Medicare and Medicare coverage continues to be a very uphill battle for those of us with lymphedema. While the Women’s Health and Cancer Rights Act (WHCRA) mandates that all insurance companies and HMOs provide coverage for physical complication of mastectomy including lymphedema, other secondary lymphedemas and primary lymphedema continues to have very limited coverage. Clearly, there is a significant need for legialtive reform. The tragic reality though is that the lymphedema world seems hopelessly divided on legislative actions, and strategies.
This page will give you a brief overview of Medicare, provide links to important Medicare pages and links directly to our own Medicare Pages:
We will continue to update our information both on existing pages and with newer pages.
June 22, 2008
Medicare is the federal health insurance program that covers most people age 65 and older. Some younger people who are disabled or who have End-Stage Renal Disease (permanent kidney failure) are also eligible for coverage.
People covered by Medicare are called beneficiaries. Medicare pays for much of their health care, but not all of it. That is, Medicare covers most acute medical conditions – conditions from which a patient usually recovers. But, Medicare does not cover most care given at home, in assisted living facilities or in nursing homes, for people with chronic disabilities and lengthy illnesses. And for many people, there are large gaps in Medicare's prescription drug plans.
Medicare benefits are provided in 4 parts – A, B, C and D. Part A helps pay for inpatient hospital care, some skilled nursing facilities, hospice care, and some home health care. Part A is premium-free for most people. Most beneficiaries do pay a monthly premium to be covered under Medicare Part B – the part that helps pay for doctors, outpatient hospital care, and some other care that Part A doesn't cover, such as physical and occupational therapy.
Part C allows various HMOs, PPOs and similar health care organizations to offer health insurance plans to Medicare beneficiaries. At a minimum, they must provide the same benefits that the Original Medicare Plan provides under Parts A and B. Part C organizations are also permitted to offer additional benefits such as dental and vision care. But, to control costs, Part C plans are allowed to limit a patient's choice of doctors, hospitals, etc., to just those who are members of their networks. This can be a major disadvantage if a patient's favorite doctor or hospital is not a member of their networks.
Medicare's Part D provides prescription drug benefits through various private insurance companies. For more information, including how to enroll, click on Medicare Prescription Drugs benefit. Like Part B, most people have to pay extra premiums each month to be covered for prescription drugs under Part D. Premiums for Part D vary from state-to-state, and from company-to-company. For more information, visit Medicare's website.
Most seniors are covered under the Original Medicare Plan. That plan requires them to pay for some of their health care in addition to their monthly Part B and Part D premiums. Those additional amounts are called deductibles and coinsurance. All premiums, deductibles and coinsurance amounts change every year on January 1st. To see the current Part B premiums, deductibles and coinsurance amounts, click on 2008 Medicare benefits.
Seniors can purchase other insurance policies to cover part or all of Medicare's deductibles and coinsurance amounts, or to cover many types of care that it doesn't cover. These include:
Supplemental Medicare insurance (Medigap) from a private insurance company. To avoid confusion, 12 standardized plans have been defined by federal law, but not all states allow all 12, and not all companies offer all 12. For more information, click on Supplemental Medicare Insurance for Seniors.
Employer or union coverage
Long-Term Care insurance
Other kinds of insurance
Seniors don't need to buy Supplemental Medicare insurance if they are covered under Medicaid, or if they are enrolled in a Part C plan such as a …
Managed Care Plan (a Medicare HMO)
Private Fee-for-Service Plan
Medical Savings Account
Religious Fraternal Benefit Plan
Medicare has more than 40 booklets to help people understand the program. To review the list: Medicare Publications
In this era of rapidly rising medical, pharmaceutical and insurance costs, the American people and Congress are talking a lot about Medicare. Medicare is the federally-funded medical plan for Americans age 65 and over that covers medical expenses such as doctor's visits, hospital stays, drugs and other treatment. The need for a medical program for senior citizens became evident in the 1950s, but it was not until 1965 that Congress passed the laws that established Medicare. The law was amended in 1972 to include people with disabilities and end-stage renal disease.
As with many government programs, wading through the Medicare jungle can be confusing at best. Even insurance agents may not know all the ins and outs of dealing with Medicare, what it will cover and what it will not, or which doctors accept Medicare and which won't. It's a true labyrinth.
