RE: [BULK] Re: Fwd: Issue24,November 25,2008

[Guest guest]

Hi Lavinia, It doesn't matter that he didn't have part B till one month after transplant. As long as he had part A at the time of transplant and has part B when he wants the immunos covered, so he should be good now for his immunos to be covered. When they ask if he had a Medicare covered transplant, the answer is yes because he had part A. Hope that helps. Pat Hogan Transplant Financial Coordinator Lahey Clinic 41 Mall Rd. Burlington, MA 01805 phone fax [bULK] Re: Fwd: Issue 24, November25, 2008All heart transplant patients as well as other solid organ transplanthave that 24 month waiting period. This would seem unjust in that ESRDpatients receive Medicare at the time of transplant or when they begindialysis, i.e. home dialysis they get Medicare right away, incenter theyonly have a 3 month wait. At the time the law was written there were noother transplant organs viable. That is not the case now. Hearttransplant suffer because they can not get their immunosuppressivemedications. It would make one think it could be declared discriminationto all other organ transplant patients that they have to wait 24 monthsfor Medicare and help with medications. Bev LarsonBeverly A. Larson,Transplant Financial Coord.Sentara Norfolk Gen. Hosp.Transplant DepartmentPhone: Fax: email: balarson@ sentara.com>>> Louis <gonzallmail (DOT) rockefeller.edu> 11/25/2008 2:15 PM>>>Welcome to MEDICARE WATCH, a biweekly electronic newsletter of theMedicare Rights CenterVol. 11 , No. 24 : Novemeber 25, 2008Contents:1. FAST FACT 2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD 3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPER4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICAREPRIVATE HEALTH PLAN 1. FAST FACTMedicare private health plans (also known as “Medicare Advantageâ€Âplans) received $6.8 billion in improper payments in 2006, primarilyfrom plans’ errors in documenting their enrollees’ diagnoses. Theimproper payments are equal to 10.6 percent of total payments toMedicare Advantage plans for the year. (Centers for Medicare & MedicaidServices, CMS Issues Improper Payment Rates for Medicare, Medicaid, andSCHIP, November 2008)2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD Over 75 health advocacy organizations this month launched the Coalitionto End the Two-Year Wait for Medicare, sending a letter to healthleaders in the House and Senate demanding that next year’s healthreform efforts make a priority of covering people with disabilities whoare struggling to survive as they wait for Medicare coverage. Close to 1.5 million people are stuck in this waiting period annually.â€ÂNearly 40 percent of these individuals are without healthinsurance coverage at some point during their wait for Medicare; 24percent have no health insurance during this entire period. Many cannotafford to pay COBRA premiums to maintain coverage from their formeremployer, and private coverage on the individual market is unavailableor too expensive for this high-cost population. The economic downturnmakes it difficult for states to extend Medicaid coverage beyond themost impoverished people with disabilities,†the coalition letterreads. “No one with disabilities severe enough to qualify for SSDIshould be without health insurance.†The coalition includesorganizations such as the American Cancer Society –“ Cancer ActionNetwork, Amputee Coalition of America, Alzheimer’s Association, EasterSeals and the Medicare Rights Center. In 1972, when Congress expanded Medicare to include people withdisabilities, it created a “waiting period†that requires people towait 24 months from when they begin receiving their Social SecurityDisability Insurance (SSDI) payments before they can receive health carethrough Medicare. Costs for the elimination of the waiting period are estimated to bearound $9 billion annually. These costs would be offset by about $4billion in Medicaid savings. In the Senate, S.2102 is sponsored by Senator Jeff Bingaman (D-NM), andcosponsored by 23 senators, including President-elect Barack Obama. Inthe House, H.R. 154, sponsored by Representative Gene Green (D-TX) has103 cosponsors. This legislation would eliminate the waiting periodthrough a ten-year phase out. 3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPERSenator Max Baucus, Democrat of Montana and chairman of the SenateFinance Committee, outlined an agenda for health care reform that buildson existing private and government-funded sources of coverage, requiresall individuals to buy insurance and prohibits insurance companies fromdenying coverage to people with pre-existing conditions.The Baucus plan would eventually ensure that every individual hasaccess to affordable coverage by creating a nationwide insurance pool.Those who already have insurance can keep what they have, but for peoplewho need access to guaranteed, affordable coverage this would allowpeople to easily compare plans before purchasing one. Private insurancecompanies would not be allowed to discriminate against people withpre-existing conditions. In the short term, Baucus would provide individuals who are 55 andolder an option to buy into the Medicare program. Medicare would chargeenrollees electing the buy-in option an annual premium that iscalculated to keep the total costs budget-neutral. Therefore theMedicare buy-in option would not increase costs for Medicare or thetaxpayers. By providing coverage to a population