Chancy Bella

Hi! I am Chancy Bella, an expert in Insurance Industry and I am working in this Industry for the last 5 years. I am not the owner of the content which has been published here. This content is only for knowledge purposes. This content belongs to the respective owners and I do not hold any right for this content.

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Do You Know About Medicare's Eligibility Age Rules?

Medicare is the federal government’s health insurance program for older citizens and people with disabilities. If you’re age 65 or older, you qualify for Medicare, but that doesn’t mean that you receive it automatically.

Once you meet certain age benchmarks or other criteria for Medicare, it’s up to you to enroll in the program.

Enrolling in Medicare can be a confusing process. It requires understanding some of the basics of how the program works. Still if you got any doubt then don't hesitate to get in touch with the medicare providers in Pennsylvania.

This article will cover what you need to know about:

what Medicare is

how to apply

how to meet important deadlines

how to figure out if you qualify

What is the eligibility age for Medicare?

The eligibility age for Medicare is 65 years old. This applies whether or not you’re still working at the time of your 65th birthday. You don’t need to be retired to apply for Medicare.

If you have insurance through your employer at the time you apply for Medicare, Medicare will become your secondary insurance.

You can apply for Medicare:

as early as 3 months before the month you turn age 65

during the month you turn age 65

up to 3 months after the month you turn age 65

You have a 7-month window to get enrolled.

Are there exceptions for the Medicare eligibility age requirement?

There are many exceptions to Medicare’s eligibility age requirement.

If you’re age 65 or younger but you’re receiving Social Security because you have a disability, you may be eligible for Medicare.

After 24 months of receiving Social Security due to having a disability, you become Medicare-eligible. If you have amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s Disease), you’re eligible for Medicare as soon as your Social Security Disability benefits begin. You’re not subject to the 24-month waiting period.

If you have End-Stage Renal Disease (ESRD), you become Medicare eligible after a kidney transplant or 3 months after dialysis treatment begins.

What does it mean if the eligibility age changes?

Policymakers and elected officials sometimes discuss changing the age of eligibility for Medicare from 65 to 67 years old. If this were to happen, it would be a gradually implemented change.

For example, if legislation to change the eligibility requirement passed the year you turned 65, you would still be eligible as you would have been if the law hadn’t changed.

According to the Congressional Budget Office (CBO), the age requirement would most likely increase gradually by 2 months each year until the age was firmly 67 years old. It would take several years for the age requirement criteria to fully take effect.

What are other Medicare eligibility requirements?

There are a few other Medicare eligibility criteria in addition to the age requirement.

You must be a U.S. citizen or a legal permanent resident who has lived in the United States for at least 5 years.

You or your spouse must’ve paid into Social Security for what amounts to 10 years or more (also referred to as having earned 40 credits), OR you must’ve paid Medicare tax while you or your spouse was an employee of the federal government.

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How Much Medicaid and Medicare Cost Americans

Medicare and its means-tested sibling Medicaid are the only forms of health coverage available to millions of Americans today. They represent some of the most successful social insurance programs ever, serving tens of millions of people including the elderly, younger beneficiaries with disabilities, and those with low incomes or limited resources. Everyone in the workforce is required to pony up their share to fund these programs—either through payroll deductions or when they file taxes each year.

In an unprecedented move, both programs will receive major additional funding in the wake of the coronavirus outbreak. On March 27, President Trump signed the CARES (Coronavirus Aid, Relief, and Economic Security) Act—a $2 trillion coronavirus emergency relief package—into law. A sizeable chunk of those funds is earmarked for healthcare providers, including those that are Medicare and Medicaid enrolled.

Medicare is administered by The Centers for Medicare and Medicaid Services (CMS), which is a component of the Department of Health and Human Services. CMS works alongside the Department of Labor and the Treasury to enact insurance reform. The Social Security Administration determines eligibility and coverage levels.

Medicaid, on the other hand, is administered at the state level. Although all states participate in the program, they aren't required to do so. The Affordable Care Act (ACA) increased the cost to taxpayers—particularly those in the top tax brackets—by extending medical coverage to more Americans.

According to the most recent data available from the CMS, national healthcare expenditure (NHE) grew 4.6% to $3.6 trillion in 2018. That's $11,172 per person. This figure accounted for 17.7% of gross domestic product (GDP) that year. If we look at each program individually, Medicare spending grew 6.4% to $750.2 billion in 2018, or 21% of total NHE, while Medicaid spending grew 3% to $597.4 billion in 2018, or 16% of total NHE.

The CMS projects that healthcare spending is estimated to grow by 5.4% each year between 2019 and 2028. This means healthcare will cost an estimated $6.2 trillion by 2028. Projections indicate that health spending will grow 1.1% faster than GDP each year from 2019 to 2028. This projection in growth is primarily due to higher Medicare enrollments.

The projected health care spending estimates by the CMS do not take into account costs related to coronavirus pandemic.

Additional CARES Act Funding

The CARES Act will provide additional funding to healthcare providers and suppliers—including those that are Medicare and Medicaid enrolled—by $100 billion for expenses related to COVID-19.

