review of aetna US heathcare - Medicare HMO plan

Aetna US Healthcare (Medicare HMO)

For more information regarding Aetna US Healthcare's Medicare services, consult the chart below.

Benefits	Golden Medicare Plan	Golden Choice Plan (out-of-network benefit)
Doctor and Hospital Choice	You must go to network doctors, specialists, and hospitals. You need a referral to go to network hospitals and certain doctors, including specialists forcertain services.	You do not need a referral to go to network doctors, specialists and hospitals. You can go to doctors, specialists, and hospitals in orout of the network. Higher costs apply for out-of-network services.
Monthly Premium	$0-$25	$95-$130
Inpatient Hospital Care	$100-$150/day for days 1-5, $0 days 6-90	$350 for each Medicare-covered stay in a network hospital, no copayment for additional days in a network hospital, covered for unlimited days each benefit period
Skilled Nursing Facility	$20-$25/day for days 1-100 for Medicare-covered stay	No copayment, covered for 100 days each benefit period
Home Health Care	$20 for Medicare-covered visits	No copayment
Doctor Office Visits	$10-$30 for each primary care doctor office visit; $15-$35 for each specialist visit	$10-$20 for each primary care doctor office visit, $20 for each specialist visit
Prescription Drugs	You pay 100% for most prescription drugs; some plans offer $10 for each prescription or refill of generic drugs up to a 30-day supply and $20 for mail order generic drugs up to a 90-day supply	For each prescription or refill, $15 for generic drugs up to a 30-day supply, $30 for mail order generic drugs up to a 90-day supply
Routine Physical Exam	$10-$20 for each exam, covered for 1 exam every year	$20 for each exam, covered for 1 exam every year

For more information regarding Aetna US Healthcare, visit the company website at www.Aetna.com.

How medicare advantage and drug plan are rated

Health plans are rated on how well they perform in five different categories:

·       Staying Healthy: Screenings, Tests and Vaccines (13 measures)

§  Members  have at least one primary care doctor visit in the last year

§  The percentage of members who have had breast cancer screening in the last year

§  The percentage of members who have had colorectal cancer screening in the last year

§  The percentage of members with heart disease who have had cholesterol screening in the last year

§  The percentage of members with diabetes who have had cholesterol screening in the last year

§  The percentage of members who have had glaucoma testing in the last year

§  The percentage of members who have had osteoporosis testing in the last year

§  The percentage of members who have had an annual flu vaccine

§  The percentage of members who have had an annual Pneumonia vaccine

§  The percentage of members taking long-term medications who have been monitored  

§  The percentage of members who were advised by their physician to start, increase, or maintain physical activity

§  The percentage of members who improved or maintained their physical health after two years

§  The percentage of members who improved or maintained their mental health after two years

·       Managing Chronic (Long-Lasting) Conditions (10 measures)

§  Osteoporosis management

§  Eye exam to check for damage from diabetes

§  Kidney disease monitoring for members with diabetes

§  Percentage of plan members with diabetes whose blood sugar is under control

§  Percentage of plan members with diabetes whose cholesterol is under control

§  Controlling blood pressure

§  Rheumatoid arthritis management

§  Testing to confirm chronic obstructive pulmonary disease

§  Improving bladder control

§  Reducing the risk of falling

·       Ratings of Health Plan Responsiveness and Care (6 measures)

§  Doctors who communicate well

§  Getting appointments and care quickly

§  Ease of getting needed care and seeing specialists

§  Overall rating of health care quality

§  Members’ overall rating of health plan

§  Customer service

·       Health Plan Member Complaints and Appeals (4 measures)

§  Complaints about the health plan (number of complaints for every 1,000 members)

§  Health plan timely decisions about appeals

§  Fairness of health plan’s denials to member appeals, based on an independent reviewer

§  Beneficiary access problems Medicare found during an audit of the plan

·       Health Plan Telephone Customer Service (3 measures)

§  Time on hold when customer calls health plan (minutes; seconds)

§  Accuracy of Information members get when they call the health plan

§  Availability of TTY/TDD services and foreign language interpretation when Members call the health plan

Drug plans are rated on how well they perform in four different categories:

·       Drug Plan Customer Service (7 measures)

§  Time on hold when customer calls drug plan (minutes: seconds)

§  Time on hold when pharmacist calls drug plan (minutes: seconds)

§  Accuracy of information members get when they call the drug plan

§  Drug plan provides pharmacist with up-to-date and complete enrollment information about plan members

§  Drug plan’s timeliness in giving a decision for members who make an appeal.

§  Fairness of drug plan’s denials to a member’s appeal, based on an independent reviewer

§  Availability of TTY/TDD services and foreign language interpretation when members call the drug plan

·       Member Complaints and Staying with Drug Plan (5 measures)

§  Beneficiary access problems Medicare found during an audit of the plan

§  Complaints by members about joining and leaving the drug plan (rate per 1,000 members)

§  All other complaints about the drug plan (per 1,000 members)

·       Member Experience with Drug Plan (3 measures)

§  Drug plan provides information or help when members need it

§  Members’ overall rating of drug plan

§  Members’ ability to get prescriptions filled easily when using the drug plan

·       Drug pricing and Patient Safety (4 measures)

§  Completeness of the drug plan’s information on members who need extra help

§  Drug plan provides accurate price information for Medicare’s Plan Finder web site and keeps drug prices stable during the year

§  Drug plan’s members 65 and older who received prescriptions for certain drugs with a high risk of side effects, when safer drug choices may be possible

§  Using the appropriate blood pressure medication recommended for people with diabetes

MEDICARE PREMIUMS, DEDUCTIBLES FOR 2011

Second, for most Part B beneficiaries a “hold-harmless” provision prevents their net Social Security benefit from decreasing as a result of an increase in the Part B premium. There was no increase in Social Security benefits for 2010, and, as a result of slow growth in the CPI, this result will occur again for 2011. Consequently, the increase in the Part B premium for 2011 will be paid by only a small percentage of Part B enrollees. Approximately 27 percent of beneficiaries are not protected by the hold-harmless provision because they are subject to the income-related additional premium amount (5 percent), they are new enrollees during the year (3 percent), or they do not have their Part B premiums withheld from Social Security benefit payments (19 percent, 17 percentage points of whom qualify for both Medicare and Medicaid and have their Part B premiums paid by Medicaid).

