Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
SEPTEMBER 1998 NICA NEWS
ISSUES
WEB SITES
Need a grant, a link to agency partnerships or consumer information? www.nonprofit.govwww.ahca.org This web page is for the American Health Care Association (AHCA). The AHCA represents the Long-Term Care community to the nation at large--to government, business leaders, and the general public. It also serves as a force for change within the Long-Term Care field, providing information, education, and administrative tools that enhance quality at every level. This site includes Long-Term Care news, consumer information and current research.
www.va.gov This web page is the Department of Veterans Affairs. The web site is a world wide resource that provides information on VA programs, veterans benefits, VA facilities worldwide and links to other VA sites.
www.opm.gov/insure This site is for Federal Employees Health Benefits. The site includes frequently asked questions, filing disputed claims and plan information.
www.alz.org This is the Alzheimer's Website. Included are facts, resources, medical issues, progress and how to locate the local Alzheimer's chapters.
INSURANCE COMPANY RATINGS AND/OR COMPARISONS
Many clients wish to know the rating of the insurance company or HMO they have chosen. We do not give out ratings, but recommend they go to the reference section of their local library and look for rating agencies books. Clients may also call the professional corporations who rate companies and obtain the pertinent information.We have a brochure called "Some Questions To Consider in Choosing an Insurance Company" with the names and numbers clients can reach these businesses. Remember, if you give out the number of one corporation you need to give out all of the numbers.
| A.M. Best | 900-555-2378 |
| Demotech, Inc. | 614-761-8602 |
| Duff & Phelps, Inc. | 312-368-3157 |
| Fitch Investors Service | 212-908-0500 |
| Moody's Investors Service | 212-553-0377 |
| Standard & Poor's | 212-208-1527 |
| Wiess Research, Inc. | 800-289-9222 |
NEBRASKA MEDICARE BENEFICIARY COALITION TO HELP CONSUMERS!
NICA has joined several other organizations to create the new Nebraska Medicare Beneficiary Coalition. The mission of the coalition is to help Medicare consumers understand and access their available benefits. In an effort to provide quality service, the Nebraska Medicare Beneficiary Coalition is coordinating efforts to provide information about Medicare programs to consumers and their caregivers, pre-retirees, or human resources representatives. As a team, or individual, the following representatives are available for presentations and seminars at no cost.Coalition Contacts
Medicare Part B Carrier Intermediary
Blue Cross Blue Shield of Kansas
Paula Salsbury
(800) 430-1276
Medicare Part A
Mutual of Omaha
Barb Mull, (402) 351-4713
Blue Cross Blue Shield of Nebraska
Cory "Mickey" Pelnar
(402) 398-3709
Peer Review Organization
The Sunderbruch Corporation--Nebraska
Laura Ousley
(800) 422-2812
Senior's Health Insurance Counseling
Nebraska Health Insurance Information Counseling and
Assistance Program
Tiffany Geis
(402) 471-2201
DMERC Region D Medicare Carrier
CIGNA-Medicare
Dolly Baughman
(208) 333-2140
DEFINITIONS
There are three different deductibles with Medicare. There is the Blood deductible, the Part B deductible and the Part A deductible. A deductible is an amount you owe before Medicare begins paying for services and supplies covered by the program.
The Annual Deductible:
You must pay the first $100 in approved charges for covered medical expenses in 1998. This is called the Medicare Part B annual deductible. You need to meet this $100 deductible only once during the year, and the deductible can be met by any combination of Part B covered expenses. You do not have to meet a separate deductible for each different kind of covered Part B service you receive.
Inpatient Hospital Deductible:
During 1998, from the first day through the 60th day in a hospital during each benefit period, Part A pays for all covered services except the first $764. This is called the inpatient hospital deductible. This deductible is paid once per benefit period. The Part A deductible is an amount a person owes before Medicare begins paying for services and supplies covered by the program.
A deductible is the amount a person pays before Medicare pays benefits. The Part A deductible is $764.00.
The Blood Deductible:
You must pay for or replace the first three pints or units of blood and blood components you use each year. This is called the blood deductible. After you have replaced or paid for the first three pints of blood and you have met the $100 annual deductible, Medicare will pay 80 percent of the approved amount for blood, starting with the fourth pint.
