What is SilverSneakers?

SilverSneakers is a fitness program for Medicare Advantage members offering programs that encourage older adults and seniors to become involved in physical activity and at the same time offers a social activity. I visited the SilverSneakers website, here’s what they say the program offers:

• access to conditioning classes, exercise equipment, pool, sauna and other available amenities
• customized SilverSneakers classes designed exclusively for older adults who want to improve their strength, flexibility, balance and endurance
• health education seminars and other events that promote the benefits of a healthy lifestyle
• a specially trained Senior Advisor^SM at the fitness center to introduce you to SilverSneakers and help you get started
• member-only access to online support that can help you lose weight, quit smoking or reduce your stress
• SilverSneakers Steps for members without convenient access to a location

Just a few days ago, I visited one of our local area facilities and talked to the front desk about the SilverSneakers Fitness Program.  They told me members who come in have a great time, regain flexibility, balance and strength and it offers them social recreation.

How to Join

If you are enrolled in a Medicare Advantage plan offering SilverSneakers, go to http://www.silversneakers.com.

The site is interactive and you can click on the question “Do I have SilverSneakers” and select your state and it will bring up a listing of the plans that are connected with the SilverSneakers program.

Someday it could happen and you need the services of a Skilled Nursing Facility (SNF).  Whether you are enrolled in Original Medicare or an Advantage Plan you should have a basic understanding of the requirements, because these facilities can become quite expensive and might become your financial responsibility.

What is a SNF?

A Skilled Nursing Facility is a health care facility that is licensed and inspected by your State Health Department.  These facilities offer both short and long term services.

Services vary from one facility to another and there is a possibility that Medicare or your Advantage plan may not pay for these services.  You or your caretaker should take the time to confirm what services will be covered.  Here are some of the services:

• Medical treatment prescribed by a doctor
• Physical therapy
• Speech therapy
• Occupational therapy
• Assistance with personal care activities such as eating, walking, bathing, and using the toilet (custodial care)
• Case management
• Social services

Some SNFs offer:

• Specialized care programs for Alzheimer’s or other illnesses/conditions
• Short-term respite care for very frail or disabled persons when a family member requires a rest from providing care in the home

What are Medicare’s Requirements?

Medicare has requirements for you to be admitted to a SNF.

• Your hospital stay must be at least 3 days to qualify for a Skilled Nursing Facility and it cannot include your discharge date.
• You must enter the SNF within 30 days of your hospital stay
• The SNF must be ordered by a physician
• The level of care must be supervised by a professional such as a registered nurse, licensed practical nurse, physical therapist, or intravenous injections.
• The level of skilled care provided cannot be obtained at home or on an outpatient basis

What Does Medicare Pay and How Long Can You Stay?

1. From Days 1 – 20: you pay $0 each day
2. From Days 21 – 100: you may have to pay up to $137.50 each day
3. Beyond 100 days you are responsible for 100% of the costs.

Medicare care also caps your stay at 100 days of Medicare Part A coverage for each benefit period.

REMEMBER

Being admitted to a skilled nursing facility can be expensive and can become your responsibility as Medicare generally does not cover long-term stays in a nursing home.

If you have original Medicare the co-payment is generally paid by a Medigap policy if you have one.

If you or your caretaker has a question, contact Medicare.  Call 1-800-MEDICARE (1-800-633-4227) and TTY users should call 1-877-486-2048

Medicare Advantage Plan enrollees or their caretakers should contact their plan to get complete information on what is covered, for how long and what, if any, out of pocket charges you are responsible for.

As I have said before Medicare Part D is the “best” prescription drug plan for people on Medicare, because it’s the only plan and offers some assistance.  If you don’t have a chronic condition, then it’s a great plan.

But many people because of their health condition are required to take numerous prescription medications and some can be quite costly forcing them into the “donut hole” early in the year. When they reach the “donut hole” they are required to pay, in some instances, thousands of dollars out of their own pocket for their medications.

The sad part over the last few years, many seniors have opted out of taking their medications because it’s too expensive.  Here’s how the Affordable Care Act is going to help.

$250 Reimbursement for 2010

During 2010, Medicare will be working with your Part D providers and when you reach the “donut hole”  you  will receive a one-time $250 rebate check.  If you are already receiving Medicare Extra Help, you will not be entitled to the rebate.  Checks will start being mailed out sometime in June and continue for the remainder of the year.