Although Part B premiums will remain flat in 2011 for the great majority of beneficiaries, program costs will still increase significantly.  In order for Part B to be adequately funded in 2011, the 2011 contingency margin has been increased to account for this situation. However, this adjustment results in a larger-than-usual premium paid by or on behalf of a minority of Part B enrollees.  No other means is available under current law to prevent a substantial decrease in account assets, which would jeopardize the ability to pay Part B benefits.

As required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, beginning in 2007 the Part B premium a beneficiary pays each month is based on his or her annual income.  Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2011 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.  In addition to the standard 25 percent premium, affected beneficiaries must pay an income-related monthly adjustment amount.  About 5 percent of current Part B enrollees are expected to be subject to the higher premium amounts.

The 2011 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or who file a joint tax return are shown in the following table:

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Part B income-related monthly adjustment amount	Total monthly Part B premium amount
Less than  or equal to $85,000	Less than or equal to $170,000	$0.00	$115.40
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000	$46.10	$161.50
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000	$115.30	$230.70
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	$184.50	$299.90
Greater than $214,000	Greater than $428,000	$253.70	$369.10

In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at any time during the taxable year are as follows:

Beneficiaries who are married but file a separate tax return from their spouse:	Part B income-related monthly adjustment amount	Total monthly Part B premium amount
Less than or equal to $85,000	$0.00	$115.40
Greater than $85,000 and less than or equal to $129,000	$184.50	$299.90
Greater than $129,000	$253.70	$369.10

As a result of the Medicare Modernization Act, the Part B deductible was increased to $110 in 2005 and is indexed by the annual percentage increase in the Part B actuarial rate for aged beneficiaries.  In 2011, the Part B deductible will be $162.  (The actuarial rate is set by law at one-half of the total estimated per-enrollee cost of Part B benefits and administrative expenses, adjusted as necessary to maintain an adequate contingency reserve.)

cost of Mediare advantage plan

What Does a Medicare Advantage Plan Cost?

Each month, Medicare pays your advantage plan a fixed amount of money to provide your care. The advantage plan is then responsible for paying your doctor, hospital, and other providers of care.

Although your advantage plan must follow Medicare’s rules, it can charge you a premium and additional out-of-pocket expenses, such as a copayment for a doctor visit, coinsurance for durable medical equipment (such as a wheelchair), and an annual deductible for prescription medications.
You also are responsible for your Medicare Part B monthly premium, which is taken out of your social security check.

For example: George C. lives in Massachusetts and has a Medicare Advantage Plan through Fallon Community Health, one of the highest-rated health plans in the country. He has an HMO plan with drug coverage. His monthly premium cost for the plan is $208.40 (the Medicare Part B premium of $96.40 plus $112 charged by Fallon). Also, his out-of-pocket expenses include a $15 copay for each PCP visit, $20 for each specialist visit, 10% coinsurance for durable medical equipment, and an annual deductible of $310 for prescription medications.

Joining Medicare advantage plan - how

How Do I Join a Medicare Advantage Plan?

Generally, you can join a Medicare Advantage Plan if you have Medicare Part A and Part B and you live in an area where there is an advantage plan that accepts new members. Some plans only cover certain counties within a state and you must live in one of those counties where the plan is offered.

Some Medicare Advantage Plans hold local seminars to introduce their plans and you can get and complete a paper application at that time. You also can enroll by calling the plan, visiting the plan’s website, or on www.medicare.gov. The Medicare site also lets you compare plans in your area. You also can join by calling Medicare at 800-633-4227.

If you are switching to a different advantage plan, all you have to do is join the new plan and you will automatically be disenrolled from your old plan. You will not have any lapse in your coverage.
Medicare limits when you can join, switch, or drop a Medicare Advantage Plan. You can join a plan when you first become eligible for Medicare. This is anytime beginning three months before the month you turn 65 and ends three months after the month you turned 65.

For example, if you turn 65 on April 28th, your eligibility period starts on January 1st and ends on July 30th.
If you are disabled and have Social Security Disability Insurance, you can join an advantage plan three months before to three months after your 25th month of disability.
You also can switch or drop your advantage during an enrollment period between November 15 and December 31 of each year.

Things you must know about Medicare advantage plan

What Else Do I Need to Know About a Medicare Advantage Plan?

It’s important that you understand the differences between Original Medicare and Medicare Advantage Plans. Some things to remember about advantage plans are:

•    You must follow the rules! For example, if you are in an advantage plan HMO, you must choose a PCP and only use network services.
•    You can join an advantage plan even if you have one or more pre-existing conditions. There is no waiting period.
•    If your advantage plan decides to no longer participate in Medicare, you can join another plan or return to Original Medicare.
•    If your advantage plan does not include prescription drug coverage, you can join a Medicare Part D plan in your state. However, according to Medicare: “If you are in a Medicare Advantage Plan that includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.”
•    As long as you are enrolled in a Medicare advantage Plan, you do not need to buy a Medicare Supplement Insurance policy (Medigap). In fact, it is illegal for anyone to sell you a Medigap policy if you are in an advantage plan. The benefits offered by a Medigap policy are covered by your advantage plan and the supplement does not pay for your plan's deductibles, copayments, or coinsurance.

Medicare Advantage Plans and Health Reform

Medicare Advantage plans cost the federal government more than traditional Medicare. Beginning in 2012, Medicare will start to decrease the subsidies to these plans.
If you are enrolled in a Medicare Advantage plan, you may have to pay a higher premium or deal with reduced benefits. However, these plans cannot reduce any of the benefits that you would normally receive from traditional Medicare.

Medicare update on advantage plan and drug benefit

PROPOSED CHANGES TO THE MEDICARE ADVANTAGE AND THE MEDICARE PRESCRIPTION DRUG BENEFIT

 

PROGRAMS FOR CONTRACT YEAR 2012 AND DEMONSTRATION ON QUALITY BONUS PAYMENTS

Background

This proposed rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act of 2010 (the Affordable Care Act) that are related to the Medicare Advantage (MA, or Part C) and Prescription Drug Benefit (Part D) Programs.  This proposed rule also sets forth programmatic and operational changes to the Medicare Advantage and Prescription Drug Benefit programs for contract year 2012 based on our continued experience with the administration of the Parts C and D programs.  We are proposing to publish the final rule before the beginning of the 2012 contract year, in time to prepare plans for 2012 bids.  Most provisions will be in effect 60 days after the publication of the final rule (see Tables 1 and 2 in the proposed rule for provisions with different effective dates).

