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The Changing Face of Medicare


With all the recent changes to Medicare Advantage plans, many members of Original Medicare do not recognize that their health plan is consistently changing. One of the biggest concerns of centers for Medicare and Medicaid is how to control Medicare costs.

Medicare Advantage plans are able to manipulate their networks and send members to "high performance practices" that deliver consistent quality at lower costs. Medicare Advantage plans can end contracts with low performing providers or simply because they have too many of one type of provider such as cardiologists or ophthalmologists. Because Original Medicare does not have a provider network, they have to make cost containment through other methods.

One of the most common Medicare cost control methods is using authorizations for treatment or to allow treatment to be continued. An example of this is Medicare’s use of authorizations for days stayed in a hospital-skilled nursing facility or number of visits for various therapies. Previously continuing treatment was only provided if there was patient improvement only. Recent lawsuits have challenged this approach. The Jimmo vs. Sibelius lawsuit settled in January 2013 forced Medicare to stop discontinuing care and allowed for additional treatments to maintain health or prevent the decline of health status.

Some of the changes over the past few years are limiting types of treatment available. Cancer patients once received PET scans if medically necessary for diagnosis. Those same patients now receive only three PET scans per lifetime as of last year.

In July 2013 Medicare changed its durable medical coverage to trim inflated fee for service pricing for specified durable medical supplies to most major markets. This program was mandated as part of the 2010 passage of Obamacare. CMS used competitive bidding to determine new lower rates for durable medical items like oxygen, wheelchairs and CPAP machines. The program also incorporates using specified mail order providers for diabetic testing equipment and supplies.

The program requires you use Medicare's contracted durable medical providers in order to have Medicare pay for the equipment. Otherwise you will be personally responsible. This program is active in St. Petersburg and Tampa and will eventually be rolled out to the Sarasota and Bradenton zip codes. Scooters and powered mobility devices already are subject to authorization regardless of zip code. There continues to be pushback from durable medical providers and both sides of Congress on the rollout of competitive bidding

More fallout from the changes is the practice of keeping a Medicare covered patient in the hospital for observation without admitting them. When you are in observation you pay all medications and over-the-counter drugs and cannot bring medications from home for safety reasons. Observation is considered outpatient treatment. Hospitals can make an effort not to admit you in the event that if you are readmitted at a later date there are stiff penalties the hospital must pay. If you are not admitted for at least three days, Medicare will not pay for your stay at a skilled nursing facility after you leave the hospital.

Keep your eyes on the changes that are coming. They do not happen overnight but occur gradually. You are responsible for your own Medicare experience.Let it be a good one.

Betsy Vipond is CEO of The Senior Health Advisor and has been in insurance for over 38 years. She is a board member of Tampa Bay Health Underwriters part of the National Association of Health Underwriters and specializes in Medicare products. You may contact her at 800.603.0901


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