Below are some examples of what the additional funding will cover:

A 20% increase in Medicare payments to hospitals for COVID-19 patients

A scheduled payment reduction will be eliminated for hospitals treating Medicare patients from May 1 through the end of 2020

An increase in Medicaid funds for states

Medicare Taxes

Taxpayers who receive wages, salaries, or self-employment income are required to pay Medicare tax on all of their wages. There was previously a limit on the amount of income on which Medicare tax was assessed, but this was eliminated in 1993. Now all earned income of any kind is assessed a 2.9% tax. Employers who pay their employees W-2 income cover half of this amount, or 1.45%, and the employee must pay the other half.

In most cases, the employer withholds the amount the employee owes so no balance is owed at tax time. Self-employed taxpayers must pay the entire amount themselves but are allowed to deduct half of this cost as a business expense. This amount is coded as a deduction for adjusted gross income (AGI), so it isn't necessary for the taxpayer to have to itemize.

Fast Fact

Although self-employed taxpayers are responsible for the entire 2.9% Medicare tax, they may deduct half of this cost as a business expense.

On Jan. 1, 2013, the ACA also imposed an additional Medicare tax of 0.9% on all income above a certain level for high-income taxpayers. Single filers have to pay this additional amount on all earned income they receive above $200,000 and married taxpayers filing jointly owe it on earned income in excess of $250,000. The threshold is $125,000 for married taxpayers who file separately.

Unearned Income Medicare Contribution Tax

There is also an additional tax on unearned income, such as investment income, for those with AGIs higher than the thresholds mentioned above. It is known as the unearned income Medicare contribution tax. Taxpayers in this category owe an additional 3.8% Medicare tax on all taxable interest, dividends, capital gains, annuities, royalties, and rental properties that are paid outside of individual retirement accounts or employer-sponsored retirement plans. It also applies to passive income from taxable business activity and to income earned by day traders.

This tax is applied to the lower of the taxpayer’s net investment income or modified AGI exceeding the listed thresholds. This tax is also levied on income from estates and trusts with income exceeding the AGI threshold limits prescribed for estates and trusts. Deductions that can reduce the amount of taxable net investment income include early withdrawal penalties, investment interest and expenses, and the amount of state tax paid on this income.

When this tax was legislated in 2010, the IRS stated in the preamble to its list of regulations that this was a surtax on Medicare. The Joint Committee on Taxation specifically stated: "No provision is made for the transfer of the tax imposed by this provision from the General Fund of the United States Treasury to any Trust Fund." This means that the funds collected under this tax are left in the federal government's general fund.

Example of Medicare Tax Bill for High Earner

The total tax bill for Medicare that could be paid by a high-income taxpayer could look something like this:

Jerry is single and has inherited several pieces of land that produce oil and gas income at the wellhead. He also works as a salesman for a local technology company and earned $225,000 of 1099 income this year. His oil and gas royalties for the year total $50,000, and he also realized capital gains of about $20,000 from the sale of stock.

Jerry will owe 2.9% on his $225,000 of earned income, which equals $6,525. He also will owe another 0.9% on the amount of his earnings in excess of $200,000, which in this case is $25,000. This comes to $225. Finally, he must pay 3.8% of his $70,000 of combined investment income, which is an additional $2,660. The grand total he will pay to Medicare for the year is $9,410 ($225 + $6,525 + $2,660).

How Medicare Is Funded

Medicare is funded via two trust funds that can only be used for Medicare. The hospital insurance trust fund is funded via payroll taxes paid by employees, employers, and the self-employed. These funds are used to pay for Medicare Part A benefits. Medicare's supplementary medical insurance trust fund is funded via Congress, premiums from people enrolled in Medicare, and other avenues such as investment income from the trust fund. These funds pay for Medicare Part B benefits, Part D benefits, and program administration expenses. The standard monthly premium set by the CMS for 2020 for Medicare Part B is $144.60, although that number increases for higher-income earners.

Benefit payments made by Medicare cover the following services:

Home health care

Skilled nursing facilities

Hospital outpatient services

Outpatient prescription drugs

Physician payments

Hospital inpatient services

Medicare Advantage Plans, also known as Part C or MA Plans, which are offered by Medicare-approved private companies

Other services

The CARES Act expands Medicare's ability to cover treatment and services for those affected by COVID-19 including:

Providing more flexibility for Medicare to cover telehealth services

Authorizing Medicare certification for home health services by physician assistants, nurse practitioners, and certified nurse specialists.

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Life Insurance for the Unemployed

Buying life insurance when unemployed may be necessary. This guide will share hints to help you get coverage while you look for work.                  

You've lost your job, but you're not down and out. You study your finances, sign up with unemployment and hit the job boards. You know that nearly two thirds of those unemployed find new work in less than 14 weeks on average, according to the Bureau of Labor Statistics. You're on the ball, putting your energies into what's important - finding a new job and making ends meet in the meantime.

