The Med Diva

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Archive for the category “Affordable Care Act”

Medicare No Longer Pays for Vitamin B-12 Injections — and it’s All Obama’s Fault

Medicare True or False
Is the headline of this post true or false?

If you are a person who believes everything you read on the Internet, then you may be inclined to say it’s true. If, on the other hand, you question everything that sounds too good to be true or simply too unbelievable, then you probably think it’s false—but you’re going to do more research to double-check.

A recent State Farm commercial features a man and a woman discussing mobile apps. During the conversation, the man asks the woman why she believes something he said, and she tells him it’s because she read it on the Internet. “They can’t put anything on the Internet that isn’t true,” she tells him. Right then, an unattractive man walks into view. The woman tells her friend that the boorish man said he was a French male model on the Internet.

The point is, there are a lot of lies out there on the World Wide Web. And many of them have to do with horrible changes to Medicare coverage under the Patient Protection and Affordable Care Act (ACA). Many of the lies are ludicrous and primarily designed to instill fear in people.

The other day, my mom sent me an e-mail that she had received from a former coworker. She told me she was concerned about some of the things the letter said about Medicare coverage under the ACA, aka, Obamacare. Here’s just one excerpt from the e-mail:

Today I went to the doctor for my monthly B-12 shot that I have been getting for a number of years. The nurse came and got me, got out the needle filled and ready to go and then looked at the computer and got very quiet and asked if I was prepared to pay for it. She said that Medicare had turned it down and went to talk to my doctor about it. Fifteen minutes later she came back and said she was sorry, but they had tried everything they could but Medicare is beginning to turn many things away for seniors because of the projected Obamacare coming in.

I did some quick research on and and found out that this letter was one of many that began circulating when Congress was considering a healthcare bill called America’s Affordable Health Choices of 2009 (H.R. 3200). This bill was never passed by Congress. However, the letters continue to circulate, even though most of the points made in these letters are completely irrelevant, outdated, and have nothing to do with Obama’s Affordable Care Act (H.R. 3590).

Yes, Medicare does pay for B-12 injections – if deemed reasonable and necessary
Under Section 1862 (a) (1) (A) of the Social Security Act, Medicare covers services that are deemed reasonable and necessary “for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” For example, vitamin B-12 injections are covered, but only for diagnoses such as pernicious anemia, gastrectomy, and dementias secondary to vitamin B-12 deficiency. In addition, the frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections.

You should also make sure your doctor’s office uses the correct codes when billing Medicare for B-12 injections. According to what I read on the American Academy of Professional Coders website, some Medicare Advantage Plans will not pay for the injection if the doctor also bills Medicare for an Evaluation and Management service. Other plans require a diagnosis code in addition to the codes for the administration and drug code. So if you get your coverage from a Medicare Advantage Plan or Medigap supplemental plan, you should ask what documentation the plan requires for coverage before getting your first injection.


What They Won’t Tell You about the Medicare Coverage Gap Discount Program

Generic drugs in Coverage Gap

Generic drugs are the best value in any stage of your Part D benefit.

Although many people are opposed to the Affordable Care Act (aka Obamacare) for one reason or another, the law is making Medicare prescription drug coverage more affordable by slowly closing the Coverage Gap.  

This year, if you reach the gap (also called the donut hole), you will get a 52.5 percent discount on brand-name drugs. That’s up slightly from the 50 percent discount on brands in 2011 and 2012. So if your copayment was $50 for a $100 drug last year, your copay will be just $47.50 for the same drug in 2013.

But here’s the catch: Although the Coverage Gap Discount Program is certainly helpful if you reach the Coverage Gap and use brand-name drugs, what you may not know—and what the big drug companies won’t tell you—is that even with the 52.5 percent discount on brand-name prescription drugs, lower-cost generic drugs are still the best bang for your buck in most cases.

For the past few years, the government and the media have all been touting the brand discount as a great way to lower drug costs when you’re in the Coverage Gap. What they should be telling you, however, is although the discount is helpful, the real savings lie in generics, no matter what stage of the benefit you’re in. Using generic drugs whenever possible will not only delay your entry into the gap, but it can even keep you out of it.

I’ve always recommended FDA-approved generic drugs as one of the best ways to lower your drug costs and delay entering the Coverage Gap. Not only do they generally cost up to 80 percent less than brands to begin with, but this year you get an additional 21 percent discount on generics when you’re in the gap (that’s up from 14 percent in 2012). So even with the 52.5 percent discount on brand-name drugs, generics still provide more value for your Medicare dollars.

