RE: [BULK] Re: Fwd: Issue24,November25,2008

[Guest guest]

So right -- key questions for the patient case:

*

what was his Medicare eligibiilty/entitlement based on (ESRD? disability?

age?)?

*

what was the first date he would have been Medicare entitled?

*

when did he apply for Medicare?

Daryl Battin, LICSW

Department of Transplantation -- Kidney Program

Financial Coordinator/Social Worker

Lahey Clinic

41 Mall Road

Burlington, MA 01805

Phone: /

FAX:

Page:

________________________________

From: TxFinancialCoordinators on behalf of BEVERLY A LARSON

Sent: Tue 12/2/2008 8:24 AM

To: TxFinancialCoordinators

Subject: RE: [bULK] Re: Fwd: Issue24,November25,2008

You did not say if it was a Kidney Transplant or what? If it is a kidney

transplant, yes he will be eligible for Medicare (immunosuppressive meds) back

to the effective date of his transplant when he was eligible for Medicare. If

he filed for B back to the time of his transplant, he should have

immunosuppressive coverage

Beverly A. Larson,

Transplant Financial Coord.

Sentara Norfolk Gen. Hosp.

Transplant Department

Phone:

Fax:

email: balarson@ sentara.com

>>> " Lavinia Pitts " 12/1/2008 9:08 AM >>>

Good morning fellow TFC's,

I hope everyone had a nice holiday. I have a situation and would like

some feedback.

I have a patient that received a transplant in 2005. His Part B

benefits became effective one month after transplant, so his immunos are

not covered. Is it possible to have Part B retroactively effective to

the month of the transplant to assist with the immunos? All

correspondence will be greatly appreciated.

Thanks,

La'Vinia Pitts

Financial Coordinator

Albert Einstein Medical Center

Philadelphia, PA

>>> " BEVERLY A LARSON " 11/25/2008 3:09 PM >>>

I understand that and unfortunately while they wait they are unable to

get their medications and see doctors and their medical condition goes

untreated.

Bev

Beverly A. Larson,

Transplant Financial Coord.

Sentara Norfolk Gen. Hosp.

Transplant Department

Phone:

Fax:

email: balarson@ sentara.com

>>> " Delson, Sheila " 11/25/2008 2:32 PM >>>

Agreed. But this 2 year wait period for medicare due to disability

affects many more people in the U.S. than the transplant population.

[bULK] Re: Fwd: Issue 24, November

25, 2008

All heart transplant patients as well as other solid organ transplant

have that 24 month waiting period. This would seem unjust in that ESRD

patients receive Medicare at the time of transplant or when they begin

dialysis, i.e. home dialysis they get Medicare right away, incenter they

only have a 3 month wait. At the time the law was written there were no

other transplant organs viable. That is not the case now. Heart

transplant suffer because they can not get their immunosuppressive

medications. It would make one think it could be declared discrimination

to all other organ transplant patients that they have to wait 24 months

for Medicare and help with medications. Bev Larson

Beverly A. Larson,

Transplant Financial Coord.

Sentara Norfolk Gen. Hosp.

Transplant Department

Phone:

Fax:

email: balarson@ sentara.com

>>> Louis 11/25/2008 2:15 PM

>>>

Welcome to MEDICARE WATCH, a biweekly electronic newsletter of the

Medicare Rights Center

Vol. 11 , No. 24 : Novemeber 25, 2008

Contents:

1. FAST FACT

2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD

3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPER

4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS

5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICARE

PRIVATE HEALTH PLAN

1. FAST FACT

Medicare private health plans (also known as âEURoeMedicare AdvantageâEUR

plans) received $6.8 billion in improper payments in 2006, primarily

from plansâEUR errors in documenting their enrolleesâEUR diagnoses. The

improper payments are equal to 10.6 percent of total payments to

Medicare Advantage plans for the year. (Centers for Medicare & Medicaid

Services, CMS Issues Improper Payment Rates for Medicare, Medicaid, and

SCHIP, November 2008)

2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD

Over 75 health advocacy organizations this month launched the Coalition

to End the Two-Year Wait for Medicare, sending a letter to health

leaders in the House and Senate demanding that next yearâEURs health

reform efforts make a priority of covering people with disabilities who

are struggling to survive as they wait for Medicare coverage.

Close to 1.5 million people are stuck in this waiting period annually.

âEURNearly 40 percent of these individuals are without health

insurance coverage at some point during their wait for Medicare; 24

percent have no health insurance during this entire period. Many cannot

afford to pay COBRA premiums to maintain coverage from their former

employer, and private coverage on the individual market is unavailable

or too expensive for this high-cost population. The economic downturn

makes it difficult for states to extend Medicaid coverage beyond the

most impoverished people with disabilities,âEUR the coalition letter

reads. âEURoeNo one with disabilities severe enough to qualify for SSDI

should be without health insurance.âEUR The coalition includes

organizations such as the American Cancer Society - " Cancer Action

Network, Amputee Coalition of America, AlzheimerâEURs Association, Easter

Seals and the Medicare Rights Center.

