Hospital Admission vs. Observation

If you're looking at this title and thinking, "What the heck is this all about?" just hang in there for a quick minute - this might save you tens of thousands of dollars some day.  Let me ask you a question, when you spend the night in the hospital you're considered an inpatient, right?  Not necessarily.  Increased pressure from Medicare is causing some hospitals to keep patients under "observation" status rather than "inpatient" status.  Okay, so what's the big deal?  Well, should you need skilled care after you leave the hospital it's going to be a HUGE deal! 

But, you ask, doesn't Medicare cover skilled nursing care?  Yes, but with a qualification.  Medicare requires that you have a 3-day inpatient hospital stay prior to being admitted to the skilled nursing facility.  So, if you spend four days in a hospital, but were only classified under "observation" status, your skilled nursing stay will not be covered by Medicare.  And this is nothing to sniff at, as the 100 days of coverage that Medicare may have approved may cost you between $25,000 and $30,000. 

Well, you may, wonder, is this common?  Yes, and it is becoming more so.  From 2006 to 2009 the number of observation stays increased almost 27%, and the number of observation stays that lasted more than 48 hours nearly tripled (Clark "Hospitals...").  There have even been reports of "observation" stays that lasted as long as 13 days and have even included surgery (Clark "CMS...").

So what can you do?  Here are a couple of suggestions.  First, be aware of your admission status.  If you receive care from a hospital make sure that you ask them exactly how you are being admitted.  It may effect your decision regarding the type of care you elect to receive when you leave the facility.  Second, make your voice heard to your congressional representatives and to Medicare.  It is Medicare, not the hospitals that are encouraging this practice.  In fact, the hospital is actually on your side as they are losing money over this too.  Even though they have to treat you the same way regardless of your admission status, they are reimbursed approximately 66% less if your stay is classified as an "observation" admission.  To that end, here are some helpful links.

Contact your Senator:  http://www.senate.gov/general/contact_information/senators_cfm.cfm

Contact your Representative:  https://writerep.house.gov/writerep/welcome.shtml

Contact a Medicare Regional Office:  http://www.cms.gov/regionaloffices/

Sources

Clark, Cheryl. "Hospitals Caught Between A Rock And A Hard Place Over 'Observation'." Health Leaders Media. n.p., 15 Sep 2011. Web. 12 Apr 2012.

Clark, Cheryl. "CMS Hears Providers Concerns Over 'Observation' Status." Health Leaders Media. n.p., 1 Sep 2011. Web. 12 Apr 2012.

Lock-In

The Medicare Lock-In.  A very ominous sounding phrase, but what is it?

In short, the Lock-In refers to the time of year when, generally speaking, a Medicare Beneficiary is unable to change from Original Medicare to a Medicare Advantage Pan (or vice-versa) or change their Prescription Drug coverage. 

As you may know, there are only two ways to receive your Medicare benefits; either through Original Medicare (Part A & Part B) or through a Medicare Advantage Pan (Part C).  However, Medicare no longer allows a beneficiary to change back and forth between the two at will.  Instead, Medicare requires that once you make your decision, you stick with it for one calendar year.  During the Annual Enrollment Period (that runs from October 15th through December 7th) you are able to choose between the two.  Your decision will take effect on January 1st, and you will be "locked-in" to that decision until December 31st. 

Likewise, you may use the Annual Enrollment Period (AEP) to add, drop, or change your prescription drug coverage (Part D).  This change also takes effect on January 1st and continues throughout the entire year. 

But as with all things government, there are exceptions.  Countless exceptions.  These exceptions are called Special Election Periods (SEPs).  If you are unhappy with the plan that you are currently on and would like to see if you qualify for an SEP, please give us a call (800-817-9223) or shoot us an email and we can let you know what your options are.

Medicare Covered Preventive Screenings

We get a lot of questions about what Medicare does and does not cover in the realm of preventive services.  So, we've decided to provide a list of the current services that Medicare covers.  Unless otherwise noted in the list, these services are covered 100% by Original Medicare (Part A & Part B).

