Tag: Centers for Medicare & Medicaid Services

  • Hospice & Part D Prescription Medications

    Earlier this year the Centers for Medicare & Medicaid Services (CMS) clarified the criteria for determining payment responsibility under the Part A hospice benefit and Part D prescription drug benefit for individuals who are under the Medicare hospice benefit. This was done to help prevent duplicate payments. CMS has issued a new guidance that requires denial of Part D claims on the basis of Prior Authorization (PA) for Medicare members who choose the hospice benefit after May 1, 2014.

    What is a “prior authorization” of a prescription drug?

    This is usually when the Medicare Part D plan will cover a particular drug, but your doctor must first show the plan that it is medically necessary for you to have that particular drug. The plans also do this to be sure that the drugs are used correctly. In this new scenario the Medicare Part D plan must confirm who is responsible for paying for the drug; the hospice benefit or the prescription drug benefit. This will also reduce the number of inaccurate claims.

    What medications does hospice benefit pay?

    This benefit will pay for medications that ease the suffering and help in pain management in a terminal condition. The Medicare approved Hospice provider will supply the medications and the copayment to the individual will be no more than $5.00 per prescription.

    What does Medicare Part D pay for?

    Your Part D plan will pay for those maintenance prescriptions not related to the hospice benefit. Medications for things like high blood pressure, heart disease, diabetes and other chronic conditions. Under this new guidance these medications will require prior authorization,

    What can I or my caregiver do so that there is not a delay in getting the medications I need?

    First, whenever possible order your refills at least seven days before your current prescription runs out. Call your Medicare Part D plan to ask for the forms and process in requesting a “coverage determination”. Talk with your hospice provider or nurse on what prescription drugs are under your hospice benefit.

    Please call for more information about this or other Medicare subjects. We have trained and certified counselors available to help navigate the Medicare health care system. If you have a group that would like more information about the upcoming Medicare Open Enrollment Period (October 15 – December 7, 2014) we are available for community presentations and annual Medicare screenings. And always, we are looking for individuals who would like to help their community by becoming a Hawaii SHIP Volunteer.

     

    Hawaii SHIP (State Health Insurance Assistance Program)
    1-888-875-9229 | 808-586-7299
    help@hawaiiship.org | www.hawaiiship.org
    For 2014 Medicare updates: www.medicare.gov

    Earlier this year the Centers for Medicare & Medicaid Services (CMS) clarified the criteria for determining payment responsibility under the Part A hospice benefit and Part D prescription drug benefit for individuals who are under the Medicare hospice benefit. This was done to help prevent duplicate payments. CMS has issued a new guidance that requires…

  • Hitting a Home Run with Medicare

    Seeing Coach Murakami on the cover made me think about how much Medicare and baseball have in common. Practice and being prepared for the big game is one way to hit a home run. It’s the same idea with Medicare.

    Innings (In Medicare they are called Enrollment Periods)

    Initial Enrollment Period is when you are first eligible for Medicare Part A and/or Part B either due to turning 65 years old; certain disabilities or 24 months after receiving Social Security Disability Benefits (SSDI). The seven-month initial enrollment period begins three months before your date of eligibility and three months after the month you are eligible. There could be penalties if you delay enrollment.

    General Enrollment Period is every year from January 1 – March 31. If you miss your initial enrollment period and there is a premium assigned to that benefit, you can enroll during this inning, but your coverage will not start until July 1. If you qualify and are eligible for premium free Medicare Part A, you can enroll at any time (in that benefit only).

    Special Enrollment Periods (SEP) occurs when you have qualified health coverage or special circumstances to delay enrolling in Medicare. Special circumstances could be if a person is covered by a qualified ACTIVE employer group health plan. The best time to see if you might qualify for a SEP is before you are eligible so that you aren’t assessed a penalty for not enrolling. Note: COBRA is not an “active” group health plan.

    Medicare Supplement (Medigap) Open Enrollment Period (OEP) Medigap has a 6-month period that starts the first month you are eligible AND enrolled in Medicare Part B. This is when you can take advantage of plans sold in Hawai‘i regardless of your health status. Once your Medigap OEP, begins it cannot be changed.

    Medicare Annual Enrollment Period (AEP) for Medicare Advantage Plans and Drug plans is annually from October 15 – Dececember 7. It is the opportunity to change, add or drop Medicare health and drug plans.

    Coaches of Medicare:

    Social Security Administration (SSA) “entitles” individuals for Medicare. In most cases Medicare premiums are deducted from an individual’s benefit. SSA is also in charge of qualifying individuals for help paying for Medicare’s prescription drug program. SSA also determines enrollment periods and penalties for Medicare Part B. Call your local office at 1-800-772-1213 to make an individualized appointment.

    Centers for Medicare & Medicaid Services (CMS) is the federal agency that the Medicare program. Medicare is just one program (very large) under CMS. For more CMS information, visit www.cms.gov/history.

    State Health Insurance Assistance Programs (SHIP) are a CMS grant and the goal is to provide Medicare beneficiaries with information and assistance with benefits. Hawai‘i’s SHIP is the Sage PLUS Program and we are volunteer-based and in the Executive Office on Aging.

    Other Team Members That Affect Your Medicare

    The following players may affect your Medicare coverage and who pays first.

    • Retirement medical coverage through former employment
    • Military or Veterans benefits
    • State assistance due to limited income and assets
    • Active employer group health coverage through yourself or a spouse

    Game Strategies Start studying Medicare about four months before you are eligible. Become a SHIP Volunteer and learn about Medicare, help your community and stay active. For more information about Medicare call the Hawai‘i SHIP/Sage PLUS Program at 586-7299 or e-mail help@hawaiiship.org.

    Enjoy the Seventh Inning Stretch!

    Seeing Coach Murakami on the cover made me think about how much Medicare and baseball have in common. Practice and being prepared for the big game is one way to hit a home run. It’s the same idea with Medicare. Innings (In Medicare they are called Enrollment Periods) Initial Enrollment Period is when you are…