Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
DECEMBER 2003 NICA NEWS
CHANGES
2004 Medigap High Deductible Amount
The deductible amount for Medigap high deductible options for Calendar Year 2004 will be $1,690.00. High deductible policy options are those with benefit packages classified as "F" or "J" that have a high deductible feature. The deductible amount represents the annual out-of-pocket expenses (excluding premiums) that a beneficiary who chooses one of these options must pay before the policy begins paying benefits. The high deductible amount is determined yearly based on the Consumer Price Index for all urban consumers (CPI-U) as determined by the Bureau of Labor Statistics, Department of Labor. The $1,690.00 high deductible amount is effective January 1, 2004. (Manual Page F6)Outpatient Therapy Cap Suspended
The Medicare limits on physical therapy, speech/language pathology, and occupational therapy that became effective on September 1, 2003, have been suspended with the new Medicare reform legislation. The caps will have a moratorium placed on them for two years, and began immediately when President Bush signed the bill on December 8, 2003. In effect for only two months, Medicare limits on the outpatient therapy had already been taking their toll on people with Medicare. By the end of 2003, it was estimated that five million Americans would reach the limit set by the federal government. Once the limit is reached, seniors and people with disabilities--who on average already spend 22 percent of their incomes on health care--would have had to pay out-of-pocket for additional therapy needs. For more information on the therapy caps, see Page 13 of the September NICA News.Medicare Saving Programs
Congress approved a bill extending the Qualifying Individual Program-1 (QI-1) program through March 31, 2004. The benefits for this program were scheduled to expire on September 30, 2003. Through QI-1, Medicaid provides low-income beneficiaries help with their monthly Part B premiums. The QI-1 program pays the full Medicare monthly Part B premium for individuals with monthly incomes between 120 percent and 135 percent of the federal poverty line. The income cap is $1,030 for an individual and $1,384 for a couple in 2003. These rates will change for 2004. (Manual Page I14)QIO Mediation Program for Beneficiary Complaints
Mediation is a new option to resolve a quality of care complaint under Medicare. Under the mediation program - facilitated by the Quality Improvement Organization (QIO) in Nebraska, CIMRO - the Medicare beneficiary and their doctor or provider determine the solution to their complaint with the help of an impartial third party (the mediator) and the mediator then can write up an agreement that is acceptable to both sides. This is at no direct cost to Medicare beneficiaries. Participation in mediation is voluntary, and either party may withdraw at any time. Whether the beneficiary chooses to participate or not, their benefits under Medicare are not affected. If agreed to by the other party, the Medicare beneficiary may bring a family member, designated representative or a mediation advisor to the mediation. Not all complaints are appropriate for mediation. A CIMRO physician reviewer determines if the case is suitable to be resolved by both parties. If the Medicare beneficiary is interested in mediation they should call CIMRO of NebIMPACT OF MEDICARE BILL
The Center for Medicare & Medicaid Services has provided some answers to the questions most often asked by Medicare beneficiaries regarding the upcoming changes in the law:Q: When do prescription drug benefits go into effect?
A: The drug benefit kicks in fully in 2006. But a discount card will be available before June 2004.
Q: How will the discount card provision work?
A: In the coming two years, beneficiaries will have a chance to buy a discount card saving them 10 to 25 percent on all prescriptions. The cost of the cards has not been set, but they aren't expected to be more than $30 a year. People on Medicare with incomes up to 135 percent of the federal poverty line ($12,123 for an individual) will get a free discount card along with a $600 subsidy toward drug purchases in 2004 and 2005.
Q: How does the benefit change in 2006?
A: Recipients will pay about $35 a month for prescription drug coverage, though premiums will vary slightly around the country. They'll pay for the first $250 of their drugs, and after that will get 75 percent of the cost of the drugs up to $2,250. Then they get no coverage until paying out $3,600 of their own money. After that, Medicare will pick up 95 percent of drug costs.
Q: The Kaiser Family Foundation says the average senior in 2006, the year the Medicare provisions take full effect, would have $3,160 in annual drug bills. How would the bill affect that?
A: A senior who has an average drug cost of $3,160 would end up spending $2,080 out of his or her own pocket for those drugs under the new bill -- $420 for the monthly premiums, $250 for the deductible and $500 for the next $2,000 worth of prescriptions (covered 75 percent under the new bill). He or she would pay an additional $910 for the remaining prescriptions, which receive no coverage until the senior hits the $3,600 out-of-pocket cap.
Q: If a senior is now getting prescription-drug coverage under Medicare from an HMO or a former employer's health plan, what happens under the new bill?