In addition to the proposed rule, CMS is posting the 2011 Medicare Plan Star Ratings and announcing a Demonstration Project to accelerate quality bonus payments for four and five-star plans and add quality bonus payments for three and three ½ star plans.  The Demonstration Project builds on the quality-related bonus payments authorized in the Affordable Care Act by providing stronger incentives for plans to improve their performance thereby accelerating quality improvements during the three-year period of the demonstration. 

PROPOSED RULE

The proposed rule addresses the following:

·       Implementing provisions of the Affordable Care Act;

·       Clarifying various program participation requirements;

·       Strengthening beneficiary protections;

·       Strengthening Medicare’s ability to distinguish stronger health plans for participation in Medicare Parts C and D and to remove consistently poor performers; and

·       Implementing other clarifications and technical changes.

 

Medicare advantage and drug plan rating and review

2011 Medicare Plan Star Ratings

·       The Medicare Plan Finder web site provides tools to help beneficiaries compare Medicare health plans with or without prescription drug plans, and stand-alone prescription drug plans.  It includes Medicare Plan Star Ratings, which measure plan quality and performance.  This information will help beneficiaries choose a plan that meets their specific needs. 

·       Plans receive a star rating for each category and every individual measure within the category. A contract can get ratings between one to five stars:

*                    means poor performance

* *               means below average performance

* * *          means average performance
* * * *      means above average performance

* * * * *  means excellent performance

·       Additionally, health and drug plans receive an “Overall Plan Rating” that summarizes all category measures into a single rating: one for health plans, one for health plans with prescription drug coverage, and one for stand-alone prescription drug plans. This overall rating includes half-stars to provide more differentiation between contracts. 

Distribution of Overall Plan Ratings for MA-PD Contracts (2011) * **

Overall Score	Contract Count	%	MA-PD % Weighted By Enrollment
5 stars	3	0.5	1.0
4 stars	74	13.2	23.2
3 stars	271	48.4	60.4
2 stars	48	8.6	7.2
Not enough data to calculate overall rating	104	18.6	3.6
Plan too new to be measured	60	10.7	4.5
Total	560	100	100

  *   Half-star ratings are rounded down for these distributions

        **  These ratings summarize all Part C and Part D measures combined.

            This star rating distribution is the same as the star rating  distribution for purposes of the quality bonus determination  under the demonstration. 

Distribution of Overall Plan Ratings for PDP Contracts (2011)

(These scores are the same as Part D summary rating for PDP contracts)

* Half-star ratings are rounded down for these distributions

For plan year 2011, plans that have received fewer than three stars for three consecutive years, will have a “low performer” icon affixed to the plan name on the Medicare Plan Finder.  Beneficiaries who are considering a plan that has received the low performer icon should study in more detail all specific quality information provided on www.Medicare.gov for the plan they are considering.

Medicare rule update on Obesity coverage

Medicare Revises Obesity Coverage Policy

A simple revision to a government policy manual may at last make it possible for seniors and disabled Americans to have treatments for diseases related to obesity covered under Medicare.
The revised policy announced by the Department of Health and Human Services (HHS) removes language in the Medicare Coverage Issues Manual stating that obesity is not an illness. This step allows members of the public to request that Medicare review medical evidence to determine whether specific treatments related to obesity would be covered by Medicare.

"Obesity is a critical public health problem in our country that causes millions of Americans to suffer unnecessary health problems and to die prematurely. Treating obesity-related illnesses and complications adds billions of dollars to the nation's health care costs," said HHS Secretary Thompson during testimony before the Senate Appropriations Subcommittee on Labor, Health and Human Services and Education. "With this new policy, Medicare will be able to review scientific evidence in order to determine which interventions improve health outcomes for seniors and disabled Americans who are obese and its many associated medical conditions."
By law, Medicare covers specified medically necessary services for illness and injury. The prior manual language, because it stated that obesity was not an illness, could prevent Medicare from covering treatments for diseases related to obesity.
"From the standpoint of Medicare coverage and the health of our beneficiaries, the question isn't whether obesity is a disease or a risk factor. What matters is whether there's scientific evidence that an obesity-related medical treatment improves health," said CMS Administrator Mark McClellan, M.D., Ph.D. "This change in Medicare's coverage policy puts the focus on public health. The medical science will now determine whether we provide coverage for the treatments that reduce complications and improve quality of life for the millions of Medicare beneficiaries who are obese."

The new policy is not expected to have an immediate impact on Medicare coverage. It does not affect the existing Medicare coverage of treatments of diseases resulting in or made worse by obesity, in particular currently covered surgical treatments for morbidly obese individuals.
However, as requests for coverage of obesity treatments are made by the public, Medicare will implement timely review of the scientific evidence, using the coverage determination procedures established in 1999 and modified by the Medicare Modernization Act of 2003. Detailed information on this process can be found on the Medicare coverage Web site www.cms.gov/coverage. Essential to this process is the submission of published, clinical trial data that demonstrate that obesity-related treatments improve the health of Medicare beneficiaries.

"We encourage and we're expecting requests to review scientific evidence evaluating the benefits of a range of treatments for obesity in the Medicare population," said CMS Chief Medical Officer Sean Tunis, M.D. "As a first step, we expect to convene our Medicare Coverage Advisory Committee in the fall to evaluate the evidence on obesity-related surgical procedures that may reduce the risk of heart disease and other illnesses."

Medicare drug plan and is there a limit on drugs plan

Is there a limit on the number of drugs a plan will cover in a given year?

No. There is no limit on the amount of drugs that can be covered. However, each Medicare drug plan will have a list of the specific prescription drugs that it will cover (called a formulary), and not all plans will cover exactly the same drugs. If your doctor thinks you need a drug that is not on the plan’s list, you can ask the plan for an “exception” to its list. Plans may cover both generic and brand-name prescription drugs. These drugs must be approved by the FDA (Food and Drug Administration) as safe and effective.


Will some drugs still be covered under Part B?

Yes. Medicare Part B will still cover drugs that it covers now (like some cancer drugs) that are usually given out by a doctor in his or her office. Drugs that are not covered under Part A or Part B will, in most cases, be covered under Medicare prescription drug coverage.


What does a Medicare drug plan cover?

Medicare drug plans will cover generic and brand-name drugs.  Plans may have rules about what drugs are covered in different drug categories to be sure people with different medical conditions can get the treatment they need.