Essentially, all Americans are eligible for Medicare when they turn 65. There is an initial enrollment period for seven months after one's 65th birthday, when one can enroll in Medicare for free. After the enrollment period, someone who decides he wants Medicare may be subject to enrollment fees and penalties. Special enrollment periods may apply, but these are also complicated to navigate. Then, the senior citizen must decide whether to enroll in Medicare Part A only, which offers basic Medicare coverage, or also in Part B, which offers supplemental coverage. Some seniors who are covered by their company's group health insurance, or their spouse's, may decline to enroll at all, or may just decide to enroll in Part A since it is cheaper.
Some Medicare coverage is administered by HMOs, which means a private company is paid by the federal government to administer Medicare. The debate over HMOs has raged for several years. Some seniors may receive better care under an HMO, while for others, the benefits may not be as good as a federally-managed plan. It all depends on the HMO and the state where the senior lives. Each state has a different way of dealing with Medicare.
Medicare reform issues have plagued Congress for several years, and a reform bill with a prescription drug benefit was passed in 2003. Because of the changing needs of senior citizens and rising medical costs, this is an issue that Congress will probably continue to wrestle with for many more years. It is difficult to create a “one-plan-fits-all” system.
A senior citizen picking his way through the Medicare jungle will probably need help. This may come in the form of an educated insurance agent or through classes that are available in many communities. There are also numerous resources on the Internet to help a senior citizen find her way. Medicare is complicated — with many exceptions, provisions, rules, limitations, and so forth — making it seemingly impossible to unravel. The wise senior citizen will get assistance long before the time comes to enroll in Medicare.
Medicare Part A helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits.
Cost: Most people don’t have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while they were working. If you (or your spouse) didn’t pay Medicare taxes while you worked and you are age 65 or older, you may be able to buy Part A. If you aren’t sure if you have Part A, look on your red, white, and blue Medicare card. If you have Part A, “Hospital (Part A)” is printed on your card. You can call Social Security at 1-800-772-1213, or visit your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.
Medicare Part B helps cover medical services like doctors’ services, outpatient care, and other medical services that Part A doesn’t cover. Part B is optional. Part B helps pay for covered medical services and items when they are medically necessary. Part B also covers some preventive services like exams, lab tests, and screening shots to help prevent, find, or manage a medical problem.
Cost: Most people will pay the standard monthly Part B premium of $93.50 for 2007. However, starting January 1, 2007, some people will pay a higher premium based on their modified adjusted gross income. If you file an individual tax return and your annual income is more than $80,000 (or if you are married (file a joint tax return) and your annual income is more than $160,000), your monthly Medicare Part B premium may be higher than the standard 2007 monthly premium of $93.50. These amounts change each year. In some cases, your monthly premium amount may be higher if you didn’t sign up for Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn’t sign up for it. You will have to pay this extra amount as long as you have Part B, except in special cases.
For more information about enrolling in Medicare, look in your copy of the “Medicare & You” handbook, call Social Security at 1-800-772-1213, or visit your local Social Security office. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.
The 1997 Balanced Budget Act expanded the kinds of private health-care plans that may offer Medicare benefits to include managed care plans and private fee-for-service plans. The new Medicare Part C programs are in addition to the fee-for-service options available under Medicare Parts A and B.
If you have Medicare Parts A and B, you can join a Medicare Advantage plan. With one of these plans, you do not need a Medigap policy, because Medicare Advantage plans generally cover many of the same benefits that a Medigap policy would cover, such as extra days in the hospital after you have used the number of days that Medicare covers.
Medicare Advantage plans include:
If you decide to join a Medicare Advantage plan, you use the health card that you get from your Medicare Advantage plan provider for your health care. Also, you might have to pay a monthly premium for your Medicare Advantage plan because of the extra benefits it offers.
People who become newly entitled to Medicare should enroll during their initial enrollment period (as explained under Signing up for Medicare ) or during the annual coordinated election period from November 15 – December 31 each year. There also will be special enrollment periods for some situations.
The Medicare Part D program provides beneficiaries with assistance paying for prescription drugs. The drug benefit, added to Medicare by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, (MMA), began in January 2006. Unlike coverage in Medicare Parts A and B, Part D coverage is not provided within the traditional Medicare program. Instead, beneficiaries must affirmatively enroll in one of many hundreds of Part D plans offered by private companies.
The Annual Enrollment Period for Part D runs from November 15 – December 31. During this period people with Medicare can enroll in a plan or change their enrollment from one plan to another. Individuals who are already in a plan should decide whether it will be right for them in the coming year; if they do not choose to switch they will remain in their current plan.
All plans will have different costs and benefits from year to year, thus it is advisable for all beneficiaries to consider their options and make the best choice they can for the coming year.
