Posts tagged 'medicaid'
We have written and discssed some o the positives involved in home health care. There are a lot of home health care agencies who make home visits - especially elderly patients and/or those who have a very difficult time getting around. These agencies do a great service and are so valuable to the people they serve. The only negative is that if a patient needs extensive care, tests, or medical care by a physician most of the home health care companies do not have physicians available, which can often result in individuals ending up in the emergency room, which is always an expensive situation. However, if there is a doctor available, much of the care - and many times, all of it - can be taken care of at home, on the spot and without causing extra stress and strain on the patient.
It used to be very common for doctors to make house calls, but expense and other factors all but eliminated. That situation has started to change in the last few years for quite a few reasons. When looking at the changes that have taken place in the past decade or more, portability has made it possible for doctors and other healthcare professionals.
Which would you choose if you were elderly or disabled or both and had to keep going to the doctor? Would you rather have the doctor come to you once every 3 to 6 weeks and keep you healthier and more comfortable and, in addition have the capacity to perform most tests and procedures from the patient's home, fax or send information by computer and receive results without the patient having to go through the difficulty, inconvenience, and sometimes, discofort of having to get to the doctor's office.
In addition, research shows that most of the patients served in their homes stay healthier, live longer, stay out of the hospital and emergency room, and it is all because they are getting regular care. If they didn't have regular care, studies show that they would end up seeing the doctor much less often and end up in the emergency room or hospital mor often. With changes in healthcare and with improvements in Medicare and Medicaid coverage, it is possible for many more people who need care at home to receive it.
If you are in a situation that would make it better for you to get treatment at home, checkk with Medicare, Medicaid and any other health coverage you have to see if you can receive care by a physician at home. Then talk to your physician and see if he or she proides that type of care or can recomment a colleague who makes house calls. It may take a little time finding a doctor to make house calls, but there are more and more who are willing to do so.
Once you are able to make the arrangements and get started you will likely feel much more relaxed about seeing the doctor. So, which would you choose? Look at your circumstances and see if you would rather get out of the house, see the doctor, go to the grocery store or go to lunch - which many people do, and it makes them feel better - or if it would be easier for you and more comfortable for the doctor to make a house call to you. Either way, do what you think is the best for your situation and will keep you healthy.
Doctor's Visits 21st Century Style
So you are on Medicare and you have to go to the doctor. 10 years ago it cost a mere pittance for the Medicare premiums and the copay for the doctor. Little by little over the years the mere pittance has risen to a ore hefty amount and has become confusing to boot.
Now there is regular basic Medicare and a barrage of Medicare supplements. This was all created to save money for Medicare recipients and doctors, too, but soehow it has all turned into a confusing mess. Even the people at Medicare and at Center for Medicare and Medicaid Services (CMS) who are trained in this stuff have a hard time explaining it to us so that it makes sense and so that we can decide what plan we need to be on to cover our needs the best.
For instance, a person with dibetes or heart problems who needs to see the doctor and go to the hospital repeatedly and often probably needs a different or additional plan than a person who has asthma and only sees the doctor once every month or two unless there is an unusual problem.
On top of everything else, everyone is a specialist now. You just can't go to a regular general practicioner for a problem and, if, in his or her opinion be sent to a specialist if absolutely necessary. You are sent from one doctor to another to another, often without ever getting an answer because each doctor has a piece of your medical puzzle.
For example, a friend of mine took a fall at work at the beginning of August, 2008. She filled out the right papers and did all she was told to do by her employer and Worker's Comp. Worker's Comp paid her for a couple of weeks because she couldn't work, but then stopped because they decided that a knee injury that happened in 1975, was fullly healed, and never required further treatent after surgery and physical therapy is considered a pre-existing condition. In the 30 years since the knee injury, this woman has been hiking and camping numerous times, horseback riding, scuba diving, playing basketball with her grandchild who is now almost 15, oh, and she has also worked full time - trudging through disasters for FEMA to make sure that people are OK. Yet, this is still a pre-existing condition.
On top of everything else, while she is waiting for Medicaid approval, she is being shuffled from "specialist" to "specialist" to determine what to do. Some doctors won't see her because she can't pay them and they won't wait until Medicaid kicks in. The problem is that the most important doctor who insists she needs surgery on both knees will not see her until he gets some money. That has become a full time job with a lawyer and everything. The doctor sent her to another doctor to deal with the pain. He is a gem and is more worried about the patient than the money. He is trying to help her with the pain and trying to help her get on Social Security because he recognizes - as the first doctor should - that this will definitely take at least a year and there is no guarantee as to how things will turn out.
