by Ginger Kanzer-Lewis RN, BC, EdM, CDE

If you think reimbursement for healthcare isn’t confusing, you must have missed the furor that is still going on about healthcare reform. It’s astonishing to me that people do not understand who pays for their healthcare, what the Medicare system pays for, and what choices they have to make to protect themselves and their family.

This article will talk about Medicare because you need to know what is and what is not covered. Specific benefits for diabetes supplies and education will also be looked at.

Can you explain reimbursement issues to your patients, colleagues, and staff members? Please do not conclude that this is not your job and that this complicated matter is best left to the business office, accounting department, or office staff. Your patients need to know that you understand this and are looking after their best interests.

The crux of the matter is that often patients are not getting the care they need and are having to make choices between medications, healthcare supplies and services, and the basic necessities of life. This directly affects their health.

If you don’t understand Medicare, how can you help your patients get the care they need? Can you explain the “Welcome to Medicare Benefit”? It is such a wonderful tool for patients and brings significant reimbursement to healthcare providers. Too many patients miss this opportunity because no one tells them about this free benefit.

“Can you explain reimbursement issues to your patients? They need to know that you understand this and are looking after their best interests…This directly affects their health.”

Much of this information is available in “Medicare & You 2009” available from the Centers for Medicare and Medicaid Services free of charge. You can get copies to keep in your office and it’s a wonderful tool to explain these benefits to your patients. You may want to consider an in-service for your staff so everyone is using the same language and giving patients and their families the same information. It’s complicated enough without sending out different messages.

Medicare 101: Simple, clear and basic

Point 1. Who is eligible for Medicare?

Anyone over 65, under 65 with certain disabilities, and anyone with end-stage kidney disease.

“Healthcare professionals should encourage seniors to sign up for Medicare Part B if at all possible…Without the Part B coverage, many seniors hesitate to visit their doctor when they become ill…This risky business is like playing Russian roulette with their lives.”

Point 2. What are the 4 key parts of Medicare?

Medicare Part A (hospital insurance)
This helps cover inpatient hospital care, skilled nursing facilities, hospice, and home health care. Patients usually do not pay for this service if they were employed and it was deducted from their salary. When people first apply for Medicare, they receive a card that tells them which Medicare parts they’re covered for. Patients must sign up for Medicare three months before their 65th birthday. If they do not, they may pay 10% more. When patients apply for Social Security benefits, they automatically are enrolled in Part A. They need to know that there are deductibles and that the first day of hospitalization may not be covered completely or at all.

Medicare Part B. (medical insurance)
Healthcare professionals should encourage seniors to sign up for Medicare Part B if at all possible. Part B helps cover doctors services, outpatient care, and now some preventive services such as flu and pneumonia shots. This service requires a premium and patients pay it monthly. The cost is income based, but if they are filing with their spouse and earn less than $170,000 per year, it’s $96 per month. If they receive social security, it’s deducted automatically from that check. It’s so important for patients to know about this option. Without the Part B coverage, many seniors hesitate to visit their doctor when they become ill. They delay treatment until they present themselves at the emergency room which is covered by Medicare Part A. This risky business is like playing Russian roulette with their lives.

Medicare Part C. (Medicare Advantage Plans)
These are the plans patients buy from private insurance companies and are referred to as supplementary plans. They can be a wonderful addition because they usually pay the deductibles and additional fees for services not covered by Part A or Part B. There’s a premium payment each month and that may be too expensive for some patients. Other people have benefits remaining from their employers and may use this as their supplementary insurance.

Medicare Part D. (Prescription Drug Plans)
This relatively new program has been a wonderful service to patients who can afford the premiums. They are not expensive and can save patients thousands of dollars. The person’s medications are covered for the first $2,830 in 2010. They just pay the co-payments. Then they fall into “the gap” or what is called “the donut hole.” The patient then pays for their drugs until they spend $1,720 out-of-pocket. Once that deductible is satisfied, they are then listed as “catastrophic coverage” and only pay a small co-payment. People don’t realize that even if they have coverage, they must pay the first $295 for their meds each calendar year. They are so shocked in January when they get their first prescription along with a $295 co-pay. We need to remind them of this when we give them prescriptions in December.

