Medicare Part D | The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants

PODCAST: Medicare Traditional [A and B] v. Advantage [C] v. Part [D] v. Supplements

Posted on January 23, 2023 by Dr. Marcinko

By Eric Bricker MD

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CITE: https://www.r2library.com/Resource/Title/082610254

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ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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Filed under: "Ask-an-Advisor", "Doctors Only", Career Development, Ethics, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Quality Initiatives, Videos | Tagged: Aetna, Eric Bricker MD, Humana, medicare, Medicare Advantage, Medicare Part A, Medicare Part B, Medicare Part D, medicare supplements, MMA, Part C, traditional medicare, UHC | 1 Comment »

MEDICARE SUPPLEMENT INSURANCE: Part G

Posted on January 16, 2023 by Dr. Marcinko

What is it and How Does it Work?

By Staff Reporters

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Did you know that Medicare Plan G is the most popular Medicare Supplement with Baby Boomer clients? Everyone has heard of Plan F, but what is Medicare Supplement Plan G? What does Plan G cover?

Medicare Plan G coverage is very similar to Plan F, which is no longer available for people new to Medicare on or after January 1st, 2020. Plan G offers great value for beneficiaries willing to pay a small annual deductible. After that, Plan G provides full coverage for all of the gaps in Medicare. It pays for your Medicare Part A hospital deductible, co-pays, and coinsurance. It also covers the 20% that Medicare Part B doesn’t cover. Doctors and other healthcare providers must accept a Medigap Plan G if they accept Original Medicare. Plan G policies can be used across the U.S. since they do not have network limitations, and the premium costs can be very reasonable for the coverage you receive.

As you can see below, Supplement Plan G covers almost everything that F does, except for the Part B deductible.

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Medicare Plan G, also called Medigap Plan G, is an increasingly popular Supplement

Reasons:

First, Plan G covers each of the gaps in Medicare except for the annual Part B deductible. This deductible is only $226 in 2023. In fact, if you have a Plan F that has been in place for years, it can probably help you on premiums by looking at Plan G. When you shop for benefits, you can often find a Supplement Plan G that saves quite a bit in premiums over Plan F, usually substantially more than the $226 deductible that you’ll pay out.

Second, it has great coverage. For hospital stays, it covers all your hospital expenses. Most importantly, it pays the hospital deductible, which is over $1,600 in 2023. It also covers the expensive daily co-pays that you might encounter for a hospital stay that runs longer than 60 days. It provides an additional 365 days in the hospital after your Medicare benefits run out, and it covers your skilled nursing facility co-insurance, too.

What Other Medical Services Does Plan G Cover?

Medicare Supplement Plan G covers your percentage of any medical benefit that Original Medicare covers, except for the outpatient deductible. So, it helps to pay for inpatient hospital costs, such as the first three pints of blood, skilled nursing facility care, and hospice care. It also covers outpatient medical services such as doctor visits, lab work, diabetes supplies, cancer treatment, durable medical equipment, x-rays, ambulance, surgeries and much more. This means Plan G covers the coverage gaps with Original Medicare and all Plan G products must provide you with the exact same coverage.

Medicare pays first, then Plan G pays the remaining amount after you pay the once annual deductible. In addition, Plan G Medicare Supplements offer up to $50,000 in foreign travel emergency benefits (up to plan limits).

Related Article: Medicare Costs for 2023

CITE: https://www.r2library.com/Resource/Title/082610254

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ORDER: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

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Filed under: "Ask-an-Advisor", Glossary Terms, Health Insurance, Health Law & Policy, Healthcare Finance, Managed Care | Tagged: Health Insurance, medicare, Medicare G, Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D, Medicare Part F, Medicare Part G, medicare supplements, medigap | 1 Comment »

On Medication Therapy Management (MTM)

Posted on September 6, 2022 by Dr. Marcinko

What it is – How it works

By wikipedia

DEM 2

David Edward Marcinko

http://www.HealthDictionarySeries.org

Medication therapy management (MTM) is medical care provided by pharmacists whose aim is to optimize drug therapy and improve therapeutic outcomes for patients.

Eleven national pharmacy organizations adopted this definition in 2004. Medication therapy management includes a broad range of professional activities, including but not limited to performing patient assessment and/or a comprehensive medication review, formulating a medication treatment plan, monitoring efficacy and safety of medication therapy, enhancing medication adherence through patient empowerment and education, and documenting and communicating MTM services to prescribers in order to maintain comprehensive patient care.