The third doctor who both other doctors referred her to will not see her until she has Medicaid or something. The problem is that the pain from the accident has dirven up her blood pressure to stroke level, averaging 225/135 when it should be less than 140/90 at most. A simple change of medications - which the patient has all the information on from her old internest from a year ao - would lessen the danger of a heart attack or stroke, yet this doctor will not wait for her $55 dollars for a patient visit just to talk for 5 or 10 minutes and give the patient the prescriptions to help lower the blood pressure and the risk.
This is the state of medical care today. If you have Medicare it is much better, but you need to know which coverage is the best for you so that you don't have to run from doctor to doctor only to find out that you are at the wrong doctor who can 't or won't help you. Do your research, stay as healthy as possible - especially through exercise and diet, and find out all you can about syptoms and medications so that you walk into the doctor's office with the upper hand and a clue of what you need to get help.
Most of us hope we and our loved ones won't end up in the hospital. In the event that we do, we have the hope that we will get through what we are in the hospital for and go home better off than we came to the hospital for.
The remarkable thing that many people don't know is that nearly 100,000 people per year get terrible infections in the hospital and die from them. One out of 20 patients get infections that they contracted in the hospital and some patients survive but have to be on medication for months or years, or even end up with long term or permanent illnesses or disabilities due to these infections.
What are some of the ways to avoid this situation? Several things have been suggested. A 2005 report showed that hospitals could charge the cost of health care-associated infections to third-party payers such as Medicare and Medicaid. Medicare has changed its rules in response to these concerns and will no longer reimburse hospitals for the excess costs associated with the care of patients who contract a hospital-associated infection. But now hospitals have no incentive to accurately report their infection levels. If Medicare were to provide hospitals with more resources for infection control, rather than just penalize them for caring for very sick patients who contract a hospital-associated infection, hospitals might perform better. Really? Why not just perform better and be more careful now?
Last month, the U.S. Department of Health and Human Services released a plan urging hospitals and other health care facilities to adopt increased use of sterile techniques and follow strict protocols to prevent such infections. These include guidelines on the proper insertion of catheters and disinfection of ventilators, as well as practices that minimize risk of infection before, during and after surgery.
The University of Maryland Medical Center screens all patients at high risk for MRSA when they are admitted. Screening includes patients in intensive care units and those who have been in another health care facility during the past year. The tests are repeated during the hospital stay. Isolation precautions are instituted for those who test positive for MRSA. During the past year, the hospital has performed more than 33,000 MRSA screening tests. This aggressive action has slashed the hospital's rate of MRSA infection by more than 30 percent and has saved lives.
Patients with health care-associated infections move among hospitals, other health care facilities and nursing homes, and can spread the infections regionally. That means that a specific hospital does not necessarily receive all of the benefits from its infection control activities.
What's the solution? Infection control efforts should be a coordinated effort involving hospitals and HHS and the Centers for Medicare and Medicaid Services. Hospitals could be provided with tools and incentives to work together so that they can coordinate infection-control measures. If regional coordination existed, infections wouldn't just be transferred from one place to the next.
Health care-associated drug-resistant infections are a complex problem. The overselling and overuse of antibiotics, as well as the lack of new antibiotics in the research pipeline, are driving the high rates of resistant infections. Timely prescribing of antibiotics can help reduce infections in hospitals, but we have to work to reduce overprescribing as well. Hopefully government and hospitals will work together to come up with a policy that will bring this situation under control.
On July 1, 2006 the Deficit Reduction Act went into effect. The act required all immigrants to give proof of legal immigration or citizenship when they are applying for Medicaid for the first time. This applies to children, as well. Most legal immigrants cannot receive Medicaid benefits for the first five years that they are in the U.S. Undocumented immigrants can only receive emergency Medicaid services.
Once the bill became law, it also restricted citizens, as well. Medicaid enrollment has declined since the law was enacted, partially because even U.S. citizens are finding it difficult to locate some of the documents required to enroll for Medicaid services. This is because some of the documents need to be original documents, and it can be difficult to obtain original documents in many cases.
As far as Medicaid goes, they receive matching federal funds to help run the program and pay claims. As a result, even if they wanted to assist individuals without documentation it would be a problem for Medicaid both in a financial sense and in a legal sense.
The rules for Medicare and Medicaid are so stringent that CMS has instituted a rule that even requires child welfare agencies to document citizenship for children being placed into foster care. There are some issues where people receive extra time to provide documentation, however, they are limited and must adhere to very specific rules and time frames.