The Blood deductible can be met using Part A, Part B or a combination of both.
FLU SHOT TIME
Remember flu and pneumonia vaccinations are covered services by Medicare. They are free and we need to help spread the word. The flu shot is recommended by the Center for Disease Control for all persons over the age 65 of age as well as adults and children in high-risk groups. The flu shot may be administered anytime during the influenza season, which runs from September through March in the United States.If you or your provider has specific questions, call Blue Cross Blue Shield, the Medicare Carrier at: 1-800-633-1113.
5 Reasons why you should get a flu shot
- The flu is serious business. Influenza (commonly called the flu) is not just a runny nose or upset stomach. It is a serious illness that can lead to pneumonia. Many Americans die each year from pneumonia and other health problems caused by the flu.
- The flu can be very dangerous for people over 65. Almost everyone 65 years and older should get a flu shot. It's also important for those with long-term illness, and for those who spend a lot of time around sick or elderly people. People in these groups are more likely to get very sick if they get the flu.
- A flu shot is safe and helps you protect others. And when you get a flu shot you help yourself and those around you. By avoiding the flu, you avoid giving it to friends and family.
- The flu can make you "blue". Even if you don't develop serious problems, the flu can make you feel bad for days. It can cause fever, chills, headache cough and sore muscles.
- Medicare Part B pays for it. You pay no "coinsurance" or "deductible". Also, if the person giving the shot agrees not to charge more than the amount Medicare pays, you pay nothing. (NOTE: HMO members may be required to get shots from their HMO. Ask your HMO for more information.)
LONG-TERM CARE
Each day people ask of our NICA Volunteers questions regarding Long-Term Care policies. People want to know what the polices provide, which company is best, and what to look for in choosing a company. The following is a summary of commonly asked questions.Q. In Nebraska, how many Activities of Daily Living (ADL's) are insurance companies required to specify in policies? How many of these activities must an individual be unable to perform in order to qualify for Long-Term Care?
A. The number that each insurance company requires will be within its own policy definitions. Make certain they are spelled out, so that there can be no misunderstanding when the policy needs to be activated. If you are uncertain of something in the policy, get a written explanation from the company. Activities of Daily Living (ADLs) can include such things as:
- Walking (Ambulating),
- Bathing,
- Dressing,
- Using the Toilet, (sometimes with maintaining proper hygiene),
- Continence (control of bowel and bladder functions),
- Transferring (moving into and out of a chair or bed) and,
- Feeding Oneself (once food has been made available).
Q. In Nebraska, what are the consumer protection standards that must be included in qualified policies?
A. Nebraska has no specific consumer protection "standards" for Long-Term Care policies, but there are regulations written to directly address consumer protection in Long-Term Care coverage.
Q. Can insurance companies in Nebraska exclude coverage for Alzheimer's disease?
A. No
Q. Does Nebraska law prohibit insurance companies from selling policies that require hospital stay before receiving Long -Term Care benefits?
A. Yes, since 1989 three day hospital stays have been prohibited. Policies sold before 1989 might contain this clause.
Q. Does Nebraska require that policies with automatic increases be compounded?
A. Nebraska does not require that automatic increases in a LTC policy be compounded, but the company must offer the option of increases at the time of application. The benefit levels would increase annually and the increases are not less than five percent.
Q. Which type of Long-Term Care insurance will provide the "best" tax break?
A. The Nebraska Department of Insurance does not provide tax consultation. It is best to discuss this situation with your individual tax person.
Q. How are rate increases regulated in Nebraska?
A. When a company determines the need to raise its rates, it shows just cause to the State of Nebraska. The need to raise rates usually reflects a decreasing pool of paid members, so that rates need to be increased in order to pay the benefits. Rate increases vary per company and amount. There is no fixed percentage per se.
Q. How long is the free-look period in Nebraska?
A. Thirty (30) days. Make certain that you make your checks payable to the Insurance Company, not the agent. Also, obtain the agent's phone number and the insurance company's phone number when you sign the insurance application.