Core Elements

Medication therapy management includes five core components: a medication therapy review (MTR), personal medication record (PMR), medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up. A MTR is a systematic process of collecting patient and medication-related information which occurs during the pharmacist-patient encounter.

In addition, the MTR assists in the identification and prioritization of medication-related problems. During the MTM encounter, the pharmacist develops a PMR for use by the patient. The PMR includes all prescription and nonprescription products and requires updating as necessary. After assessing and identifying medication-related problems, the pharmacist develops a patient-specific MAP. The MAP is a list of self-management actions necessary to achieve the patient’s specific health goals.

Moreover, the patient and pharmacist utilize the MAP to record actions and track progress towards health goals. During the MTM session, the pharmacist identifies medication-related problem(s) and determines appropriate intervention(s) for resolution. Often, the pharmacist collaborates with other health care professionals to resolve the identified problem(s). Following the patient encounter and/or intervention, the pharmacist must document his/her encounter and determine appropriate patient follow-up.

Pharmaceutical care defined

Hepler and Strand define pharmaceutical care as the provision of drug therapy in order to achieve definite outcomes that improve a patient’s quality of life. Outcomes include cure of a disease, elimination or reduction of a patient’s symptoms, arresting or slowing of a disease process, and preventing a disease or symptom. The process includes pharmacist collaboration with other health care professionals in designing, implementing, and monitoring a therapeutic plan for a patient. Pharmaceutical care focuses on the pharmacist’s role in achieving therapeutic goals to improve the patient’s quality of life.

MMA of 2003 – Part D

The Medicare Modernization Act of 2003, requires Medicare Part D prescription drug plans to include medication therapy management services delivered by a qualified healthcare professional, including pharmacists, beginning in 2006. MTM services target beneficiaries who have multiple chronic conditions (such as diabetes, asthma, hypertension, hyperlipidemia, and congestive heart failure), take multiple medications, or are likely to incur annual costs above a predetermined level.

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Assessment

Medication therapy management is a unique niche for the pharmacy profession, allowing pharmacists to apply their extensive medication knowledge as medication experts with the intent of improving patient outcomes.

Conclusion

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Filed under: Drugs and Pharma | Tagged: Medicare Modernization Act of 2003, Medicare Part D, Medication Therapy Management, medication therapy review, MMA, MTM, personal medication record | 10 Comments »

PODCAST: Medicare Part D [Rx Drugs]

Posted on July 29, 2022 by Dr. Marcinko

LATE ENROLLMENT PENALTY CALCULATIONS

Medicare – CMS

CITE: https://www.r2library.com/Resource/Title/0826102549

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Filed under: Drugs and Pharma, Funding Basics, Health Insurance, iMBA, Inc., Videos | Tagged: drug insurance coverage, medicare drugs D, medicare late enrollment penalty, Medicare Part D, Part D penalty, prescription drugs | 1 Comment »

PODCASTS: All You Need to Know About Government Healthcare

Posted on April 2, 2022 by Dr. Marcinko

By Eric Bricker MD

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1) Traditional Medicare: Health Insurance for Seniors 65 and older. Medicare Part A is coverage for hospital services. Medicare Part B is coverage for doctor, physical therapist and other provider services and for outpatient services such as labs and imaging.

2) Medicare Advantage: Health Insurance for Seniors 65 and older administered through a private health insurance company. It is sometimes referred to as Medicare Part C. It can be chosen instead of Traditional Medicare and often includes Dental Insurance, Vision Insurance, Hearing Aid Insurance and Prescription Drug Coverage.

3) Medicare Part D Prescription Coverage: Additional insurance for people on Traditional Medicare to cover their prescription medications as well. Medicare Part D is administered by private insurance companies.

4) Medicare Supplement Plans: Insurance that can be purchased in addition to Traditional Medicare to cover the expenses that Traditional Medicare does not cover, such as hospitalization deductibles and Medicare Part B co-insurance.

5) Medicaid: The health insurance program administered by each state for it’s economically disadvantaged residents. It is funded in part by the Federal Government and in part by each state. It is administered by private health insurance companies.

6) Affordable Care Act (ACA) Exchange Plans: Health insurance for people under 65 who make too much money to qualify for Medicaid, but do not received health insurance through their employer. ACA Exchange Plans are subsidized by the Federal Government and administered by private insurance companies.