Most plans will have a formulary, which is a list of drugs covered by the plan.  This list must always meet Medicare's requirements, but it can change when plans get new information.  Your plan must let you know at least 60 days before a drug you use is removed from the list or if the costs are changing.  In most cases, if you are actively taking a formulary medication, you will be able to continue on it for the full calendar year.  If your doctor thinks you need a drug that isn't on the list, or if one of your drugs is being removed from the list, you or your doctor can apply for an exception or appeal the decision.

why consultation codes are not covered by Medicare

Consultation Codes


In the proposed rule, CMS requests input on Medicare coding and payment policies, including the discontinuation of CPT consultation codes this year. As conveyed in a June 18 letter signed by the AMA and 33 medical specialty organizations, the policy has forced some physicians to cut back services to Medicare patients and discouraged communication between clinicians at the very time CMS is looking for ways to improve care coordination. A survey of affected specialties suggests that continuation of the current policy will lead to additional cutbacks in care and make it impossible for many specialists to purchase electronic medical records systems and adopt new technologies required to launch the transformation envisioned in the ACA.

Specific Survey Findings include:

• Twenty percent of the 5,500 physicians who completed the survey have reduced the number of new Medicare patients in their practice, 12% have reduced time spent with Medicare patients and 10% have reduced or eliminated consultations on hospital inpatients.

• Thirty-nine percent say they will defer purchase of new equipment and/or information technology to compensate for lost revenues. More than a third (34%) are eliminating staff.

• Six percent have already followed CMS’s suggestion that they no longer need to send a written report back to the referring physician and 19% plan to stop providing a report.

• Although CMS predicted that no specialty would see Medicare revenues decline by more than 3%, nearly three-fourths (72%) of survey respondents saw declines of more than 5% and 30% faced losses greater than 15%.

These findings confirm the AMA’s view that CMS should reverse its current policy and resume payment for consultation codes in Medicare. If the agency declines to adopt a complete solution, it should, at the very least, modify two other policies—involving prolonged services and new patient definitions—that have compounded the problem caused by elimination of the consultation codes.

As laid out in the previously-mentioned letter, in determining whether a service meets the prolonged service criteria, CPT stipulates that, for the inpatient setting, in addition to time spent “face-to-face” with patients, physicians can include time spent on the patients’ floor or unit performing other tasks related to their care. Were CMS to apply the same definition as CPT, consulting specialists could use the prolonged services to obtain fairer reimbursement for particularly long and challenging cases they previously would have billed as consultations. CMS only recognizes the face-to-face time, however, and further discourages coordination of care by essentially denying payment for activities such as creating and reviewing charts, communicating with the family and coordinating with other health care professionals. Cases where it would benefit a physician to use the prolonged service code are relatively limited and their use could be monitored through claims edits. Consequently, it does not appear that conforming to CPT policy on these codes would lead to large increases in Medicare expenditures and the AMA is again requesting that CMS modify its interpretation of the prolonged service codes to match the CPT descriptors.

The issue involving new patient definitions occurs because unlike the consultation codes, visit codes distinguish between new and established patients. The difference can be significant—about $60 for the most complex office visits—and it affects a substantial number of specialist physicians. In the aforementioned survey, for example, 33% of all respondents and more than 70% of some specialties said that more than 25% of their consultations in 2009 were with patients who had been seen previously by another member of the same specialty and group within the past three years.

In CPT, new patients are defined as those who have not been seen by the same physician or another member of the same group and sub-specialty within the last three years. In Medicare, however, a new patient is one “who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. The problem is that physicians often focus on a narrower range of services than are recognized in Medicare’s current list of 42 medical specialties. Thus, for example, if an electrophysiologist treats a particular patient and two years later, the patient is seen by an interventional cardiologist in the same group, the patient will be viewed as an established patient even though the two cardiologists have different areas of expertise.

The current situation is inequitable and the AMA believes that Medicare should comply with the CPT policy of identifying patients seen by physicians in a different sub-specialty as “new” patients. As pointed out in the June 18 letter, correcting its budget neutrality assumptions would provide some additional funding CMS could use to offset or partially offset any cost associated with this change. We recognize, however, that due to variations in the way that different specialties have dealt with the issue of extended training and focused expertise, setting the criteria for determining Medicare-recognized sub-specialties or equivalent expertise will require some further analysis. The AMA would be pleased to assist CMS in identifying affected specialties and creating a work group that could help with this analysis.

Medicaid and low income people

How can Medicaid help people with low incomes?

Medicaid is a joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. To qualify for Medicaid, you must have a low income and few savings or other assets. Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not paid for by Medicare. Medicaid has programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have a low income.

Medicare modifier list - AA - GP

Modifier Listing for Medicare Part B 


AA Anesthesia performed by anesthesiologist
AD Supervision by anesthesiologist of more than 4 concurrent anesthesia
AE Registered Dietician
AF Specialty Physician
AH Clinical psychologist
AJ Licensed clinical social worker
AM Physician services, team member services
AR Physician providing service in a physician scarcity area
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
AT Active/corrective treatment for chiropractic service only
CB Services ordered by a dialysis facility physician as part of the ESRD beneficiary’s dialysis benefit,
is not part of the composite rate, and is separately reimbursable.
CC Procedure code change or a change in provider charges resolution
DD Powdered enteral supplies
EJ Subsequent claims for a defined course of therapy
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
FP Services provided as part of family planning program
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
GA Waiver of liability statement on file
GC Teaching physician services that meet the requirement
GE Teaching physician services rendered under exemption to policy
GG Performance and payment of a screening mammography and diagnostic mammography on same patient same day.
GH Diagnostic mammography to screening mammography
GJ Opt out physician or practitioner emergency or urgent services
GN Services delivered under an outpatient speech-language pathology plan of care
GO Services delivered under an outpatient OT plan of care
GP Services delivered under an outpatient PT plan of care