The Medicare law establishes a standard Part D drug benefit. Plans must offer a benefit package that is at least as valuable as the standard benefit. The standard benefit is defined in terms of the benefit structure, not the particular drugs that must be covered. In 2008, this standard benefit includes an initial $275 deductible. After meeting the deductible the beneficiaries pay 25% of the cost of covered Part D prescription drugs, up to an initial coverage limit of $2,510. Once the initial coverage limit is reached, beneficiaries are subject to another deductible, known as the “Donut Hole,” or “Coverage Gap,” in which they must pay the full costs of drugs. When total out-of-pocket expenses on formulary drugs reach $4,050 - including the costs of the deductible and coinsurance - beneficiaries reach the “Catastrophic Coverage “ benefit. Beneficiaries entitled to Catastrophic Coverage pay $2.25 for a generic or preferred drug and $5.60 for other drugs, or a flat 5% coinsurance, whichever is greater. Note that this out-of-pocket amount is calculated annually. Beneficiaries who reach the $4,050 out-of-pocket threshold in one year have to begin to meet it again on January 1st of the next year.
Because the deductible, initial coverage limit, and annual out-of-pocket threshold change each year according to the changes in expenditures for Part D drugs, beneficiary out-of-pocket expenses may increase annually. The Medicare law does not mandate a set premium amount. These costs as well as the list of covered drugs vary from plan to plan and from region to region. Beneficiaries should take time to review the various plans available to them in light of their current and anticipated needs and financial resources. Decisions do no have to be made until December 31st.
Yet another choice is called Medigap, which is a health insurance policy sold by private insurers to fill the “gaps” in Medicare parts A and B. There are 10 standardized Medigap plans, each of which offer a different set of benefits.
When you buy Medigap, you pay a premium to the insurance company in addition to the Part B premium. Similar to Medicare+Choice, you must be enrolled in Medicare A and B. You don't need a Medigap policy if you are in a Medicare+Choice plan, and may not have both Medigap and Medicare+Choice.
“Shop around wisely for plans that offer Medigap and Part C benefits, because premiums vary widely and the benefits are the same,” says Robert M. Hayes, president of the Medicare Rights Center.
The government will mail you a Medicare information packet, including the Medicare Handbook, before your 65th birthday. If you don't receive it, contact your local Social Security Office or call toll-free at 1-800-772-1213 to request the information.
Getting Medicare to recognize lymphedema therapy as essential medical expenditure has been a difficult task. Lymphedema patients have been long trying to get the benefit of Medicare for the expenses that they incur for the therapy that continues throughout their life. The Women's Health and Cancer Rights Act states that complications arising due to breast cancer surgery, which includes lymphedema, must be covered by all insurance providers. However, this coverage does not extend to those who suffer from primary or secondary lymphedema. In February 2008, the compression garments considered an essential part of lymphedema therapy were classified as covered items for Medicare.
Lymphedema is a condition that has no medical cure, although it can be managed with therapy which is known as the Complete Decongestive Therapy or CDT. The process involves a lymphatic massage combined with the use of compression bandages and compression garments, a skin care routine and a regular exercise regimen. The most important aspect of the therapy is the manual lymph drainage (MLD) which aims at draining the stagnated lymph to reduce the swelling. Occasionally, the therapist might use the Sequential Gradient Pump to loosen fibrotic tissues before the massage. The therapist performing the lymphatic massage is a specialized professional trained in the technique. Therapy sessions in the early stages may be held frequently, at least five days a week. Those who do not have easy access to the lymphedema therapist may use a sequential gradient pump for the lymphatic drainage process.
Medicare covers the lymphedema pump therapy, but recently the coverage rules have been modified. Previously, although the pneumatic compression devices were included in coverage, the patient had to attempt all other methods of treatment first, a process that took many months. This has changed now. Compression devices have been included under durable medical expenses for both primary and secondary lymphedema. There is a four-week trial period which the doctor must observe. A course of medication, use of compression garments and elevation of the limb is followed by the patient and if no improvement is seen, the doctor prescribes a pneumatic pump. The doctor is required to give a Certificate of Medical Necessity to enable the patient to procure a lymphedema pump from a Medicare authorized supplier. The supplier of the pump must be enrolled with Medicare and possess the Medicare Supplier Number, or you will not be reimbursed the claim.