• Abdominal Aortic Aneurysm Screenings: A one-time screening ultrasound for people at risk.
• Alcohol Misuse Counseling: Medicare covers one alcohol misuse screening per year. Counseling may be covered if your screening result is positive.
• Bone Mass Measurements: Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria.
• Cardiovascular Screenings: Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels.
• Colon Cancer Screenings (Colorectal): Medicare covers colorectal screening tests to help find pre-cancerous polyps (growths in the colon) so they can be removed before they turn into cancer.
  • You pay 20% of the Medicare-approved amount for barium enemas.  The Part B deductible does not apply.  If done in a hospital facility, you will also have to pay the hospital copay.
• Depression Screenings: Medicare covers depression screenings by your primary care doctor once every 12 months.
• Diabetes Screenings: Diabetes screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. 
  • You pay 20% of the Medicare-approved amount after the yearly Part B deductible for any glucose monitors, test strips, and lancets.
  • Insulin and syringes are covered under Part D.
• Diabetes Self-Management Training: Your doctor or other health care provider must provide a written order. 
  • You pay 20% of the Medicare-approved amount after the yearly Part B deductible.
• EKG Screenings: Medicare covers a one-time screening EKG if you get a referral for it as a result of your one-time "Welcome to Medicare" Preventive Visit.
• Flu Shots: Covered once a flu season in the fall or winter.
• Glaucoma Tests: Covered once every 12 months for people at high risk for glaucoma. 
  • You pay 20% of the Medicare-approved amount after the yearly Part B deductible.
• Hepatitis B Shots: This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia,End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
• HIV Screenings: Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. 
  • You pay nothing for the tests, but you generally have to pay 20% of the Medicare-approved amount for the doctor visit.
• Mammograms: Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39.
• Medical Nutrition Therapy Services: Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service.
• Obesity Screening and Counseling: If you have a body mass index of 30 or more, Medicare covers intensive counseling to help you lose weight. This counseling may be covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan. Talk to your primary care physician or practitioner to find out more.
• Pap Tests and Pelvic Exams: Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years.
• Preventive Visits: Medicare will cover two types of preventive visits—one when you’re new to Medicare and one each year after that. 
  • You pay nothing for the yearly “wellness” visit if the doctor or other health care provider accepts assignment. If you get additional tests or services during the same visit that aren’t covered under these preventive benefits, you may have to pay coinsurance, and the Part B deductible may apply.
• Pneumococcal Shots: Most people only need this preventive shot once in their lifetime.
• Prostate Cancer Screenings: Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50. 
  • Generally, you pay 20% of the Medicare-approved amount for the digital rectal exam after the yearly Part B deductible.
• Smoking Cessation (counseling to stop smoking): Medicare covers smoking cessation counseling as a preventive service and you'll pay nothing for the counseling sessions.

This information was provided by Medicare.  For more detailed information on these services, visit the Medicare Preventive Services page by clicking here.

2012 Part B Premium

CMS recently released the rate for the 2012 Part B premium.  The rate for next year will be $99.90 per month.  For many beneficiaries, those enrolled in Part B prior to 2009, this represents a $3.50 increase (3.6%) - the first increase since 2009.  For anyone who enrolled in Part B subsequent to 2009, these rates are lower than the 2011 rates.  For instance, a person who enrolled in Part B during 2011 has been paying $115.40 per month.  If you're one of these people, break out your party pants because you just got a $15.50 per month (13.4%) decrease!

For a full chart of the 2012 Part B premium rates, click here.

2012 Medicare Deductibles Released

Medicare has recently released the 2012 Medicare deductibles, copays, and coinsurance rates.  If you are covered by Original Medicare and do not have a Medicare Supplement, these are the cost-sharing figures you can expect to pay in 2012.  If you have a Medicare Supplement, your coverage may most or all of these costs on your behalf.

Click here to see the 2012 amounts.