In 1972, when Congress expanded Medicare to include people with

disabilities, it created a âEURoewaiting periodâEUR that requires people to

wait 24 months from when they begin receiving their Social Security

Disability Insurance (SSDI) payments before they can receive health care

through Medicare.

Costs for the elimination of the waiting period are estimated to be

around $9 billion annually. These costs would be offset by about $4

billion in Medicaid savings.

In the Senate, S.2102 is sponsored by Senator Jeff Bingaman (D-NM), and

cosponsored by 23 senators, including President-elect Barack Obama. In

the House, H.R. 154, sponsored by Representative Gene Green (D-TX) has

103 cosponsors. This legislation would eliminate the waiting period

through a ten-year phase out.

3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPER

Senator Max Baucus, Democrat of Montana and chairman of the Senate

Finance Committee, outlined an agenda for health care reform that builds

on existing private and government-funded sources of coverage, requires

all individuals to buy insurance and prohibits insurance companies from

denying coverage to people with pre-existing conditions.

The Baucus plan would eventually ensure that every individual has

access to affordable coverage by creating a nationwide insurance pool.

Those who already have insurance can keep what they have, but for people

who need access to guaranteed, affordable coverage this would allow

people to easily compare plans before purchasing one. Private insurance

companies would not be allowed to discriminate against people with

pre-existing conditions.

In the short term, Baucus would provide individuals who are 55 and

older an option to buy into the Medicare program. Medicare would charge

enrollees electing the buy-in option an annual premium that is

calculated to keep the total costs budget-neutral. Therefore the

Medicare buy-in option would not increase costs for Medicare or the

taxpayers. By providing coverage to a population that is without health

care during the ten years before they become eligible for Medicare, the

Medicare program might benefit from cost savings through prevention

efforts, according to the Baucus plan.

In addition to expanding coverage to those 55-64, the Baucus plan would

also begin the phase-out of the two-year waiting period for Medicare

coverage for people with disabilities. The current Medicare policy

requires people to wait 24 months from when they begin receiving their

SSDI payments. It is estimated that around 400,000 people are without

insurance during this waiting period, and many more are underinsured.

The Baucus plan anticipates that with more access to affordable

coverage, those with disabilities would eventually be able to buy

insurance on the private market as well.

Currently, Federal law does not require states to cover all adults

under Medicaid unless they are disabled, elderly, or pregnant. The

Baucus plan also calls for expanding eligibility to Medicaid to everyone

living below the poverty level and expanding eligibility for the State

ChildrenâEURs Health Insurance Program to more middle-income families

without coverage.

4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS

AARP launched an investigation into its âEURoesupplemental indemnity

plans,âEUR plans that cap what the insurer pays for services but not what

policyholders might owe. While the marketing materials for these plans

imply they provide full insurance coverage, the plans are actually

designed to be used in conjunction with other insurance and provide no

limits to an enrolleeâEURs out-of-pocket health care costs.

AARP took action in response to Ranking Member of the Senate Finance

Committee, Senator GrassleyâEURs concerns about the quality of

coverage provided by supplemental indemnity plans.

Senator GrassleyâEURs inquiry began after testimony by before

the Senate Finance Committee last June. , an enrollee in AARPâEURs

Medical Advantage Plan, one of the supplemental indemnity plans in

question, testified that she was shocked when the doctor providing

treatment for her leukemia demanded $45,000 up front because her health

care plan did not cover the cost of the service. âEURs AARP plan

paid a flat amount to enrollees for out-of-pocket health care costs,

rather then covering a percentage or portion of the cost of medical

services.

In early November, Senator Grassley sent a letter to AARP criticizing

these plans for providing enrollees with little or no financial

protection against catastrophic medical costs.

Additionally, in his November letter, Senator Grassley stated that his

staff found AARP marketed and sold supplemental indemnity plans to

people with Medicare, including people who already had supplemental

Medicare coverage. The marketing of these plans to people with Medicare

occurred even though AARP advertised the supplemental indemnity plans as

a âEURoebridgeâEUR to Medicare for retired people under 65.

âEURoeThe pitch for these products should be straight up and informative,

instead of designed to leave the impression of being comprehensive when

the product is, in fact, very limited and leaves consumers seriously in

debt if they need intensive medical care,âEUR Senator Grassley said in a

November 3 press release.

AARP responded to GrassleyâEURs letter by suspending the sales and

marketing of these plans, which are provided through United Healthcare

under the AARP brand. More than one million people have bought this type

of coverage, according to the New York Times.

5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICARE

PRIVATE HEALTH PLAN

Mrs. B and her husband, Mr. B, are both enrolled in a Medicare private

health plan. Last month, Mr. B had invasive surgery that made it very

difficult for him to walk. He then entered a skilled nursing facility

(SNF) for physical therapy to help him regain his strength. A few weeks

later, Mr. BâEURs therapist told Mrs. B that because her husbandâEURs

progress had âEURoeplateauedâEUR and he did not seem capable of full

recovery, his health plan would probably not pay for his care for much

longer. Mrs. B was concerned that Mr. B was not yet strong enough to

leave the SNF, so she consulted with Mr. BâEURs doctor. The doctor said

that she disagreed with the therapist and that the plan should still pay

for the SNF care because Mr. B still needed skilled care from a physical

therapist to keep his condition from deteriorating. Soon after, Mr. B

received a notice from the SNF, called a Notice of Medicare

Non-Coverage, which told him that his coverage would end in two days.