Medicare part b coverd modiferi list GQ - Q1

Modifier Listing for Medicare Part B 

GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication system
GV Attending physician not employed or paid under agreement by the patient’s hospice provider
GW Services not related to the hospice patient’s terminal condition
GY Item or service statutorily non-covered or is not a Medicare benefit
GZ Item or service may not be reasonable and necessary
G1 Most recent URR reading of less than 60
G2 Most recent URR reading of 60 to 64.9
G3 Most recent URR reading of 65 to 69.9
G4 Most recent URR reading of 70 to 74.9
G5 Most recent URR reading of 75 or greater
G6 ESRD patient for whom less than 6 dialysis sessions have been provided in a month
G7 Pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening
G8 Monitored anesthesia care for deep, complex, complicated or marked invasive surgical procedure
G9 Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
J1 Competitive Acquisition Program (CAP) “ no pay for prescription number
J2 Competitive Acquisition Program (CAP) restock of emergency drug
J3 Competitive Acquisition Program (CAP) drug unavailable as written
JA Administered intravenously
JB Administered subcutaneously
JW Discarded drug not administered
KO Single drug unit dose formulation
KP First drug of multiple drug unit dose formulation
KQ Second or subsequent drug of a multiple drug unit dose formulation
KS Glucose monitor supply for diabetic beneficiary not treated with insulin
KZ New coverage not implemented by managed care
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LR Laboratory round trip
LS FDA-monitored intraocular lens implant
LT Left side of the body
M2 Competitive Acquisition Program (CAP) Medicare secondary payer
QB Physician providing services in a rural HPSA
QC Single channel cardiac monitoring
QJ Services/items provided to a prisoner or patient in a state or local custody, however, the state or
local government, as applicable, meets requirements in 42 CFR 411.4(B)
QK Medical direction of two, three or four concurrent anesthesia
QP Documentation is on file showing that the laboratory test(s) was ordered individually
QQ Service for which a statement of intent was submitted, deemed as valid, and an acknowledgment letter was received
QS Monitored anesthesia care service
QT Recording and storage on tape by an analog tape recorder
QU Physician providing services in an urban HPSA
QW CLIA waived lab tests
QX CRNA anesthesia with medical direction
QY Anesthesiologist medically directs one CRNA
QZ CRNA anesthesia without medical direction
Q0 Item/service in Medicare study
Q1 Item or service provided as routine care in a Medicare Clinical Research study

Medicare covered modifier list - part B

Modifier Listing for Medicare Part B

Q3 Live kidney donor
Q4 Services for ordering or referring physician qualifies as a service exemption
Q5 Services provided by substitute physician under reciprocal billing
Q6 Services furnished by a locum tenens physician
Q7 One class A finding
Q8 Two class B findings
Q9 One class B finding and two class C findings
RC Right coronary artery
RT Right side of body
SF Second opinion ordered by provider
SG Ambulatory surgical center facility fee
TA Left foot, great toe
TC Technical component only
TS Follow up service
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
UN Portable X-ray – two patients served
UP Portable X-ray – three patients served
UQ Portable X-ray – four patients served
UR Portable X-ray – five patients served
US Portable X-ray – six or more patients served
VP Aphakic patient
1P PQRI Performance Measure Exclusion due to medical reason
21 Prolonged E/M service
22 Specific unusual or difficult services
23 Unusual anesthesia
24 Unrelated E/M or eye exam during post-op by same provider
25 Separate E/M on the same day as another service by same provider.
26 Professional component
2P PQRI Performance Measure Exclusion due to patient reason
32 Services related to mandated consultation and or related service
3P PQRI Performance Measure Exclusion due to system reason
47 Anesthesia by surgeon
50 Bilateral procedure
51 Multiple surgical procedures on same day
52 Less than usual service
53 Discontinued Procedure
54 Surgical procedure only, no follow-up care
55 Follow-up care only
56 Pre-operative management only
57 Decision for surgery
58 Related service by same physician during post-operative
59 Distinct procedural service
60 Altered surgical field
62 Two surgeons
66 Surgical team
73 Discontinued procedure pre-anesthesia
74 Discontinued procedure post-anesthesia
76 Repeat procedure, same provider
77 Repeat procedure, different provider
78 Return to operating room for a related service, post-operative
79 Unrelated procedure, same physician, post-operative
80 Assistant surgeon above minimum fee
81 Assistant surgeon at minimum fee
82 Assistant surgeon – when qualified resident is not available
8P PQRI Performance Reporting-action not performed, reason NOS
91 Repeat clinical diagnostic laboratory test
99 Multiple modifiers

who is responsible for Medicare 20% coinsurance?

Part B Coinsurance

After the deductible has been satisfied, coinsurance of 20 percent is usually applicable.

For providers and suppliers that bill intermediaries, the 20 percent may be based on the allowed amount, billed charges, or a preset rate per service (APC), depending upon the type of service. See Claims Processing instructions for a description of coinsurance calculation for each benefit type.

Physicians and other suppliers will be paid 80 percent of allowed amount under the fee schedule amounts or in some instances reasonable charges incurred during the balance of the calendar year. The patient is responsible for a coinsurance amount equal to 20 percent of the fee schedule amounts or reasonable charges for the items and services.

Medicaid eligibility requirements and covered service

Medicaid

Like Medicare, A Medicaid plan is a Federal health insurance program that provides much needed care for select low-income families. The plan offers health insurance to such people as the disabled, the blind, the aged, and select families with dependent children. Although a Federal program, a Medicaid plan is run by the individual states, allowing for discrepancies amongst whom is eligible, and the extent of the services provided within the resepctive plan. Look below for more information:


Eligibility Requisites:

    * Qualify for the Aid to Families with Dependent Children (AFDC) program.
    * Children under the age of 6 whose family income is at or below 133% of the Federal Poverty Level. (FPL)
    * Pregnant women at or below 133% of the FPL.
    * Most States' Supplemental Security Income (SSI) recipients.
    * Recipients of adoption or foster care assistance.
    * Children under the age of 19 who have incomes below the FPL.

Services Provided by Medicaid plan:

    * Inpatient & outpatient hospital services.
    * Prenatal care.
    * Vaccines for children.
    * Physician services.
    * 21 and older nursing facility services.
    * Family planning services.
    * Rural health clinic services.
    * Home health care for persons eligible for skilled-nursing services.
    * Lab & X-ray services.
    * Pediatric and family nurse practitioner services.
    * Nurse-midwife services.
    * Screening, diagnostic & treatment services for children under 21.

Aetna US Healthcare (Medicare HMO)

Aetna US Healthcare (Medicare HMO)

Aetna has been one of the leading providers of quality health insurance in the United States for the last 150 years. There dedication to providing families with safe, cost effective health insurance plans places this provider amongst the crème de la crème of customer service firms. They maintain their position as a leader in the health industry through the practice of these core values:

    * Integrity.
    * Quality service and value.
    * Excellence and accountability.
    * Employee engagement.

Aetna US Healthcare provides effective service and easy to understand information regarding the benefits involved with choosing one of their many, high quality health insurance plans. This is a smart choice when it comes to health insurance.


