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

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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 DepartmentPhone: 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. -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of BEVERLY A LARSONSent: Tuesday, November 25, 2008 2:29 PMTo: txFinancialCoordinators Subject: [bULK] Re: Fwd: Issue 24, November 25, 2008All 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 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 the Medicare 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 MEDICARE PRIVATE HEALTH PLAN 1. FAST FACTMedicare private health plans (also known as “Medicare Advantage†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 PAPERSenator 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.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 medicarewatchmedicarerights (DOT) org.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 infomedicarerights (DOT) org or write to:Medicare Rights Center520 Eighth Avenue, North Wing, 3rd Floor New York, NY 10018Telephone: Fax: Web site: www.medicarerights.orgMedicare 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 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-mailCleveland Clinic is ranked one of the top hospitalsin America by U.S. News & World Report (2008). 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