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Filed under: Experts Invited, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Insurance Matters, Videos | Tagged: ACA, Affordable Care Act., Eric Bricker MD, Health Insurance, Medicaid, medicare, Medicare Advantage, Medicare Part C, Medicare Part D, medigap, Prescription Insurance Coverage | Leave a comment »

On Higher Prescription Drug Cost-Sharing and Mortality?

Posted on July 7, 2021 by Dr. Marcinko

Raises Mortality among Medicare PART D Beneficiaries

QUERY: What are the health consequences when patients reduce their use of prescribed medications in response to higher out-of-pocket costs?

In The Health Costs of Cost-Sharing (NBER Working Paper 28439), researchers Amitabh Chandra, Evan Flack and Ziad Obermeyer use the distinctive out-of-pocket cost-sharing features of Medicare Part D to demonstrate that such reductions can increase mortality.

ASSESSMENT: Your thoughts are appreciated.

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Filed under: Drugs and Pharma, Experts Invited, Funding Basics, Health Economics, Health Insurance, Healthcare Finance | Tagged: Amitabh Chandra, Evan Flack, Medicare Part D, NBER, out of pocket cost shring, Prescription Cost Sharing, prescription drugs | Leave a comment »

Medicare Part D – Drug Plan Enrollment

Posted on June 14, 2019 by Dr. Marcinko

Distribution 2019

By http://www.MCOL.com

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Filed under: Drugs and Pharma | Tagged: Medicare Part D | 3 Comments »

Medicare Part D Prescriptions

Posted on July 26, 2018 by Dr. Marcinko

And … Rebates in 2016

By http://www.MCOL.com

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Filed under: Drugs and Pharma | Tagged: mcol.com, Medicare Part D | 3 Comments »

Medicare Spending on EpiPens

Posted on October 21, 2016 by Dr. Marcinko

Part D

By http://www.MCOL.com

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2015 Medicare Part D [What it is = How it works]?

Posted on February 13, 2015 by Dr. Marcinko

Update on the Medicare prescription drug benefit program

[By Staff Reporters]

Medicare Part D, also called the Medicare prescription drug benefit, is a United States federal-government program to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries. It was enacted as part of the Medicare Modernization Act of 2003 (which also made changes to the public Part C Medicare health plan program) and went into effect on January 1, 2006.

Medicare Part D Premiums

The monthly Medicare Part D base premium is set to pay 25.5 percent of the cost of standard coverage, established by bids submitted annually by Part D plans. CMS releases the Medicare Part D base premium in early August each year. Actual premiums are based on this set premium, but can vary greatly. The premium for 2014 was $32.42.

As of 2011, beneficiaries with higher incomes must pay a premium adjustment based on their income. This premium adjustment is called the Income-Related Monthly Adjustment Amount (IRMAA), and is paid directly to the Federal government (deducted from Social Security, Railroad Retirement Board, or Office of Personnel Management benefits).

Medicare Part D Deductible

The annual deductible for the standard Medicare Part D benefit was $310 in 2014, which is a decrease of $10 from the 2013 deductible. No Medicare drug plan may have a deductible more than $310 in 2014, although some plans may have a lower deductible or no deductible at all.

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CMS Part D 2015 Standard Benefit Model Plan Details

Here are the highlights for the CMS defined Standard Benefit Plan changes from 2014 to 2015. The chart below shows the Standard Benefit design changes for plan years 2011, 2012, 2013, 2014 and 2015. This “Standard Benefit Plan” is the minimum allowable plan to be offered.

Initial Deductible: will be increased by $10 to $320 in 2015
Initial Coverage Limit: will increase from $2,850 in 2014 to $2,960 in 2015
Out-of-Pocket Threshold: will increase from $4,550 in 2014 to $4,700 in 2015
Coverage Gap (donut hole): begins once you reach your Medicare Part D plan’s initial coverage limit ($2,960 in 2015) and ends when you spend a total of $4,700 in 2015. In 2015, Part D enrollees will receive a 55% discount on the total cost of their brand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will still apply to getting out of the donut hole, however the additional 5% paid by your Medicare Part D plan will not count toward your TrOOP. Enrollees will pay a maximum of 65% co-pay on generic drugs purchased while in the coverage gap.
Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**: will increase to greater of 5% or $2.65 for generic or preferred drug that is a multi-source drug and the greater of 5% or $6.60 for all other drugs in 2015
Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $2.65 for generic or preferred drug that is a multi-source drug and $6.60 for all other drugs in 2015.