Available in certain areas of California, New Jersey, New York and Pennsylvania, the Golden Medicare is a managed care plan like an HMO. This plan doesn’t allow for as much flexibility as a fee-for-service plan, only offering coverage within an established network of doctors, specialists and hospitals. A PCP, or primary care physician, is selected. This PCP will have access to all your medical history and manage your care. To be eligible for Aetna US Healthcare's Golden Medicare plan you must, first and foremost, live in the designated area: you need to qualify for Medicare Part A, and enrolled in Medicare Part B. Aetna US Healthcare's Golden Choice plan allows for a little more flexibility. This is a Medicare + Choice plan with out of the network benefits. These benefits include: visit any licensed out-of-network physician, and pay applicable deductible and coinsurance, visit any in-network physician and pay applicable specialist copay, or visit your PCP and pay the applicable PCP copay.

Medicare HMO - cigna healthcare review and coverage

Cigna Health care (Medicare HMO)

Cigna Healthcare offers you customized Healthcare plans that are perfectly molded to the specific needs of your company, whilst at the same time allowing the flexibility that is needed in this constantly changing industry. Cigna Healthcare provides a wide variety of healthcare options ranging from HMO plans and flex care plans, to open access plans, indemnity plans and preferred provider plans. A few examples of these plans follow below:

PPO Plus ( Preferred Provider Plan )

Key Features:

    * Access to a wide range of physicians, specialists and hospitals across the company, all providing quality care and service.
    * 450,000 available physicians to choose from.
    * Nationwide emergency care coverage. (24-hour service)
    * Customized cost-sharing options readily available - copayments, deductibles and coinsurance.

Advantages:

    * No primary care physicians required.
    * Simple "away-from-home" care, through a toll free number, offering nearby participating physicians.
    * 24-hour health information line offering all the answers to your health insurance related queries.
    * A large network of quality physicians across the country.

Indemnity Basic and Extensive Medical Coverage ( Indemnity Plan )

Key Features:

    * Unlimited choice of providers for members.
    * Hospital Savings Program offers discounts for hospitalization.
    * Lifesource Transplant service for transplant services that are specialized.
    * Discounts towards health products and services made available through Healthy Rewards program.

Advantages:

    * Available services in all 50 states.
    * Can be grouped with numerous other options to allow for a "complete benefits program."

For more information regarding Cigna Healthcare and their many services and plans, visit their website at www.Cigna.com.

Part A and part B - 2011 premium and deductible - Medicare

MEDICARE PREMIUMS, DEDUCTIBLES FOR 2011

The Centers for Medicare and Medicaid Services (CMS) has set the Medicare premiums, deductibles and coinsurance amounts to be paid by Medicare beneficiaries in 2011.

For Medicare Part A, which pays for inpatient hospital, skilled nursing facility, and some home health care, the deductible paid by the beneficiary when admitted as a hospital inpatient will be $1,132 in 2011, an increase of $32 from this year's $1,100 deductible. The Part A deductible is the beneficiary's cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay an additional $283 per day for days 61 through 90 in 2011, and $566 per day for hospital stays beyond the 90th day in a benefit period. For 2010, the per-day payment for days 61 through 90 was $275, and $550 for beyond 90 days. For beneficiaries in skilled nursing facilities, the daily co-insurance for days 21 through 100 in a benefit period will be $141.50 in 2011, compared to $137.50 in 2010. Those who enroll in Medicare Advantage plans may have different cost-sharing arrangements. All of these Part A program payment changes are determined in accordance with a statutory formula.

About 99 percent of Medicare beneficiaries do not pay a premium for Medicare Part A services since they have at least 40 quarters of Medicare-covered employment. However, some enrollees age 65 and over and certain persons with disabilities who have fewer than 30 quarters of coverage obtain Part A coverage by paying a monthly premium established according to a statutory formula. This premium will be $450 for 2011, a decrease of $11 from 2010. Individuals who have between 30 and 39 “quarters of coverage” may buy into Part A at a reduced monthly premium rate of $248 in 2011.

The monthly premium paid by beneficiaries enrolled in Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items.  The standard Medicare Part B monthly premium will be $115.40 in 2011, a $4.90 increase (or 4.4-percent) over the 2010 premium.  However, the majority of Medicare beneficiaries will continue to pay the same $96.40 premium amount they have paid since 2008.

Part A premiums are decreasing because spending in 2010 was lower than expected and the Affordable Care Act implemented policies that lower Part A spending due to payment efficiencies and efforts related to waste, fraud and abuse.  Part B premiums are increasing because of growth in the use of services like outpatient hospital care, home health and physician-administered drugs.  In addition, the premium accounts for a likely Congressional action to avert a precipitous decrease in physician  payments, which the Administration supports, and has occurred every year since 2003.  The Administration is committed to permanent reform of the physician payment formula.

By law, the standard premium is set to cover one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over, plus a contingency margin. The contingency margin is an amount appropriate to (i) cover incurred-but-unpaid claims costs, (ii) provide for possible variation between actual and projected costs, and (iii) amortize any surplus assets or unfunded liabilities.  The remaining Part B costs are financed by Federal general revenues.  (In 2011, $2.5 billion in Part B expenditures will be financed by the new fees on manufacturers and importers of brand-name prescription drugs under the Affordable Care Act.  The revenue from these fees reduces the standard Part B premium by $0.90.)

Based on current estimates, Part B assets are not sufficient to cover the amount of incurred-but-unpaid expenses and to provide for a significant degree of variation between actual and projected costs.  Thus, a large positive contingency margin is needed to increase assets to a more appropriate level.

The size of the contingency margin for 2011 is affected by two additional factors.  First, the current law formula for physician fees will result in a payment reduction of 23 percent in December 2010 and, in this analysis, is projected to cause an additional reduction of about 6.5 percent starting January 2011.  (The actual reduction in physician fees under current law for January 2011 is now known to be 2.5 percent.  As is typical, the final adjustment was not available in time to include in the premium determination.)   There is a strong likelihood that these reductions will be overridden by legislation enacted after Part B premiums are established for 2011.  For each year from 2003 through November 2010, Congress has acted to prevent smaller physician fee reductions from occurring.

 In recognition of this strong possibility of higher Part B expenditures resulting from similar legislation to override the decreases in physician fees in December 2010 and January 2011, it is appropriate to maintain a significantly larger Part B contingency reserve than would otherwise be necessary.  The asset level projected for the end of 2010 would otherwise not be adequate to accommodate this contingency.