But is it possible that you've overlooked something? Life insurance may not be your first thought, but, for anyone with family and assets to protect, its importance shouldn't be underestimated. If you've relied solely on your employer's group life insurance up to this point, then it may be critical for you to find a new policy to ensure there isn't a long lapse in coverage.

Read on for our advice on how to tackle buying life insurance during unemployment.

Can you be denied life insurance based on your unemployment?

Being unemployed is certainly not an immediate disqualifier for a life insurance policy; however, it is one of many factors taken into consideration when you're applying for an individual policy. Applying for a life insurance policy requires an investment in you by the life insurance company, and because of that, if they believe you won't be able to make the payments on your policy, they may not want to continue your application. Don't be discouraged though. They are many things that you can do to make yourself more attractive as a policyholder. Let's take a look.

What will help you get a life insurance policy if you're unemployed?

Don't wait too long.

If you've only been unemployed for a short period of time and you're prospects of employment are promising, you'll likely be viewed more favorably by a life insurance company. Promising employment prospects could include factors such as the fact that you are skilled or educated, or you earned a good income in your last job. Report your assets. Sharing all of your assets, including any homes or cars you own, could help you obtain a life insurance policy. These types of assets show your financial responsibility and likelihood to pay your premiums. You will be considered less of a risk to the life insurance company.

Request a policy with a shorter term or for a smaller amount of coverage.

A life insurance company may be more likely to work with you if you are looking for a more affordable policy based on your current unemployment. The term length or coverage amount of your policy can generally be reviewed and updated at a later date, so you likely won't be locked into a policy that doesn't suit you in the long term.

Consider a different type of insurance.

There are several types of insurance that involve less underwriting or red tape, and thus, can be granted in a much shorter time span. If you want a policy quickly that covered you just during your unemployment, consider accidental life or final expense insurance. These policies may better fit your short term needs.

What's a good way to maintain life insurance while you're unemployed?

As self-evident as it may seem, a good way to help keep your family protected during your unemployment is to pursue an individual life insurance policy while you still have a job. Once you secure a policy, as long as you pay your premiums, it will continue without interference for the length of the term you designate. Planning ahead can save you a lot of headache when life deals you an unexpected hand.

Your spouse should also be an important consideration in the life insurance discussion. If you are not able to secure life insurance for yourself during your period of unemployment, it's likely that your working spouse could. If they already have a policy, they can review and increase their coverage while you're out of work. While this doesn't offer full protection for your family, it is a good stopgap to help keep your family financially secure during hard times.

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Some Benefits of CHIP

If a state has elected to use its chip funds to expand Medicaid coverage for children, the Medicaid program rules on benefits and the scope of coverage will apply to the group of children covered under the expansion in the same manner that they apply to children already eligible under the Medicaid program. However, if a state elects to use its CHIP funds to cover children under a separate state program, states have other options for meeting minimum federal benefit standards.

States can choose health benefits coverage equivalent to those offered under:

The standard Blue Cross/Blue Shield preferred provider option offered to federal employees;

A health plan available to a state’s public employees; or

The HMO within the state that has the highest commercial enrollment (excluding Medicaid enrollment).

A state can also choose one of these three plans to serve as a “benchmark” for an alternative package of benefits. Finally, federal officials have the authority to allow states to use alternative benefit packages if they determine that they are appropriate for low‐income children. CHIPRA made dental services a mandatory benefit for states with separate CHIP plans, and gave states the option to provide supplemental dental coverage to CHIP-eligible children with private coverage that does not provide dental.

States also have the option to use chip program for “premium assistance,” which helps families with the cost of private insurance rather than covering children in traditional CHIP coverage.

Premiums and Cost-sharing

States may impose cost-sharing (i.e., deductibles, coinsurance, and co‐payments) for some children enrolled in CHIP, within federal guidelines.

In general, states cannot adopt cost-sharing or premium policies that impose costs that exceed five percent of family income or that favor higher‐income families over lower‐income families. They also are prohibited from imposing cost-sharing for well‐baby and well‐child care, including immunizations. Finally, states cannot count money raised through premiums or cost-sharing as state dollars for purposes of meeting the block grant’s matching requirements.

Research has shown that premiums in Medicaid and CHIP depress enrollment because of the financial burden they impose on families, potentially increasing the number of uninsured children.

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What is Medicare Part C?

Medicare Part C is a bundled Medicare plan that includes hospitalization, medical and prescription drug coverage for most people. It also covers other services that are not covered by traditional medical insurance plans, such as dental, hearing and vision care. However, the coverage of these, varies from plan to plan. Another name for these plan is Medicare Advantage. Although it usually offer more coverage than traditional Medicare plans, people with Medicare Advantage must choose from a network of doctors and healthcare providers agreed by Medicare and the plan provider. Receiving care outside of these networks will be more expensive.

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Is CHIP Coverage Free of Cost?