Closing the Medicare Part D Coverage Gap

You will continue to save on covered brand-name and generic drugs while in the Coverage Gap until the gap is closed in 2020. Here is what you’ll pay for drugs while you are in the gap:

  • 2013: 47.5% for brand-names and 79% for generics
  • 2014: 47.5% for brand-names and 72% for generics
  • 2015: 45% for brand-names and 65% for generics
  • 2016: 45% for brand-names and 58% for generics
  • 2017: 40% for brand-names and 51% for generics
  • 2018: 35% for brand-names and 44% for generics
  • 2019: 30% for brand-names and 37% for generics
  • 2020: 25% for brand-names and 25% for generics



No, Mom. Your Medicare Part B premiums are not going up $247 because of Obama.

Ever since Mitt Romney picked Representative Paul Ryan of Wisconsin as his running mate, there has been a lot of discussion, misinformation, and confusion about Medicare and its outlook for current and future beneficiaries. Although I said in a past post that I have absolutely no intention of joining the Ryan-Romney-Medicare bandwagon, I just changed my mind — because now it has gotten personal.

Last night while having dinner with Mom, we got into a discussion about her Medicare supplement plan. “I have to ask you a question,” she said. “Is it really true that my Medicare premiums are going to go up about $200 in two years? That’s what one of my Republican friends told me. She said it’s all Obama’s fault, too.”
Okay, that does it, I thought to myself. I can’t keep quiet on these ridiculous, outrageous lies any more.

“No, Mom. Your Medicare Part B premiums are not going to go up because of President Obama or the Affordable Care Act. This is a complete lie based on a bogus email that went viral before the 2010 elections in an attempt to scare people like you.”

 I then explained to her that, contrary to what has now become popular belief (thanks to this email), the Affordable Care Act does not change the calculation of the Part B premium at all. The Balanced Budget Act of 1997 permanently set standard Part B premiums to cover 25% of projected program costs for beneficiaries. This rule is not changing.

Under this standard calculation, if projected Part B costs increase or decrease, the premium rises or falls. Monthly Medicare Part B premiums may increase, may stay the same, or may even decrease, depending on formulas established before the Affordable Care Act was signed into law. 

AARP Bulletin Senior Editor Patricia Barry (Ms. Medicare) does a good job covering all the details about this myth and Part B premiums, so check it out here if you want all the facts.

Granny, Get Your Gun — And No, Medicare Won’t Make You Tell Your Doctor!

Lately, there have been a lot of crazy rumors about Medicare spreading like wildfire on the Internet. Like the rumor that Medicare premiums are going to jump to $247 in 2014 thanks to the Affordable Care Act, or that Medicare is going to refuse procedures for seniors over 75 unless an ethics panel (aka, death panel) reviews them—again, thanks to Obamacare.

But this rumor that I came across today on the Huffington Post Politics blog isMedicare Does not Ask About Guns by far the most absurd falsehood I have heard yet: Apparently, a Vietnam Vet and/or retired police officer started spreading a rumor via e-mail that Medicare regulations require doctors to ask you if you own a gun. “Be forewarned and aware,” the e-mails state. “The Obama administration has gone on record as considering veterans and gun owners potential terrorists.”

There’s a long and convoluted story behind this rumor, which you can read for yourself on Snopes, but just know that this rumor is wrong and belongs way out in left field (or maybe that should be right field in this case). Although doctors (particularly pediatricians) in most states can ask patients if they own guns if the question is relevant to the person’s medical care or safety, this question is most definitely not required by Medicare. 

So as I stated in my last post, don’t believe everything you read or hear. If you want to sort through the rumors and get to the truth, do some searches on Google to find reputable sources, or check out these fact-finding sites: or or

Will Coverage Gap Discount Disappear if Supreme Court Repeals Affordable Care Act?

Will Supreme Court strike down Coverage Gap DiscountIn the past two years, hundreds of thousands of Medicare beneficiaries with high medication costs have gotten some relief from a provision of the Affordable Care Act aimed at shrinking the Medicare drug Coverage Gap (aka, Donut Hole). Now the big question is whether that provision will stay intact if the Supreme Court repeals the Affordable Care Act.