Once an individual has completed the documentation process and is approved for coverage, they will be covered retroactively to the date of the application or to the month of the application depending on the state they are living in and a few other variables. Trust me when I tell you that this can be a true adventure that seems to take forever. Just when you think you have sent in everything that is needed you get a letter or phone call asking for more. Just take a deep breath and send the requested paperwork in. Be prepared for at least a couple of follow-up requests. As long as you comply with the requests, you will get the coverage you applied for and qualify for.
The primary types of identification include a state driver’s license, Certificate of Naturalization, Certificate of Citizenship or a U.S. passport. Secondary types of identification for naturalized citizens include a U.S. Birth Certificate, data verification with Systematic Alien Verification for Entitlements (SAVE) documentation, or documentation and data match with a state verification agency, as well as other documents.
It is important to know the law, your rights, your responsibilities and your entitlements in order to receive the benefits you need. You can research them on the web by going to the CMS website.
As the new administration takes on the responsibility of fixing some of the issues left behind from the old administration, it has become apparent that this will be no easy task.
Everybody from people on main street to the people on Wall Street have known for quite some time that things have needed to change. Main street is just trying to survive, and as the economy has gotten worse many on main street are losing the battle of surviving financially.
Folks on Wall Street are not immune, either. They may not feel the pinch as much, but many of them have lost millions and more. Some of the wealthiest people in the world have committed suicide due to the fact that they lost so much money, yet they were still some of the very richest people in the world even after they lost the money.
One of te issues that begs to be cleaned up is Medicare and Medicaid. With general budgets out of control and lawmakers divided as to how to fix a number of programs, especially healthcare, this is a battle that will be hard fought.
As it is, people can barely keep up with various premiums and copays. Time will tell what affect lawmakers will have in trying to adjust benefits and premium so that people can still afford Medicare and Medicaid and not lose some of the services they need.
Even though there have been promises of non-partison ways to work on the many serious issues facing Congress, from the beginning there has been a tremendous divide between Republicans and Democrats. In fact, trying to fix the economy by passing a bill was a tremendous task. The President and many of the Democrats adjusted the proposed bill over and over to accommodate Republicans. In the end however no Republicans voted for the bill. In other words, the President and the Democrats could hav left the original bill the way they wrote it rather than take the time to give the Republicans the changes they asked for and not get any support anyway. That would have saved a lot of time and delivered a more solid bill, according to the Democrats.
The President and Congress are trying to fix the Medicare Mess as well as the entire financial situation that has gone from bad to worse. Here's hoping that this can be done sooner rather than later from Main Street to Wall Street.
Many people are confused about Medicare and Medicaid including the question of what the differences are between the programs. There are some major differences between the two, but they are easy to sort out.
Medicare is a program that is funded by the federal government as an entitlement program, which mainly focuses on the older population. It is a social insurance program for individuals age 65 and over and it also covers medical bills of many individuals with disabilities. Medicare also covers individuals of all ages with end stage renal (kidney) disease.
There are several parts to Medicare. Part A covers hospital bills, Part B covers medical insurance and Part D covers prescriptions. There are other parts, as well, and they act as supplements, however, that discussion is for a different article.
Medicaid is different from Medicare in several ways. Medicaid is also an entitlement program, however, Medicaid is not funded only by federal government, there is a state component as well, and in some states, counties pay part of the cost, too.
Medicaid is based on need and social welfare, with eligibility based on income. If a person has limited income and/or limited financial resources, Medicaid covers a broader amount of services than Medicare does. It usually covers children, pregnant women, parents of eligible children, seniors and individuals with disabilities. Though poverty is used to determine eligibility, a person must fall into one of the other coverage groups in addition to being determined eligible due to being in poverty. Medicaid benefits are paid directly to the provider of services. So, if you go to the doctor, the doctor gets the payment, if you go to the pharmacy, Medicaid pays the pharmacy directly. In addition to covering individuals who meet financial requirements, in some states Medicaid covers individuals who cannot otherwise afford insurance.
Some individuals qualify for coverage by both programs. For more information regarding Medicare and Medicaid, go to www.medicaid.gov or www.medicare.gov or simply go to Google or another search engine and type in Medicare or Medicaid and you will get pages of information.
Dual eligibility is a term that is heard but not always understood by Medicare beneficiaries. What it basically means to have dual eligibility is that a person qualifies for both Medicare and Medicaid.
To qualify for dual eligibility an individual must meet the requirements for both Medicare and Medicaid. Most individuals meet the requirements for only one or the other; however there are quite a number of people who also meet Medicaid guidelines based on income and assets.