It is important to remember that CHIP is different from Medicaid and usually requires payment of premiums. Various types of visits, such as regular doctor checkups and dental visits, are provided free of charge. But, you may need to pay to get certain medical services covered by your child's insurance. Chip health insurance, pa varies from state to state, so it is necessary to contact the local agent to obtain more information about the exact cost you may have to pay. 

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5 Things You Might Not Know About Medicare

When it comes to healthcare, it’s important to know what is covered and what isn’t. Because there are so many different plans for Medicare, it can be confusing to know which plan will give you the right coverage. Fortunately, medicare providers in Pennsylvania will make it easier for you.

Medicare is the insurance plan offered by the federal government for people aged 65 and over, as well as people with disabilities, and people who have permanent kidney failure.

There are four parts to the Medicare plan: A, B, C, and D. Each part covers different aspects of healthcare. You can enroll in one or more parts of Medicare, but the most common parts people enroll in are Parts A and B, as these cover the majority of services. People usually have to pay a monthly premium, but this varies widely based on income.

Medicare Part A

Medicare Part A, also called “original Medicare,” is the insurance plan that covers hospital stays and services. It also covers stays in skilled nursing facilities, walkers and wheelchairs, and hospice care. It even covers home healthcare services if you’re unable to get to a hospital or skilled nursing facility.

If you need a blood transfusion, Part A covers the cost of the blood.

Medicare Part A covers hospital inpatient costs. However, just because you visit a hospital doesn’t mean that you’re an inpatient. An overnight stay doesn’t mean you’re an inpatient either.

You’re an inpatient when you’re formally admitted to a hospital with a doctor’s order.

You’re an outpatient if you receive any type of hospital services without being formally admitted to a hospital with a doctor’s order. This may include emergency services, outpatient surgery, lab tests, and X-rays. In these cases, you’re an outpatient even if you stay overnight at the hospital.

Make sure you know if you’re an inpatient or outpatient, as this will affect your coverage.

Also, Medicare Part A will only cover a skilled nursing facility if you have a qualifying inpatient hospital stay — three consecutive days resulting from a formal inpatient admission order written by your doctor.

What Medicare Part A costs

Depending on your income, you may have to pay a premium for Part A coverage. You may also have to pay copayments or a deductible for any services under Medicare Part A. You can apply for assistance or help if you can’t pay. Beginning in 2017, in general, these are the costs for each service:

Hospital services: $1,316 for up to 60 days, $329 per day for 61-90 days, and $658 per day for stays beyond 91 days

Skilled nursing facilities: No charge for the first 20 days, $164.50 per day for 21-100 days, and all costs after 101 days

Hospice care: No charge for hospice care, $5 copayment for medication, and 5 percent for inpatient respite care (periodic care so your caretaker can rest)

Remember, you have to be approved for these services and you have to make sure you are in an approved facility.

Medicare Part B

Medicare Part B is also a part of “original Medicare” and it covers your doctor services and preventive healthcare, such as yearly doctor visits and tests. People often have Parts A and B together to get the most coverage.

For example, if you stay in a hospital, the stay would be covered under Medicare Part A and the doctor’s services would be covered under Part B.

Part B covers a wide range of tests and services, including:

screening for cancer, depression, and diabetes

ambulance and emergency department services

influenza and hepatitis vaccinations

electrocardiograms (ECGs)

medical equipment

some drugs, diabetes supplies, and some prescriptions for eyewear

What Medicare Part B costs

If you have Part A, chances are you will have to also buy Part B coverage as well. For Part B beginning in 2017, most people will have to pay a monthly premium of $134 a month. This could be more or less depending on your income.

Some services are covered under Medicare Part B at no additional cost to you if you see a doctor that accepts Medicare. If you need a service outside of what is covered by Medicare, you will have to pay for that service. Services from doctors who do not accept Medicare may cost more and you might have to pay the full amount up-front. If some of the cost is covered, you will get paid back through a claims process.

Medicare Part C

Medicare Part C plans, also called Medicare Advantage plans, are supplemental plans that provide more coverage for an additional cost. They are private insurance plans approved by Medicare that fill in the gaps in services and hospital care. People with Medicare Part C must already be enrolled with Parts A and B.

Under these plans, you can get prescription drug coverage, dental and eye coverage, and other benefits.

You usually pay a premium for these plans, and you have to see doctors within your network. Otherwise, copayments or other fees may apply. The cost depends on the type of plan you select.

Medicare Part D

Medicare Part D is the plan that covers prescription drugs not covered by Part B, which are typically the kind of medications that need to be administered by a doctor, like an infusion or injection. This plan is optional, but many people choose to have it so their medications are covered.

The cost for Medicare Part D varies depending on what kinds of medications you take, the plan you have, and which pharmacy you choose. You will have a premium to pay and, depending on your income, you may have to pay additional costs. You may also have to make copayments or pay a deductible.

What’s not covered

While Medicare covers a wide range of care, not everything is covered. Most dental care, eye exams, hearing aids, acupuncture, and any cosmetic surgeries are not covered by Medicare Parts A and B.

Long-term care is also not covered by Medicare. If you think you or a loved one will need long-term care, consider a separate long-term care (LTC) insurance policy.

