Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

JUNE 2000 NICA NEWS

ISSUES

Prescription Drug Website

Do you have clients who cannot afford their prescription drug costs? You can learn more about the Pharmaceutical Assistance Program and have direct access to the list of covered prescription drugs at the following website: www.institute-dc.org.

How Do You Choose the Right Company When You Decide to Buy Long-Term Care Insurance?

Notice, we didn't say: the right policy. No matter how good a LTC policy sounds, it's worth little or nothing if the company cannot stand behind it. Think of Long-Term Care insurance as you would think of a long-term financial investment.

Consumers should only buy from companies that: (1) Have strong financial reserves and are likely to be financially sound far into the future; (2) Are well-known and have an excellent reputation; and (3) Have a good track record for customer service and few, if any, disciplinary actions made by the Department of Insurance.

Although there is no foolproof method for assessing a company's financial strength, a useful measure is the company's rating by independent rating services. Your agent should be able to show you the recommended insurance company's rating. Remember to ask for the rating and its meaning before purchasing a policy.

Most public libraries have this information, or you may call the agencies directly. For a listing of rating agencies and their phone numbers, NICA volunteers can offer beneficiaries the brochure "Some Questions To Consider In Choosing An Insurance Company."

Physical Therapy

Medicare has ended the $1,500 benefit limit on therapy. New rules went into effect January 1, 2000. The new rules apply for 2000 and 2001.

After an illness or injury, you may receive therapy to help you recover. Medicare pays for physical, speech and occupational therapy. You can receive your therapy in a hospital, a clinic, a doctor's office or at home.

Most therapies are paid by Medicare Part B. You must meet the annual Part B $100 deductible. Then Medicare pays 80% of approved amounts. If you have other insurance, it may pay all or part of the remaining 20%.

To qualify for Medicare payment, your doctor needs to write a plan of treatment. The therapy you receive must be medically necessary. Results are reviewed every 30 days. As long as you meet the guidelines for benefits, Medicare will continue to pay.

Update Information You Need About Medicare

Railroad Retirement: HCFA is working to find a replacement for the Railroad Retirement Board Medicare carrier. United Health Care, Inc., is ending its contract with Medicare. It will process claims until a new company is selected sometime between late summer and the end of the year.

Home Health Agencies: On October 1, 2000, Medicare will begin paying all home health agencies under a prospective payment system. This change was required under the Balanced Budget Act (BBA) of 1997. Watch for more information as we get closer to that date.

Insulin Infusion Pumps: Medicare now covers insulin infusion pumps for people with Type I diabetes. Type I diabetes is less common than Type II among Medicare beneficiaries. Infusion pumps have not been shown to be effective for Type II patients. If you have additional questions, contact the Durable Medical Equipment carrier at (800) 899-7095.

Arthritis Drug For Limited Cost

Patients with limited resources turn to the Rheumatoid Arthritis Foundation for help obtaining ENBREL.

We have had many calls regarding assistance in paying for the drug ENBREL. The Rheumatoid Arthritis Foundation was established to improve access to the drug for patients who have limited resources. To be eligible for assistance, patients must meet the criteria set by the Foundation Board of Directors. Clients may call (800) 282-7704 for more information or to discuss eligibility. (Eligibility criteria are subject to change without notice.)

FIRST MEDICARE+CHOICE PRIVATE FEE- FOR-SERVICE PLAN APPROVED

The Health Care Financing Administration has approved a request by the Sterling Life Insurance Company to offer the first private fee-for-service health plan option for people with Medicare, which will be available in 17 states beginning July 1, 2000.

The new Medicare+Choice plan will be available to beneficiaries beginning in July. Medicare beneficiaries who choose to enroll in the new private fee-for-service plan, Sterling Option I, will not be restricted to a network and may get health care services from any provider in the country who can be paid by Medicare.

"This is the first private fee-for-service plan to apply under the Medicare+Choice program created by Congress in the Balanced Budget Act of 1997," HCFA Administrator Nancy-Ann DeParle said. "While most beneficiaries still receive their health care through original fee-for-service Medicare, we welcome every opportunity to give seniors and people with disabilities alternative health plan choices.

"This plan will serve many rural counties that currently have no Medicare+Choice options," said DeParle.

A private fee-for-service plan is a private insurance program that charges enrollees a premium and cost-sharing amounts and lets beneficiaries choose the providers they want to see. In most cases, beneficiaries enrolled in the private fee-for-service plan will pay less to see a doctor than under original fee-for-service Medicare.

The Sterling Option I plan will furnish enrollees with coverage of all Medicare Part A and B services and in addition will provide worldwide emergency care and coverage of increased inpatient hospital days. Providers who choose to provide care to beneficiaries enrolled in a private fee-for-service plan will be paid on a fee-for-service basis by the plan and are not subject to utilization review.