Some people qualify for Medicare and partial dual eligibility, meaning that they have Medicare coverage and can also have Medicaid coverage if they pay a very small monthly premium for it. Others qualify for total dual eligibility, meaning that they can be covered by both Medicare and Medicaid and because their income and assets are below a certain point, they do not have to pay any Medicaid premiums.
The importance of having both Medicare and Medicaid is that they cover different things, and when an individual – especially with a low income – qualifies for both through dual coverage, they are basically covered for hospital care as well as doctor visits and medication with low or no copayments. In addition, certain features of dual coverage may help pay your Medicare Part D coverage premiums.
If you have questions about dual coverage, how it works, whether your state provides it and whether you qualify, you can get information from your local health department. You can also find an excellent explanation of how dual coverage works on the Centers for Medicare and Medicaid Services (CMS) website.
For more information go to the CMS website at www.cms.hhs.gov/DualEligible.
Medicare can help offset medical expenses, which is a good thing. However; there are gaps in coverage with Medicare, and they need to be filled. One way to fill these gaps is to take the money out of your pocket, your bank account your life savings or your retirement.
Especially if you have the original Medicare plan, you need to look into supplements, also called Medigap. These will help you pay for expenses that are not covered and pay for some – or most, or all – of those costs.
There are 12 Medigap policies and each is a little different and covers different things. The premiums can differ a lot, as well, so it is essential that you thoroughly check each company selling these supplemental policies to make certain which covers offered through
Study each Medigap plan before deciding which one to select. This is extremely important, particularly because there are so many people on Medicaid and/or Medicaid who don’t understand how the program works and often don’t realize that their billing. Information you receive could make a vast difference as to whether your medical bills will be covered and how much you could save by only having to pay a basic and affordable for the most part.
Why not find out what benefits you qualify for and which ones are right for you? Study all the Medigap plans to figure out the differences and which one would suit you the best. You can check the internet for a vast amount of information, you can talk to someone by calling 1-800-MEDICARE, and you can call your local insurance agent.
Whatever you decide, it is essential to find out what coverage is available and how it works, as well as, which plan will work best for you.
Reports have surfaced showing that many states have underestimated and under-funded the cost of long term care. Medicare has done so as well. This has left many seniors understandably worried.
The estimates for the costs of long term care seem to be nearly $4.5 billion dollars below actual costs of providing quality care. The main states affected are California, Florida, Wisconsin, Massachusetts, New York, Illinois, Ohio, Pennsylvania, New Jersey and Texas.
Because of the fact that the gap between what quality care costs and what Medicaid actually pays is substantial, states are looking for a solution to eliminate at least part of the shortfall. Extreme budget pressures have states in a quandary as to what to do. They are looking for extra dollars, because if they cannot make up at least part of the difference between cost of care and payment for care, some seniors may not be able to get long term care services.
The American Healthcare Association (AHCA) President and CEO, Bruce Yarwood, feels that “a post-election stimulus package must include state Medicaid relief to help prevent problems with accessing this essential care in 2009.” The long term care industry hopes this will happen. One bright sign is that the head of the Federal Reserve recently indicated that in order to bolster the country’s economy, federal dollars need to be injected into state budgets to help provide essential services.
According to the National Governors’ Association, combined state shortfalls total $50 billion for the fiscal year from July 2008 to July 2009. Without federal help this will be an insurmountable amount. In addition, Medicaid is being “propped up” by Medicare, according to Yarwood, who feels that this leaves Medicaid in a very vulnerable and precarious position.
For now, all that seniors can do is to protect themselves the best they can with the coverage they can get and wait to see what lawmakers will do when working out the federal budget. Hopefully they will see the value in helping states stabilize programs such as Medicaid to ensure long term care for the nation’s senior population.
There have been many debates recently as to how to handle the situation of healthcare for individuals who are living in the United States but are not U.S. citizens. With elections around the corner, this issue has become an intense topic for discussion on all sides of the aisle.
There are many varied opinions regarding healthcare for these individuals and families. Studies have shown that the money they generate in the economy and sometimes in taxes offsets most or all of the medical expenses they incur. Other studies say the opposite.
With Medicare and Medicaid budgets and services struggling financially there have been questions raised as to how these individuals receive medical care and what it costs the system.
In Ohio, the Columbus Dispatch Newspaper stated in an article that the poor and/or undocumented in central Ohio, line up at the free health clinic near Ohio State University. The lines begin to form hours before the clinic – which is staffed by volunteer doctors and nurses - opens for services.
