Medicaid: Information on Inmate Eligibility and Federal Costs for Allowable Services

10-6-2014 National:

In 2013, the Medicaid program financed health care services for more than 72 million individuals, and an additional 7 million beneficiaries are expected to enroll in 2014 as a result of states choosing to expand Medicaid eligibility as allowed under the Patient Protection and Affordable Care Act (PPACA). Most of these newly eligible individuals will be low-income adults, a population that may include individuals who are inmates in state prisons and local jails.

In the 27 states that opted to expand Medicaid eligibility as allowed under PPACA, the majority of inmates are likely to have incomes that would qualify them for Medicaid, a circumstance that did not generally exist before 2014, since Medicaid eligibility for adults has generally been limited to certain categories of low-income individuals, such as pregnant women and individuals who are aged or disabled. For example,

Federal health board rules Medicare can pay for recipients' sex reassignment surgeries

5-30-2014 National:

Medicare can no longer automatically deny coverage requests for sex reassignment surgeries, a federal board ruled Friday in a groundbreaking decision that recognizes the procedures are medically necessary for people who don't identify with their biological sex.

Ruling in favor of a 74-year-old transgender Army veteran whose request to have Medicare pay for her genital reconstruction was denied two years ago, the agency's Departmental Appeals Board said there was no justification for a three-decade-old HHS rule excluding such surgeries from procedures covered by the national health program for the elderly and disabled.

"Sometimes I am asked aren't I too old to have surgery. My answer is how old is too old?" the veteran, Denee Mallon, of Albuquerque, New Mexico, said in an email interview before the board issued its decision. "When people ask if I am too old, it feels like they are implying that it's a 'waste of money' to operate at my age. But I could have an active life ahead of me for another 20 years. And I want to spend those years in congruence and not distress."

Jennifer Levi, a lawyer who directs the Transgender Rights Project of Gay & Lesbian Advocates and Defenders in Boston, said the ruling does not mean Medicare recipients are necessarily entitled to have sex reassignment surgery paid for by the government.

How Much Medicare Pays for Your Doctor’s Care

4-29-2014 National:

Use the form below to find a doctor or other medical professional among the more than 800,000 health care providers that received payments in 2012 from Medicare Part B, which covers doctor visits, tests and other treatments. Payments may also cover overhead, such as staff salaries and drug costs. In some cases, when doctors work as salaried employees of group practices, the payments that show up under their names go to their institutions. ..Click for the Form.. by NYT (Source: The information presented here is from a database released by the Centers for Medicare and Medicaid Services. The database excluded, for privacy reasons, any procedures that a doctor performed on 11 or fewer patients. The total reimbursements for each doctor does not include those procedures either. Results shown above include only individuals like doctors, nurses or technicians but not organizations like Walgreens. While some providers could have multiple offices, the address shown is the main address indicated in the database. Descriptions of the medical procedures are from the Current Procedural Terminology (CPT®) code set, which is copyrighted by the American Medical Association. )

Judge Dismisses Suit Brought by Plaintiffs Seeking to Opt Out of Medicare

3-17-2011 National:

U.S. District Judge Rosemary Collyer dismissed a suit brought by a group of men seeking to cease their Medicare Part A coverage. In an opinion [.pdf] issued today, Collyer wrote that while the plaintiffs, which include former House Majority Leader Dick Armey, had a point that they are caught in a bind – the statute dictates that they can only opt out of Medicare Part A by forfeiting all of their Social Security retirement benefits – the court did not find that the government is required to provide a different way out.

The plaintiffs are three men over age 65 who want to opt out of Medicare coverage, arguing in their complaint that Medicare Part A coverage is inferior because of budget constraints and that staying enrolled in Medicare Part A could put their private coverage at risk. They also claim that they are entitled to less privacy under Medicare Part A coverage.

In the complaint, filed in U.S. District Court for the District of Columbia, the men claimed that the rules governing Social Security retirement benefits dictated that they could only pull out from Medicare coverage by forfeiting their Social Security benefits entirely. They argued that this statutory scheme is at odds with the Social Security Act and unconstitutional.

The U.S. Department of Health and Human Services and the U.S. Social Security Administration were named as defendants. A spokesperson for the U.S. Department of Justice declined to comment on Collyer's decision.

Frank Northam of Washington’s Webster Chamberlain & Bean represented the plaintiffs. He could not immediately be reached for comment.

Collyer wrote that she agreed the men are “trapped in a government program intended for their benefit,” but that the statutory scheme in question is legal, since the laws governing Medicare are clear that anyone entitled to Social Security retirement benefits is automatically enrolled in Medicare Part A when they turn 65.

“Requiring a mechanism for Plaintiffs and others in their situation to “disenroll” would be contrary to congressional intent, which was to provide “mandatory” benefits under Medicare Part A for those receiving Social Security Retirement benefits,” she wrote.

Updated at 7:25 p.m. to identify former House Majority Leader Dick Armey as one of the plaintiffs. ..SOurce.. by Zoe Tillman

Medicare's Hospice Benefit

4-17-2009 Washington DC:

Summary:
Hospice care provides an interdisciplinary approach to services for Medicare beneficiaries with a terminal illness. This care specializes in the relief of the pain and symptoms associated with a terminal illness and in the provision of supportive and counseling services to patients and their families during the final stages of a patient's illness and death.

The benefit covers a broad range of services, including prescription drugs for pain control and symptom management, skilled nursing care, physician services, home health aide services, homemaker services, patient counseling, and family bereavement counseling. Services are provided primarily in the patient's home, but may also be provided in institutional settings, such as nursing homes.

Hospice care is provided in lieu of most other Medicare services related to the curative treatment of the terminal illness. For a person to be considered terminally ill and eligible for Medicare's hospice benefit, the beneficiary's attending physician and the medical director of the hospice (or physician member of the hospice team) must certify that the individual has a life expectancy of six months or less.

Beneficiaries electing hospice are covered for two 90-day periods, followed by an unlimited number of 60-day periods. Medicare payments to hospices in 2007 totaled $10.1 billion, having more than tripled since 2000. Medicare spending for hospice is expected to continue growing and to more than double by 2018, reaching a projected $21 billion and outpacing the projected growth rates for Medicare payments in hospitals, skilled nursing facilities, physician services, and home health care.

Growth in spending to date has been driven, in part, by increased utilization of hospice as well as spending per hospice user. For example, spending per user grew between 2004 and 2005 by 8%. Growth in spending per user may be in part a result of increasing lengths of stay among certain hospice providers.

The number of hospices participating in Medicare also grew by 33.4% during the four-year period from 2003 to 2007. As of 2007, for-profit hospices constituted the majority of these hospices, and since 2000, made up over 90% of hospices participating in Medicare. Medicare pays hospices using a prospective payment system containing four categories of daily rates, which are predetermined, fixed amounts intended to pay for the costs of care for a hospice beneficiary, on average.

These amounts are adjusted annually by the hospice market basket. Hospice payments are also adjusted for geographical differences. Total payments to hospices may not exceed an aggregate per beneficiary cap amount. Some analysts have expressed concerns about Medicare margins earned by certain types of hospice providers, the growing number of hospices exceeding the aggregate per beneficiary cap, increasing lengths of stay, and the three-year phase out of the budget neutrality factor authorized under regulation in August of 2008. All of these topics are discussed in this report, which will be updated as necessary.

For the full report: by Medicare