What will the new MAPD ranking system look like?

I feel that improving the ratings system is integral to Medicare reform. While costs and coverage are indeed incredibly important facets of every Advantage plan, quality of care and benefits are equally important for seniors. Relying on price alone may net a senior an affordable plan while sacrificing quality.  Unfortunately, many seniors do rely on price. According to Jaffe, over 75% of Advantage plan beneficiaries select plans with less than 3 stars.  Improving the ratings system can make seniors more aware of the quality of their Advantage plan, and possibly provide them with improved health care.  Adding the incentive to perform better could ultimately help seniors out.  However, that incentive needs to be clear and the ratings system needs to be solid.

Another part to the issue raised by Jaffe is that not all plans are rated, and not all areas boast 4 or 5 star rated plans.  By expanding the ratings system, and breaking down all the benefits and coverage associated with the plan, perhaps CMS can provide more comprehensive analyses to facilitate Advantage plan selection for seniors. At the same time, plans need the opportunity to improve their ratings and quality. Improvement should be recognized as a factor in the ratings.   Perhaps adding incentives for improvement in addition to overall rating might be helpful, although not necessarily cost-effective. By making providers accountable for their services and seniors more aware of the ins-and-outs of Advantage plans, perhaps there can be genuine improvements in the Medicare system.

At the same time, I feel that it might be difficult for the bonus system to work as it should, especially because standards of care vary across the country.  Jaffe quotes Vicki Gottlich of the Center for Medicare Advocacy, who raises the concern that a simple average score might bury a plan’s deficiencies beneath its stronger points. And is it really fair to rate a 3 star plan in say, Idaho, to a 5 star plan in Florida? How can the rating system be most effective when there are so many variables involved?

Although the new bonuses may help improve the quality of care available for Medicare, CMS must ensure that all the wrinkles in the rating system are ironed out before applying the ratings to all plans. Perhaps a better path for CMS to follow would be to improve the ratings, helping out both consumers and providers, before analyzing each Medicare Advantage plan.

Medicare fraud has been on the news a lot recently. In recent years, Medicare fraud schemes have resulted in hundreds of millions of dollars in false billings to Medicare. Most Medicare fraud happens when people bill Medicare for services that were never provided. For example, a doctor may bill Medicare for a service that you came in for yet you never were at the doctor. Fraud most commonly occurs in billing for institutional facilities (hospitals, nursing homes, etc.), billing for physician services and visits, and billing for medical equipment.

There are a few ways that you can avoid medicare scams:

• Examine any notices you get from Medicare and make sure you received all the services and prescriptions listed.
• Protect your Medicare card number and don’t give the information to anyone else
• Never accept medical supplies from door to door salespeople
• Don’t accept “free” services in return for your Medicare number
• Educate yourself about Medicare and know your rights.

If you suspect Medicare fraud, call your health care provider and contact the U.S. Department of Health and Human Services at 1-800-447-8577

Doctors who are enrolled in the Medicare insurance system are considered either participating or nonparticipating. Nonparticipating doctors receive a lower reimbursement from Medicare therefore the patient must pay for more of the bill. Doctors who have opted out of the Medicare insurance system entirely cannot bill Medicare for reimbursement nor can the patient. Doctors can also charge patients whatever they want.

To find a doctor that accepts Medicare, you can visit the Medicare.gov website or research online insurance brokers like Medicare Solutions that specialize in helping Medicare beneficiaries get the affordable health insurance coverage they need. Other options available include walk-in and urgent care facilities. Among the roughly 18,000 in the United States, a majority take Medicare and offer services such as x-rays, do minor surgery, diagnose ailments, and write prescriptions.

If you are not yet eligible for Medicare but will be soon, start the search. Try to find a doctor that accepts Medicare way before you are eligible for it.

Connecticut

• ConnPACE- covers prescriptions, insulin, and insulin syringes with a $16.25 co-pay for each medication.

Delaware

• Delaware Prescription Assistance Program- provides each eligible individual with up to $3000 annually toward medically necessary prescription drugs

Illinois

• SeniorCare- assists people with or without Medicare for almost all prescription drugs.

Indiana

• HousierRx- helps pay for Medicare beneficiaries’ monthly Part D premiums

Maine

• The Main Low Cost Drug Program for the Elderly and Disabled- the state pays 80% minus $2.00 for generic drugs and brand name drugs.

Maryland

• Maryland Pharmacy Assistance Program- Recipients pay $2.50 for generic drugs and $7.50 for brand name drugs

Missouri

• Missouri Rx Plan- the state covers 50% of the out of pocket costs including deductibles, copayments, and coverage gap costs.

Montana

• Big Sky Rx Program- The state program will pay up to $33.19 of monthly Medicare Part D premiums.

New Jersey

• Pharmaceutical Assistance to the Aged and Disabled- PAAD participants will pay no more than $6 per prescription for generic drugs and $7 for brand name drugs
• Senior Gold Prescription Drug Program- Co-pays are $15 plus 50% of the remaining cost of the prescription drug cost

New York

• The New York State Elderly Pharmaceutical Insurance Coverage- EPIC helps pay for most prescription drugs as well as insulin and insulin syringes.

Pennsylvania

• Pharmaceutical Assistance Contract for the Elderly- $6 copayments for generic drugs and $9 copayments for brand name drugs.

Texas

• Texas Kidney Health Care Program- provides assistance for texas residents with a diagnosis of End-Stage Renal Disease. Services include prescription drug benefits, coinsurance, and certain medical expenses.

Again, if your state isn’t listed above you may call your state health department.

If you need help deciding what plan is best to fit your needs, there are many resources at your disposal to help during the open-enrollment period. In order to make an informed decision, you must know the basics first.

Medicare Advantage Prescription Drug Plans include Medicare Part A (hospital), Medicare Part B (doctor’s office visits), and Part D (prescription drug coverage). Medicare Part D plans only include prescription drug coverage and are usually purchased by people who already have Original Medicare (Part A and B).

Since the lists of covered drugs are changing as well as restrictions and costs, Medicare beneficiaries are being advised to review their current plans to make sure it will still benefit them in 2009. Because the enrollment period will soon come to a close, beneficiaries should review their plan and then begin viewing other plans and pricing. You should consider costs, doctors/providers, and travel when choosing a plan. Costs, such as premium, copayments, coinsurance, and deductible expenses, are changing. You also need to make sure that you’re able to visit the providers you want on your current plan and check to see if there will be additional costs if the provider is out of network or referrals are needed. You may also be travelling in the near future. Are you drugs covered if you travel to another state? You should make sure that your plan provides coverage in other states.

According to the Centers for Medicare and Medicaid (CMS), average monthly premiums for standard Part D coverage will be $28 in 2009, as opposed to the $25 in 2008.

What do you need to do when considering Medicare Part D plan?

1)Assess your needs. What prescription drugs are crucial to your life style?

2)Consult your doctor and pharmacist. Make sure they are still in your network under the plans you are considering.

3)Review all plans and prices to see which is best fit for you.

The Open Enrollment period for Medicare Part D ends on December 31^st which gives you two more weeks to make some very important decisions. Plans begin on January 1, 2009 and late charges and penalties may apply if you wait too long.