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How to Choose a Life Insurance Beneficiary

Choosing who will receive your life insurance payout is an important step in purchasing a policy, and it isn’t as simple as you might think.

What is a beneficiary?

A beneficiary is the person or entity that you designate to receive the cash benefit from your life insurance policy in the event of your death.  A life insurance beneficiary could be a spouse, a child or another loved one, but it could also be a trust, estate or even a non-profit organization.

A beneficiary also doesn't have to be singular. While you can leave your entire policy to one person, you can also designate multiple people to receive portions of your life insurance payout. Your beneficiary can also be conditional, allowing you to elect a primary, secondary and even final recipient. What this means is that if your primary beneficiary is already deceased when you pass away, then a secondary beneficiary would receive the cash benefit. In that same vein, if both the primary and secondary beneficiaries have passed at the time of your death, your final beneficiary would receive payment.

How exactly do you choose each of these beneficiaries and what factors should you consider? There's a lot to reflect upon before you choose your beneficiary, including how exactly you want your cash benefit to be used if something were to happen to you. Here are 5 things to think about:

What to consider when choosing your beneficiary?

The rules in your state

Depending on what state you live in, you may be subject to different rules and regulations regarding who you can, and cannot, designate as a life insurance beneficiary. For example, in a community property state, a spouse may be able to claim a cash benefit regardless of who is named on a policy. It's important to know these regulations and if they apply to you.*

Know who you want to help

If choosing your beneficiary isn't a snap decision, consider who it is that you want to help. While you may be buying your life insurance policy to help protect your spouse and children, you may also want to pay off student debt or help your self owned business survive your loss. It's important to know why you're purchasing life insurance as you choose one or more beneficiaries.

Who will be last in line?

It may be a good idea to determine a first, second and third beneficiary to receive your cash benefit. You may want to elect a trust or charity as your final beneficiary given that the lifespan of an entity can be longer.

Different policies for minors

It's important, if you've designated a minor as your beneficiary; to make sure the minor is not only designated to receive your life insurance payout in the policy, but also in your will. The reason for this is that often the court will decide who receives your payout, and a judge will likely use your will as a reference.

Can my beneficiary live in another country? In most cases, the answer is Yes. As long as the insured meets residency requirements, foreign nationals and non- U.S. residents may be designated as your beneficiary. If this is a concern, we recommend confirming with your life insurance agent when you apply for your policy.

Can I change my beneficiary?

With many life insurance policies, you can change your life insurance beneficiary at any time. Review your policy often (at least once a year) and examine your circumstances. Have you married or divorced? Had another child? Has someone passed away? These could all be factors that would change your beneficiary.

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Defrauding Medicare is a Multibillion-Dollar Industry

Imagine your eye doctor has diagnosed you with wet macular degeneration, a rare condition that could cause vision loss.You follow your doctor’s advice to get further diagnostic testing, laser eye surgery, and treatments that could increase the risk of a heart attack.

It might be difficult and painful, but you’ll do anything to prevent vision loss. Now imagine, months later, you and more than 500 patients of two Florida eye clinics discover your doctor, Dr. David M. Pon, has been defrauding Medicare.

“The fraud committed by Dr. Pon, a well-trained ophthalmologist, was particularly egregious,” federal prosecutor A. Lee Bentley III said in a statement after Pon was convicted of 20 counts of healthcare fraud last year. “He instilled fear in his victims, performed unnecessary and sometimes dangerous medical procedures on their eyes, and asked the taxpayers of this country to pick up the tab.” And they did to the tune of $7 million.

Spotting the fraud

Pon’s eye scheme had one major flaw. While wet macular degeneration is responsible for 90 percent of legal blindness, it only accounts for 10 percent of all cases of macular degeneration. When comparing Pon’s billing records to those of other eye doctors — a process called peer comparison analysis — federal investigators found something amiss in the data.

And there’s a lot of data. Medicare sees about 4.4 million claims every day, so investigators are focusing on better ways to sift through that data to find fraud, waste, and other problems. Caryl Brzymialkiewicz, chief data officer for the Health and Human Services (HHS) Office of Inspector General (OIG), said the peer comparison generator helps spot outlying doctors, as well as patterns among pharmacies and others who could be gaming the system.

“Either the data can lead us to somebody that is potentially committing fraudulent activity, or our investigators can have a hotline call where they can have a witness or a whistleblower come tell them that they suspect criminal activities happening, and we can bounce that against the data,” she said earlier this month on the OIG’s podcast.

Between whistleblower complaints and the oceans of data, investigators are able to connect the dots in small and large-scale operations that bilk the government out of billions every year. Earlier this month, the Department of Justice (DOJ) announced criminal and civil charges have been brought against 301 people — including doctors, nurses, and other medical professionals — for allegedly falsely billing Medicare for more than $900 million.

The scope of fraud

In March 2007, the OIG, DOJ, Offices of the United States Attorneys, the Federal Bureau of Investigation (FBI), and others formed the Medicare Fraud Strike Force. Since then, it has charged more than 2,900 defendants who falsely billed the Medicare program for over $8.9 billion.

