Wednesday, August 31, 2016

Only One New Jersey Hospital Not Penalized by CMS for Medicare Reimbursement

The Center for Medicare & Medicaid (CMS) engages in a Hospital Readmission Reduction Program that aims to penalize any hospital if they have a higher readmission rate than determined in the year 2017. They do so by withholding Medicare reimbursements.

Only one hospital in New Jersey did not receive a penalty, and that hospital was Hunderton Medical Center.

hunderton medical center

CMS compares actual readmission rates with expected rates based on patient risk factors for five conditions including: acute myocardial infarction (heart attack), congestive heart failure, pneumonia, chronic obstructive pulmonary disease, and total joint replacements. If the actual readmission rate exceeds the expected rate, the hospital receives a reduction in their Medicare reimbursement for the next year.


Fines were determined based on data for the period from July 2012 to June 2015. Each hospital was assessed by what their reported readmission rate was and what CMS determined to be an appropriate rate based on national and demographic information.


“Hunterdon Medical Center has been analyzing our readmission rates and implementing measures to improve them for many years. Once discharged from the hospital, patients are followed up by a specialist or primary care physician within three to five days after being released from the hospital. In fact, we are now making these appointments for our patients while he/she is still in the hospital,” explained Robert Coates, M.D., Vice President of Medical Affairs.

Read full article.

Technology seems to be on their side as Hunderton has been using more advanced software to try and determine which patients might be at a higher risk for readmission so that they can be cared for more closely. If you think about it, this is a very smart way of predicting what patients might have a more severe health problem that needs to be dealt with now rather than later. Should more hospitals adopt this strategy?

Interestingly enough, technology has had another major influence in the way doctors are examining patients and then collecting on Medicare procedures.

Technology Influences Medicare from the Doctor’s Office

In Woodbridge, NJ, Robert Boyd uses a new medical device to perform an evaluation in his office rather than referring to another doctor or specialist. He began using this device to test for a specific neurological condition:

He used a device to test whether people sweat in response to a low-voltage current, a way to diagnose nerve damage. In 2014, he collected $105,905 from Medicare for the procedures.

Testing for the condition rose nationwide in recent years after a device became available that allows doctors to perform tests in their offices—and to make more profit from Medicare for doing so. The federal program for seniors and disabled people paid out $16.7 million for the test in 2014, according to the latest data, a 10-fold increase from two years earlier.


Such increases are commonplace after the introduction of medical devices that allow doctors to provide services in their offices that they used to refer elsewhere. A Wall Street Journal analysis of recently released Medicare billing data showed that four of the top 10 fastest-growing Medicare services from 2012 to 2014 involved new devices.


Medicare’s tab for those four services rose by $123.5 million from 2012 to 2014, to $135 million, the data show. In each case, a small cadre of doctors adopted the services much faster than their peers. Less than 10% of doctors accounted for more than half the rise in spending for each service, the Journal found. The Journal studied only services performed throughout that period with at least $5 million in 2014 payments.

Read more at the WSJ.

As time moves on, technology is influencing our culture at a rapid pace. Doctors are now given more choices which can help them make better decisions in the office without spending more time or delaying an evaluation by sending the patient to another appointment. Will this have a greater influence on Medicare in New Jersey? Only time will tell.

The 2017 Medicare enrollment period is approaching and seniors should begin to consider looking at their NJ Medicare Plans in order to make the right decision moving into the new year. Insurance brokers can assist with this decision as it can be a confusing and complex level of detail to navigate. Some providers like Aetna are leaving the healthcare marketplace, which means your Medicare Advantage plan could be affected.

Need help during the upcoming enrollment period?

Your Recommended Agent is Greg from BGA Insurance Group

greg gudis

Greg Gudis – Licensed agent ready to assist you during the enrollment period in October 2016. Please fill out the form below to send your information to Greg so that he can contact you with the best advice and plan information for your current situation. He can also provide expert advice on retirement planning, life insurance, and long-term care.

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The post Only One New Jersey Hospital Not Penalized by CMS for Medicare Reimbursement originally appeared on The Aging Adult Guide

Monday, August 29, 2016

Aetna to Leave Federal Insurance Marketplace in 2017

If you are a senior looking to enroll in Medicare for 2017, you may have heard that Aetna will be withdrawing from the federal health insurance marketplace in Pennsylvania in 2017. The reason for this is unexpectedly high claims which have resulted in massive losses of more than $430 million. This loss has come since the plans launched in January of 2014.