Under healthcare reform, drug companies have agreed to offer a 50 percent discount on brand-name medications to beneficiaries who are in the Coverage Gap stage of their prescription drug benefit. In addition, the provision gives beneficiaries a 14 percent discount on generic drugs (beneficiaries pay 86 percent of the cost of generics and Medicare picks up the remaining 14 percent).  Those discounts are scheduled to increase until 2020, when a single discount of 75 percent will apply to all prescription drugs. In 2011, 3.6 million Medicare beneficiaries caught in the donut hole saved an average of $604 each on their prescription drugs, according to the U.S. Department of Health and Human Services.

If the law is repealed this week, companies could stop offering the discounts, which would mean that beneficiaries will have to go back to paying 100 percent of the costs for brand-name drugs. And if the law is repealed, Medicare could also stop picking up 14 percent of the tab on generic drugs.

According to recent articles I have read on financial websites, Wall Street stock experts who follow the drug industry aren’t sure whether companies will stop offering the discounts if the law is repealed. As part of the negotiations in the health care debate in 2009, drug makers pledged $80 billion over 10 years to cut the Donut Hold expenses for consumers and help provide funding to cover the uninsured. Drug companies spent a lot of time negotiating the discounts, and so they may be reluctant to throw all that work away.

Of course if drug makers do decide to stop offering the discounts, insurance companies that sell Part D plans could always step in and provide the discount to their members on their own (hint, hint). So far no insurance companies that I know of have announced any plans to help out if the law is repealed and the discounts go away. But I’ll keep you posted if I hear otherwise.

Mission ola lāhui: Increasing awareness of preventive services covered by Medicare in Hawaii

Medicare beneficiaries in HawaiiThis morning I read in Kaiser Health News that only 1 percent of Medicare beneficiaries living in Hawaii have taken advantage of the free annual wellness visit they are entitled to, courtesy of healthcare reform. I immediately sent a tweet via Twitter to my friend Claire Santos, RN, who is a nurse and health communicator and educator in Hawaii. Claire, I tweeted, you now have a mission to increase awareness of preventive services covered by Medicare in your home state.

According to the Centers for Medicare & Medicaid Services, only 890 beneficiaries in the Aloha State have had a free wellness exam this year, which is the lowest percent of any state. Even worse, the state with the highest percentage of seniors who have taken advantage of the wellness visit is Rhode Island — coming in at just 8 percent. 

Nationally, only about 3.6 percent of beneficiaries, or 1.1 million seniors, have had a wellness visit since January.  Jim Firman, CEO of the National Council on Aging (NCOA), a nonprofit advocacy group, theorizes that many seniors simply do not know what additional Medicare benefits are provided in the Affordable Care Act. Speaking at a White House event highlighting benefits to seniors in the health law, Firman said of the annual wellness visit, “This is a really good benefit, but you have to use it to maximize the opportunity.”

What exactly is the annual Medicare wellness visit?

It’s important to understand that the wellness visit is not a physical exam. It’s actually just a great opportunity to talk to your doctor and develop or update a personalized prevention plan based on your current health and risk factors. Anyone who has had Medicare Part B for longer than 12 months is eligible for this annual visit, which includes: 
• A review of medical and family history
• A list of current providers and prescriptions
• Height, weight, blood pressure, and other routine measurements
• A screening schedule for appropriate preventive services
• A list of risk factors and treatment options for you

Other preventive services covered by Medicare

Thanks to the Affordable Care Act, numerous preventive services are now provided free under Medicare. These services include various exams, shots, lab tests, and screenings, plus counseling and education to help you take care of your own health. This year, only 43 percent of Medicare beneficiaries, or about 14 million people, have taken advantage of the free care this year.  CMS put out a great guide to Medicare’s preventive services, which I highly recommend you check out if you are among those eligible who have not yet taken advantage of these services – especially if you are among the 99 percent of beneficiaries in Hawaii who have not yet had your wellness visit.

By the way, if you’re wondering what “ola lāhui” means: According to online sources, it is defined as, “So that the people will live and thrive.” The term is often used with health care services or professionals — like my friend Claire — to show intent to improve the health and being of the Hawaiian people.

Some Medicare beneficiaries with employer-sponsored Rx benefits could get the boot in 2013

Medicare beneficiaries get the bootFor what seems like forever, everyone has been talking about the Affordable Care Act (healthcare reform) and whether the Supreme Court is going to strike it down or Republicans are going to repeal it. While no one knows for certain what is going to happen, I can tell you this: Many employers are planning ahead and thinking about dropping retiree prescription drug coverage in 2013 or later.