That’s still a small fraction of the totality of fraud inside the medical industries.

As healthcare and social assistance are the largest industries in the United States, fraud is a major industry of its own. Some experts estimate it could cost taxpayers hundreds of billions of dollars every year.

According to the Centers for Medicare and Medicaid Services, of the $491 billion spent on Medicaid in 2014, $17 billion went to fraud, waste, and abuse. Medicare now spends more than $600 billion a year providing health insurance to more than 54 million people 65 years of age and older.

How much is lost to fraud? That’s anyone’s guess. Both Medicare and Medicaid are on the Office of Management and Budget’s “high-error” list because there are more than $750 million in improper payments every year.

How hard is it to commit fraud?

One of the largest running scams — which included television ads to recruit Medicare patients — was providing electric scooters to people who didn’t need them.

The chairs cost about $900, but Medicare would reimburse up to $5,000, leaving plenty of profit margin for paying people to recruit patients and pay off doctors, according to a Washington Post investigation.

That was before anyone was checking. Now they are, so the criminals have moved onto other scams. Now the easiest way to commit healthcare fraud is to simply bill for services and not perform them.

That’s how the majority of fraud cases happen, according to a Government Accountability Office (GAO) report filed earlier this year. The office examined 739 fraud cases from 2010.

Of those cases, billing for services not provided or ones that were not medically necessary accounted for 68 percent of all the cases. Others included falsifying records, paying kickbacks, or fraudulently obtaining controlled substances.

In 62 percent of the cases, providers were complicit in the schemes, and beneficiaries were knowingly complicit in 14 percent of the cases. Individual doctors, clinics, and others involved in these schemes can glean millions of dollars from the Medicare system before they’re caught.

Pon’s net worth, not including his millions of dollars in holdings in China — was valued at $10 million, according to the Orlando Sentinel.

In the new $900 million cases, which involved numerous sites across the United States, alleged schemes involved kickbacks for supplying patients’ Medicare information for fraudulent bills and then laundering the money through shell companies.

Of the 301 people involved, 61 were licensed, medical professionals. One case in Texas involved unlicensed people performing medical services and billing Medicare as if a doctor performed them.

Preying on the elderly

As Medicare is for people 65 years of age and older, large-scale fraud cases typically stem from states with high concentrations of residents who are older adults. At the foreground is Florida, where nearly 20 percent of its residents are over the age of 65.

In April, 25 people in the Miami area were arrested and charged for allegedly defrauding the Medicare Part D program, the government’s $120 billion prescription drug program.

The defendants were accused of fraudulently billing for prescription drugs that didn’t go to Medicare beneficiaries.

“Unfortunately, South Florida remains ground zero for these types of scams,” Assistant Special Agent in Charge, William J. Maddalena of the FBI’s Miami Division, said in a statement.

A recent case in eastern Michigan involved luring patients with kickbacks to go into physical therapy clinics to obtain $36 million in unnecessary prescriptions for drugs like hydromorphone, methadone, Demerol, oxycodone, and fentanyl.

Not only did the Michigan case contribute to Medicare fraud, it also helped fuel the availability of powerful painkillers in the midst of an opioid addiction epidemic.

Doctors across the country who were part of these “pill mills” are now facing criminal charges, including defrauding Medicare. Some of the cases involve murder charges related to the deaths of their patients.

“While it is impossible to accurately pinpoint the true cost of fraud in federal healthcare programs, fraud is a significant threat to the programs’ stability, and endangers access to healthcare services for millions of Americans,” Inspector General Daniel Levinson of the HHS OIG, said in a statement.

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10 Essential Health Benefits Insurance Plans Must Cover Under the Affordable Care Act

One popular aspect of the Affordable Care Act is its requirement that all individual and small group health plans (for people who don’t have traditional job-based coverage) cover important health benefits like maternity, mental health, preventive, and pediatric dental care. Members of Congress and the Trump administration have frequently proposed measures that would eliminate or undermine these essential health benefits (EHBs), as they are known.

Essential health benefits ensure that health plans cover care that patients need

EHB requirements ensure that everyone in the individual and small group health insurance markets has access to comprehensive coverage that actually covers the services they need. These essential health benefits fall into 10 categories:

Ambulatory patient services (outpatient services)

Emergency services

Hospitalization

Maternity and newborn care

Mental health and substance use disorder services, including behavioral health treatment

Prescription drugs

Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices

Laboratory services

Preventive and wellness services and chronic disease management

Pediatric services, including oral and vision care

The Affordable Care Act eliminated caps on how much coverage people got for these essential health benefits

The Affordable Care Act’s requirement that essential health benefits be covered without annual dollar caps provides patients with more health benefits and a lesser financial burden. While plans before the ACA stated that they covered many of these services, actual coverage was often uneven—patients often faced unexpected dollar limits on services that were technically covered by their plans, forcing them to pay the remainder of costs.

