8/07/2024 Wishful Wednesday nursing. My preparation for this change was the same as I do now- I go directly to the Federal and State Laws and review them. Back then, I printed them and highlighted the sections that were most applicable. I just want to mention that where I went to work, I made sure all my documentation followed the laws. In recent years, there have been updates and to be reimbursed, the insurance company must follow these requirements.
Sometimes, I am asked to assist with insurance denials for various reasons for the denial is in general documentation of the issue and the documented improvement. I just want to say that by the time someone requests assistance with a denial, it is usually too late as there are time limits.
Over the years, and I don’t have a poll to document this-but I have yet to meet anyone in the general public that could define the difference between Medicare and Medicare Advantage Plans. We watch TV so metimes and I do see commercials for Medicare Advantage Plans and they usually give a contact number for their sales team though it could seem like that is a number to Medicare. Over the past few years, when I have seen advertisements that called themselves Medicare instead of Mrdicare Advantage Plans, I have reported them through proper channels. Also, about five years ago we got overwhelmed by official looking Medicare similar envelopes, sometimes 5 per day. What I did was call each one and requested no more mailings, I completed a Post Office form for each one and in some cases reported the company to the Federal Trade Commision. This definitely halted the mailings for these plans, very effectively.
So ask your family, what is the difference between Medicare and Medicare Advantage Plans? The simple answer is that Medicare is not-for-profit and government funded while Medicare Advantage Plans are through private companies. Se below some references: If help is needed please call Medicare directly and make an appointment. Last year we needed the change our Part D plans and the help was wonderful and we now have a new Part D plan for a fraction of the cost of the previous company and was sent new cards and official letters within 30 days.
Under original Medicare, you can access care anywhere in the United States as long as the provider accepts Medicare. Medicare Advantage plans are based around networks of provider...
The Big Choice: Original Medicare vs…
www.aarp.org/health/medicare-insurance/info-…
Differences between Medicare and Medicare Advantage (Medicare Part C)12345:
Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance) provided directly by the federal government.
Medicare Advantage is offered by private insurance companies approved by Medicare.
Coverage: Medicare Advantage plans cover all the same services under Original Medicare Part A and Part B, but often include prescription drug coverage and extra benefits
https://www.aarp.org/health/medicare-insurance/info-2020/original-medicare-vs-advantage.html
Medicare Laws and Regulations refers to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and its implementing regulations at 42 C.F.R. Parts 400-423, and all CMS guidance, manuals, policies, bulletins, instructions or directives related thereto1.Here are 7 essential Medicare rules2:
Eligibility begins at 65.
There are penalties for signing up late.
Higher earners pay more for Part B.
You can have original Medicare or Medicare Advantage -- but not both.
You can have Medicare plus private insurance.
Medicare and health savings accounts don't mix.
You can enroll in Medicare before Social Security.
Learn more:
Medicare Laws and Regulations refers to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and its implementing regulations at 42 C.F.R. Parts 400-423, and all CMS guidance, manuals, policies, bulletins, instructions or directives related thereto1.Here are 7 essential Medicare rules2:
https://www.bing.com/search?q=medicare+laws+and+regulations&pc=EMMX04&FORM=EMMXA2&mkt=en-us
https://www.ssa.gov/pubs/EN-05-10043.pdf
Do Medicare Advantage Plans Follow CMS Guidelines?
If you are 65 years old, younger than 65 with a disability, or have end-stage rental disease, you are eligible for the U.S. federal health insurance program known as Original Medicare. Ever since its beginning in 1965, Medicare has provided medical services to millions of people for free or at a reduced cost.
Original Medicare is divided into parts. Part A is hospital insurance which pays for inpatient hospital stays, skilled nursing facility stays, some types of surgery, hospice care, and other forms of home health care. Part B is medical insurance which pays for medical services and supplies that are certified as medically necessary for treating a health condition.
In 1997, a law named the Balanced Budget Act created what is called Medicare Part C. Its purpose was, and still is, to provide more options for Medicare coverage through private insurance plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), or other private plan insurance providers. These Medicare Part C plans are also known as Medicare Advantage plans.
Enrolling in a Medicare Advantage plan is not mandatory for individuals who are eligible for Medicare; it’s an alternative to Original Medicare. If you decide to enroll in a Medicare Advantage plan, you receive all your health care and Medicare coverage through the policy you choose. From the date your plan begins, you get all your Medicare Plan A and Plan B coverage, as well as any additional coverage provided, through the plan’s provider.
Medicare Advantage Plans Must Follow CMS Guidelines
In the United States, according to federal law, Part C providers must provide their beneficiaries with all services and supplies that Original Medicare Parts A and B cover. They must also provide any additional benefits proclaimed in their Part C policy. Medicare Advantage policies can provide additional benefits that are approved by the Centers for Medicare & Medicaid Services (CMS). These must be services that are not covered by Original Medicare Parts A and B. In some policies, the additional benefits may also include the reduction of premiums, deductibles, and coinsurance payments found in Original Medicare (Parts A and B) coverage.
Your Medicare Advantage plan may cover additional services such as hearing exams, vision care, dental care, or fitness plans, for example. As a Medicare Advantage enrollee, you are also required to adhere to all the plan regulations that have been set by CMS. For example, your policy does not cover services you receive outside your provider network unless it is an emergency or something urgent, therefore, you must receive services inside the plan’s network for them to be covered by your policy.
Any person eligible for Original Medicare is eligible for Medicare Advantage. Even if you have a Medicare Advantage plan, you remain in Medicare and possess the same rights and protections that it offers to all Medicare beneficiaries. You have the right to join a Medicare Advantage plan even if you have a pre-existing condition, with the exception of end-stage renal disease.
https://www.medicare.org/articles/do-medicare-advantage-plans-follow-cms-guidelines/
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare®, Wellcare, WellPoint
If you have questions, contact Medicare directly. See below the contact information for the Federal Trade Commision. I do want to add that if you choose a Medicare Advantage Plan, there are time limits for switching back to Medicare. I have had persons that wanted to switch back and that did not work out for them. I think that would be a great question to ask.
https://en.wikipedia.org/wiki/Federal_Trade_Commission
Federal trade Commission
Thank you kindly,
Sandra