In case of compression garments, which can be a large recurring expense, lymphedema sufferers have had to deal with legislatures which prevented their inclusion in Medicare coverage lists. A positive judgment in February 2008 has come to the aid of lymphedema patients. Compression garments were classified as items meeting the standards for covered items. Items like compression bandages, compression sleeves and stockings were considered medically essential and would be covered as prosthetic devices under Medicare for lymphedema therapy. The lymphedema patients can take advantage of this edict and claim a compensation for these medically essential items that help them to manage the lymphedema.
Peter Hodges has been studying the lymphatic system and how to heal it vigorously since 2003. After many years of research he has now discovered how to heal the lymphatic system, reduce lymphedema swelling and return the body to optimal health.
September 2003 newsletter for California Medicare Beneficiaries, The Medicare Source Published Quarterly by NHIC, A CMS
CMRI is a nonprofit federally funded Quality Improvement Organization for Medicare in the state of California. CMRI assists and advocates for Medicare beneficiary rights and works with healthcare providers to improve the quality of care Medicare beneficiaries receive.
When you have Medicare, you have the right to the care you need. You also have the right to be fully informed and to be involved in decisions made about your care. This means you also have the right to question decisions you think aren’t best for you.
As a Medicare beneficiary there are other rights that are also assured to you:
* The right to protection from discriminating in marketing and enrollment practices * The right to information about what is covered and how much you have to pay * The right to all treatment options available to you * The right to appeal decisions to deny or limit payment for medical care. * The right to know how your Medicare health plan pays its doctors * The right to choose a women’s health specialist * The right, if you have a complex or serious medical condition, to receive a treatment plan that includes direct access to a specialist * The right to receive emergency care
CMRI’s services for Medicare Beneficiaries and their representatives are free. Beneficiaries can contact CMRI to either appeal for a hospital discharge notice or file a quality of care complaint.
If you are being discharged from a hospital before you are medically ready to leave, talk with your doctor or discharge planner first. If your health care provider cannot provide an extension of discharge for you, ask for the decision in writing, sometimes called “Notice of Noncoverage” or “Denial Notice.” Once you get the notice call CMRI by noon the next business day. CMRI will appeal the decision and review the case. While the case is being reviewed by CMRIs’ medical staff, the Medicare beneficiary can stay in the hospital and Medicare will cover the additional days until a decision is made.
CMRI can also help if a Medicare beneficiary has concerns about the quality of healthcare received in all settings of care. If you feel your healthcare has been put at risk because of poor care, call CMRI and we will review the care you received and send you our findings in writing. If we find there was a problem, we will work with that provider to improve the care they give to patients in the future.
CMRI works continuously with Medicare healthcare providers across California to implement statewide best practices for Medicare beneficiaries. CMRI has a toll-free multilingual Helpline. A live customer service representative will answer your call during business hours, M-F 9:00 a.m. to 4:00 p.m. 1-800-841-1602. TTD line for the hearing impaired 1-800-881-5980. During non-business hours, you may leave a message and a Customer Service Representative will contact you the next business day.
For more information: 1-800 Medicare or 1-800-633-4227 CMRI encourages healthy partnerships for quality care; It’s your Right.
In a message dated 11/4/03 7:37:15 PM, Dyanna & Jay writes:
«If you develop LE as a result of cancer treatments the cancer patient's rights act (Bob Weiss for details, pretty sure I got the name wrong) mandates that insurance companies must cover treatment of LE as a result of the original cancer treatment. If it is primary (the default diagnosis for an undetermined etiology) then you are NOT guaranteed coverage. This is a pet peeve of mine, so it's probably just as well my email ate my first reply… If you develop LE, make sure it's labelled as 2ndary by your doc to get coverage…»
The law that Dyanna & Jay refer to is the Womens' Health and Cancer Rights Act of 1998 (WHCRA). Only about half of the states have passed state legislation that complies with the Federal law. There are three things you can do to help.
1. Urge that your Congressional representatives (your two Senators and Representative) fix the WHCRA and, if your state has not passed compliance legislation, then do it.
2. Request that your Congressional representatives (your two Senators and Representative) sponsor a new law to mandate lymphedema treatment and save Medicare millions of taxpayer money every year. I can provide you with a proposed law ready for their sponsorship.
3. Request that your State Senators and State Assemblyman sponsor a state law for the treatment of lymphedema from all sources, primary and secondary. I have the text of the new Virginia Law, the proposed Masschusetts bill, and a proposed California bill, plus support materials.
Contact me for materials for you to give to your representatives.
Bob Weiss LymphActivist
Medicare Managed Care Appeals and Grievances