that is without healthcare during the ten years before they become eligible for Medicare, theMedicare program might benefit from cost savings through preventionefforts, according to the Baucus plan.In addition to expanding coverage to those 55-64, the Baucus plan wouldalso begin the phase-out of the two-year waiting period for Medicarecoverage for people with disabilities. The current Medicare policyrequires people to wait 24 months from when they begin receiving theirSSDI payments. It is estimated that around 400,000 people are withoutinsurance during this waiting period, and many more are underinsured.The Baucus plan anticipates that with more access to affordablecoverage, those with disabilities would eventually be able to buyinsurance on the private market as well.Currently, Federal law does not require states to cover all adultsunder Medicaid unless they are disabled, elderly, or pregnant. TheBaucus plan also calls for expanding eligibility to Medicaid to everyoneliving below the poverty level and expanding eligibility for the StateChildren’s Health Insurance Program to more middle-income familieswithout coverage.4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS AARP launched an investigation into its “supplemental indemnityplans,†plans that cap what the insurer pays for services but not whatpolicyholders might owe. While the marketing materials for these plansimply they provide full insurance coverage, the plans are actuallydesigned to be used in conjunction with other insurance and provide nolimits to an enrollee’s out-of-pocket health care costs. AARP took action in response to Ranking Member of the Senate FinanceCommittee, Senator Grassley’s concerns about the quality ofcoverage provided by supplemental indemnity plans. Senator Grassley’s inquiry began after testimony by beforethe Senate Finance Committee last June. , an enrollee in AARP’sMedical Advantage Plan, one of the supplemental indemnity plans inquestion, testified that she was shocked when the doctor providingtreatment for her leukemia demanded $45,000 up front because her healthcare plan did not cover the cost of the service. ’s AARP planpaid a flat amount to enrollees for out-of-pocket health care costs,rather then covering a percentage or portion of the cost of medicalservices. In early November, Senator Grassley sent a letter to AARP criticizingthese plans for providing enrollees with little or no financialprotection against catastrophic medical costs.Additionally, in his November letter, Senator Grassley stated that hisstaff found AARP marketed and sold supplemental indemnity plans topeople with Medicare, including people who already had supplementalMedicare coverage. The marketing of these plans to people with Medicareoccurred even though AARP advertised the supplemental indemnity plans asa “bridge†to Medicare for retired people under 65. “The pitch for these products should be straight up and informative,instead of designed to leave the impression of being comprehensive whenthe product is, in fact, very limited and leaves consumers seriously indebt if they need intensive medical care,†Senator Grassley said in aNovember 3 press release. AARP responded to Grassley’s letter by suspending the sales andmarketing of these plans, which are provided through United Healthcareunder the AARP brand. More than one million people have bought this typeof coverage, according to the New York Times. 5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICAREPRIVATE HEALTH PLAN Mrs. B and her husband, Mr. B, are both enrolled in a Medicare privatehealth plan. Last month, Mr. B had invasive surgery that made it verydifficult for him to walk. He then entered a skilled nursing facility(SNF) for physical therapy to help him regain his strength. A few weekslater, Mr. B’s therapist told Mrs. B that because her husbandâ€sprogress had “plateaued†and he did not seem capable of fullrecovery, his health plan would probably not pay for his care for muchlonger. Mrs. B was concerned that Mr. B was not yet strong enough toleave the SNF, so she consulted with Mr. B’s doctor. The doctor saidthat she disagreed with the therapist and that the plan should still payfor the SNF care because Mr. B still needed skilled care from a physicaltherapist to keep his condition from deteriorating. Soon after, Mr. Breceived a notice from the SNF, called a Notice of MedicareNon-Coverage, which told him that his coverage would end in two days.Mrs. B called the Medicare Rights Center right away and spoke with ahotline counselor. The counselor advised Mrs. B that Medicare does notrequire that full recovery be possible for SNF care to be covered. SNFcare is considered “medically necessary,†and so can be covered ifit is needed to maintain your condition or prevent it from gettingworse. The counselor then explained that when a plan says it will nolonger pay for SNF care, you still have the right to appeal. However, inorder to meet the appeal’s strict deadlines, Mrs. B would have to getto work right away. The hotline counselor told her that on the Notice ofMedicare Non-Coverage, there would be instructions explaining how tocontact an organization called a QIO, or a Quality ImprovementOrganization, to start an appeal. Mrs. B found the QIO’s telephonenumber and the hotline counselor told her to call the QIO to say shewanted to start an appeal by noon on the day before Mr. B’s serviceswere set to terminate. The counselor explained to Mrs. B that after