There is now a proposed bill requiring Clinica Latina and other clinics that serve undocumented residents to check for immigration status and turn away any individuals who do not have documentation. The bill states that the reason is that part of the funds for this particular clinic and some others come from Ohio State University. If the clinic were to receive funds only from private sources, they could continue treating these individuals without checking their status.
The issue that this leaves could have a huge financial impact on Medicare, Medicaid and the healthcare system because it would leave undocumented citizens with only the hospital emergency room for treatment. Unlike clinics, federal law states that hospitals cannot deny services to individuals based on various issues, including immigration status. As a result, seeing a doctor at the free clinic and receiving a $5 prescription for blood pressure or diabetes medication could now cost hundreds of dollars at the emergency room, and Medicare, Medicaid and taxpayers would have to absorb those costs.
The issue of undocumented residents in this country is not a simple one, nor will it be solved simply or quickly, however, it is important for lawmakers and administrators to look at the big picture and the overall costs before eliminating programs that could save an already struggling system money just to prove a point.
Most of us start getting creaky knees as we get older. Some of our knees just creak here and there and other creak all the time. Others creak and hurt too often, usually as a result of osteoarthritis.
This is actually an uncomfortable situation, but it is normal for these symptoms to begin to happen to us between age 45 and 55 and develop into chronic problems after age 60.
Medicare used to pay for arthroscopic surgery on the knee to address the issue of osteoarthritis. In 2002, a study was done stating that there was no better improvement in the knees of patients who had arthroscopic surgery than there was in those who simply had physical therapy and used ibuprofen and other medications.
Many doctors and patients were quite unhappy with the fact that this study prompted Medicare to stop covering the procedure. They felt that this particular study, which was performed on about 175 men, was too limited to make such a sweeping decision which affected hundreds of thousands of Medicare recipients. Medicare finally has the results of another study performed by Boston University School of Medicine and a separate study performed by the University of Western Ontario in Canada.
The results of both recent studies confirm the results of the 2002 study: arthroscopic knee surgery for osteoarthritis is over-performed and does no better than physical therapy and medication. Of the nearly 1300 participants in the studies, the individuals who received physical therapy reported that they felt better and had less pain after receiving physical therapy, taking anti-inflammatory medication and sometimes using glucosamine. The results of those who had arthroscopic surgery were exactly the same.
The biggest difference was that the bill for the surgery alone is about $5,000 or more, plus any doctors fees, lab and hospital fees and other ancillary fees. That is much more than some physical therapy, exercises the patient can do at home and medication. In addition, the studies show that the procedure is unnecessary.
In some cases arthroscopic surgery is warranted, and certainly, in some more severe situations arthroscopic or other knee surgery would be appropriate. It is important to get a second opinion and to try physical therapy and other treatment before you opt for arthroscopic surgery. There are two reasons: first, experts are saying that it doesn’t work and some doctors are simply making money on the procedure. Second, Medicare will not pay for it.
So, if your knees are creaking or hurting, or both, look into your options to determine what will be best for you.
Medicaid is supposed to help families take care of medical and dental needs, and this is especially important for children. A recent study by the United States government revealed that millions of poor children on Medicaid are not getting the dental treatment they need because they cannot find dentists willing to accept Medicaid as payment.
This leaves many children in a very vulnerable state. The findings, released by the Government Accountability Office stated that millions of poor children between the ages of 2 and 18 have untreated dental decay and disease because they cannot get the needed treatment.
It might not sound like a huge issue to have a cavity that doesn’t get taken care of, but think about whether you have ever had a toothache that grew worse and worse over a weekend. When you went to the dentist you discovered that you had a cavity that, if it had been addressed sooner, could have been filled. The dentist feels that you now need a root canal or other serious procedure because the cavity has destroyed too much of your tooth and that is what is causing your pain.
Now think about a child or young adult who has not one but 5 or 10 of these festering in their mouth. They are in pain. They probably are not able to eat right. Perhaps they cannot concentrate – especially in school – because of the pain and headaches due to the dental problems.
If they –or their parents – are conscientious about brushing, flossing and rinsing with mouthwash, they may avoid infection. If not, like 12 year old Deamonte Driver, even though they try to do everything to keep the condition under control, they are unable to. In Deamonte’s case, he ended up with a serious tooth infection that led to a brain infection and he died.
Deamonte had Medicaid coverage. He had a simple cavity. His mother tried to find a dentist – any dentist – that would help him and treat the condition while it was a simple situation and no dentist would do so because they would not accept Medicaid as payment. Because of a few more dollars, 12 year old Deamonte is dead.