“The Welcome to Medicare Benefit is a very special service available to all people who sign up for Medicare. Unfortunately, it is not well advertised to patients and is not explained to health care practitioners well or at all.”

Point 3. Additional help

There is another issue that most people don’t consider. We all know that people over 65 are entitled to Medicare. We also know that “poor” people, (I hate that term but I’ll use it for the purpose of clarification) are entitled to Medicaid. Most people do not know that the elderly poor are entitled to both. A person can get Medicare and then apply for Medicaid to help them pay for the co-pays, additional healthcare, and nursing homes, etc. It will also help with food stamps if they are on a special diet for diabetes.

Point 4. Special programs

Many states have special programs to help seniors pay for most of the costs of Medicare drug coverage. These “extra help” programs are federally funded but administered by each state and are state specific. I’d like to make a recommendation. Most of us are connected in some way to a hospital or healthcare facility. One call to the social service department will get you the answers you need for your local program. Also check online or in a phone directory for your state’s Services for the Elderly program. They have all kinds of materials you can give your patients.

Point 5. The underutilized Welcome to Medicare benefit

The “Welcome to Medicare Benefit” is a very special service available to all people who sign up for Medicare. Unfortunately, it is not well advertised to patients and is not explained to health care practitioners well or at all. The program was revised and expanded on Jan 2009. This is a one time physical exam and there are no deductibles. It also includes a full screening for diabetes, a flu shot and pneumonia inoculation. Until Jan 2009, you had only 6 months to use this benefit after joining Medicare or you lost it. Now you will have a year and no Part B deductible is applied. Three years ago I personally recommended to the people from Social Security that the “Welcome to Medicare” flyer be sent to every person that started receiving Social Security benefits. They said it was a wonderful idea but I’m still waiting. Perhaps this article will help our patients and increase utilization of this important Medicare benefit.

Point 6. Take advantage of the diabetes education and supplies benefits

In 1997 President Clinton signed the Omnibus Budget Reconciliation Act of 1998. It allowed Medicare to cover diabetes self-management education and diabetes supplies. I was there when he announced what was a major victory for the diabetes community. The benefits are divided into two sections:

Section 1. Diabetes self-management education
Every person is entitled to 10 hours of education in an accredited group program the first year of diagnosis. Thereafter, they’re allowed 2 hours of education in an accredited program every year. The Medical Nutrition Therapy Benefit adds 3 hours of nutrition counseling the first year and 2 hours every year there after. This is a great benefit and under utilized. More patients need to be referred to these programs. It’s amazing how many patients who have diabetes for many years have never attended an education program and have such a knowledge deficit. I hate hearing the line, “nobody ever told me that.”

Section 2. Diabetes supplies.
Patients are entitled to Medicare coverage for glucose meters and strips. Please remember that patients with Type 1 are covered for insulin pumps and supplies that accompany them. Patients can get supplies from two sources, pharmacies and durable medical equipment supply houses (DMEs). I call them the two silos. Patients who buy strips from pharmacies have the funds deducted from their drug benefit program. The result is that they may run out of money or reach the “gap” or “donut hole” before the end of the year. However, if they buy their supplies from a DME, where more money is allocated to cover things like wheel chairs etc, this will preserve the patient’s money in the drug pool. That is an important consideration when making purchase choices. Did you know about that?

Point 7. Did you know that Medicare sets the standard?

Aside from all that has been discussed, why is it so important that you know all of this about Medicare? Because Medicaid and private insurance follow Medicare rules. What is set for Medicare usually sets the standards and benefits for all healthcare reimbursement. It affects all of your patients.

I feel so strongly about the importance of this advocacy for patients that I include “reimbursement” as a session in all my diabetes self-management education programs. I strongly suggest to all educators that they are neglecting a basic need if they omit it from their classes.

I hope this basic explanation of reimbursement issues will help you in your practice. I also hope it will benefit your patients.