she called the QIO, itwould contact the SNF to request documentation. The hotline counselorencouraged Mrs. B to ask her husband’s doctor for a letter explainingwhy ending Mr. B’s SNF care would be harmful to his health and whyphysical therapy was necessary for Mr. B to maintain his condition. Mrs.B was advised that it would also be helpful for her to submit thatwritten statement to the QIO as well. The counselor informed Mrs. B thatshe had a right to see the information that the SNF submitted to the QIOif she asked for it. The QIO would have to make its decision within 48 hours. If the QIOagreed with the therapist (that SNF care should no longer be covered forMr. , Mr. B might be able to continue to receive care, but he wouldhave to pay for it himself. If the QIO agreed with Mr. and Mrs. B, Mr. Bwould have the right to continue to get covered SNF care.Mrs. B called the QIO right away and began the appeal. She then calledMr. B’s 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 favorabledecision. 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 MedicareWatch, please send an e-mail to medicarewatchmedicarerights (DOT) org.To sign up for additional newsletters, please visit our onlineregistration form athttp://www.medicarerights.org/subscribeframeset.html.If you want more information about the Medicare Rights Center, send ane-mail to infomedicarerights (DOT) org or write to:Medicare Rights Center520 Eighth Avenue, North Wing, 3rd Floor New York, NY 10018Telephone: Fax: Web site: www.medicarerights.org Medicare Watch is the Medicare Rights Center’s fortnightlynewsletter, established to strengthen communication with national andcommunity-based organizations and professional agencies about currentMedicare policy and consumer issues. Each edition contains news ofrecent policy developments affecting Medicare and health care generallyand a case story from our hotline that illustrates steps professionalscan take to get older adults and people with disabilities the healthcare they need.The Medicare Rights Center is a national, not-for-profit consumerservice organization that works to ensure access to affordable healthcare for older adults and people with disabilities through counselingand 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-mailCleveland Clinic is ranked one of the top hospitalsin America by U.S. News & World Report (2008). Visit us online at http://www.clevelandclinic.org fora complete listing of our services, staff andlocations.Confidentiality Note: This message is intended for useonly by the individual or entity to which it is addressedand may contain information that is privileged,confidential, and exempt from disclosure under applicablelaw. If the reader of this message is not the intendedrecipient or the employee or agent responsible fordelivering the message to the intended recipient, you arehereby notified that any dissemination, distribution orcopying of this communication is strictly prohibited. Ifyou have received this communication in error, pleasecontact the sender immediately and destroy the material inits 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.

[Guest guest]

When was his Part A effective?  If A waseffective at the time of the transplant his B will cover his immunos.  Part Acan be retroactive back to a year prior to applying for Medicare (or wheneverpatient became Medicare entitled based on dialysis or transplant).  Was thepatient on dialysis prior to transplant?  If not, then the A can be retro tothe 1st day of the month of the transplant. Daryl Battin,LICSWFinancial Coordinator/SocialWorkerLahey ClinicKidney Transplant 41 Mall Road, Burlington,MA  01805Ph:/FAX: Page: From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Lavinia PittsSent: Monday, December 01, 20089:09 AMTo: TxFinancialCoordinators Subject: RE: [bULK] Re: Fwd: Issue24,November 25,2008 Goodmorning fellow TFC's, I hope everyone had a nice holiday. I have a situation and would likesome feedback.I have a patient that received a transplant in 2005. His Part Bbenefits became effective one month after transplant, so his immunos arenot covered. Is it possible to have Part B retroactively effective tothe month of the transplant to assist with the immunos? Allcorrespondence will be greatly appreciated. Thanks, La'Vinia Pitts Financial CoordinatorAlbert Einstein MedicalCenterPhiladelphia, PA>>> " BEVERLY A LARSON " <BALarsonSentara>11/25/2008 3:09 PM >>>I understand that and unfortunately while they wait they are unable toget their medications and see doctors and their medical condition goesuntreated. BevBeverly A. Larson,Transplant Financial Coord.Sentara Norfolk Gen. Hosp.Transplant DepartmentPhone: Fax: email: balarson@ sentara.com>>> " Delson, Sheila " <delsonsccf (DOT) org>11/25/2008 2:32 PM >>>Agreed. But this 2 year wait period for medicare due to disabilityaffects many more people in the U.S.than the transplant population. -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ]On Behalf Of BEVERLYA LARSONSent: Tuesday, November 25, 2008 2:29 PMTo: txFinancialCoordinators Subject: [bULK] Re: Fwd: Issue 24, November25, 2008All heart transplant patients as well as other solid organ transplanthave that 24 month waiting period. This would seem unjust in that ESRDpatients receive Medicare at the time of transplant or when they begindialysis, i.e. home dialysis they get Medicare right away, incenter theyonly have a 3 month wait. At the time the law was written there were noother transplant organs viable. That is not the case now. Hearttransplant suffer because they can not get their immunosuppressivemedications. It would make one think it could be declared discriminationto all other organ transplant patients that they have to wait 24 monthsfor Medicare and help with medications. Bev LarsonBeverly A. Larson,Transplant Financial Coord.Sentara Norfolk Gen. Hosp.Transplant DepartmentPhone: Fax: email: balarson@ sentara.com>>> Louis <gonzallmail (DOT) rockefeller.edu>11/25/2008 2:15 PM>>>Welcome to MEDICARE WATCH, a biweekly electronic newsletter of theMedicare Rights CenterVol. 