50% Discount in 2011

During 2011 when you reach the “donut hole” you will receive a 50% discount on Part D covered brand-named prescription drugs.

Around May 1^st, Medicare released what the Medicare Part D Plan will look like in 2011:

• Initial Deductible – $310 (unchanged)
• Coverage Amount: $2,840 – a $10 increase over 2010 ($2,830)
• Out-of- Pocket costs, including the donut hole – $4,550 (unchanged)
• Catastrophic Co-payments
  • Generic drugs – $2.50 – (unchanged)
  • Other drugs – $6.30 – (unchanged)

Beyond 2010

Closing the “donut hole” will take 10 years. Each and every year there will be additional savings until it’s closed in 2020.

If you are looking for more information on the new law, you can visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227).  Don’t forget your State Health Insurance Assistant program (SHIP) or call Medicare to get your State’s telephone number.  TTY users should call 1-877-486-2048.

What Medicare Pays

Part A covers the cost of inpatient laboratory services when you are admitted to the hospital and the charges become part of the hospital charge. Part A pays for most services but you are responsible for any coinsurance and deductible.

Part B pays 100 percent of the cost of Medicare-covered laboratory tests for outpatients if performed by a Medicare-certified laboratory.

Part C must pay for everything that is covered in Medicare Part A and B, but sometimes Part C providers offer enhanced benefits.

Why Medicare Disallows the Claim

Here are two major reasons why a diagnostic test might be disallowed:

1. Wrong or no Diagnostic Code on the prescription;
2. Test prescribed too many times.

When you receive your prescription from your doctor, ask his assistant to look over the prescription to make sure the necessary diagnostic codes are there.  This will save you a lot of aggravation and hopefully your claim will be processed without a problem.

If in doubt about the frequency of your tests, contact Medicare to find out what their policy is and find out how you can still have the test.

Are You Responsible for the Charges?

Understand that Medicare has negotiated pricing with the laboratory.  The prices are very good.  But if your doctor doesn’t have the correct codes on the prescription, Medicare will disallow the charge and you are responsible for whatever the laboratory list price is for that test.

The laboratory usually has you sign a waiver stating you take full financial responsibility should Medicare not pay the claim.

If you become responsible for the charges, be prepared for “sticker shock” as the laboratory charges you a much higher price than what they will accept from Medicare.

Fact: Medicare disallowed a diabetes A1C test because (1) the diagnostic code was missing, and (2) The frequency was more than allowed.  Medicare’s allowed charge in our area is $27.50 for this test.  Because the claim was disallowed, we received a bill from the laboratory for $111.00.

After appeal, the claim was paid.

Remember – when in doubt contact Medicare.

Did you know that one of the easiest ways for your identity to be stolen is if you lose your Medicare card?

Everyone receives their Medicare card when they turn 65 years old.  But, your Medicare number is tied directly to your social security number – something identity thieves just love.

Keep It Safe

First thing you need to do is to keep your Medicare card in a safe place.  It is recommended that you do not carry your card with you.  What if you should lose your wallet?  There’s your social security number.  All it takes is one identity thief.

Instead, make a copy of the card and blackout the last 4 digits of the number and keep that with you.  This just shows someone that you are covered by Medicare should you need any type of medical help.

What you should do is make a few extra copies of your card and keep those copies in a safe place too.  Now should you need to visit a doctor, you can just hand them the copy of your Medicare number.  You don’t have to hand them your original card and forget to get it back. Also, you are not carrying your original card with you.

Identity theft is on the rise and senior and elderly populations seem to be a prime target for the thieves.

Look for the Red Flags

The Internet is another area for identity theft. I try to make it a rule if and when I visit a site never to give out important or personal information if I don’t know who they are.  The “Red Flags” should come up when someone asks for your social security number, Medicare number or your bank account number.

Is Someone “Phishing”

What the site or an email could be doing is “Phishing” pronounced “Fishing.”

From Wikipedia: In the field of computer security, phishing is the criminally fraudulent process of attempting to acquire sensitive information such as usernames, passwords and credit card details by masquerading as a trustworthy entity in an electronic communication. Communications purporting to be from popular social web sites, auction sites, online payment processors or IT administrators are commonly used to lure the unsuspecting public.

No matter where you are – at your local grocery store or on the Internet, please protect yourself from identity theft.