Here is a the information according to the Post-Gazette and Mark Bertolini, Chairman and CEO of Aetna:

Because of those losses, “We have decided to reduce our individual public exchange presence in 2017,” said Aetna Chairman and CEO Mark Bertolini said in a statement.

Aetna, headquartered in Hartford, Conn., will continue to participate in the Delaware, Iowa, Nebraska and Virginia marketplaces next year while leaving 11 other states including Pennsylvania.


Pennsylvania Insurance Department Commissioner Teresa Miller said in a statement Tuesday that she was disappointed by Aetna’s decision, while acknowledging the insurer’s financial difficulties, but added that “all Pennsylvanians continue to have choices” among other insurers’ plans.

She said Aetna serves about 31,000 Pennsylvanians, representing about 6 percent of the state’s individual health insurance market.

Teresa Miller, Insurance Commissioner of PA had this to say:

It is unfortunate that decisions made by the federal government are negatively impacting Pennsylvania’s marketplace,” Commissioner Miller said, “but all of Pennsylvania’s marketplace consumers continue to have options and therefore will have access to the federal subsidies only available through the marketplace.

Read more here.


If you are a senior citizen in Pennsylvania that has had an Aetna Medicare coverage plan, you may be asking “what do I do now?”

There is no easy answer to this question, as it can be complicated to explain all of the details as it will greatly depend on your current health and financial situation. The best thing you can do at this time is to consult with a Medicare insurance broker agent to discuss alternatives.

Teresa Miller had more to say on this issue at a recent public hearing:

“The cost of health insurance and the impact these costs have on consumers is something my department takes very seriously when reviewing requests for rate increases,” said Commissioner Miller. “However, cost is not the only measure of impact on consumers. As Insurance Commissioner, I am also charged with ensuring this market is sustainable and that Pennsylvania’s consumers continue to have choices when they seek health insurance coverage.”


Miller said many health insurance companies have absorbed higher spending on healthcare in recent years, more than originally anticipated, and are looking to offset losses that might otherwise convince them to leave Pennsylvania markets.


“We’ve come a long way in a very short time, but the law is not perfect,” said Paula Sunshine, senior vice president and chief marketing executive of Independence Blue Cross, in reference to the Affordable Care Act (ACA). “We’re trying to balance both access and uncertainty. There are consequences to carriers not getting payments they expect.”

View the original source.


How does this affect my current plan? Should I enroll in new coverage?

This is a good question and many seniors are wondering the very same thing.

Seniors that are looking to replace a lost Medicare Advantage plan in PA should speak with a local insurance agent to ensure that they can continue their coverage without interruption. This can be a stressful or uneasy time but if you know what to do, things will work out.

You can learn more about Pennsylvania Medicare Advantage plans by visiting our resource which covers this information.

If you would like to schedule a consultation with an insurance broker in your area, we recommend the agent below.

Your Recommended Agent is Greg from BGA Insurance Group

greg gudis

Greg Gudis – Licensed agent ready to assist you during the enrollment period in October 2016. Please fill out the form below to send your information to Greg so that he can contact you with the best advice and plan information for your current situation. He can also provide expert advice on retirement planning, life insurance, and long-term care.

home button


  • This field is for validation purposes and should be left unchanged.

The post Aetna to Leave Federal Insurance Marketplace in 2017 originally appeared on The Aging Adult Guide

Saturday, August 27, 2016

2017 Medicare Enrollment – Advice from PA Insurance Commissioner

Recently in Harrisburg, PA, Secretary of Aging and Insurance Commissioner Teresa Miller provided a consumer alert that many seniors in Pennsylvania should acknowledge. The following is a breakdown of her advice and what should be done given that the 2017 … Read More

The post 2017 Medicare Enrollment – Advice from PA Insurance Commissioner originally appeared on The Aging Adult Guide

Wednesday, August 17, 2016

About Medicare Part A

How Medicare Part A Works

If you are turning 65 or you have recently found out that you are eligible for Medicare, you most likely have many questions. Figuring out how Medicare works is not always easy. There are two coverage choices with Medicare. You can get original Medicare or Medicare Advantage.