11 , No. 24 : Novemeber 25, 2008Contents:1. FAST FACT 2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD 3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPER4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICAREPRIVATE HEALTH PLAN 1. FAST FACTMedicare private health plans (also known as “Medicare Advantageâ€Âplans) received $6.8 billion in improper payments in 2006, primarilyfrom plans’ errors in documenting their enrollees’ diagnoses. Theimproper payments are equal to 10.6 percent of total payments toMedicare Advantage plans for the year. (Centers for Medicare & MedicaidServices, CMS Issues Improper Payment Rates for Medicare, Medicaid, andSCHIP, November 2008)2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD Over 75 health advocacy organizations this month launched the Coalitionto End the Two-Year Wait for Medicare, sending a letter to healthleaders in the House and Senate demanding that next year’s healthreform efforts make a priority of covering people with disabilities whoare struggling to survive as they wait for Medicare coverage. Close to 1.5 million people are stuck in this waiting period annually.â€ÂNearly 40 percent of these individuals are without healthinsurance coverage at some point during their wait for Medicare; 24percent have no health insurance during this entire period. Many cannotafford to pay COBRA premiums to maintain coverage from their formeremployer, and private coverage on the individual market is unavailableor too expensive for this high-cost population. The economic downturnmakes it difficult for states to extend Medicaid coverage beyond themost impoverished people with disabilities,†the coalition letterreads. “No one with disabilities severe enough to qualify for SSDIshould be without health insurance.†The coalition includesorganizations such as the American Cancer Society –“ Cancer ActionNetwork, Amputee Coalition of America,Alzheimer’s Association, EasterSeals and the MedicareRights Center.In 1972, when Congress expanded Medicare to include people withdisabilities, it created a “waiting period†that requires people towait 24 months from when they begin receiving their Social SecurityDisability Insurance (SSDI) payments before they can receive health carethrough Medicare. Costs for the elimination of the waiting period are estimated to bearound $9 billion annually. These costs would be offset by about $4billion in Medicaid savings. In the Senate, S.2102 is sponsored by Senator Jeff Bingaman (D-NM), andcosponsored by 23 senators, including President-elect Barack Obama. Inthe House, H.R. 154, sponsored by Representative Gene Green (D-TX) has103 cosponsors. This legislation would eliminate the waiting periodthrough a ten-year phase out. 3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPERSenator Max Baucus, Democrat of Montana and chairman of the SenateFinance Committee, outlined an agenda for health care reform that buildson existing private and government-funded sources of coverage, requiresall individuals to buy insurance and prohibits insurance companies fromdenying coverage to people with pre-existing conditions.The Baucus plan would eventually ensure that every individual hasaccess to affordable coverage by creating a nationwide insurance pool.Those who already have insurance can keep what they have, but for peoplewho need access to guaranteed, affordable coverage this would allowpeople to easily compare plans before purchasing one. Private insurancecompanies would not be allowed to discriminate against people withpre-existing conditions. In the short term, Baucus would provide individuals who are 55 andolder an option to buy into the Medicare program. Medicare would chargeenrollees electing the buy-in option an annual premium that iscalculated to keep the total costs budget-neutral. Therefore theMedicare buy-in option would not increase costs for Medicare or thetaxpayers. By providing coverage to a population that is without healthcare during the ten years before they become eligible for Medicare, theMedicare program might benefit from cost savings through preventionefforts, according to the Baucus plan.In addition to expanding coverage to those 55-64, the Baucus plan wouldalso begin the phase-out of the two-year waiting period for Medicarecoverage for people with disabilities. The current Medicare policyrequires people to wait 24 months from when they begin receiving theirSSDI payments. It is estimated that around 400,000 people are withoutinsurance during this waiting period, and many more are underinsured.The Baucus plan anticipates that with more access to affordablecoverage, those with disabilities would eventually be able to buyinsurance on the private market as well.Currently, Federal law does not require states to cover all adultsunder Medicaid unless they are disabled, elderly, or