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Medicare Part D Benefit Parameters for Defined Standard Benefit 2011 through 2015 Comparison
Part D Standard Benefit Design Parameters:	2015	2014	2013	2012	2011
Deductible – (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit.	$320	$310	$325	$320	$310
Initial Coverage Limit – Coverage Gap (Donut Hole) begins at this point. (The Beneficiary pays 100% of their prescription costs up to the Out-of-Pocket Threshold)	$2,960	$2,850	$2,970	$2,930	$2,840
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap – Catastrophic Coverage starts after this point. See note (1) below.	$6,680.00 (1)	$6,455.00 (1)	$6,733.75 (1)	$6,657.50 (1)	$6,447.50 (1)
Out-of-Pocket Threshold – This is the Total Out-of-Pocket Costs including the Donut Hole. 2015 Example: $320 (Deductible) +(($2960-$320)25%) (Initial Coverage) +(($6680.00-$2960)100%) (Cov. Gap) = $4,700 (Maximum Out-Of-Pocket Cost prior to Catastrophic Coverage – excluding plan premium)	$4,700 $320.00 $660.00 $3,720.00 $4,700.00	$4,550 $310.00 $635.00 $3,605.00 $4,550.00	$4,750 $325.00 $661.25 $3,763.75 $4,750.00	$4,700 $320.00 $652.50 $3,727.50 $4,700.00	$4,550 $310.00 $632.50 $3,607.50 $4,550.00
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2).	$7,061.76 plus a 55% brand discount	$6,690.77 plus a 52.50% brand discount	$6,954.52 plus a 52.50% brand discount	$6,730.39 plus a 50% brand discount	$6,483.72 plus a 50% brand discount
Catastrophic Coverage Benefit:
Generic/Preferred Multi-Source Drug (3)	$2.65 (3)	$2.55 (3)	$2.65 (3)	$2.60 (3)	$2.50 (3)
Other Drugs (3)	$6.60 (3)	$6.35 (3)	$6.60 (3)	$6.50 (3)	$6.30 (3)
Part D Full Benefit Dual Eligible (FBDE) Parameters:	2015	2014	2013	2012	2011
Deductible	$0.00	$0.00	$0.00	$0.00	$0.00
Copayments for Institutionalized Beneficiaries	$0.00	$0.00	$0.00	$0.00	$0.00
Maximum Copayments for Non-Institutionalized Beneficiaries
Up to or at 100% FPL:
Up to Out-of-Pocket Threshold
Generic/Preferred Multi-Source Drug	$1.20	$1.20	$1.15	$1.10	$1.10
Other	$3.60	$3.60	$3.50	$3.30	$3.30
Above Out-of-Pocket Threshold	$0.00	$0.00	$0.00	$0.00	$0.00
Over 100% FPL:
Up to Out-of-Pocket Threshold
Generic/Preferred Multi-Source Drug	$2.65	$2.55	$2.65	$2.60	$2.50
Other	$6.60	$6.35	$6.60	$6.50	$6.30
Above Out-of-Pocket Threshold	$0.00	$0.00	$0.00	$0.00	$0.00
Part D Full Subsidy – Non Full Benefit Dual Eligible Full Subsidy Parameters:	2015	2014	2013	2012	2011
Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources < $8,580 (individuals) or < $13,620 (couples) (4)
Deductible	$0.00	$0.00	$0.00	$0.00	$0.00
Maximum Copayments up to Out-of-Pocket Threshold
Generic/Preferred Multi-Source Drug	$2.65	$2.55	$2.65	$2.60	$2.50
Other	$6.60	$6.35	$6.60	$6.50	$6.30
Maximum Copay above Out-of-Pocket Threshold	$0.00	$0.00	$0.00	$0.00	$0.00
Partial Subsidy Parameters:	2015	2014	2013	2012	2011
Applied and income below 150% FPL and resources between $8,581-$13,300 (individuals) or $13,621-$26,580 (couples) (category code 4) (4)
Deductible	$66.00	$63.00	$66.00	$65.00	$63.00
Coinsurance up to Out-of-Pocket Threshold	15%	15%	15%	15%	15%
Maximum Copayments above Out-of-Pocket Threshold
Generic/Preferred Multi-Source Drug	$2.65	$2.55	$2.65	$2.60	$2.50
Other	$6.60	$6.35	$6.60	$6.50	$6.30
****** (1) Total Covered Part D Spending at Out-of-Pocket Threshold for Non-Applicable Beneficiaries – Beneficiaries who ARE entitled to an income-related subsidy under section 1860D-14(a) (LIS)