If you choose to get original Medicare, you will automatically get Part A coverage unless you choose Medicare Advantage. This coverage is for Part A, which is Hospital Insurance and Part B, which is Medical coverage. 

If you choose regular Medicare, you get coverage for 80 percent of all costs in most cases, but you are responsible for the remaining 20 percent out of your pocket. Private insurance companies provide Medicare Advantage plans. These plans cost you a monthly premium, but your coverage takes care of all expenses except for monthly premiums and deductibles or copayments.

Whichever way you choose to get Medicare, you will be covered under Part A for hospital care. Here is a guide to that section of Medicare. 

This is a general guide, and it should be noted that different individuals with certain circumstances like End-stage Renal Disease have to sign up specifically for Part A. More information can be obtained from the Department of Social Security.

Medicare Part A Services

Part A comes with either type of Medicare coverage. This coverage does not normally entail paying a premium. You use your red, white and blue Medicare card to get services from hospitals that participate in Medicare. You use your insurance-issued Medicare card for these services if you have a Medicare Advantage plan. 

Part A covers inpatient care when you are in a hospital. It also covers inpatient care at a skilled nursing facility. These facilities are not the same thing as long-term care facilities. Part A will also cover hospice care, home health care, and inpatient services in a religious non-medical health care facility. 

Part A coverage will also supply your hospital with blood from a blood bank. If your hospital has to buy the blood for you, you must pay the hospital for the first three units used in a calendar year. Otherwise, you can opt to have someone donate the blood to you.

These are general services covered by Medicare Part A. You can find out more about you are going to be covered specifically by contacting Social Security or by going online to the Medicare website. In order to understand Medicare Part B, read more on the next page.

Monday, August 15, 2016

How Medicare Part B Works

If you are turning 65 or you have become eligible for Medicare for another reason, you are probably confused about the different parts. There are two parts including A and B. You can also opt for  Part C which is comprised of independently sold insurance plans as well as Part D which is for prescription drug coverage.

However you get Medicare, you get Part B, generally speaking. This is the case whether you choose the “original” form which is what most people automatically get, or you choose an Advantage or Part C plan. Part B is medical insurance that includes doctor’s care, outpatient services, durable medical equipment and home health care.


Medicare Part B in More Detail

Part B takes care of those medical services which are deemed medically necessary. In Medicare terms, that means that the services and supplies are necessary for the diagnosis or treatment of a disease, injury or illness.

These services must fall under accepted standards of medical care, according to Medicare. This means that most naturopathic services would not be able to be covered under Part B if you chose to take that path for your care.

Some Part B services are preventative. This means that things like breast cancer screenings or cardiovascular disease screenings are covered.  Colorectal cancer screenings are also covered.  Other services that are covered are three month’s worth of CPAP or continuous positive airway pressure services.

Some of the durable equipment covered under Part B includes walkers or diabetes supplies. For diabetics, if the insulin is necessary to your health that will also be covered. In some cases, however, insulin is covered by Part D. It will also be important to understand the benefits of enrolling in a New Jersey supplement plan as opposed to a Medicare advantage plan.

Very often people want to consult with another doctor to get a second opinion regarding a proposed surgery. These second opinions are covered under Part B.

Flu shots are covered at least once per flu season. You can also get a glaucoma test once a year if you are at a high risk for it.

Hearing exams might be covered if your doctor deems them to be necessary as part of determining how to treat you for a hearing problem. Also, you may get one pair of eyeglasses if you get cataract surgery wherein you are given an intraocular lens.

There are many more health services covered under this section of Medicare. You can find out more by visiting Medicare online.

Sunday, August 14, 2016

What is Medicare Part C (Medicare Advantage)?

What is Medicare Part C Coverage?

If you have heard the term Medicare Part C, it might have confused you. This is what most people refer to as the Medicare Advantage plans. These are separate insurance plans that are sold through private health insurers.

You can buy them much like you would any traditional form of health insurance once you are enrolled in Medicare Part A and B. These plans take care of all of your Medicare Part and B coverage. They also offer vision, dental and hearing plans. Some of them will also take care of your prescription drug coverage.

These plans must be paid for separately. They require that you continue to pay your Medicare Part B premiums. However, they are useful in providing subscribers with a predictable monthly payment rather than unexpected increases for the 20 percent of services that Medicare coverage will not take care of.