pregnant. TheBaucus plan also calls for expanding eligibility to Medicaid to everyoneliving below the poverty level and expanding eligibility for the StateChildren’s Health Insurance Program to more middle-income familieswithout coverage.4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS AARP launched an investigation into its “supplemental indemnityplans,†plans that cap what the insurer pays for services but not whatpolicyholders might owe. While the marketing materials for these plansimply they provide full insurance coverage, the plans are actuallydesigned to be used in conjunction with other insurance and provide nolimits to an enrollee’s out-of-pocket health care costs. AARP took action in response to Ranking Member of the Senate FinanceCommittee, Senator Grassley’s concerns about the quality ofcoverage provided by supplemental indemnity plans. Senator Grassley’s inquiry began after testimony by beforethe Senate Finance Committee last June. , an enrollee in AARP’sMedical Advantage Plan, one of the supplemental indemnity plans inquestion, testified that she was shocked when the doctor providingtreatment for her leukemia demanded $45,000 up front because her healthcare plan did not cover the cost of the service. ’s AARP planpaid a flat amount to enrollees for out-of-pocket health care costs,rather then covering a percentage or portion of the cost of medicalservices. In early November, Senator Grassley sent a letter to AARP criticizingthese plans for providing enrollees with little or no financialprotection against catastrophic medical costs.Additionally, in his November letter, Senator Grassley stated that hisstaff found AARP marketed and sold supplemental indemnity plans topeople with Medicare, including people who already had supplementalMedicare coverage. The marketing of these plans to people with Medicareoccurred even though AARP advertised the supplemental indemnity plans asa “bridge†to Medicare for retired people under 65. “The pitch for these products should be straight up and informative,instead of designed to leave the impression of being comprehensive whenthe product is, in fact, very limited and leaves consumers seriously indebt if they need intensive medical care,†Senator Grassley said in aNovember 3 press release. AARP responded to Grassley’s letter by suspending the sales andmarketing of these plans, which are provided through United Healthcareunder the AARP brand. More than one million people have bought this typeof coverage, according to the NewYork Times. 5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICAREPRIVATE HEALTH PLAN Mrs. B and her husband, Mr. B, are both enrolled in a Medicare privatehealth plan. Last month, Mr. B had invasive surgery that made it verydifficult for him to walk. He then entered a skilled nursing facility(SNF) for physical therapy to help him regain his strength. A few weekslater, Mr. B’s therapist told Mrs. B that because her husbandâ€sprogress had “plateaued†and he did not seem capable of fullrecovery, his health plan would probably not pay for his care for muchlonger. Mrs. B was concerned that Mr. B was not yet strong enough toleave the SNF, so she consulted with Mr. B’s doctor. The doctor saidthat she disagreed with the therapist and that the plan should still payfor the SNF care because Mr. B still needed skilled care from a physicaltherapist to keep his condition from deteriorating. Soon after, Mr. Breceived a notice from the SNF, called a Notice of MedicareNon-Coverage, which told him that his coverage would end in two days.Mrs. B called the MedicareRights Centerright away and spoke with ahotline counselor. The counselor advised Mrs. B that Medicare does notrequire that full recovery be possible for SNF care to be covered. SNFcare is considered “medically necessary,†and so can be covered ifit is needed to maintain your condition or prevent it from gettingworse. The counselor then explained that when a plan says it will nolonger pay for SNF care, you still have the right to appeal. However, inorder to meet the appeal’s strict deadlines, Mrs. B would have to getto work right away. The hotline counselor told her that on the Notice ofMedicare Non-Coverage, there would be instructions explaining how tocontact an organization called a QIO, or a Quality ImprovementOrganization, to start an appeal. Mrs. B found the QIO’s telephonenumber and the hotline counselor told her to call the QIO to say shewanted to start an appeal by noon on the day before Mr. B’s serviceswere set to terminate. The counselor explained to Mrs. B that after she called the QIO, itwould contact the SNF to request documentation. The hotline counselorencouraged Mrs. B to ask her husband’s doctor for a letter explainingwhy ending Mr. B’s SNF care would be harmful to his health and whyphysical therapy was necessary for Mr. B to maintain his condition. Mrs.B was advised that it would also be helpful for her to submit thatwritten statement to the QIO as well. The counselor informed Mrs. B thatshe had a right to see the information that the SNF submitted to the QIOif she asked for it. The QIO would have to make its decision within 48 hours. If the QIOagreed with the therapist (that SNF care should no longer be covered forMr. , Mr. B might be able to continue to receive care, but he wouldhave to pay for it himself. If the QIO agreed with Mr. and Mrs. B, Mr. Bwould have the right to continue to get covered SNF care.Mrs. B called the QIO right away and began