(2) Total Covered Part D Spending at Out-of-Pocket Threshold for Applicable Beneficiaries – Beneficiaries who are NOT entitled to an income-related subsidy under section 1860D-14(a) (NON-LIS) and do receive the coverage gap discount. For 2015, the weighted gap coinsurance factor is 90.693%. This is based on the 2013 PDEs (85.9% Brands & 14.1% Generics)

(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2015, beneficiaries would be charged $2.60 for those generic or preferred multisource drugs with a retail price under $52 and 5% for those with a retail price greater than $52. As to Brand drugs, beneficiaries would pay $6.60 for those drugs with a retail price under $132 and 5% for those with a retail price over $132.
(4) The actual amount of resources allowable may be updated for contract year 2015.

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Filed under: Health Insurance, iMBA, Inc. | Tagged: Medicare Part D, Medicare prescription drug benefits | 7 Comments »

Retail Perscription Drug Expenditures

Posted on June 1, 2014 by Dr. Marcinko

By Payer 2001-2011

http://www.MCOL.com

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What is Form 834?

Posted on December 12, 2013 by Dr. Marcinko

President Obama’s Most Important Number

[By Staff Reporters]

This is an “834 EDI transmission.”

Health Insurers sometimes call it, more simply, “an 834.” It is a technical, back-end reporting tool that consumers never see on the Federal Website. It is meant to be read by computers, not human beings. It’s the form that tells the insurer’s system who you are and what you need. And, it might be the new health-care law’s biggest problem.

Insurers report that, in some cases, 834s are coming in wrong. That’s a much more serious problem than the online traffic bottlenecks that have dominated coverage of the health-care law’s rollout.

Washington Post Article:

This is an “834 EDI transmission.” Insurers sometimes call it, more simply, “an 834.” It is a technical, back-end reporting tool that consumers never see. It is meant to be read by computers, not human beings. It’s the form that tells the insurer’s system who you are and what you need. And it might be the new health-care law’s biggest problem.

What is the ANSI 834 Enrollment Implementation Format?

The 834 Transaction is the HIPAA-compliant Benefit Enrollment and Maintenance Transaction. Its purpose is to electronically transmit enrollment and dis-enrollment information.

In 2004, DHCS implemented a 4010 834 solution, however, this was implemented along with a supplemental transaction that held eligibility history.

The HIPAA 5010 version of all transactions is scheduled to be implemented on January 1st, 2012. DHCS will implement a compliant 5010 834 on this date. The current FAME file will continue to be made available for a short period of time after this date to allow plans time to transition. Once this transition period has been completed the FAME file will no longer be made available to managed care plans.

Impacted Covered Entities

Internal DHCS program areas and DHCS Health Plan trading partners.

5010 834 Documents

5010 834 Generic Test Data Overview (pdf)

General FAME Documents

FAME Data Element Dictionary (pdf)

MEDICARE PART D INFORMATION

Project Information

DHCS Medicare Part D information web page

MMA Part D Carrier Cross Reference Table (pdf)

File Layouts

MMEF 2100 Medicare Part D layout (pdf)

MMEF REC Medicare Part D layout (pdf)

Assessment

Conclusion

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Filed under: Drugs and Pharma, Health Insurance, Information Technology, Risk Management | Tagged: ACA, Accountable Care Act, Form 834, Medicare Part D, PP-ACA | Leave a comment »

On Medicare Part D Savings?

Posted on August 6, 2013 by Dr. Marcinko

An infographic

By www.MCOL.com

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More

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Filed under: Drugs and Pharma | Tagged: Medicare drugs, Medicare Part D | 7 Comments »

ProPublica Launches Prescriber Checkup [Interactive Database]

Posted on May 13, 2013 by Dr. Marcinko

The Doctors and Drugs in Medicare Part D

By Jeff Larson, Jennifer LaFleur, Charles Ornstein, Tracy Weber and Lena Groeger

ProPublica, Updated at May 10, 2013

Medicare’s popular prescription-drug program now serves more than 35 million people, but the names of prescribers and the drugs they choose have never previously been public … Until now.