Only 1 out of 3 children on Medicaid are receiving dental care, mainly because nobody will provide it. It is essential that while lawmakers are looking at a Medicare fix, they look at Medicaid, as well. It is also essential that practitioners, schools, lawmakers and Medicaid work together to fix this problem. 2 out of 3 children on Medicaid that cannot find dental care should not remain vulnerable to the unconscionable outcome that Deamonte Driver and his family suffered.
If you are an individual receiving Medicaid benefits there are various rights that you are entitled to. For example, if your are denied services for any reason, you are entitled to appeal the decision. The appeal is supposed to be addressed within 90 days from the time it is filed.
Since Medicaid is a program which is jointly funded by state and federal funds, there are definite rules that govern appeals and decisions. In Georgia, where many lawsuits have been filed – especially by and on behalf of individuals with disabilities who have been denied the right to a timely appeal.
Some lawsuits which have been filed against the officials of the Department of Community Health allege that Medicaid has been violating both state and federal law by delaying hearings for people with disabilities who have appealed decisions about their care. The lawsuit states that hundreds of Georgians – many of them disabled – have been subjected to extremely long waits that are illegal trying to get hearings for their appeals of medical services that they have been denied.
The most unfortunate part of this situation is that while there are “backlogs” and delays, individuals are not receiving the care that they desperately need, so in many cases, their health declines, eventually costing Medicaid more money.
Some examples of this situation are:
• An individual who is a paraplegic with other health issues needs 4 more hours per day of home health care or she will have to return to a nursing home which would cost many times the expense of extra home care. Medicare declined her latest request in January and she appealed in February. Her appeal has still not been heard and it is nearly August. Her case has not even been sent to the office that hears appeals.
• A second plaintiff in an individual with Multiple Sclerosis who has been living in a nursing home. He would like to be in his own apartment because it is a better environment for him and a much better environment for his children. Living in an apartment and receiving home health care would be far more cost efficient than the nursing home. He has been waiting since early March for a hearing regarding his appeal.
These are just two cases in a sea of backlogged appeals. While individuals suffer delay after delay, Medicaid continues to spend more money on services that are not necessarily appropriate or cost effective for too many people in the system. The decisions in these and other cases will hopefully set a precedent and turn the process around so that it is efficient, effective and helpful for those who are depending on it to help them enhance their lives.
Many doctors and caregivers have long felt that with the right information, equipment and know-how, patients can get – and stay – well with the help of family and maintain or increase their recovery and their health.
To that end, the Patient Centered Primary Care Collaborative (PCPCC) was pleased that The Medicare Improvements for Patients and Providers Act of 2008 that was just passed by the Senate, included a provision for a demonstration project for the PCPCC model.
The PCPCC is a collaborative of over 150 major employers, consumer groups, physicians groups and others working together to raise the quality of care to patients by giving them a “medical home.” This system of care will also improve delivery of services by using
The PCPCC works with the whole person – in a situation where primary care physicians are responsible for arranging that person’s care. The person sees a particular physician and the physician’s team, who will arrange for specialists and others who can help the individual. In addition, where appropriate and wherever possible, primary care physicians coordinate and collaborate with families of their patients regarding their care. The primary physician works across all fields of medicine and coordinates all care to make it easier and less confusing to the patient.
In addition, patients would be able to access care on an open-scheduling basis. Since they would be cared for by a team and would not have to necessarily go to the physician’s office for all treatment and assistance, some help could be obtained by using technical assistance during expanded hours.
The PCPCC promotes a new way of thinking when it comes to medicine and could especially help individuals covered by Medicare and Medicaid. It is endorsed by The American Academy of Family Physicians, The American Academy of Pediatrics, The American College of Physicians and The American Osteopathic Association.
The demonstration project funding as well as funding for further full-blown pilot projects will help determine if the PCPCC has developed an idea that will create better outcomes for patients while paying doctors and other medical professionals what they should rightfully be paid and still contain costs, especially to programs such as Medicare and Medicaid. Hopefully this will create a win-win situation for all parties.
It has been about two years since the Deficit Reduction Act went into effect (7/1/06) requiring all immigrants to give proof of legal immigration or citizenship when they are applying for Medicaid for the first time. This applies to children, as well. Most legal immigrants cannot receive Medicaid benefits for the first five years that they are in the U.S. and undocumented immigrants can only receive emergency Medicaid services.
Once the bill became law, it also restricted citizens, as well. Medicaid enrollment has declined since the law was enacted, partially because even U.S. citizens are finding it difficult to locate some of the documents required to enroll for Medicaid services. This is because some of the documents need to be original documents, and it can be difficult to obtain original documents in many cases.