Medicare only covers 80 percent of your medical expenses. When you stop to think about it, the remaining 20 percent can be quite high depending on the types of medical help or services you need. Buying a Medicare Advantage plan is a great way to avoid having to go through the financial challenges that you otherwise might go through if you donĂ­t get this type of coverage.

With most plans, they work just like traditional HMOs or PPOs. You will need to work with in-network doctors and specialists to get the care covered by the insurer. Take your time comparing the various plans available from insurance companies. The price you pay for both A and B along with the Advantage plan will vary depending on the types of services you get with your coverage.

Different plans charge different out-of-pocket costs. They also have different rules for getting referrals or whether you must stay within your network to see specialists or use specific facilities. There are a variety of plans including those for individuals with special needs, so it is really important to shop around.

You might want to get the help of a qualified insurance agent in your area to help provide you with your plan options. Let them know what your budget is and what types of care you require most. This will help them find the most suitable plan for you.

A Part C plan includes Medical Savings Accounts and skilled nursing facility care. It also takes care of the deductibles for Part A and B. Plus, when you travel abroad, you can get any emergency help that you need under your Advantage plan.

The only limits to getting a Part C plan are not having Original Medicare or living outside the area served by the plan that you are considering. You cannot get this coverage if you have end-stage renal disease, but there are sometimes exceptions to this.  You can select and sign up for a Medicare Part C Advantage plan once a year during the Annual Enrollment period from October 15th to December 7th, 2016. This is how you elect a plan for 2017.

In order to understand all of your options, you should also consider reading about Part D.

What You Need To Know To Get Started With A Medicare Part D Policy

Before a person reaches age 65, they should begin researching their initial enrollment for Medicare coverage. Once they reach age 65, there is an open enrollment period where they can buy Medicare supplement policies without answering a lot of extra questions about their health.  The typical open enrollment period lasts from the time that you reach your Medicare eligibility and then for the next three months, so you want to be prepared. It's best to have most of your research done before you reach her 65th birthday, so you have time to spare during the enrollment period.

Being Able To Get Any Medicare Insurance Is An Advantage

During this open enrollment time not only do you not have to answer a slew of invasive medical questions, but most insurers cannot deny you the issuance of a policy due to previous health conditions. When it comes to coverage for prescription drugs the Medicare part D is designed for that very purpose.

This is a voluntary coverage that is not required for enrollment in other parts of Medicare but does help with many of the high costs of prescription drugs. There is a small penalty that is assessed for those who do not enter a Medicare part D plan during the initial enrollment period that is designed to penalize people that wait until they have a high-cost prescription before they apply.

Although the penalty is an additional $.32 more for each month that you failed to carry the insurance, it can add up to a substantial amount of money after a few years.

Medicare Part D Plans Will Vary On A State By State Basis

Depending on which state you live in, the different Medicare part D plans can vary. They will have different rates, deductibles and co-pays so you should read the information carefully to know exactly what you're getting.

Usually, there is a standard deductible that needs to be met for each year, then the insurance will kick in and pay about 75% of each prescription after that. There will also be a yearly cap on benefits as well so that an insured could be responsible for any costs over a certain amount per year.

Even Though A Recipient Has Reached Their Maximum Yearly Payout There Is Help

There is also another coverage called catastrophic coverage that is made to cover huge costs of medicine that reach over a $6-$7000 per year out-of-pocket expense. Although coverage vary, many times, once catastrophic levels have been achieved generic drugs are only three dollars per prescription and brand-name drugs are limited to six dollars out-of-pocket.

Not all drugs will be covered under a Medicare part D insurance policy. There are many experimental drugs with extremely high costs that won't be covered in addition to drugs prescribed off-label and drugs that are simply ineligible for coverage.

If you are nearing age 65 and haven't spent some time researching your Medicare Plan D insurance benefits, it would be a good time to start reading information online. It is important to try to find the newest information available as some of the older stories that you might find may have outdated information that could be misleading when it comes time to purchase your policy.

Finally, there will be gaps in coverage that you need to consider. It is a good idea to work with an insurance broker to help you determined the right plan for your needs. Read more about Medicare supplement plans in NJ on The Aging Adult Guide website.