Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
MARCH 2001 NICA NEWS
CHANGES
MEDICARE EXPANDS COVERAGE OF PET SCANS
The Health Care Financing Administration (HCFA) announced it is expanding Medicare coverage of positron emission tomography (PET), an innovative imaging technology, to improve the care of patients who have or may have one of six types of cancer.Additional coverage is also provided for some patients with refractory epilepsy or who may be candidates for coronary revascularization.
"PET is a technology that has tremendous promise," said Jeffrey Kang, director of HCFA's Office of Clinical Standards and Quality. "Our expanded coverage of this diagnostic tool provides additional clinical information to physicians that may influence the management of care for many Medicare beneficiaries."
This science-based coverage decision provides important expanded coverage of dedicated full circular ring PET scanners and some partial ring systems for any clinically appropriate use for six types of cancer - lung, colorectal, lymphoma, melanoma, esophageal, and head and neck (but not brain or thyroid) cancer - and new coverage of the neurologic and cardiac applications. The effective date will be announced shortly.
The use of PET may allow some Medicare beneficiaries to avoid undergoing invasive procedures and may also give beneficiaries and their physicians information that will increase confidence in the management of their care.
Consideration of requests for coverage of three additional applications - myocardial viability, dementia, and breast cancer - will be referred to the Medicare Coverage Advisory Committee, a panel of top private sector experts created to advise HCFA on important coverage issues.
PET is a specialized imaging technique that was developed in the 1970s. It involves the injection into a patient of a very small amount of a radioactively labeled natural compound such as sugar or water. The most commonly used radiopharmaceutical in PET is fluorodeoxyglucose (FDG), which is similar in structure to glucose or simple sugar. Once FDG is injected, a PET scanner is used to image a specific function or physiological process within the body by measuring the concentration and distribution of the radioactive FDG throughout the body. Prior to today's coverage decision, only specific uses for PET, such as localization of recurrence for any given cancer, have been covered by Medicare. This new policy decision provides coverage for all clinically appropriate uses of PET for six cancer types. This means broader coverage for previously covered cancers as well as for two additional ones.
This change is a significant modification in HCFA's approach to PET scans and a major step toward broad coverage. HCFA will now cover diagnosis, staging and re-staging for any covered cancer for which there is empirical evidence for at least one clinically appropriate indication. For example, HCFA previously covered PET scans for colorectal cancer for one narrow indication - in the case of recurrent colon cancer evidenced by a rising carcinoembryonic antigen level. Now, HCFA has expanded coverage of PET for colorectal cancer for all other diagnostic, staging and re-staging reasons.
For coverage of PET in primary cancer diagnosis, PET must be used to potentially avoid or direct an invasive diagnostic procedure. For use in staging or restaging of disease, PET is only covered if the stage of the cancer remains uncertain following a conventional imaging work-up and if the clinical management of the patient differs according to the stage of the disease. Where the evidence demonstrates PET is not clinically useful, that use in a specific cancer type will be explicitly excluded from coverage.
High Deductible
As you know, some insurance companies offer a high deductible option for Medicare supplement Plans F & J. The deductible for these plans represents the amount the insured is responsible for before the plan will begin paying benefits. The out-of-pocket costs on these two plans increased from $1,530 in 2000 to $1,580 in 2001. Last year, six insurance companies listed their high deductible Medicare supplement option in the 2000 Comparison Rate Guide. This year, nine companies have listed their high deductible Medicare supplement option in our 2001 Rate Comparison Guide, an increase of three.
The High Deductible Out-of pocket Expense
For Med Supps F & J for 2001 is $1,580.00
FYI: HCFA just started its HIPAA online feature
which provides information about its internet website.
http://www.hcfa.gov/medicaid/hipaa/default.asp
Nearing Age 65? Check on Your Medicare
Age 65 is a milestone for most folks. Whether you're retired or not, you are likely eligible for Medicare health insurance. If you don't receive Medicare information about three months before your 65th birthday, it's time to call your Social Security office.Farmers and others who are self-employed often don't approach age 65 like other people. They may not contact their Social Security Office if they aren't ready to take their Social Security benefits. Some assume they are automatically enrolled in Medicare, which isn't the case. They could be without Medicare coverage when they really need it, or they may have to pay a higher Medicare Part B premium for the rest of their lives because they didn't enroll in Medicare at age 65.
Knowing the rules and checking with the right people can help avoid problems. When you or your spouse continue to work past age 65, you may choose to keep the employer health plan and delay your enrollment in Medicare Part B, but you should check with the Social Security Office before deciding. Check reliable sources if your situation is different in any way from the "normal" routine of retiring and going on Medicare at age 65. It is best to get answers directly from Social Security. If you are told you don't need Medicare Part B, ask for an answer in writing in case you need it in the future. Call Social Security toll-free at 1-800-772-1213.