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Assessment

Use this tool to find and compare doctors and other top prescribers in 2010.

Link: http://projects.propublica.org/checkup/

More:

FAQ: What You Need to Know About Prescriber Checkup
Solutions: Eight Ways to Strengthen Medicare’s Drug Benefit
Editors’ Note: Lifting the Veil on Dangerous Prescribing

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Filed under: Drugs and Pharma | Tagged: Medicare Part D, prescription drugs, ProPublica Launches Prescriber Checkup | 2 Comments »

Clarifying Some NPI Number Mis-Understandings

Posted on January 29, 2012 by Dr. Marcinko

The NPI Number: What is is – How it works?

By Carol S. Miller RN, MBA

The National Provider Identifier (NPI) is a HIPAA Administrative Simplification Standard that provides a unique identification for covered health care providers, all health plans and health care clearinghouses. The NPI must be used in administrative and financial transactions adopted under HIPAA and with one identifying number will simplify security and allow greater protection or encryption of the provider number. The NPI can be used to identify the health care provider on prescriptions, COB between health care plans, inpatient medical record systems, program integrity files, and other areas.

Dependent on his/her medical practice, the provider can obtain an individual or group NPI; however, there are situations where an individual NPI number is required such as with the submission of pharmacy and lab claims. The NPI remains with the provider regardless of job or location change. NPI will eventually be the standard identifier for all e-prescribing under Medicare Part D.

A Ten Digit Number

The NPI is a ten digit, intelligence-free numeric identifier with a check digit in the last position to help detect keying errors. If there is a security breach, the number in itself cannot identify the protected health organization. The use of one identifier with a check digit simplifies encryption of this number when transmitted electronically and thereby enhances security.

On HIPPA

HIPAA also requires that employers have standard national numbers that identify them on standard transactions. The Employer Identification Number (EIN), issued by the Internal Revenue Service (IRS) was selected as the identifier for employers. This number is used as a Federal tax identification number for the means of identifying any business entity and for the purpose of reporting employment taxes. The EIN number should be protected as a social security number is.

ITL and NIST

Both the Information Technology Laboratory (ITL) and the National Institute of Standards and Technology (NIST) are involved in the development of technical, physical, administrative, and management standards and guidelines for cost-effective security and privacy of sensitive unclassified information in federal computer systems. These standards and guidelines can be applied to the management of medical IT.

Assessment

Additional reference material for NPI can be found at: www.cms.gov/nationalprovidentstand.

Conclusion

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Filed under: Information Technology, Practice Management, Recommended Books | Tagged: carol s. miller, EIN, HIPAA, Hospitals and Healthcare Organizations, Information Technology Laboratory, ITL, Medicare Part D, National Institute of Standards and Technology, National Provider Identifier Number, NIST, NPI | 3 Comments »

Understanding Hierarchical Condition Category Management for MAPs

Posted on October 21, 2010 by Dr. Marcinko

An Emerging Management Trend for Medicare Advantage Plans [MAPs]

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

So called Hierarchical Condition Category Management (HCCM) is an emerging healthcare management trend designed to accurately reflect the health status of Medicare Advantage Plan [MAP] members and to help them remain financially viable in Part D of the system.

HCCM Indications

Since the Medicare risk adjustment payment system uses clinical coding information to calculate risk premiums for Medicare Managed Care Organizations (MMCOs), HCCM seems best to address the following:

CMS risk adjustment system.
Strategic and financial implications for Medicare plans.

Assessment

Any initiatives required to effectively managed care under a risk adjustment payment system is ripe for HCCM and the key success factors associated with these initiatives.

Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936901/

Conclusion

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Filed under: "Doctors Only", Drugs and Pharma, Managed Care, Practice Management | Tagged: HCCM, Hierarchical Condition Category Management, MAPs, Medicare Advantage Plans, Medicare HMOs, Medicare Part D | 2 Comments »

Update on Senior Donut Hole Rebate Checks

Posted on July 13, 2010 by Dr. Marcinko

More Seniors to Receive One-Time Donut Hole Rebate Checks

By Staff Reports

Medicare Beneficiaries Whose High Prescription Drug Costs Have Put Them in the Medicare Part D Donut Hole to Receive $250 Rebate Checks as a Result of the Affordable Care Act

WASHINGTON – The next round of more than 300,000 eligible seniors who have entered the Medicare Part D “donut hole” this year have been mailed their tax-free, one time rebate check for $250, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced recently. These one-time rebate checks are the first step in closing the prescription drug coverage gap under the Affordable Care Act. The first round of checks were distributed in the middle of June. As qualifying Medicare recipients “fall into the donut hole,” they will be sent a rebate check by Medicare.