Q. What does the Long-Term Care Policy cover?
A. Long-Term Care providers may include nursing homes, assisted living facilities, congregate care facilities, home health agencies, hospice centers, adult day care centers, respite centers, continuing care retirement communities, therapists in speech, hearing, physical or occupational rehabilitation, chore workers, social workers, home-health aides, nutritional counseling.
Some or all of the above providers will be specified in the Long-Term Care Policy or contract and in addition to which service will be covered and where the service will be covered. The licensing of Long Term Care Facilities is done by the Department of Health and Human Services, not the Department of Insurance.
Q. Should I keep my old policy or switch to a new one?
A. This depends how the old and new policies compare. Your NICA Volunteer can go over each policy and compare the benefits with you. Often people bring their family members with them when discussing policies, which helps to make a more informed decision.
Q. Is it very difficult to file for Long -Term Care benefits?
A. If have any concerns about how complicated it will be to file a claim, call a company's "800" number before buying the policy or before using it. Make certain you understand what the company is looking for in terms of proper claim documentation. For instance, will it accept the doctor's orders, or does it want the progress notes from the care facility as well? However, most company's are unable to specifically state whether an admission will be covered until the patient is in the facility.
HEALTH AND HUMAN SERVICES ANNOUNCES PROGRAM TO REWARD REPORTS OF MEDICARE FRAUD
U.S. Heath and Human Services Secretary Donna E. Shalala announced a new regulation which will make citizens eligible for reward if they alert Medicare to possible acts of fraud and their information leads directly to the recovery of Medicare money."Senior citizens are our first line of defense in the battle to fight Medicare fraud. They can be our eyes and ears in the field," Shalala said. "This program is another weapon in our fight against fraud and abuse -- and protecting the Medicare Trust Fund."
The final regulation detailing the Incentive Program for Fraud and Abuse Information, created in the Health Insurance Portability and Accountability Act, is on display in at the Federal Register. Under this program, which starts in January, 1999, rewards of up to $1,000 will be paid to Medicare beneficiaries and other who report fraud and abuse in the Medicare program.
"It is critical that we enlist the support of Medicare beneficiaries in our fight against health care scams and unscrupulous providers," said Nancy-Ann Deparle, administrator of the Health Care Financing Administration, which oversees Medicare. "Working with the Administration on Aging, one of our partners in Operation Restore Trust, and its national aging network across the nation, thousands of volunteers have been trained to recognize and report fraud and abuse in nursing homes and other long-term care settings as well as local communities."
"This new program underscores the continuing contributions that older Americans continue to make to our country, by enabling them to work closely with their family members, colleagues and peers to fight fraud and abuse," said Jeanette Takamura, assistant secretary for aging. "It is truly a people's campaign."
To receive a reward, the information reported on fraud and abuse must directly contribute to the recovery of Medicare funds for fraudulent activity not already under investigation by law enforcement agencies, the HHS Inspector General, state agencies or Medicare's contractors.
Rewards will be for 10 percent of the recovered overpayment up to a $1,000 maximum and will be financed from the collected overpayments, after all other fines and penalties have been recovered.
Program funds will be used for the administrative costs of the incentive program.
Some examples of the types of potential fraud that Medicare beneficiaries and others can help spot include Medicare being billed for services that were never provided, being billed twice for the same procedure, being billed for a more expensive procedure than the one received, or being billed for a procedure that is not medically necessary; providers using Medicare card numbers that they obtained deceptively; and telemarketing scams.
The incentive program is the latest step in the current unprecedented focus on fighting Medicare fraud, waste and abuse. Medicare alone saved more than $7.5 billion through anti-fraud and abuse efforts in fiscal 1997, and with its law enforcement partners returned another $1 billion to the Medicare Trust Fund. Efforts of the highly successful Operation Restore Trust anti-fraud program identified $23 in money owed back to the Trust Fund for every $1 spent on fraud detection and recoveries. Lessons learned in that pilot project are now being applied nationwide.
