Medicare News

Current news for Medicare beneficiaries and the community that serves them.

CMS Improves Medicare Drug and Health Plans

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Measures including expanded prevention and health improvement incentives are being implemented to improve benefits and quality of care for seniors.

Measures including expanded prevention and health improvement incentives are being implemented to improve benefits and quality of care for seniors.

The Centers for Medicare & Medicaid Services (CMS) has issued final regulations for the Medicare Advantage and prescription drug benefit (Part D) programs that continue efforts to curb fraud and abuse and to improve benefits and the quality of care for seniors and people with disabilities enrolled in these programs.

Key final provisions include:

• Requiring Part D prescribers to enroll in Medicare: CMS is requiring that physicians and eligible professionals who prescribe covered Part D drugs be enrolled in Medicare, or have a valid record of opting out of Medicare, in order for their prescriptions to be covered under Part D.  Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals.  The final rule allows more time – until June 1, 2015 – for implementation.

• Revoking Medicare enrollment for abusive prescribing practices and patterns: CMS will have the authority to revoke a physician or eligible professional’s Medicare enrollment if CMS determines that he or she has a pattern or practice of prescribing that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements.  CMS will also be able to revoke a physician or eligible professional’s Medicare enrollment if his or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked, or if the applicable licensing or administrative body for any state in which he or she practices suspends or revokes his or her ability to prescribe drugs.   Read more


Skilled nursing facility care – What are the requirements?

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Question: My mother is unable to walk without assistance by wheelchair or walker, cannot bathe on her own, has lower body assist, has dementia and fear of falling, and is on diapers, but the facility says she is highly functional. What are her chances of getting into a skilled nursing facility?

Skilled Nursing Facility Question

To receive Medicare-covered skilled nursing facility care, you have to have a qualifying 3-day hospital stay prior to being admitted to the facility.

Answer: In order for Medicare to cover skilled nursing facility care, you have to meet the following requirements:

 

  1. You have to have a qualifying hospital stay. This means an inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital. (Remember, the time you are being observed in a hospital before you are admitted doesn’t count toward the 3-day qualifying inpatient hospital stay.) You must enter the skilled nursing facility (SNF) within a short period of time (generally 30 days) of leaving the hospital.In addition:
  2. You have to have Medicare Part A (Hospital Insurance) and have days left in your benefit period. A benefit period begins on the day you start using hospital or SNF benefits under Part A of Medicare. You can get up to 100 days of SNF coverage in a benefit period. [Note: If you aren’t sure if you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital (Part A)” on the lower left corner of the card. You can also find out if you have Part A if you call your local Social Security office, or call Social Security at 1-800-772-1213.]
  3. Your doctor has to order the services you need for SNF care, which require the skills of professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists, and are furnished by, or under the supervision of, these skilled personnel.
  4. You require the skilled care on a daily basis and the services must be ones that, as a practical matter, can only be provided in an SNF on an inpatient basis. If you are in an SNF for skilled rehabilitation services only, your care is considered daily care even if the therapy services are offered just 5 or 6 days a week.
  5. You need these skilled services for a medical condition that was treated during a qualifying 3-day hospital stay, or started while you were getting SNF care for a medical condition that was treated during a qualifying 3-day hospital stay. For example, if you are in an SNF because you broke your hip and then have a stroke, Medicare may cover rehabilitation services for the stroke, even if you no longer need rehabilitation for your hip.
  6. The skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.
  7. You get these skilled services in an SNF that is certified by Medicare.

Home Health Spending Grows While National Health Spending Slows

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The home health industry experienced billion dollar growth in 2012, despite low national health spending overall, according to a recent report from the Centers for Medicare & Medicaid Services (CMS).

 

In 2012, there was slower growth in prescription drug, nursing home, private health insurance and Medicare expenditures, but home health spending increased.

In 2012, there was slower growth in prescription drug, nursing home, private health insurance and Medicare expenditures, but home health spending increased.

While national health spending slowed for the fourth consecutive year at an annual rate of 3.7% in 2012, home health spending growth accelerated 5.1% to $77.8 billion, notes the report published Monday by the CMS Office of the Actuary.

Home health spending in 2012 represents significant growth compared to 2011 when the industry reported a spending increase of 4.1%. In 2012, Medicare and Medicaid accounted for approximately 81% of total home health care spending, while the former grew at a faster rate than the latter.

Several factors contributed to the nation’s low spending growth overall in 2012, including slower growth in prescription drug, nursing home, private health insurance and Medicare expenditures.

Despite a large uptick in Medicare enrollment in 2012, program spending increased by 4.8% compared to growth of 5% in 2011. Total Medicare spending per enrollee grew 0.7% in 2012.

The Office of the Actuary also found that the impacts of the Affordable Care Act contributed to the slow growth for the Medicare program in 2012, but had a limited impact on overall spending as reforms were still being implemented in 2012.

Medicare also had an impact on nursing home spending, which the report notes is due to a one-time Medicare rate adjustment for skilled nursing facilities.

Free-standing nursing home facilities and continuing care retirement communities increased only 1.6% in 2012, down from 4.3% growth in 2011.

While overall health spending slowed for the fourth consecutive year, 2012 was the second straight year where overall health care costs grew slower than the economy as a whole, said CMS Administrator Marilyn Tavenner, in a statement.

Courtesy Home Health Care News