“Seniors and other Medicare recipients in the Medicare donut hole are struggling to afford the medications they need and their basic living expenses. Seventy percent of our first round of these $250 rebate checks were cashed within a week of eligible Medicare recipients receiving them; so, we know that folks really need some help,” said Secretary Sebelius. “The Affordable Care Act starts to close the donut hole this year, giving much-needed relief to millions of seniors. In 2011, the Affordable Care Act takes an additional step for Medicare beneficiaries in the donut hole by providing them with a 50 percent discount on their brand name medications. Every year from 2012 until 2020, the Affordable Care Act will take progressive steps to close the donut hole.”

“Seniors also need to know that they will just receive their check at their usual address – they don’t have to take any extra steps,” said Centers for Medicare & Medicaid Services Deputy Administrator and Director for the Center for Medicare, Jonathan Blum. “And they should never give out their personal information. If someone asks for your personal Medicare information over the phone who isn’t a trusted resource like Medicare, please don’t provide it. Seniors or family members should contact us at 1-800-MEDICARE to report any of these types of calls or go to www.stopmedicarefraud.gov to learn more about efforts to fight fraud and scams against seniors.”

On Thursday, July 8th, at 2:00 p.m., HHS Secretary Kathleen Sebelius joined local officials in Manchester, N.H., for a forum with senior citizens to discuss the rebate checks and other benefits of the Affordable Care Act as well as efforts to fight Medicare fraud.

The $250 checks are being mailed to those Medicare beneficiaries who entered the Medicare Part D donut hole, also known as the coverage gap, in the second quarter of 2010 and are not eligible for Medicare Extra Help (also known as the low-income subsidy or LIS) or enrolled in a qualified retiree prescription drug plan. The donut hole is the period in the prescription drug benefit in which the beneficiary pays 100 percent of the cost of their drugs until they reach the catastrophic coverage phase.

About Medicare Extra Help

Medicare Extra Help provides assistance to seniors so they don’t face higher costs or a coverage gap in their prescription drug coverage. Qualifying Medicare beneficiaries who entered the donut hole in the first quarter of 2010 who were not eligible for Medicare Extra Help received a check in the first round of rebates mailed June 10^th. Going forward, a check for qualifying beneficiaries newly reaching the donut hole in 2010 will be mailed monthly.

Assessment

More information about the “donut hole” rebate checks, please contact www.HealthCare.gov or 1-800-MEDICARE. For further questions about Extra Help (or the LIS) benefit under Part D, please contact the Social Security Administration at www.ssa.gov.

Conclusion

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Filed under: Health Economics, Health Law & Policy, Healthcare Finance | Tagged: Affordable Care Act., CMS, Donut Hole, Donut Hole rebate checks, Jonathan Blum, Kathleen Sebelius, low-income subsidy, medicare, Medicare Extra Help, Medicare Part D | 4 Comments »

Implementation of the Healthcare Deficit Reduction Act

Posted on June 23, 2010 by Dr. Marcinko

Signed by President Bush in 2006

By Gregory O. Ginn; PhD, MBA, CPA, MEd

By Hope Rachel Hetico; RN, MHA, CMP™

The Deficit Reduction Act (DRA), S. 1932, was signed by President Bush on February 8, 2006, and became Public Law No. 109-171. Implementation of the act includes these provisions:

www.CertifiedMedicalPlanner.com

Subtitle A – Provisions Relating to Medicare Part A

hospital quality improvement (section 5001);
improvements to Medicare-dependent hospital (MDH) programs (section 5003);
reduction in payments to skilled nursing facilities (SNFs; section 5004);
phase-in of inpatient rehabilitation facility classification criteria (section 5005);
development of a strategic plan regarding investment in specialty hospitals (section 5006);
demonstration projects to permit gain-sharing arrangements (section 5007); and
post-acute care payment reform demonstration programs (section 5008).