the appeal. She then calledMr. B’s 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 favorabledecision. Mr. B would be able to continue to receive covered SNF care.This message was generated by the MedicareRights Centerlist-serve.If you have trouble (un)subscribing or have questions about MedicareWatch, please send an e-mail to medicarewatchmedicarerights (DOT) org.To sign up for additional newsletters, please visit our onlineregistration form athttp://www.medicarerights.org/subscribeframeset.html.If you want more information about the Medicare RightsCenter, send ane-mail to infomedicarerights (DOT) orgor write to:Medicare Rights Center520 Eighth Avenue, NorthWing, 3rd Floor New York, NY 10018Telephone: Fax: Web site: www.medicarerights.org Medicare Watch is the Medicare Rights Center’s fortnightlynewsletter, established to strengthen communication with national andcommunity-based organizations and professional agencies about currentMedicare policy and consumer issues. Each edition contains news ofrecent policy developments affecting Medicare and health care generallyand a case story from our hotline that illustrates steps professionalscan take to get older adults and people with disabilities the healthcare they need.The Medicare Rights Centeris a national, not-for-profit consumerservice organization that works to ensure access to affordable healthcare for older adults and people with disabilities through counselingand advocacy, educational programs and public policy initiatives.© 2008 by MedicareRights 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-mailCleveland Clinic is ranked one of the top hospitalsin Americaby U.S. News & World Report (2008). Visit us online at http://www.clevelandclinic.orgfora complete listing of our services, staff andlocations.Confidentiality Note: This message is intended for useonly by the individual or entity to which it is addressedand may contain information that is privileged,confidential, and exempt from disclosure under applicablelaw. If the reader of this message is not the intendedrecipient or the employee or agent responsible fordelivering the message to the intended recipient, you arehereby notified that any dissemination, distribution orcopying of this communication is strictly prohibited. Ifyou have received this communication in error, pleasecontact the sender immediately and destroy the material inits entirety, whether electronic or hard copy. Thank you.This message is intended for the use of the person or entity to which it isaddressed and may contain information that is privileged and confidential, thedisclosure of which is governed by applicable law. If you are not the intendedrecipient, or the employee or agent responsible to deliver it to the intendedrecipient, you are hereby notified that any disclosure, copying, or distributionof this information is strictly prohibited. If you have received this messageby error, please notify the sender immediately to arrange for return ordestruction 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.

[Guest guest]

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 DepartmentPhone: 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 likesome feedback.I have a patient that received a transplant in 2005. His Part Bbenefits became effective one month after transplant, so his immunos arenot covered. Is it possible to have Part B retroactively effective tothe month of the transplant to assist with the immunos? Allcorrespondence will be greatly appreciated. Thanks, La'Vinia Pitts Financial CoordinatorAlbert Einstein Medical CenterPhiladelphia, PA>>> "BEVERLY A LARSON" <BALarsonSentara> 11/25/2008 3:09 PM >>>I understand that and unfortunately while they wait they are unable toget their medications and see doctors and their medical condition goesuntreated. BevBeverly A. Larson,Transplant Financial Coord.Sentara Norfolk Gen. Hosp.Transplant DepartmentPhone: Fax: email: balarson@ sentara.com>>> "Delson, Sheila" <delsonsccf (DOT) org> 11/25/2008 2:32 PM >>>Agreed. But this 2 year wait period for medicare due to disabilityaffects many more people in the U.S. than the transplant population. [bULK] Re: Fwd: Issue 24, November25, 2008All heart transplant patients as well as other solid organ transplanthave that 24 month waiting period. This would seem unjust in that ESRDpatients receive Medicare at the time of transplant or when they begindialysis, i.e. home dialysis they get Medicare right away, incenter theyonly have a 3 month wait. At the time the law was written there were noother transplant organs viable. That is not the case now. Hearttransplant suffer because they can not get their immunosuppressivemedications. It would make one think it could be declared discriminationto all other organ transplant patients that they have to wait 24 monthsfor Medicare and help with medications. Bev LarsonBeverly A. Larson,Transplant Financial Coord.Sentara Norfolk Gen. Hosp.Transplant DepartmentPhone: Fax: email: balarson@ sentara.com>>> Louis <gonzallmail (DOT) rockefeller.edu> 11/25/2008 2:15 PM>>>Welcome to MEDICARE WATCH, a biweekly electronic newsletter of theMedicare Rights CenterVol. 