good thing that you are reading your Medicare Summary Notice (MSN).

The MSN is a summary of claims for health care services that Original Medicare processed for you during the previous three months. The statement includes submitted charges, the amount that Medicare paid and the amount you may be required to pay (see a sample). The MSN is not a bill.

As a non-participating provider, a doctor who does not take assignment (Medicare’s approved amount for services), your specialist is allowed to request that you pay in full and up front for services. But he is still required to file a claim with Medicare. If he doesn’t, you won’t be reimbursed the 80 percent of the Medicare-approved amount (50 percent for mental health services) that you are owed. You should know that as a non-participating provider he is also allowed to bill up to 15 percent more than the Medicare-approved amount for most services. (For example, if Medicare approves $100 for the appointment, he can charge up to $115, of which you should be reimbursed $80 by Medicare.)

Note: Some states may have stricter restrictions on what doctors may charge you. For example, in New York doctors can only charge you 5 percent more than the Medicare-approved amount for most services. Call your State Health Insurance Assistance Program (SHIP) to find out more.

Generally, doctors file claims with Medicare soon after they provide services, but your specialist could just be behind in filing his claims. You should know that there is a limit on how long he can wait to file though. After you receive a service, your doctor generally must file a claim with Medicare by the end of the next calendar year. For example, if you received this service on June 15, 2006, then the doctor has until December 31, 2007, to file.

However, if the service was provided between October and December, your doctor has until the end of the second calendar year to file a claim with Medicare. So, if you received the service on October 1, 2006, then the doctor has until December 31, 2008, to file.

Because MSNs are now only mailed four times a year (quarterly), it may be sometime before you see that the claim has been filed. You can wait and see if it is on your next MSN, or you can call and ask the doctor if the claim has been sent to Medicare. Should the specialist miss the filing deadline or if he refuses to bill Medicare, you should take action.

A refusal to bill Medicare at your expense is often considered to be Medicare fraud and should be reported. You can report the problem to the administrators at the clinic or hospital where your doctor works;

your Medicare Part B carrier;

your State Attorney General’s office;

your state medical licensing board.

To locate the appropriate contact in your area, see the link in Spotlight on Resources below.

Doctors will be reprimanded for their refusal to follow Medicare policy and may lose their right to bill Medicare altogether.

Doctors who wish to charge their Medicare patients whatever they want must officially opt out of Medicare. These doctors do not submit any claims to Medicare and are not subject to the Medicare law that limits the amount doctors can charge patients. If you see one of these doctors, the doctor must have you sign a private contract that states that you understand you are responsible for the full cost of the services. Medicare will not pay for any of the cost of services you receive.

Medicare- Medicare will cover an ambulance to or from the closest appropriate hospital, skilled nursing facility (SNF) or medical provider if an ambulance is the only safe way to transport you (medically necessary) during an emergency. Note: A doctor does not have to certify in advance that you need ambulance transportation.

Examples of when an ambulance would be the only safe way to transport you include

when you are in shock, unconscious or severely bleeding;

when you suffer symptoms of a serious medical condition, such as chest or abdominal pain, shortness of breath, dizziness or headache;

when you must lie flat and need a stretcher;

when you need medical services during transportation that are only available in an ambulance, such as administration of medication, monitoring of vital signs including heart rate and rhythm, respiratory rate, blood pressure, and oxygen saturation.

If the trip is scheduled as a way to transport you from one location to another when your health is not in immediate danger, it is not considered an emergency. And there are only a very limited number of situations for which Medicare will cover the cost of nonemergency ambulance services.

If covered, Medicare will pay for 80 percent of its approved amount for the ambulance service. You or your supplemental insurance policy will be responsible for the remaining 20 percent. All ambulance providers must accept Medicare assignment, meaning they must accept the Medicare-approved amount as payment in full.

Are you getting the health and drug coverage you need from Medicare? Everyone needs to review their drug coverage for 2007. Even if you are happy with what you have, it may be changing or there may be a better deal next year. Plans all have different costs, covered drugs, limitations and pharmacy networks. That means another plan may offer: a cheaper premium, coverage of more drugs, coverage in the gap or fewer restrictions.

To help you understand your Medicare health and drug plan choices during the upcoming enrollment period, the Medicare Rights Center (MRC) is making its online counseling and assistance system, Medicare Interactive (MI) Counselor, available to the public FREE of charge.