As far as Medicaid goes, they receive matching federal funds to help run the program and pay claims. As a result, even if they wanted to assist individuals without documentation it would be a problem for Medicaid both in a financial sense and in a legal sense.
The rules are so stringent that CMS has instituted a rule that even requires child welfare agencies to document citizenship for children being placed into foster care. There are some issues where people receive extra time to provide documentation, however, they are limited and must adhere to very specific rules and time frames.
Once an individual has completed the documentation process and is approved for coverage, they will be covered retroactively to the date of the application or to the month of the application depending on the state they are living in and a few other variables.
The primary types of identification include a state driver’s license, Certificate of Naturalization, Certificate of Citizenship or a U.S. passport. Secondary types of identification for naturalized citizens include a U.S. Birth Certificate, data verification with Systematic Alien Verification for Entitlements (SAVE) documentation, or documentation and data match with a state verification agency, as well as other documents.
It is important to know the law, your rights, your responsibilities and your entitlements in order to receive the benefits you need. You can research them on the web by going to the CMS website.
Ohio Congressman and Republican Leader John Boehner was praised today for advancing the bipartisan efforts to stop the Bush Administration’s plan to cut senior’s Medicare Part A Nursing Home funding. If the cuts are put through, they could badly hurt the most vulnerable seniors in the country, creating a $45 million loss in Ohio in the next year alone.
Congressman Boehner sent a letter to Health and Human Services Secretary Mike Leavitt, stating that high quality nursing home care will be seriously threatened if the Centers for Medicare and Medicaid Services (CMS) allows the proposal that would cut $770 million from nursing home funding in 2009, the most vulnerable in society would be hurt the most. After 2009, there would be $4 billion more in cuts over the next five years.
Not only will these cuts impact Ohio nursing homes and the seniors that need them most, but will also impact the economy of the state. Though Congressman Boehner is from Ohio and trying to help Ohio seniors, the same issues hold true in states throughout the nation. The bill will be detrimental to seniors in every state and the economies of every state as well, and as a result.
Boehner’s letter to Secretary Leavitt also states “The administration should be commended for its previous support for policies that moved many high acuity patients into Skilled Nursing Facilities. While these patients may have otherwise been cared for in higher cost facilities, the success of these policies helped to save Medicare $709 million in 2006 alone.”
The Ohio Healthcare Association, a non-profit organization that thanked Congressman Boehner and backs him in his efforts to stop the Bush Administration’s cuts, is the largest healthcare association in Ohio, and represents 700 of the nursing homes and long term care facilities in the state, plus assisted living residences and facilities for people with mental retardation and developmental disabilities, is the only Chartered Ohio Affiliate of the American Healthcare Association, which represents 12,000 long term care facilities throughout the United States.
With backing and endorsement from an organization of that magnitude, hopefully the results will help Ohio’s – and America’s seniors.
Medicare Centers for Medicare and Medicaid Services (CMS) has been working on a pilot program for three years. The pilot program has involved over 250 hospitals and has monitored quality measures in those hospitals during that time, offering rewards for high quality.
This partnership between the hospital consortium and Premier and the CMS spent the three years working on the quality measures in the 250 hospitals that were part of the pilot. Premier reported that the results that were achieved included a 15.8% increase in quality in these hospitals that served 1.1 million patients. Premier President and CEO Richard Norling said, “The findings from the first three years of the project clearly show that transparency with rewards for quality achieves a higher level of performances in American hospitals.
This project actually brought up the performance standards of all hospitals involved to a better level, bringing those on the lower levels closer to the higher levels and closing the gap between them. This is great news, and if the pilot program works to raise quality levels in these 230 hospitals, it would be a tremendous idea to expand the program or at least use the standards and rewards in the pilot to improve quality of more hospitals throughout the country. The money saved because of the improvements of quality and efficiency could be used to fund the pilots or other programs for other hospitals in other areas across the country.
There was an announcement by Acting CMS Administrator Kerry Weems said in a statement, “Given these results it is time for us to take the next step and implement hospital Value Based Purchasing for the Medicare program, so that citizens across the nation can benefit from improved safety and quality [and] get the right care every time.”
Long term care has long been an important issue that needs to be addressed and has been debated many times. With Medicare and Medicaid systems under so much financial strain and with proposals in the works for revisions and provisions, it seems that Congress on both sides of the aisles is grappling with the issue of Long Term Care funding.
This is a serious issue, as it affects millions of individuals and their families and over 10 million individuals who are living at home and receiving services in there homes and in the community. These people need assistance and services and are normally on a very limited income, being cared for by family and friends. They are often in situations where they are trying to stay at home and in the community in which they live, receiving their supports there, rather than ending up in an assisted living or long term care facility.