11 , No. 24 : Novemeber 25, 2008Contents:1. FAST FACT 2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD 3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPER4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICAREPRIVATE HEALTH PLAN 1. FAST FACTMedicare private health plans (also known as “Medicare Advantageâ€Âplans) received $6.8 billion in improper payments in 2006, primarilyfrom plans’ errors in documenting their enrollees’ diagnoses. Theimproper payments are equal to 10.6 percent of total payments toMedicare Advantage plans for the year. (Centers for Medicare & MedicaidServices, CMS Issues Improper Payment Rates for Medicare, Medicaid, andSCHIP, November 2008)2. COALITION URGES ELIMINATION OF MEDICARE TWO-YEAR WAITING PERIOD Over 75 health advocacy organizations this month launched the Coalitionto End the Two-Year Wait for Medicare, sending a letter to healthleaders in the House and Senate demanding that next year’s healthreform efforts make a priority of covering people with disabilities whoare struggling to survive as they wait for Medicare coverage. Close to 1.5 million people are stuck in this waiting period annually.â€ÂNearly 40 percent of these individuals are without healthinsurance coverage at some point during their wait for Medicare; 24percent have no health insurance during this entire period. Many cannotafford to pay COBRA premiums to maintain coverage from their formeremployer, and private coverage on the individual market is unavailableor too expensive for this high-cost population. The economic downturnmakes it difficult for states to extend Medicaid coverage beyond themost impoverished people with disabilities,†the coalition letterreads. “No one with disabilities severe enough to qualify for SSDIshould be without health insurance.†The coalition includesorganizations such as the American Cancer Society –“ Cancer ActionNetwork, Amputee Coalition of America, Alzheimer’s Association, EasterSeals and the Medicare Rights Center. In 1972, when Congress expanded Medicare to include people withdisabilities, it created a “waiting period†that requires people towait 24 months from when they begin receiving their Social SecurityDisability Insurance (SSDI) payments before they can receive health carethrough Medicare. Costs for the elimination of the waiting period are estimated to bearound $9 billion annually. These costs would be offset by about $4billion in Medicaid savings. In the Senate, S.2102 is sponsored by Senator Jeff Bingaman (D-NM), andcosponsored by 23 senators, including President-elect Barack Obama. Inthe House, H.R. 154, sponsored by Representative Gene Green (D-TX) has103 cosponsors. This legislation would eliminate the waiting periodthrough a ten-year phase out. 3. BAUCUS RELEASES HEALTH CARE REFORM WHITE PAPERSenator Max Baucus, Democrat of Montana and chairman of the SenateFinance Committee, outlined an agenda for health care reform that buildson existing private and government-funded sources of coverage, requiresall individuals to buy insurance and prohibits insurance companies fromdenying coverage to people with pre-existing conditions.The Baucus plan would eventually ensure that every individual hasaccess to affordable coverage by creating a nationwide insurance pool.Those who already have insurance can keep what they have, but for peoplewho need access to guaranteed, affordable coverage this would allowpeople to easily compare plans before purchasing one. Private insurancecompanies would not be allowed to discriminate against people withpre-existing conditions. In the short term, Baucus would provide individuals who are 55 andolder an option to buy into the Medicare program. Medicare would chargeenrollees electing the buy-in option an annual premium that iscalculated to keep the total costs budget-neutral. Therefore theMedicare buy-in option would not increase costs for Medicare or thetaxpayers. By providing coverage to a population that is without healthcare during the ten years before they become eligible for Medicare, theMedicare program might benefit from cost savings through preventionefforts, according to the Baucus plan.In addition to expanding coverage to those 55-64, the Baucus plan wouldalso begin the phase-out of the two-year waiting period for Medicarecoverage for people with disabilities. The current Medicare policyrequires people to wait 24 months from when they begin receiving theirSSDI payments. It is estimated that around 400,000 people are withoutinsurance during this waiting period, and many more are underinsured.The Baucus plan anticipates that with more access to affordablecoverage, those with disabilities would eventually be able to buyinsurance on the private market as well.Currently, Federal law does not require states to cover all adultsunder Medicaid unless they are disabled, elderly, or pregnant. TheBaucus plan also calls for expanding eligibility to Medicaid to everyoneliving below the poverty level and expanding eligibility for the StateChildren’s Health Insurance Program to more middle-income familieswithout coverage.4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS AARP launched an investigation into its “supplemental indemnityplans,†plans that cap what the insurer pays for services but not whatpolicyholders might owe. While the marketing materials for these plansimply they provide full insurance coverage, the plans are actuallydesigned to be used in conjunction with other insurance and provide nolimits to an enrollee’s out-of-pocket health care costs. AARP took action in response to Ranking Member of the Senate FinanceCommittee, Senator Grassley’s concerns about the quality ofcoverage provided by supplemental indemnity plans. Senator Grassley’s inquiry began after testimony by beforethe