If healthcare reform is in, the Retiree Drug Subsidy may be out

Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), employers that sponsor group health plans with drug benefits to retirees can receive a subsidy equal to 28 percent of covered prescription drug costs for their retirees. The MMA established this subsidy, called the Retiree Drug Subsidy, or RDS, to encourage employers to continue offering prescription drug benefits to their retirees rather than require them to get their benefits through Medicare.

Currently these subsidies from the government are tax-free for employers. However, under the ACA, corporations will have to pay taxes on the RDS starting January 1, 2013. (The law will not affect organizations that are not required to pay taxes.)

In response to this potential “increase” in cost of providing retiree drug coverage, some employers are considering eliminating these retiree benefits. According to a 2010 Medicare Trustees Report, about 20 percent of Medicare beneficiaries received their prescription drug coverage through an employer under the RDS program in 2009. As a result of healthcare reform changes, “RDS program participation is assumed to decline quickly to about 2 percent in 2016 and beyond.”

What are your options if your employer drops Rx coverage?

Although not all employers who provide retiree drug benefits participate in the RDS program, it has been a very popular choice. For example, in 2006, 82 percent of sponsors with 1,000 or more employees accepted the RDS.

So keep in mind that:
• If your employer participates in the RDS program, and
• If the ACA survives the Supreme Court or Republican knife, and
• If your employer decides to cut off your prescription drug benefits

The following three things can happen:

1. Your employer can simply drop retiree prescription drug coverage and  suggest you enroll in a Medicare Part D plan on your own.

2. Your employer can seek the help of a Medicare insurance exchange to help you choose a Medicare plan that best meets your needs.

3. Your employer can enroll you in another group benefit called an Enhanced Group Waiver Plan, or EGWP for short. An EGWP is a group Medicare prescription drug plan that, in most cases, provides benefits at least equal to the drug benefits you are receiving through your employer’s current health plan.

Of course, all of the above may be a moot point if the ACA is struck down and the tax deduction for RDS remains in place.

Why women (and men) with Medicare should know about shrinkage

Important Facts about Medicare Part D for 2013

If you’re a fan of Seinfeld, you must remember this classic dialog from the 1994 Hamptons episode, in which George’s girlfriend catches him naked after he gets out of the cold swimming pool:*

Jerry, George Costanza: Elaine!
Jerry: Do women know about shrinkage?
Elaine: What do you mean, like laundry?
Jerry: No, like when a man goes swimming afterwards.
Elaine: It shrinks?
Jerry: Like a frightened turtle!
Elaine: Why does it shrink?
George Costanza: It just does.
Elaine: I don’t know how you guys walk around with those things.

Although I’m going way out on a limb here, I like to think that the Medicare Part D Coverage Gap is also undergoing shrinkage. Albeit, not quite like a frightened turtle – more like a threatened millipede starting to coil up into a ball.

How the donut hole is shrinking

While the entire country is debating whether or not the Patient Protection and Affordable Care Act (ACA) is constitutional, the Medicare Coverage Gap, also called the donut hole, is getting smaller under the public’s radar.

As a result of the ACA, eligible prescription drug plan enrollees who are not Dual Eligibles will pay only 47.5 percent of the costs of covered brand-name drugs in 2013. That’s down slightly from 50 percent this year. If you use generic drugs in the gap (and you should whenever possible), your cost sharing will shrink to 79 percent, from 86 percent in 2012. The Coverage Gap will continue to close a little bit each year, until beneficiaries will pay only 25 percent for both brand-name and generic drugs if they reach this stage.

2013: Three strikes and you’re out

I’m writing this while listening to the Yankees play Tampa Bay on Opening Day, so I couldn’t resist the headline. Basically, what this means is that in 2013, the Centers for Medicare & Medicaid Services (CMS) will alert plan members if their Medicare Part D drug plan or Advantage (Part C) health plan has failed for three years in a row to receive at least 3 out of 5 stars from CMS. If the plan has three strikes, CMS will offer a special enrollment period to allow those members to move to a higher quality plan.

What you will pay for Part D in 2013

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 directs CMS to update the parameters for the standard Part D drug benefit each year. These parameters include the standard deductible, initial coverage limit, catastrophic coverage threshold, and minimum co-payments for costs incurred in the Catastrophic Stage.