 

Medicare Part D premium and dedcutible for 2011

MEDICARE PREMIUMS, DEDUCTIBLES FOR 2011

Enrollees in Medicare Part D prescription drug plans pay premiums that vary from plan to plan depending on each plan’s efficiency and scope of benefits.  Beginning in 2011, the Affordable Care Act requires Part D enrollees whose incomes exceed the same thresholds that apply to higher income Part B enrollees to pay a monthly adjustment amount.  These enrollees will pay the regular plan premium to their Part D plan and will pay the income-related adjustment to Medicare. The 2011 Part D income-related monthly adjustment amounts to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or who file a joint tax return are shown in the following table:

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Income-related monthly adjustment amount
Less than or equal to $85,000	Less than or equal to $170,000	$0.00
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000	$12.00
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000	$31.10
Greater than  $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	$50.10
Greater than $214,000	Greater than $428,000	$69.10

In addition, the income-related monthly adjustment amounts to be paid by Part D beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at any time during the taxable year are as follows:

Beneficiaries who are married and lived with their spouse at any time during the year, but file a separate tax return from their spouse:	Income-related monthly adjustment amount
Less than or equal to $85,000	$0.00
Greater than $85,000 and less than or equal to $129,000	$50.10
Greater than $129,000	$69.10

As noted above, states have programs that pay some or all of beneficiaries' Part A and Part B premiums and coinsurance for certain people who have Medicare and a limited income. Similarly, Part D beneficiaries with limited income and assets are eligible for Federal subsidies to reduce their premiums and coinsurance.

Proposed 2011 Physician Payment Schedule update

Proposed 2011 Physician Payment Schedule


On August 24, 2010 the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services’ (CMS) regarding the proposed physician fee schedule rule for CY 2011. The AMA's principal recommendations are as follows:

• The AMA strongly supports the proposed comprehensive review of the Medicare Economic Index (MEI). The MEI needs to reflect the realities of medical practice in the 21st century and the AMA welcomes the proposed review. Until this review of the MEI is completed, CMS should withdraw the changes it has proposed to the MEI for CY 2011, as well as the revisions to the relative value units (RVUs) and geographic practice cost indexes (GPCIs) that arise from the proposed changes to the MEI.

• CMS should revise the Physician Quality Reporting Initiative (PQRI) feedback report proposal to ensure that this process improves successful participation in the PQRI program.

• To implement a successful informal PQRI appeals process, CMS should significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff.

• The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the group practice reporting option (GPRO) for 2011.

• CMS must publish detailed specifications for individual measures and measures groups for the PQRI November 15, 2010.

• The AMA applauds CMS’ decision to reduce the PQRI reporting sample requirement from 80 percent to 50 percent for FY 2011. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.

• The AMA supports enhancing the measures and methods used in the resource use Physician Resource Use Measurement and Reporting Program (RUR). Under this program, CMS must adequately prepare for handling additional feedback report requests and distribution techniques, and until adequate risk adjustment and attribution models are widely tested and applicable, these reports should not be publicly reportable.

• We strongly support CMS’ proposed requirements for the 2011 electronic prescribing (e-prescribing) incentive payment program, which is to require reporting on only 25 services involving electronic prescriptions.

• We strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013.

• We strongly recommend that CMS add more exception categories so that more physicians facing hardship will be eligible for an exemption from e-prescribing penalties in 2012 and 2013.

• We also recommend that CMS provide feedback reports to physicians and establish an appeals process to allow physicians to appeal decisions that affect their eligibility to take part in the e-prescribing program or that affect their ability to get e-prescribing incentives.

• CMS should take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing.

• The AMA strongly supports better coverage for preventive care. CMS should work through the established Current Procedural Terminology (CPT) Editorial Panel and the Relative Value System Update Committee (RUC) process to adopt existing CPT codes for the annual preventive visits rather than establishing separate Healthcare Common Procedure Coding System (HCPCS) G-Codes for these services.

• CMS should expand the availability of the primary care incentive payments by interpreting “allowed charges” as charges under the physician fee schedule, and not as all Part B charges.

• CMS should ensure that the general surgery bonus payments promote access to these important services for patients by modifying the Health Professional Shortage Area (HPSA) criteria to allow a non-HPSA hospital to be part of a HPSA if: (i) the hospital is adjacent to a HPSA; (ii) the patient resides in a HPSA; or (iii) the general surgeon maintains an office in a HPSA.

• CMS should seek input from the RUC and its Health Care Professionals Advisory Committee on the efficiencies or reduced resources involved in services provided to the same patient in the same session or on the same day rather than implementing arbitrary multiple procedural payment reductions for imaging and therapy services.

• The ACA contained a number of provisions that apply retroactively, which requires CMS to re-process claims for various physicians’ services. CMS should issue guidance to its contractors about reprocessing these claims in a manner that minimizes the burden on physicians and avoids further confusion and payment delays. CMS should also make this guidance publicly available so that physician organizations can disseminate it to our members.

who is eligible for Medicaid and what it is ?

What is Medicaid and who does it cover?

Medicaid is a joint Federal and State program that helps pay medical costs for some people with limited incomes and resources. Most of your health care costs are covered if you have Medicare and Medicaid. Medicaid programs vary from state to state. People with Medicaid may get coverage for services such as nursing home and home health care, that aren’t fully covered by Medicare.

For more information about Medicaid, call your State medical assistance office or visit the Medicaid Section of www.cms.hhs.gov.

You may also be interested in the Medicare Savings Programs. States have programs for people with limited income and resources that pay Medicare premiums and, in some cases, may also pay Medicare deductibles and coinsurance. These programs help millions of people with Medicare save money each year. It's very important to call your State medical assistance office if you think you qualify for the Medicare Savings Programs, even if you aren't sure.


How do I know if I have “full Medicaid coverage?”

If Medicaid covers both your health care and your prescription drugs, you have “full” Medicaid benefits.

difference between Medicare and Medicaid insurance

What is the difference between Medicare and Medicaid?

While Medicaid and Medicare sound similar, they are in fact very different programs. One of the biggest differences is Medicaid is a state governed program and Medicare is a federal governed program. Here are some other differences:

Medicaid is for low income:
     Pregnant women
     Children under the age of 19
     People 65 and over
     People who are blind
     People who are disabled
     People who need nursing home care
Application for Medicaid is at the State's Medicaid agency.

Medicare is for:

     People 65 and over
     People of any age who have kidney failure or long term kidney disease
     People who are permanently disabled and cannot work
Medicare is applied for at the local Social Security office.
Some people qualify for both Medicaid and Medicare, Medicaid is sometimes used to help pay for Medicare premiums. People who qualify for both programs are called 'dual eligible'.

blue shield HMO information basic benefit details

Blue Shield Insurance (Medicare HMO)

The Blue Cross Blue Shield Association is a consumer health advocate with the public interest as its driving force. Their Blue plans have been providing families with the highest quality of health insurance services for 70 years. The Blue Shield Association only offers its members the highest quality, most innovative & customer focused, health insurance plans available. As we step further into the 21st century, medical breakthroughs are going to require changes in policies and coverage, and Blue Cross Blue Shield will be there for its customers, every step of the way.