Senate Finance Committee last June. , an enrollee in AARP’sMedical Advantage Plan, one of the supplemental indemnity plans inquestion, testified that she was shocked when the doctor providingtreatment for her leukemia demanded $45,000 up front because her healthcare plan did not cover the cost of the service. ’s AARP planpaid a flat amount to enrollees for out-of-pocket health care costs,rather then covering a percentage or portion of the cost of medicalservices. In early November, Senator Grassley sent a letter to AARP criticizingthese plans for providing enrollees with little or no financialprotection against catastrophic medical costs.Additionally, in his November letter, Senator Grassley stated that hisstaff found AARP marketed and sold supplemental indemnity plans topeople with Medicare, including people who already had supplementalMedicare coverage. The marketing of these plans to people with Medicareoccurred even though AARP advertised the supplemental indemnity plans asa “bridge†to Medicare for retired people under 65. “The pitch for these products should be straight up and informative,instead of designed to leave the impression of being comprehensive whenthe product is, in fact, very limited and leaves consumers seriously indebt if they need intensive medical care,†Senator Grassley said in aNovember 3 press release. AARP responded to Grassley’s letter by suspending the sales andmarketing of these plans, which are provided through United Healthcareunder the AARP brand. More than one million people have bought this typeof coverage, according to the New York Times. 5. CASE FLASH: APPEALING A SNF TERMINATION OF CARE IN A MEDICAREPRIVATE HEALTH PLAN Mrs. B and her husband, Mr. B, are both enrolled in a Medicare privatehealth plan. Last month, Mr. B had invasive surgery that made it verydifficult for him to walk. He then entered a skilled nursing facility(SNF) for physical therapy to help him regain his strength. A few weekslater, Mr. B’s therapist told Mrs. B that because her husbandâ€sprogress had “plateaued†and he did not seem capable of fullrecovery, his health plan would probably not pay for his care for muchlonger. Mrs. B was concerned that Mr. B was not yet strong enough toleave the SNF, so she consulted with Mr. B’s doctor. The doctor saidthat she disagreed with the therapist and that the plan should still payfor the SNF care because Mr. B still needed skilled care from a physicaltherapist to keep his condition from deteriorating. Soon after, Mr. Breceived a notice from the SNF, called a Notice of MedicareNon-Coverage, which told him that his coverage would end in two days.Mrs. B called the Medicare Rights Center right away and spoke with ahotline counselor. The counselor advised Mrs. B that Medicare does notrequire that full recovery be possible for SNF care to be covered. SNFcare is considered “medically necessary,†and so can be covered ifit is needed to maintain your condition or prevent it from gettingworse. The counselor then explained that when a plan says it will nolonger pay for SNF care, you still have the right to appeal. However, inorder to meet the appeal’s strict deadlines, Mrs. B would have to getto work right away. The hotline counselor told her that on the Notice ofMedicare Non-Coverage, there would be instructions explaining how tocontact an organization called a QIO, or a Quality ImprovementOrganization, to start an appeal. Mrs. B found the QIO’s telephonenumber and the hotline counselor told her to call the QIO to say shewanted to start an appeal by noon on the day before Mr. B’s serviceswere set to terminate. The counselor explained to Mrs. B that after she called the QIO, itwould contact the SNF to request documentation. The hotline counselorencouraged Mrs. B to ask her husband’s doctor for a letter explainingwhy ending Mr. B’s SNF care would be harmful to his health and whyphysical therapy was necessary for Mr. B to maintain his condition. Mrs.B was advised that it would also be helpful for her to submit thatwritten statement to the QIO as well. The counselor informed Mrs. B thatshe had a right to see the information that the SNF submitted to the QIOif she asked for it. The QIO would have to make its decision within 48 hours. If the QIOagreed with the therapist (that SNF care should no longer be covered forMr. , Mr. B might be able to continue to receive care, but he wouldhave to pay for it himself. If the QIO agreed with Mr. and Mrs. B, Mr. Bwould have the right to continue to get covered SNF care.Mrs. B called the QIO right away and began the appeal. She then calledMr. B’s 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 favorabledecision. 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 MedicareWatch, please send an e-mail to medicarewatchmedicarerights (DOT) org.To sign up for additional newsletters, please visit our onlineregistration form athttp://www.medicarerights.org/subscribeframeset.html.If you want more information about the Medicare Rights Center, send ane-mail to infomedicarerights (DOT) org or write to:Medicare Rights Center520 Eighth Avenue, North Wing, 3rd Floor New York, NY 10018Telephone: Fax: Web site: www.medicarerights.org Medicare Watch is the Medicare Rights Center’s fortnightlynewsletter, established to strengthen communication with national andcommunity-based organizations and professional agencies about currentMedicare policy and consumer issues. 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