HHS press releases are available on the World Wide Web at: www.hhs.gov
EXPANDED COVERAGE OF BLOOD GLUCOSE MONITORS AND TESTING STRIPS FOR ALL DIABETICS--DMERC INSTRUCTIONS
The Balanced Budget Act includes several new provisions relating to Medicare beneficiaries who are diagnosed with diabetes. Previously, Medicare only covered blood glucose monitors and test strips for beneficiaries with diabetes who were insulin-dependent. BBA #4105 expands coverage to include monitors and test strips for all diabetic beneficiaries. Beginning July 1, 1998, Medicare will cover blood glucose monitors and test strips for beneficiaries with diabetes without regard to whether a beneficiary has Type I or Type II diabetes or whether a beneficiary is insulin-dependent or non-insulin dependent.Medicare pays for medically necessary blood glucose monitors, blood testing strips, and lancets subject to conditions and limitations. A written physician order must be received by the supplier prior to delivery of the item.
* Blood Glucose Monitors.--Medicare pays for blood glucose monitors if the physician treating the beneficiary's diabetic condition documents that the beneficiary or caregiver is capable of being trained to use the monitor and the beneficiary or caregiver has completed training to self-monitor the diabetes. The monitor must be designed for home use, not institutional use.
* Test Strips and Lancets for Insulin-Treated Diabetes.--Medicare will pay for up to 100 test strips and 100 lancets every month for use by a beneficiary who is an insulin-treated diabetic. Medicare will pay for more than 100 test strips and 100 lancets per month for the insulin-treated beneficiary if the physician documents the beneficiary's medical need. The supplier of the test strips and lancets maintains the physician's order in its records.
* Test Strips and Lancets for Non-Insulin-Treated Diabetes.--Medicare will pay for up to 50 test strips and 50 lancets every 2 months for use by a beneficiary. Medicare will pay for more than 50 test strips and lancets every 2 months for the non-insulin-treated beneficiary if one of the following indicators is present:
--Management of medical condition by adjusting therapy and/or oral agents:
or
--Detection of hypoglycemia when symptoms are present.
DISABILITY BROCHURE
As NICA Volunteers, we work with seniors and their health insurance issues, however, our population of people under age 65 who are disabled and on Medicare is increasing. At present, there are very few companies that have chosen to be listed in the Medicare Disability Brochure. The companies offering this type of insurance usually have a "preexisting clause" requirement. They also do not have to guarantee to issue a policy to the applicant. When a person becomes age 65 and receives Medicare they can choose a MedSupp policy. The Open Enrollment does apply at that time.The NICA Program Office currently has the Medicare Supplement for People With a Disability brochure available. As a Volunteer, if you need a supply, just call us at (402) 471-2201 or write: Tiffany Geis, Seniors Program Coordinator, Nebraska Department of Insurance, 941 "O" Street, Suite 400, Lincoln, NE 68508.
| 1998 ANNUAL PREMIUMS FOR BENEFICIARIES UNDER AGE 65 | ||||||||||||
| Company | Pre Ex | A | B | C | D | E | F | G | H | I | J | Company Phone Number |
| Aid Asociation for Lutherans | 6 | 455- 512 | 758- 853 | 658- 741 | 827- 931 | 926- 1041 | 1009- 1135 | 800-225-5225 | ||||
| American Family Life Assurance Company of Columbus (AFLAC) | 2 | 1100 | 1713 | 1546 | 800-992-3522 | |||||||
| American Insurance Company of Texas | 6 | 763- 840 | 1090- 1199 | 800-635-7526 | ||||||||
| Bankers Life and Casualty Company | NO NE | 929- 1116 | 1239- 1395 | 800-621-3724 | ||||||||
| Central Benefits | 6 | 436 | 830 | 975 | 953 | 888-633-7877 | ||||||
| Continental Life Insurance of Brentwood | 3 | 1013- 1114 | 1556- 1712 | 800-264-4000 | ||||||||
| National States Insurance Company | 3 | 862 | 1411 | 1909 | 1780 | 2750 | 5207 | 800-868-6788 | ||||
| United American Insurance Company | 6 | 1394 | 972-529-5085 | |||||||||
Most if not all, insurance company will require an applicant to meet required health criteria before a policy will be issued.
Pre-Ex MOS refers to the number of months the company will not cover a policyholder's pre-existing conditions.
The information provided here is not intended to be an advertisement for, or an endorsement of, any firm, individual, or product.
THIS BROCHURE IS NOT TO BE USED FOR MARKETING PURPOSES.