Nebraska Department of Insurance

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

DECEMBER 2002 NICA NEWS

CHANGES

Durable Medical Equipment Upgrade Option

Durable Medical Equipment prescribed by a physician is covered under Medicare Part B, with the beneficiary normally being responsible for 20% of the Medicare approved amount (after $100 Part B deductible) and any excess charges. Medicare will only pay for the specific type of equipment that the doctor prescribes, however beneficiaries do have the ability to upgrade that equipment and pay the difference. This provision became effective January 1, 2002. Prior to 2002, a beneficiary was required to accept the exact item that was prescribed. For example, currently if a physician prescribes a standard wheelchair, a beneficiary is now able to upgrade to an ultralightweight wheelchair so long as the beneficiary agrees to pay the difference in price. According to policy, this request must be beneficiary initiated, and the supplier is required to give the beneficiary an Advanced Beneficiary Notice informing them of the price difference they will be responsible for.

Appeal Procedure Changes for Medicare Part A and B Claims

Prior to October 1, 2002, Medicare Beneficiaries were allowed 60 days from the date of initial determination on a claim, to file an appeal with Part A to request reconsideration. After October 1, 2002, beneficiaries are now allowed 120 days to request reconsideration.

For Medicare Part B claims, Prior to October 1, 2002, a beneficiary had 6 months from date of initial determination to file an appeal requesting reconsideration. After October 1, 2002, beneficiaries are allowed to file the appeal up to 120 days from the date of the initial determination.

New HMO Option

Beginning January 1, 2003, United Healthcare of the Midlands will begin selling a Medicare Complete Premium plan. United Healthcare will continue selling its Medicare Complete $0 premium plan option, but has now added a Premium plan that will be offered for $71 per month. The Premium option will include all the basic benefits of the Medicare Complete plan, with additional coverage for other services, including prescription drugs. Both of the United Healthcare plans are only available for residents of Douglas County, Nebraska. For more information, contact UHC of the Midlands at 1-402-445-5599.

Avonex

Effective August 1, 2002, CMS approved payment by Medicare for the use of the drug Avonex when administered to patients with relapsing forms of MS. The drug must be administered to the patient in the doctor's office, under the doctor's direct supervision, in order for Medicare Part B to process the claim for benefits.

HHS ANNOUNCES MEDICARE PREMIUM AND DEDUCTIBLE RATES FOR 2003

Medicare law requires that the deductibles and premiums be updated annually in accordance with statutory formulas. The following rates will be effective January 1, 2003.

For each Medicare Part A benefit period in 2003, which pays for inpatient hospital, skilled nursing facility, and some home health care, the deductible paid by the beneficiary will be $840. The monthly premium paid by beneficiaries enrolled in Medicare Part B, which covers physician services, outpatient hospital services, certain home health services, durable medical equipment and other items, will increase to $58.70 for 2003. All Medicare beneficiaries enrolled in Part B pay the monthly premium. The Part A deductible applies only to those enrolled in the original fee-for-service Medicare program. Those who enroll in private Medicare+Choice plans may not be affected by the Part A increase, and may receive additional benefits with different cost-sharing arrangements.

The Part A deductible is the beneficiary's only cost for up to 60 days of Medicare-covered inpatient hospital care. However, for extended Medicare-covered hospital stays, beneficiaries must pay an additional $210 per day for days 61 through 90 for each benefit period in 2003, and $420 per day for lifetime reserve days 91 -150. For beneficiaries in skilled nursing facilities, the daily co-insurance for days 21 through 100 will be $105 in 2003.

Most Medicare beneficiaries do not pay a premium for Part A service. Seniors and persons under age 65 with disabilities may obtain Part A coverage even though they have fewer than 30 quarters of Medicare-covered employment, by paying a monthly premium of $316 in 2003. Those with 30 to 39 quarters of Medicare-covered employment pay a reduced monthly premium of $174.

