Effective April 1, Medicare Advantage and Part D plans will reject or deny claims that are submitted for items prescribed or furnished by an individual or entity on the Preclusion List. The Preclusion List consists of individuals and entities that fall within either of the following categories.
In a press release dated April 1, 2019, CMS announced finalized updates to items that Medicare Advantage (MA) plans will cover for 2020, a change that the agency says will “[give] chronically ill patients with Medicare Advantage the possibility of accessing a broader range of supplemental benefits that are not necessarily health-related but have a reasonable expectation of improving or maintaining the health or overall function of the enrollees.”
Between 2011 to 2016, Medicare fee-for-service drug spending increased from $17.6 billion to $28 billion under Medicare Part B. Medicare Part D total spending has almost doubled from 2010 to 2016, increasing from $77.5 billion to $146.1 billion, with costs projected to increase further, according to the Centers for Medicare & Medicaid Services (CMS). Drug prices for beneficiaries in the U.S. are also on the rise and can be found in places like Europe for up to 80% cheaper, according to NPR. The cause? A market full of hurdles and barriers to creating biosimilars (drugs with the same or similar active ingredients as the original and often available at a reduced price); current laws that prevent vendors from negotiating drug prices; and outrageous prices for essential drugs that treat ever-more-common chronic conditions, such as cancer, rheumatoid arthritis, and hepatitis C.
Q: If a resident has a United Healthcare Medicare Advantage Plan and wants to disenroll from it and enroll in traditional Medicare, if we do it before the 15th of the month they will have coverage by 10/1/18 correct? If so will they have a lapse in coverage?
A: As long as the resident had a qualifying event then there is no limit on when the disenrollment notice is received. Therefore a resident in a SNF can disenroll at any time during a month and the disenrollment will take effect on the 1st of the following month. The regulations state, however, that it is usually good practice to try to submit the disenrollment prior to the 15th of the month to allow them to process the paperwork and notify CMS.
On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.
Medicare Advantage Organizations (MAO) may be gaming the capitated payment model to increase their profits, an Office of Inspector General (OIG) report suggested. The September 25 report details an OIG study undertaken to address concerns that MAOs are inappropriately denying authorization of services for beneficiaries or payments to providers.
Under traditional Medicare in a SNF, diagnosis codes don’t have a significant impact on reimbursement. Medicare Advantage plans, however, contain a built in incentive that encourages providers to code all diagnoses possible in order to receive optimal payment, which in recent cases has led to retrospective chart review of patients’ medical charts to identify additional diagnosis codes for submission to CMS.
Beneficiary enrollment in Medicare Advantage plans is on the rise, increasing from 5.3 million in 2013 to 19 million in 2017, according to information published by PLOS Medicine. A study released by the nonprofit advocacy organization in June compared postacute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries with hip fractures in the United States. The results? Although MA beneficiaries experienced shorter lengths of stay and less rehab, their return to the community was more successful and their readmission rates were significantly lower compared to the FFS beneficiaries.
Considering adding chronic care as a benefit under traditional Medicare coverage started with the idea of adding it under Medicare Advantage (MA) for the 2019 benefits package. MA program managers presented the idea earlier this week in Washington, according to ThinkAdvisor, and although it was well-received, feedback from witnesses included a suggestion that adding the benefit shouldn’t exclude beneficiaries who receive traditional Medicare.
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