Blue Shield offers one group of Medicare plans, the Blue Shield 65 Plus Medicare + Choice HMO plans. These Medicare plans have no deductibles. They cover all patient care provided by the original Medicare plan, but also cover additional services such as prescription drugs, vision care and physical examinations. Similar to Aetna’s prerequisites, in order to qualify for the Blue Shield 65 Plus Medicare + Choice HMO plans, you must be a Medicare beneficiary who is entitled to both Part A and Part B, and you must live within the designated area.




For more information regarding the Blue Shield 65 Plus Medicare + Choice HMO plans, consult the chart below.

Benefits	Blue Shield 65 Plus
Doctor and Hospital Choice	You must go to network doctors, specialists and hospitals. You need a referral to go to network hospitals and certain doctors, including specialists, for certain services.
Monthly Premium	$0
Inpatient Hospital Care	$50/day for days 1-40 and $0/day for days 41-90 for a Medicare-covered stay in a network hospital, covered for unlimited days each benefit period
Skilled Nursing Facility	$0/day for days 1-20 and $50/day for days 21-100, covered for 100 days each benefit period
Home Health Care	No copayment for: Medicare-covered home health visits and respite care
Doctor Office Visits	$10 for each primary care doctor office visit, $20 for each specialist visit
Prescription Drugs	For each prescription or refill, $10 for formulary generic drugs up to a 30-day supply; $25 for formulary brand drugs up to a 30-day supply; $20 for mail order formulary generic drugs up to a 90-day supply; $50 for mail order formulary drugs up to a 90-day supply
Routine Physical Exams	After a $5/$10 copay, pays 100% of expenses

For more information regarding Blue Shield, visit their website at www.BlueShield.com.

review of blue cross Medicare HMO details.

Blue Cross insurance (Medicare HMO)

The Blue Cross is a consumer health advocate with the public interest as its driving force. Their plans have been providing families with the highest quality of health insurance services for 70 years. The Blue Cross Blue Shield Association only offers its members the highest quality, most innovative & customer focused, health insurance plans available. As we step further into the 21st century, medical breakthroughs are going to require changes in policies and coverage, and Blue Cross Blue Shield will be there for its customers, every step of the way.

Blue Cross offers a single Medicare + Choice HMO plan, the Blue Cross Senior Secure plan. The benefits of this plan include low or no, monthly premiums, low copayments for doctor office visits, and coverage for vision, dental and routine podiatry care. This plan, however, is only available in select geographic locals.




For more information regarding the many available plans to choose from, consult the chart below.

Benefits	Blue Cross Senior Secure
Doctor and Hospital Choice	You must go to network doctors, specialists and hospitals
Monthly Premium	$0-$30
Inpatient Hospital Care	Member pays $160/$165 per day until the $2,100 annual out-of-pocket maximum has been reached
Skilled Nursing Facility	100% up to 100 days per benefit period
Doctor Office Visits	$5/$10 Primary Care; $10/$15 Specialist
Prescription Drugs (on Senior Secure Approved List)	For each prescription or refill, $8 for generic drugs up to a 30-day supply; $20 for mail order generic drugs up to a 90-day supply
Routine Physical Exams	After a $5/$10 copay, pays 100% of expenses

For more information regarding Blue Cross, visit the company website at www.BlueCross.com.

what is ppo and pos with example

PPO (preferred provider organization)

This plan is somewhat similar to indemnity plans. It offers you the freedom to access the doctor of your choice. (Costs are lowered within a given network however) If you travel outside the network, you will be forced to pay a copayment based on higher charges. In addition, you might also be forced to pay the difference between the fee and the amount covered by your specific health insurance plan.

POS (point-of-service)

A POS health insurance plan is one of the more expensive insurance plans to choose from. Within a POS health insurance plan, you have a primary care physician (PCP) who has the ability to refer you to other providers within the given health insurance plan. If your PCP refers you to a physician outside of the network, all or most of the bill will be covered by your POS plan. Within the POS plan you also have the option to refer yourself outside of the network. However, in such instances, you would have to pay coinsurance.


health insurance providers

Insurance providers offer people the security and comfort that they both deserve and sorely need in such an unsure world that we are now living in. The insurance providers generally offer more than one type of plan so that consumers and employers can find the best plan to fit their unique circumstances. Although most providers do offer healthcare, in most cases they are not strictly limited to it, and, in fact, offer a wide variety of programs and services to satisfy everyone's needs.

A few of these providers include:
•    Aetna US Healthcare
•    Blue Cross Insurance
•    Blue Shield
•    Cigna Healthcare
•    United Healthcare

Medicare 4 type of plan and comparison

Medicare Health care

Today, life expectancies are considerably greater than they have ever been before. A reasonable explanation for this longer lifespan is directly related to the progress in medicine. More than ever, families are finding the health care plans that work best for them, and getting the health care and services that they so rightly deserve.

There are 4 major categories of health care. These categories are:

•    Indemnity (fee-for-service) plans.

•    PPO (Preferred Provider Organization).

•    POS (Point-of-Service Plan).

•    HMO (Health Maintenance Organization). 

For a general comparison of these four categories, consult the table below.

Indemnity                              PPO                                   POS                         HMO

More Expensive <--------------------------------------------------------->Less Expensive

More Freedom of Choice<----------------------------------->Limited Options for Care

HMO - doctors inside the HMO network will be covered. All costs outside the HMO network need to be handled independently. HMO policy holders choose a Primary Care Physician (PCP) who will be responsible for coordinating their healthcare. 

POS - Somewhat similar to an HMO plan, POS policyholders select a PCP to coordinate their healthcare. Your PCP can make referrals outside of the policy network and your POS plan will continue to finance the majority, if not all of your costs. 

PPO - PPO policies allow for a far greater amount of freedom of choice. If you stay within your PPO network, your charges will be significantly lowered. You can choose to go outside the network without a referral and still get partial coverage, however you will be responsible for the bulk of the charges. 

Indemnity - When it comes to Indemnity policies, there isn't any kind of network, freeing members up to visit the healthcare facility/personel of your choice. A claim will be submitted to your insurance company and they will pay for incurred services that are covered by your plan. This insurance is the most expensive type.