Nebraska Department of Insurance

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

SEPTEMBER 2002 NICA NEWS

CHANGES

Bankers Life and Casualty discontinues Medigap policy

The Department of Insurance was notified that Bankers Life and Casualty discontinued offering their Medicare Supplement policy that was being sold to persons under 65 years of age receiving Medicare, effective July 1, 2002. The issued policies will remain in force. This leaves two companies selling Medigap policies to those under 65 on Medicare - Bankers Fidelity and United American Insurance Company.

M+C Annual Enrollment

"Lock-in" refers to the rule that restricts people with Medicare to making only one health plan change from January through June, either to a Medicare HMO or to original Medicare, thus locking them into that option from July to December.

The lock-in which, during 2002, limited beneficiaries to make one change in the first 6-months has been eliminated. This means that there is no lock-in and beneficiaries are able to disenroll from an M+C plan at any time (as it was before 2002) and can enroll in a different M+C plan if the plan is open for new enrollment. This continuous open enrollment will continue until June 30,2005. In addition, the annual open enrollment period will run from November 15th to December 31st of each year. CMS will announce its capitation rate, payment area and risk adjustment factors by the second Monday of May in 2004 and 2005 instead of the current deadline of March 1. The M+C plans will have until the second Monday of September to announce its plan premiums, benefits and other plan information instead of the current July 1 deadline.

HHS Issues New Medicaid Managed Care Regulation

On June 13, 2002, DHHS Secretary Tommy Thompson issued a final regulation to give beneficiaries enrolled in Medicaid managed care plans similar protection to that under pending patient's rights' legislation in Congress. The new regulation adopts the "prudent layperson" standard for emergency room care; a second opinion if needed; requires adoption of an internal appeals process; provides direct access for women's health services; non interference in patient-provider communications; and requires that marketing materials and program information be provided in an easy-to-understand format. This new regulation gives states flexibility to decide how to implement patient protections and the best use of managed care in their Medicaid plans. The final regulation was published on June 14th and became effective on August 13, 2002, with states and health plans required to comply with the new regulations within a year.

10 Things You Need to Know about Your Medicare and Health Insurance Statements

All Medicare providers are required to file your claim with Medicare. The claim must be filed within one year. A Medicare provider is your doctor, hospital, or anyone from whom you get health care services.
A provider who takes Medicare assignment accepts the amount Medicare approves as full payment. You or your insurance pays for any deductible or coinsurance amounts. All hospitals in Nebraska and most doctors accept assignment. Ask your doctor if he/she accepts assignment.
When a provider does not accept assignment you may be charged more than the amount Medicare approves. This is called excess charges. Most providers cannot charge more than 15% above the amount Medicare approves. However, suppliers of medical equipment can charge more than the 15% limit.
Medicare sends payments to the provider who accepts assignment. You get a statement once a month with a summary of these claims .
When the claim is not assigned, Medicare sends you the payment with the claims statement. You must use this money to pay the provider.
Do not pay the provider when you receive your Medicare statement stating "This is Not a Bill." Wait until you receive a bill from the provider and all insurance payments have been received.
Your supplemental insurance claims can be handled three different ways.
Some insurance companies have a "crossover" contract with Medicare. This means Medicare will send claims information to your insurance company for you.
Some insurance companies do not have crossover contracts. Medicare can still forward the claim to your insurance company when the provider accepts Medicare assignment. YOU MUST ASK the provider to include your Medicare supplement information on the claim sent to Medicare.
If you are filing your own claims, ask your insurance company if you need special claim forms. If not, send the insurer a copy of your Medicare benefits statement. (Keep the original.)
What do you have to pay?
Deductibles and coinsurance amounts not covered by insurance payments
Allowed excess charges not covered by insurance payments
Costs for services not covered by Medicare or other insurance
If you disagree with a Medicare payment or Medicare denies your claim you have the right to appeal. First check with your provider to see if the claim was filed properly. Your Medicare statement will explain the time limit for appealing your claim.
Your Medicare supplement insurance policy will not pay if Medicare does not approve the charges. (Some supplements offer extra benefits not covered by Medicare.)
Keep copies of all forms for your records!