Following are the 2013 Part D parameters for the defined standard benefit:

  • Deductible: $325  ($320 in 2012)
  • Initial Coverage Limit: $2,970  ($2,930 in 2012)
  • Out-of-pocket threshold: $4,750  ($4,700 in 2012)
  • Minimum cost-sharing for generic/preferred multi-source drugs in the Catastrophic Phase: $2.65  ($2.60 in 2012)
  • Minimum cost-sharing for other drugs in the Catastrophic Phase: $6.60  ($6.50 in 2012)

*The Internet Movie Database


Coming soon to a theater near you: Son of the Medicare Donut Hole

Like the Blob, the Medicare Donut Hole can consume you.

The dreaded Medicare Coverage Gap will return if Obamacare goes away

Remember the movie Beware! The Blog (also called Son of Blog), the 1972 sequel to the horror science-fiction film The Blob? In this film, a rapidly-growing mass of red ooze returns to prey upon a small town, consuming everything and everyone in its path.  

I hate to say it, but sometime in the near future the Blob may return again, this time to consume all those new Medicare benefits made possible by the Affordable Care Act, aka, Obamacare. Like all those low-budget horror films of the 1970s, a sequel to Obamacare—be it by way of Republican repeal or Supreme Court decision—could be pretty scary and rotten for many people.

For the past few months, Mitt Romney has been going around the country telling supporters that he vows to repeal healthcare reform on Day One of his presidency. I’m not going to get into the irony of this promise or bring up any other political views here, but suffice it to say that most Republicans are in favor of doing away with both Obama and his administration’s Affordable Care Act. Mind you, repealing the law entirely would be a very difficult and lengthy process, but let’s assume it could happen.

We also have to watch out for those nine men and women in black. Starting today, the Supreme Court will begin hearing three days of arguments over the constitutionality of the healthcare reform law. There are three ways the Supreme Court could rule: It could uphold the law, strike down parts of the law, or strike down the whole law.

If there’s a sequel to Obamacare, the Blob may very well return – albeit, in the shape of a donut hole.

Under the Affordable Care Act, the donut hole is shrinking each year until it closes in 2020. Right now, 3.5 million seniors and disabled citizens with Medicare Part D coverage pay less for prescription drugs when they reach the Coverage Gap. Thanks to the ACA’s Coverage Gap Discount Program, Medicare beneficiaries have already saved an estimated $3.2 billion on prescription drugs. In addition, every senior now receives free preventive-care visits under Medicare Part B.

As Vice President Joe Biden recently told a group of seniors in Florida, if the law is appealed or struck down in its entirety, the donut hole will return and you can say good-bye to free preventive care visits. 

If you would like more information about all the benefits you are entitled to with Medicare under the Affordable Care Act, check out this short video from the Patients Aware campaign.

This campaign was created by the National Committee to Preserve Social Security and Medicare Foundation, the Herndon Alliance, and the National Physicians Alliance to help seniors understand the new Medicare benefits available to them through the Affordable Care Act.

It’s not as exciting as Son of Blob, but it helps show why Obamacare is not the horror show some people want us all to believe.

Surprising number of Medicare beneficiaries still have negative views on healthcare reform

According to the Kaiser Family Foundation’s Health Tracking Poll for December 2011, overall national opinion on the Affordable Care Act (aka, healthcare reform law) was an even split for most of 2011, with 41 percent of Americans in favor compared to 43 percent opposed. What is  more surprising, however, is that seniors over age 65 have more negative views about the law than younger Americans have, with 50 percent against the ACA and only 31 percent in favor. With so many provisions geared toward helping people age 65 and older, one would think the numbers would be reversed.

For example, a new Obama administration report finds that the ACA has produced $2.1 billion in prescription drug savings for nearly 4 million Medicare beneficiaries who were enrolled in a Part D plan in 2011. The savings are the result of a provision in the law that provides a 50 percent discount for brand-name drugs and a 14 percent discount for generic brands in the Coverage Gap (“doughnut hole”).

According to the report, which was prepared by analysts in the Office of the Assistant Secretary for Planning and Evaluation (ASPE), the average Medicare enrollee will save approximately $4,181 from 2011 to 2021, while those with high prescription drug costs could save as much as $15,710 over the same period. Beneficiaries can expect greater savings as the law begins to close the gap over time (the gap will be closed in 2020).

Keep in mind, these savings figures are just estimates, and they are based on standard Medicare coverage ($320 deductible, no coverage in the gap, etc.). If you have a first-rate Part D plan that offers full coverage in the gap, or a plan with $0 co-payments for generic drugs, for example, these numbers will not reflect your actual savings.

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