Subtitle B Provisions Relating to Medicare Part B

title transfer of certain durable medical equipment (DME) to patients after 13-month rental (section 5101);
adjustments in payment for imaging services (section 5102);
limitations on payments for procedures in ambulatory surgical centers (ASCs; section 5103);
minimum updates for physician services (section 5104);
three-year extension of hold-harmless provisions for small rural hospitals and sole community hospitals (section 5105);
updates on composite rate components of basic care-mix adjusted prospective payment systems (PPS) for dialysis services (section 5106);
accelerated implementation of income-related reductions in Part B premium subsidy (section 5111);
Medicare coverage of ultrasound screening for abdominal aortic aneurysms; National Educational And Information Campaign (section 5112);
improvements to patient access and utilization of colorectal cancer screening under Medicare (section 5113);
delivery of services at federally qualified health centers (FQHC) (section 5114); and
waiver of Part B Late Enrollment Penalty for certain international volunteers (section 5115).

Subtitle C – Provisions Relating To Parts A and B

home health payments (section 5201);
revision of period for providing payment for claims that are not submitted electronically (section 5202);
timeframe for Part A and B payments (section 5203); and
Medicare Integrity Program (MIP) funding (section 5204).

Subtitle D – Provisions Relating To Part C

phase-out of risk adjustment budget neutrality in determining payments to Medicare Advantage organizations (section 5301); and
Rural PACE Provider Grant Programs (section 5302).[1]

The goal of the act is to save nearly $40 billion over five years from mandatory spending programs through slowing the growth in spending for Medicare and Medicaid. Has it been successful to-date?

Assessment

We know from personal experience that the DRA can be implemented by all healthcare stakeholders to the benefits of the industry sector in the aggregate. But, has it been?

Conclusion

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Editors Note: Gregory Ginn has been a professor in the Department of Health Care Administration at the University of Nevada, Las Vegas, since 2000. He received his doctorate, MBA, M.Ed., and undergraduate degree from the University of Texas at Austin, and is an inactive Certified Public Accountant registrant in the States of Nebraska and Texas. Before his current position at UNLV, he spent time teaching at Clarkson College, College of Saint Mary, University of Findlay, University of Central Texas, Stephen F. Austin State University, State University of New York at Buffalo, University of Houston at Victoria, University of Texas at Austin, and the Southwest Texas State University. Prior to his academic roles, he was an accountant for Touche Ross & Co., and an Internal Revenue Service Tax Auditor. Dr. Ginn has also been a reviewer for organizations such as: Health Care Management Review and the Health Care Administration Division of the Academy of Management. He is Treasurer for the Nevada Executive Health Care Forum and was a member of the Southern Nevada Wellness Council. His graduate teaching experience in healthcare administration is abundant, having taught courses in: Management of Health Services Organizations, Quantitative Methods, The U.S. Health Care System, Health Care Systems and Policy, Health Care Finance, Group Practice Management, Long-term Care, and Health Care Law. He has been published in numerous journals, including Journal of Healthcare Management, Hospital Topics, Nursing Homes, Journal of Nursing Administration, International Electronic Journal of Health Education, and Hospital and Health Services Administration. His current and former professional memberships include: American College of Healthcare Executives, Nevada Executive Healthcare Forum, Academy of Management, Association of University Programs in Health Administration, Certified Medial Planner (Hon.) and Heartland Health Care Executives.

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Filed under: CMP Program, Health Economics, Health Law & Policy, Managed Care, Practice Management | Tagged: Deficit Reduction Act, durable medical equipment, federally qualified health centers, Gregory O. Ginn, Medicare Integrity Program, Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D, Medicare-dependent hospital, National Educational And Information Campaign, prospective payment systems, Rural PACE Provider Grant Programs, skilled nursing facilities, www.certifiedmedicalplanner.com, www.healthcarefinancials.com, www.healthdictionaryseries.com | 1 Comment »

Part D Payer Shares of Prescriptions Dispensed Rise

Posted on November 18, 2009 by Dr. Marcinko

Increase for Eight Major Drug Classes

[By Staff Reporters]

The shares of all prescriptions dispensed covered by Medicare Part D rose by at least three percentage points, between midyear 2007 and midyear 2009, in each of eight major drug classes profiled.

Assessment

The largest percentage increases over this period were in the osteoporosis (to 26.9% in 2009 from 20.5% in 2007) and anti-platelet (to 28.4% from 22.5%) markets as of September 9, 2009.

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