Medicare recently redesigned their website (www.medicare.gov) and there are a lot of new and interesting areas to explore.  One that caught my eye was to a government website about Medicare fraud (www.stopmedicarefraud.gov).

Because of the confusion with Health Care Reform, there were various scammers out-and-about and one in particular dealt with the $250 “donut hole” reimbursement.  The scammers were calling, introducing themselves from the Federal Government and telling you they need to send you your $250.  What they were requesting was your bank account number.

What became apparent after reading through the Stop Medicare Fraud website, is how easy it could be for someone to obtain your Medicare or Social Security Number if you DO NOT protect yourself and how Medicare fraud can lead to IDENTITY THEFT.

Protect Yourself from Medicare Fraud

• ALWAYS protect your Medicare and Social Security Number.
• DON’T give anyone your Medicare ID if offering a free service. A Free service doesn’t require a Medicare ID.
• DON’T let anyone use your Medicare ID or your identity.  It’s illegal and could cause you more problems.
• AVOID any provider of health care who tells you a service is not covered, but knows how to bill Medicare.

What’s Identity Theft?

What’s Identity Theft?  Identity Theft happens when someone uses your personal information to commit fraud or other crimes, without your consent.  Visit www.ftc.gov/bcp/edu/microsites/idtheft/ to learn more about identity theft.

Being more aware of how to protect yourself against Medicare fraud also protects you from identity theft.

Again, keep your personal information safe, information like your name, Social Security, Medicare, or credit card numbers, bank account information.

Don’t give your information out over the web, or to anyone who comes to your home, or anyone who calls you. Only give personal information to doctors or other providers approved by Medicare. Call 1-800-MEDICARE (1-800-633-4227) if you aren’t sure if a provider is approved by Medicare. TTY users should call 1-877-486-2048.

According to the Stop Medicare Fraud website, there are a few organizations that are safe to give personal information and they would include:

• Medicare
• Social Security
• Medicare health or prescription drug plans
• Your State Health Insurance Assistance Program (SHIP)

If you lose your Medicare card or it’s stolen, or if you need a new Social Security card, visit www.socialsecurity.gov, or call Social Security at 1‑800‑772‑1213. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board, call 1‑877‑772‑5772, or visit www.rrb.gov.

Medicare Fraud can lead to Identity Theft –ALWAYS protect your personal information.

Do you suspect Medicare fraud?  Are you reluctant to report it?  Reporting any type of fraud helps protect yourself, Medicare and millions of others who might be a potential victim.

Every Medicare beneficiary receives a payment notice from Medicare. It’s called the Medicare Summary Notice (MSN).  Take a few minutes to review it for errors.  When you see items on the notice that you question, highlight them.  Here’s what to look for:

• Was Medicare billed correctly for services you were provided? (For example, if you had an appointment on June 1 with your doctor and your next appointment was scheduled for September 1, there should only be one charge, not two or three additional office visit charges.)
• Are there any medical services, supplies or equipment you didn’t get, but have been billed?

Did you see any questionable items?  If yes, then your next step would be to contact the healthcare provider or supplier with your questions or concerns regarding the issues you found on your Medicare Summary Notice.

Seems easy enough, right? But, the provider or supplier doesn’t want to help you; you can’t seem to reach them; perhaps the phone number was disconnected.  What do you do? It’s discouraging to think someone could do this, but don’t get discouraged, be proactive.  How?

It’s time to report the errors to Medicare and here’s what Medicare suggest you do:

• Call 1-800-MEDICARE.
• Write a letter to Medicare. Mail it to: Beneficiary Contact Center, PO Box 39, Lawrence KS, 66044.
• Call the HHS Office of Inspector General Hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.
• Send an e-mail to the HHS Office of Inspector General at hhstips@oig.hhs.gov.
• Write a letter to the Department of Health and Human Services. Mail it to: HHS Tips Hotline, PO Box 23489, Washington, DC 20026‑3489.

Medicare is very discrete and they will not use your name if you ask them not to use it.