Medicare Supplement Plans F and J offer a High Deductible Option. In 2003, the calendar year deductible is $1,650.

PART A
HOSPITAL CHARGES	In 2002, You Paid	In 2003, You Pay
For the first 60 days	$812	$840
Each Day for the 61st-90th day	$203	$210
Lifetime reserve days 91-150	$406	$420

SKILLED NURSING FACILITY	In 2002, You Paid	In 2003, You Pay
Each Day 1-20 days	Nothing	Nothing
Each Day 21-100 days	$101.50	$105
Beyond 100 days	All	All

PART B
SERVICES	In 2003, MEDICARE Pays	In 2003, YOU Pay
Medical Expenses Physician's services, physical speech therapy, etc.	80% of the Medicare approved amount (after $100 deductible).	$100 deductible. 20% of approved amount, plus excess charges above the approved amount

Medicare Stop Smoking Program
1-866-65BEGIN

As reported in the September 2002 NICA newsletter, the Center for Medicare & Medicaid Services (CMS) has begun a Medicare Stop Smoking Program that will benefit Medicare beneficiaries in Nebraska. The MSSP is a study to test smoking cessation interventions to determine the most successful and cost effective service. Nebraska was one of seven states chosen to participate in the project.

Beginning in October 2002, Medicare beneficiaries 65 years or older with Part B and not enrolled in a Medicare + Choice plan can call toll-free 1-866-65BEGIN (1-866-652-3446) to enroll in the project. Upon enrollment, beneficiaries are assigned to an intervention according to their county of residence. In Nebraska, residents of Cedar, Dixon, Dakota, Wayne, Thurston, Madison, Stanton, Cuming, Burt, Colfax, Dodge, Washington, and Douglas counties are eligible to receive benefits including provider reimbursement for counseling and coverage of pharmacotherapy services such as the nicotine patch or the prescription drug buproprion. Residents of Butler, Saunders, Sarpy, York, Seward, Lancaster, Cass, Otoe, Saline, Gage, Johnson, Nemaha, Pawnee, and Richardson counties are eligible for reimbursement of provider counseling services. All other counties in Nebraska are in the intervention that will receive informational materials from Medicare if they phone the hotline. (The fourth intervention for Nebraska's study group is located in eastern Wyoming.) Beneficiaries have 12 months to enroll in the project, and those who enroll in the program will receive benefits for 12 months following enrollment.

While the project and the promotions for the MSSP began in October 2002 nationwide, many areas in Nebraska will not see advertisements until next year. The advertisements are being run on a quarterly schedule, and the marketing strategy for November-December 2002 involves newspapers, radio, or television spots in Omaha, Bellevue, Blair, Falls City, Plattsmouth, and Wahoo. Beginning early next year there will be campaigns rolled out in other parts of the state -- including Lincoln, North Platte, Kearney and Hastings -- but beneficiaries in any area of the state can call to sign up for the benefits at any time.

It is important to remember that the Medicare Stop Smoking Project is a study to evaluate possible future benefits to be incorporated into the overall Medicare benefit package. CMS needs enrollees in all parts of the state to participate in the program, and to be part of the study. Volunteers should promote the MSSP to beneficiaries, no matter which benefit area they are covered in, and encourage them to enroll if they have an interest in quitting smoking. It is important to note, however, that Nebraska also has in place the Tobacco Free Nebraska Quitline, a state-wide toll free hotline for all residents who are interested in losing their tobacco addiction.

Persons who are interested in quitting smoking should be referred to both hotlines, as some beneficiaries who may be ineligible for the MSSP (for example, if they are in an HMO or do not have Part B) could receive help from the Nebraska Quitline. The Quitline number is toll-free 1-866-632-7848. The NICA office has MSSP brochures and posters available for volunteers to use for promotional purposes. The more successful the study is, the more likely the chance that all Medicare beneficiaries will eventually receive a smoking cessation benefit.