RE: [BULK] Re: Fwd: Issue 24, November 25, 2008

[Guest guest]

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 “Medicare Advantageâ€Â

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

plans’ errors in documenting their enrollees’ 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 year’s 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.

â€ÂNearly 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,†the coalition

letter reads. “No one with disabilities severe enough to qualify for SSDI

should be without health insurance.†The coalition includes organizations

such as the American Cancer Society –“ Cancer Action Network, Amputee

Coalition of America, Alzheimer’s Association, Easter Seals and the

Medicare Rights Center.

In 1972, when Congress expanded Medicare to include people with disabilities, it

created a “waiting period†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 Children’s Health Insurance

Program to more middle-income families without coverage.

4. AARP INVESTIGATES ITS HEALTH INSURANCE OFFERINGS

AARP launched an investigation into its “supplemental indemnity

plans,†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

enrollee’s out-of-pocket health care costs.

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

Senator Grassley’s concerns about the quality of coverage

provided by supplemental indemnity plans.

Senator Grassley’s inquiry began after testimony by before the

Senate Finance Committee last June. , an enrollee in AARP’s 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. ’s 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 “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 when the

product is, in fact, very limited and leaves consumers seriously in debt if they

need intensive medical care,†Senator Grassley said in a November 3 press

release.

AARP responded to Grassley’s 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. B’s therapist

told Mrs. B that because her husband’s progress had

“plateaued†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.

B’s 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

“medically necessary,†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 appeal’s 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

QIO’s 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. B’s

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 husband’s doctor for a letter explaining why ending Mr.

B’s 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.

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 favorable decision. Mr.

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

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Medicare Watch is the Medicare Rights Center’s 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

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with disabilities the health care they need.

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