It has been shown that when a person can stay in the community and in familiar surroundings receiving long-term supports that is the best situation for them if their situation and condition permits. Congress – and other organizations – is looking further into the cost savings and health effects of helping people stay in the community vs. a healthcare facility. There are various studies that have taken place and are taking place – especially in the recent past and currently – trying to determine to continue to fund the essential service of long term care.
With Congress presently looking at ways to buy time so that Bush Medicare cuts - which affect Medicaid drastically – won’t take place immediately, there is a good chance to work on long term care issues at the same time.
In the meantime, if you are dealing with long term care issues, be sure to keep current with what is happening. For current information you can log into www.CMS.gov.
There are stories about individuals and families having some issues with services through Medicaid because of misunderstandings with providers or not understanding their coverage. Sometimes mistakes are made and must be fixed. The majority of the time providers try to work with Medicaid recipients to provide the best service they can.
In New Jersey, however, there is a company that has been in the news lately for doing just the opposite. This story has been touched on before, but there are more details continuing to come out.
The company, Assisted Living Concepts, based in Wisconsin has a large number of assisted living facilities. As in any business, some things work well and turn out right and some things sometimes do not. There are many excellent assisted living companies throughout the country who work hard every day to balance their budgets, help the residents – whether on Medicaid or not – and deal with issues – especially financial ones – that come up.
Unfortunately, at least in this case, Assisted Living Concepts has handled a situation with eight of its facilities in South Jersey in a harmful and totally inequitable way. In these particular facilities, Assisted Living Concepts had a number of individuals staying there and receiving service who were paying for their services out of their life savings. The individuals say that they were told that if their savings ran out, they would be switched to Medicaid and could stay where they were in Assisted Living Concepts facilities.
Instead, when their savings were totally gone – because they had been paid to Assisted Living Concepts for their care – they were told that they had to leave. A complaint was made and a few weeks ago the Public Advocate began an attempt to review records to see how many more individuals were – or had been – in this position with Assisted Living Concepts.
The case has gone to Superior Court, and a judge will decide on whether the records will be released for review. The case is difficult because, though all Assisted Living facilities are supposed to keep 10% of their beds for Medicaid recipients (in New Jersey), some are exempted. The lawsuit being brought by these eight evicted residents has to do with the promises that were made to them that after they used their funds – in one case over $300,000 - they would be able to stay and be switched to Medicaid. These promises were broken, and it is not known how many other promises to other individuals were handled the same way.
It is important to get to the bottom of this so that individuals who are most vulnerable are not taken advantage of in this (or other) ways, but are protected by the system and by the individuals and organizations who are supposed to serve them.
It has been known for a long while that not all healthcare is equal. In fact, whether you are on Medicare or Medicaid, have no benefits at all or are self-paying, studies show that most often the quality of healthcare has to do with the area you live in and your economic status among other things.
For instance, diabetes testing, breast cancer screening and other essential tests are not provided as often in low-income situations as in areas that have higher income levels, more doctors and hospitals and less Medicare and Medicaid restrictions. Aside from lack of essential tests and treatment, the results end up being more leg amputations, kidney failure and eye disease leading to blindness.
It is not that low income individuals and families that have some sort of assistance from Medicare or Medicaid do not work, are not legitimately disabled or don’t deserve to be treated as well as others who need medical attention. The issue is how to provide quality services to everyone who needs them, regardless of their income or neighborhood.
Studies have shown that the differences in care levels are not just simple; they are dangerously different and uneven throughout the country. This disparity begins with BASIC care to keep people somewhat well or medically stable. We are not talking about complicated, high priced procedures; this is basic medical care, which could save money, taxes and, more importantly, lives.
One example is that one in three women receiving Medicare did not receive a mammogram in the two year period between 2004 and 2005. Black patients were less likely to receive mammograms than white patients.
Diabetic patients are not receiving essential blood tests necessary to monitor and maintain safe blood sugar levels. Black patients are losing legs at a rate of 4 to 1 above whites. Heart and vascular issues are not being addressed. And the disparities are even greater between different states than they are between blacks and whites. There is also a disparity between those beneficiaries who have regular primary care physicians and those who do not.
These disparities are beginning to be addressed in the hope that raising awareness will begin to eliminate the disparities – or at least start working on them. It will take forward thinking and planning, plus incentives for doctors and hospitals to serve in underserved areas and to realize the importance of preventative and maintenance care, rather than reactive care that leads to amputations, blindness, heart failure, decreased quality of life, and often, death.
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