Mrs. B called the Medicare Rights Center right away and spoke with a

hotline counselor. The counselor advised Mrs. B that Medicare does not

require that full recovery be possible for SNF care to be covered. SNF

care is considered âEURoemedically necessary,âEUR and so can be covered if

it is needed to maintain your condition or prevent it from getting

worse. The counselor then explained that when a plan says it will no

longer pay for SNF care, you still have the right to appeal. However, in

order to meet the appealâEURs strict deadlines, Mrs. B would have to get

to work right away. The hotline counselor told her that on the Notice of

Medicare Non-Coverage, there would be instructions explaining how to

contact an organization called a QIO, or a Quality Improvement

Organization, to start an appeal. Mrs. B found the QIOâEURs telephone

number and the hotline counselor told her to call the QIO to say she

wanted to start an appeal by noon on the day before Mr. BâEURs services

were set to terminate.

The counselor explained to Mrs. B that after she called the QIO, it

would contact the SNF to request documentation. The hotline counselor

encouraged Mrs. B to ask her husbandâEURs doctor for a letter explaining

why ending Mr. BâEURs SNF care would be harmful to his health and why

physical therapy was necessary for Mr. B to maintain his condition. Mrs.

B was advised that it would also be helpful for her to submit that

written statement to the QIO as well. The counselor informed Mrs. B that

she had a right to see the information that the SNF submitted to the QIO

if she asked for it.

The QIO would have to make its decision within 48 hours. If the QIO

agreed with the therapist (that SNF care should no longer be covered for

Mr. , Mr. B might be able to continue to receive care, but he would

have to pay for it himself. If the QIO agreed with Mr. and Mrs. B, Mr. B

would have the right to continue to get covered SNF care.

Mrs. B called the QIO right away and began the appeal. She then called

Mr. BâEURs doctor, who wrote a letter of support and sent it to the QIO.

Two days later, the QIO informed Mrs. B that they had made a favorable

decision. Mr. B would be able to continue to receive covered SNF care.

This message was generated by the Medicare Rights Center list-serve.

If you have trouble (un)subscribing or have questions about Medicare

Watch, please send an e-mail to medicarewatch@....

To sign up for additional newsletters, please visit our online

registration form at

http://www.medicarerights.org/subscribeframeset.html.

If you want more information about the Medicare Rights Center, send an

e-mail to info@... or write to:

Medicare Rights Center

520 Eighth Avenue, North Wing, 3rd Floor New York, NY 10018

Telephone:

Fax:

Web site: www.medicarerights.org

Medicare Watch is the Medicare Rights CenterâEURs fortnightly

newsletter, established to strengthen communication with national and

community-based organizations and professional agencies about current

Medicare policy and consumer issues. Each edition contains news of

recent policy developments affecting Medicare and health care generally

and a case story from our hotline that illustrates steps professionals

can take to get older adults and people with disabilities the health

care they need.

The Medicare Rights Center is a national, not-for-profit consumer

service organization that works to ensure access to affordable health

care for older adults and people with disabilities through counseling

and advocacy, educational programs and public policy initiatives.

© 2008 by Medicare Rights Center. All rights reserved.

For reprint rights, please contact Sheena Bhuva.

Unsubscribe from this mailing.

Modify your profile and subscription preferences.

P Please consider the environment before printing this e-mail

Cleveland Clinic is ranked one of the top hospitals

in America by U.S. News & World Report (2008).

Visit us online at http://www.clevelandclinic.org

<http://www.clevelandclinic.org/> for

a complete listing of our services, staff and

locations.

Confidentiality Note: This message is intended for use

only by the individual or entity to which it is addressed

and may contain information that is privileged,

confidential, and exempt from disclosure under applicable

law. If the reader of this message is not the intended

recipient or the employee or agent responsible for

delivering the message to the intended recipient, you are

hereby notified that any dissemination, distribution or

copying of this communication is strictly prohibited. If

you have received this communication in error, please

contact the sender immediately and destroy the material in

its entirety, whether electronic or hard copy. Thank you.

This message is intended for the use of the person or entity to which it is

addressed and may contain information that is privileged and confidential, the

disclosure of which is governed by applicable law. If you are not the intended

recipient, or the employee or agent responsible to deliver it to the intended

recipient, you are hereby notified that any disclosure, copying, or distribution

of this information is strictly prohibited. If you have received this message by

error, please notify the sender immediately to arrange for return or destruction

of these documents.

See our web page at http://www.lahey.org for a full directory of Lahey sites,

staff, services and career opportunities.

THIS MESSAGE IS INTENDED FOR THE USE OF THE PERSON TO WHOM IT IS ADDRESSED. IT

MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM

DISCLOSURE UNDER APPLICABLE LAW. If you are not the intended recipient, your use

of this message for any purpose is strictly prohibited. If you have received

this communication in error, please delete the message and notify the sender so

that we may correct our records.