A: The HMO coverage would continue provided your plan or a successor continues offering coverage in your area through Medicare. The bill contains major payment reforms and incentives to encourage more preferred provider networks, HMOs and other health plans to serve Medicare patients in all parts of the country with coverage that would include prescription drugs. Employers have several options. They could decide to drop retiree coverage and leave it entirely to Medicare, or they could redesign their retiree drug benefits to work with the new Medicare benefit, just as they do now with medical benefits. Alternatively, they could continue their own coverage and claim a subsidy for drug costs.
Q: How does the bill affect people of limited resources?
A: Low-income beneficiaries (up to 100 percent of federal poverty level) will have no premiums, deductibles or gaps in coverage. They'll face co-pays of $1 for generics and $3 for brand name prescription drugs.
Demonstration Project to Reverse Heart Disease
A Medicare Demonstration Project in Nebraska is focused on addressing heart disease in Medicare beneficiaries. Heart disease is the leading cause of death in the United States, killing more men and women than the next six leading causes of death combined.The Dr. Dean Ornish Program for Reversing Heart Disease is a non-invasive treatment option that combines four components: moderate exercise, stress management, group support and a low-fat, whole foods nutrition plan to slow, stop and reverse heart disease. By making simple changes in diet and lifestyle, participants are able to achieve significant changes and improvements in weight, blood pressure, cholesterol, diabetes and quality of life.
The Program is offered at Alegent Health Bergan Mercy Medical Center in Omaha and Good Samaritan Health Systems in Kearney. People who are 65 and older, have been diagnosed with heart disease and have Medicare Part B may be eligible to participate.
Those that can benefit from the Dr. Dean Ornish Program for Reversing Heart Disease are people who: are contemplating bypass surgery or angioplasty, but are seeking a non-invasive treatment option, have a history of cardiac events or surgery and want to avoid or minimize the chance of recurrence, have been diagnosed with heart disease such as heart attack, angina or diabetes and people with significant risk factors such as high blood pressure, high cholesterol, heredity or obesity. To be eligible, a beneficiary must live within a 90-minute commute of the participating hospital.
The Program is one year long and participants meet twice a week for twelve weeks. They then are evaluated and continue on at various levels based on their individual needs and progress. The Ornish Team at each hospital site is made up of a physician, nurse, registered dietitian, exercise physiologist, certified stress management instructor, registered dietitian and licensed behavioral clinician.
For more information on the Dr. Dean Ornish Program for Reversing Heart Disease, call 402-398-6131 or visit www.lifestyleadvantage.org. NICA Volunteers interested in promoting the Ornish program to beneficiaries in their area can call their Regional Representative or 1-800-234-7119 to receive promotional materials and more information.
Success Story
Bob Shay is a Medicare beneficiary who is currently participating in the Dr. Dean Ornish Program for Reversing Heart Disease. This now active 66 year-old had a heart attack in February of 2002, while driving his truck. He pulled over and a passerby stopped to help him and call 911. By the time he reached the hospital, he had actually had three heart attacks. His Doctors didn't hold out much hope for him and, basically, told him to get his affairs in order. Prior to his heart attack, this slender man started his day with a pot of coffee and half of a pack of cigarettes for breakfast and repeated this menu for lunch. Then his usual practice was a fast-food meal with cola. Acting as the family cook, his specialties included meat and gravy with mashed potatoes. Somehow Bob survived the heart attack, but he knew he had to change his lifestyle or he would surely die.After the heart attack, Bob retired and quit smoking. About ten years ago, Bob and his wife heard Dr. Ornish speak, so he was somewhat familiar with the Program. When he discovered that it was offered at Alegent, he began to investigate. He attended an Ornish retreat and got a taste of the Program. Then he found out that a Cohort (the year-long class) was beginning and that he could participate in the Medicare Demonstration Project. Bob remarked that the staff was extremely helpful in taking care of all the paperwork.
Bob graduated from the one-year Program this past July and he truly is a changed man. Bob now runs several days a week on the treadmill. "My energy level is unbelievable," he said, "I haven't been able to run a mile since high school and now I do it all the time. I look forward to exercising."
Prior to his heart attack and his new "Ornish" lifestyle, Bob lacked energy, was always short of breath and had a gray complexion. Now he is looking and feeling great! At the beginning of the Program, Bob's cholesterol was over 300 and now it is 138.
Regarding the nutrition plan, Bob says that he really enjoys the food. "I am eating vegetables I had never even heard of before," he said, " the food is very tasty and I have become an extremely good cook. I feel that anything you used to eat can be adapted to meet the guidelines."
"I also feel I handle stress a lot better than I used to," Bob remarked, "The Program taught me what to do when things start to irritate me. So now, I just practice my stress management techniques and I feel calmer right away".
Ornish Program Director at Alegent, Sandy Barta, commented that Bob has done so well and has gone on to become an inspiration and mentor to the other participants. "Bob told me that he feels that this Program has saved his life. He is proud of himself and he should be. He is a wonderful role model," she said.