"As more health plan choices become available, Medicare beneficiaries will need to learn more about those options and how they affect them," said DeParle. "Detailed information is available at www.medicare.gov and 1-800-MEDICARE."

Private fee-for-service plans, Medicare managed care plans and other new Medicare+Choice health care options are available to Medicare beneficiaries where private companies choose to offer them. Currently, about 6.5 million Medicare beneficiaries -- out of a total of nearly 40 million aged and disabled Americans -- have enrolled in Medicare+Choice managed care plans. Original fee-for-service Medicare, currently chosen by more than 33 million beneficiaries, is available to all beneficiaries no matter where they live.

Congress created Medicare+Choice in the Balanced Budget Act of 1997 to expand the types of health care options available to Medicare beneficiaries. As part of Medicare+Choice, Medicare now offers new preventive benefits and patient protections, as well as a far-reaching information program that includes a national toll-free phone number -- 1-800-MEDICARE (1-800-633-4227) -- an Internet site -- www.medicare.gov -- and a coalition of more than 200 national and local organizations to provide seniors with more information.

STERLING PLAN BENEFITS

Sterling will offer uniform benefits throughout the service area that will cover all required Medicare services and some enhancements.

Member costs under the Sterling OPTION I private fee-for-service plan include:

Monthly plan premium of $55
$10 copay for primary and specialist physician care
$50 copay for each ER visit (no co-pay if admitted to hospital)
$300 copay for each hospital admission
$25 copay per day for SNF admission
$50 additional copay per day (maximum $500) for non-notification of planned inpatient admission.

Option I enhancements include worldwide emergency care ($250 annual deductible, with 80% coverage of charges, annual maximum of $25,000).

No drugs, physical exams, eye exams, hearing aids, or glasses are covered.

Other charges apply for certain other services.

Sterling is currently providing information on the Option I PFFS plan at 1-888-858-8572 or at the website, www.Sterlingplans.com.

Medicare Beneficiaries and Internet Pharmacies

By: Jim Underhill, MPA
HCFA, Region X

Medicare beneficiaries are advised to use caution when ordering drugs through the Internet. While there may be benefits gained from shopping with legitimate Internet pharmacies, a number of consumer warnings have been issued regarding Internet shopping, and these warnings should not be ignored. Put simply, "Medicare beneficiary - be alert!"

To Internet businesses, Medicare beneficiaries are a large, untapped market since the use of prescriptions is the most frequent health activity for beneficiaries. A recent survey by the Health Care Financing Administration (HCFA), the federal Medicare agency, showed that 83 percent of beneficiaries take medications each day. These prescriptions are often taken with over-the-counter medications and, increasingly, with herbal products. When taken together, some of these combinations may be harmful if not used with the guidance of your personal health care professional, and pharmacist, who know your medical history.

Being on the Internet does not guarantee that an Internet pharmacy is properly licensed to conduct its business in your state. And if not licensed, then the medications you receive may not be "safe and effective" as required by the Food and Drug Administration (FDA). HCFA and pharmacy investigators have identified a number of Internet pharmacy sites that provide no proof that the business is properly licensed. Kevin Kinkade, RPh, representing the National Association of Boards of Pharmacy (NABP), states, "As more consumers turn to the Internet marketplace as a convenient shopping alternative, the risk for exposure to deception and dangerous scams increases. There is a particular concern among the elderly population which is often the target of unscrupulous marketing ploys."

So how do 38 million elderly and disabled beneficiaries use an Internet pharmacy safely?

Before you turn on your computer, organizations like the NABP, the American Medical Association (AMA), and other professional health organizations offer the following tips:

Always have your physician, or other personal health provider, prescribe your medications. The AMA is proposing a rule that declares prescribing over the Internet unethical, unless a pre-existing valid patient-physician relation is established.
Look for a seal of approval from a recognized agency. For example, the NABP offers the Verified Internet Pharmacy Practice Sites (VIPPS) program. VIPPS certifies that the Internet pharmacy is fully licensed and complies with standards including protection of your medical information.
Select an Internet pharmacy that is enrolled in the Medicare program.
Make sure the Internet pharmacy lists its address and toll-free phone number to contact the pharmacist: It's the Law!
Do not provide your Medicare number to an Internet site you cannot verify as being properly licensed and enrolled in Medicare. If you do, your number could be shared with many businesses that may bill Medicare, and you, for services you never received.
Help protect the Medicare Trust Fund and check your Medicare Summary Notices (MSNs). To report suspected fraudulent Medicare practices, call 1-800-HHS-TIPS.

The Internet presents opportunities and bargains for all consumers, but when it comes to your health care and prescribed medications, Medicare beneficiaries need to "BE ALERT." (This information was compiled with assistance from the National Association of Boards of Pharmacy)

This information was published in the Durable Medical Equipment newsletter, GR 99-4, DMERC Dialogue Winter 1999, Page 11 through 12.