Additionally, this new definition of coverage enshrined in the ACA ensures that plans cover important services that are not currently covered by many plans:

People with mental health or substance abuse disorders will have the peace of mind of knowing that their plan must cover their needs and that their coverage for these mental health services must be as comprehensive as their coverage for medical and surgical services.

Women can rest assured knowing that they will have maternity coverage when they become pregnant.

People with developmental and intellectual disorders will benefit from habilitative services that help them learn, keep, or improve functional skills when most plans now will only cover services to regain skills.

Americans were waiting a long time for substantial coverage of services that are essential to their health. The ACA’s requirement that plans cover these essential health benefits offers a pathway to comprehensive health insurance for all Americans.

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What is CHIP? 7 things to know about the Children’s Health Insurance Program

Here are 7 things to know about CHIP:

What is CHIP?

According to HealthCare.gov, chip program is a no-cost or low-cost health insurance program that provides coverage to children in families that earn too much money to qualify for Medicaid, but who can’t afford private coverage.

The program is funded by both states and the federal government, but it is state-administered, meaning each state sets their own guidelines on eligibility and services. In Georgia, the CHIP program is PeachCare for Kids.

CHIP’s history

In 1997, Congress passed Title XXI of the Social Security Act, which enabled states to create programs for the growing number of uninsured children in the country.

The program was created during the Clinton administration by the Balanced Budget Act of 1997. At the time, 10 million children were without health insurance and many of those children were part of working families with incomes slightly above states’ Medicaid eligibility levels, according to the Medicaid and CHIP Payment and Access Commission.

The Children’s Health Insurance Program Reauthorization Act (CHIPRA) reauthorized CHIP in April 2009. The next year, the Affordable Care Act contained provisions to strengthen the program and later extended CHIP funding until September 30, 2015. It also required states to maintain eligibility standards through 2019.

By 2015, 18 years after its enactment, 3.3 million children in the U.S. were without health insurance. In October 2017, however, Congress missed a deadline to reauthorize CHIP, which expired on Sept. 30.

“Lawmakers and staffers in Congress say CHIP funding will likely be included in an end-of-year spending bill,” NPR reported Tuesday. “But as of now, there is no CHIP funding bill scheduled for consideration.”

Who is eligible for CHIP?

Eligibility varies by state, but in most states, children up to age 19 with a family income up to $49,200 per year (for a family of four) may qualify for Medicaid or CHIP, according to insurekidsnow.gov. But even if your family income is higher, children may still qualify. Some states (Colorado, Missouri, New Jersey, Rhode Island and Virginia) also provide coverage to pregnant women through CHIP. Coverage is for U.S. citizens and certain lawfully present immigrants.

What does CHIP cover?

State benefits may vary, but all states provide comprehensive coverage for routine check-ups, immunizations, doctor visits, prescriptions, dental/vision care, inpatient /outpatient hospital care, laboratory/X-ray services and emergency services.

How much does CHIP cost?

The cost depends on family income. Many families may get free health insurance coverage for their kids and others may have to pay a modest enrollment fee or premiums, as well as copayments for specific services.

But according to healthcare.gov, you won’t have to pay more than 5 percent of your family’s income for the year.

How do you apply for CHIP?

There are three ways to apply. You can either call 1-800-318-2596 (1-855-889-4325 for TTY), fill out an application through the health insurance marketplace or apply directly with your state’s CHIP agency.

How many children get health insurance from CHIP?

Nine million kids get health insurance under CHIP.

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Get ready for a new year of coverage

The beginning of the new year may bring many changes, including your Medicare coverage. If you change your health or drug plan for 2021, the new coverage will start on January 1. The fees structure may have also changed, so you need to check the basic fees for the tests, items and services covered by Medicare or you can also get in touch with the medicare providers in Pennsylvania to get the desired information. Don't forget, Medicare also provides preventive services, such as your annual health check and check for breast cancer, diabetes, heart disease and other services. Start the new year by understanding the new Medicare coverage and costs, and stay healthy by using preventive services. 

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Using Your CHIP Coverage

Once CHIP insurance is obtained for your child, it is important to understand where the insurance can be used. Each state has its own network of healthcare providers that receive CHIP coverage. Therefore, when scheduling appointments and seeking medical care for your child, you need to check the list of local providers who are considering the CHIP insurance. Seek that the CHIP and Medicaid resources are available in your state to learn more about using low-cost medical insurance.

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What Would Happen If Medicare Started Negotiating Drug Prices?