Please, before you call anyone, take time and review all the facts carefully.  Here’s the information Medicare or the Inspector General will require:

• The provider’s name and any identifying number you may have
• The service or item you are questioning
• The date the service or item was supposedly given or delivered
• The payment amount approved and paid by Medicare
• The date on your Medicare Summary Notice
• Your name and Medicare number (as listed on your Medicare card)
• The reason you think Medicare shouldn’t have paid
• Any other information you have showing why Medicare shouldn’t have paid for a service or item

You might be entitled to a reward of up to $1,000 if the suspicious activity you are reporting turns out to be Medicare fraud.  However, there are a few conditions that need to be met:

• You report your suspicion
• Your suspicion is referred to the Inspector General’s office for review
• The fraud you report isn’t already being investigated
• Your report leads directly to the recovery of at least $100 of Medicare money
• You are not related to people who work for certain federal agencies

If you want to know more about the Medicare fraud reward program, call 1‑800‑MEDICARE (1-800-633-4227). TTY users should call 1‑877‑486‑2048.

Protecting yourself from Medicare fraud is the first thing you need to do.  But learning how to identify or spot fraud is equally important.

During 2009 the Department of Justice recovered nearly a billion dollars in health care fraud.  Plus they recorded 300 convictions.  Look at what they are currently pursing and this is only during the month of April 2010.  You can read the full reports at www.stopmedicarefraud.gov:

• Maine – April 16, 2010 – Rockland Woman Sentenced on Federal Health Care Fraud and Drug Charges
• Georgia – April 16, 2010 – Rome Couple Charged with $30 Million Medicare & Medicaid Fraud Through Failure of Care at Three Nursing Homes
• California – April 15, 2010 – Orange County Cancer Doctor Charged with Defrauding Medicare and Other Health Insurers in $1 Million
• Maryland – April 15, 2010 – Maryland Woman Indicted by Federal Grand Jury for D.C. Medicaid Fraud
• Michigan – April 15, 2010 – Detroit Area Patient Recruiter Sentenced to 27 Months in Prison for Medicare Fraud Scheme
• New York – April 13, 2010 – Former Program Director of Medicaid-Funded Nonprofit Pleads Guilty in Manhattan Federal Court to Stealing Nearly a Million Dollars
• Texas – April 13, 2010 – Medical Supplier Sentenced To Federal Prison for Motorized Wheelchair Scam
• California – April 12, 2010 – Los Angeles Business Owner Pleads Guilty to Submitting Nearly Half a Million Dollars in False and Fraudulent Claims to Medicare
• Florida – April 12, 2010 – Miami Man Pleads Guilty To $61 Million Medicare Fraud Scheme

Medicare has put together some great information to help you spot/identify fraud:

Be suspicious of doctors, health care providers, or suppliers that tell you the following:

• The equipment or service is free; it won’t cost you anything, and they only need your Medicare number for their records.
• Medicare wants you to have the item or service.
• They know how to get Medicare to pay for the item or service.
• The more tests they provide, the cheaper the tests become.

Be suspicious of doctors or plans that do the following:

• Don’t charge copayments without checking on your ability to pay.
• Advertise “free” consultations to people with Medicare.
• Claim they represent Medicare or a branch of the Federal government.
• Use pressure or scare tactics to sell you high-priced medical services or diagnostic tests.
• Bill Medicare for services you didn’t get.
• Use telephone calls and door-to-door selling as marketing tools.
• Offer non-medical transportation or housekeeping as Medicare‑approved services.
• Put the wrong diagnosis on the claim so that Medicare will pay.
• Bill home health services for patients who aren’t confined to their home, or for Medicare patients who still drive a car.
• Bill Medicare for medical equipment for people in nursing homes.
• Ask you to contact your doctor and ask for a service or supplies that you don’t need.
• Bill Medicare for tests you received as a hospital inpatient or within 72 hours of admission or discharge.
• Bill Medicare for a power wheelchair or scooter when you don’t meet Medicare’s qualifications.

Watch Out For These Common Fraud Schemes:

• People who approach you in parking lots, shopping centers, or other public areas and offer free services, groceries, transportation, or other items in exchange for your Medicare number. Just walk away!
• People who call you claiming to be conducting a health survey and ask for your Medicare number. Simply hang up the phone!
• Telephone marketers who pretend to be from Medicare or Social Security and ask for payment over the phone or Internet. Don’t do it! They may want to steal your money.

What happens if you suspect Medicare fraud?  You are encouraged to report the fraud.  You can report it to:

The Office of Inspector General

Email: HHSTips@oig.hhs.gov
Call: 1-800-HHS-TIPS (1-800-447-8477) TTY: 1-800-377-4950