The people at the U.S. Department of Veterans Affairs do it as well. So why don’t the folks overseeing the Medicare program negotiate with pharmaceutical companies over the price of prescription drugs? Pharmaceutical representatives say Medicare negotiations would result in fewer choices for senior citizens who use the program to cover their drug purchases. However, consumer advocates say Medicare negotiations would drastically reduce the price of medications. They’d like to see the current policy change. So, apparently, would some members of Congress. Late last month, Democratic leaders in the House and Senate introduced the Medicare Prescription Drug Price Negotiation Act of 2017. The bill would direct the secretary of the Department of Health and Human Services (HHS) to negotiate lower drug prices under the Medicare Part D plan.  So far, President Trump hasn’t said publicly if he supports the legislation. In fact, White House officials didn’t respond to a Healthline request for a statement on whether the president would sign such a bill. The silence comes despite the fact the president said shortly before his inauguration in January that pharmaceutical companies were “getting away with murder” and the government needs to negotiate with the industry. “Before and after the election, President Trump said over and over again that drug companies were ‘getting away with murder’ and that he wanted to give the government authority to negotiate lower drug prices. That’s what this bill does,” said Rep. Elijah E. Cummings, D-Md., in a statement. “It’s time for President Trump to follow through on his promises to the American people,” added Sen. Bernie Sanders, I-Vt. “We must join the rest of the industrialized world by implementing prescription drug policies that work for everybody, not just the CEOs of the pharmaceutical industry.” What the bill would do Right now, federal law prohibits the HHS secretary from negotiating directly with pharmaceutical companies over drug prices. That is done instead by private health plans. The prices they negotiate reach the pharmacy level. The Part D program, which almost 40 million Medicare beneficiaries use, covers about 75 percent of drug costs in its basic program. The program’s enrollees pick up the remaining 25 percent. The more prescription drugs cost, the more the seniors pay. In addition, Medicare is a large participant in the prescription drug industry. In 2015, the health program for seniors accounted for 29 percent of all national pharmaceutical retail spending. The bill in Congress would allow the HHS secretary to use this leverage to negotiate directly with pharmaceutical companies. It also would establish a “fallback price” that would automatically kick in if the negotiations failed. This price would be based on what other federal agencies and other countries pay for medications. In addition, the legislation would restore rebates on drugs covered under Part D for low-income beneficiaries. These were eliminated when Part D was created in 2006. Pros and cons

The pharmaceutical industry sees a number of problems with the bill. For starters, they say the federal government wouldn’t do a better job than private plans in negotiating lower drug prices.

In a statement to Healthline, industry representatives said the current negotiation system has resulted in Medicare Part D recipients paying 35 percent less than manufacturers’ list prices for drugs. “The so-called Medicare Drug Price Negotiation Act of 2017 isn’t about negotiation at all. Instead, it imports price controls from foreign countries while allowing the government to decide which medicines Part D plans cover,” said the statement from the Pharmaceutical Research and Manufacturers of America (PhRMA). “In reality there is already significant price negotiation that occurs within the Medicare prescription drug program. Large, powerful purchasers negotiate discounts and rebates directly with manufacturers.” They also say the legislation could dissuade pharmaceutical companies from conducting research and could also lead to fewer medication choices for seniors. “This newly introduced legislation undermines the competitive structure of Medicare Part D and replaces it with government imposed price controls,” the PhRMA statement added. “It could jeopardize access to critical medicines for seniors and people living with disabilities, ultimately reducing choice and restricting coverage.” Supporters of the legislation don’t see it this way. They point out that Medicare Part D pays 73 percent more than Medicaid and 80 percent more than the Veterans administration for brand name drugs. Congressional Democrats estimate that Medicare negotiations would save beneficiaries at least $15 billion a year if Part D programs paid the same prices as Medicaid and the Veterans Administration do for drugs. Patients for Affordable Drugs, a nonprofit consumer organization, strongly supports the bill. In a statement sent to Healthline, organization leaders say negotiations would “leverage the purchasing power of millions of Medicare beneficiaries while protecting the needs of patients to select drugs that work best for them in consultation with their doctor.” “Medicare negotiation is at the headwaters of solutions to lower drug prices for patients,” added David Mitchell, the organization’s president, in the statement. Kurt Mosley, vice president of strategic alliances at Merritt Hawkins healthcare consultants, agrees. He told Healthline that it “doesn’t make any sense” for Medicare not to be negotiating drug prices when Medicaid and the Veterans Administration do. He said the bill would “absolutely” reduce drug prices for Medicare recipients. “More people will be able to afford their prescriptions. There’s no question about it,” he said. “Millions of people would be better served.” Mosley added that these lower prices would also lower overall healthcare costs for seniors. He said older adults getting proper medications would reduce illnesses and result in less medical care, especially for lower-income beneficiaries. However, the pharmaceutical industry feels things are currently headed in the right direction. 

As Part D enters its second decade and the marketplace evolves, America’s seniors and people living with disabilities must continue to be able to rely upon the program to provide access to the range of medicines they critically need,” said the PhRMA statement. “But this legislation would take Part D in the wrong direction, toward a system that would allow the government to decide which medicines patients can and cannot get.” Supporters, however, say this is what the country wants. They point to a Kaiser Health tracking poll released in April, which showed that 92 percent of Americans want the Medicare program to negotiate drug prices. “It’s time to make a move,” said Mosley. “The best drug in the world doesn’t do any good if you can’t afford it.”

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Medicare Enrollment & Eligibility Information – How to Apply for Medicare Coverage

10,000 people turn 65 every day and understanding Medicare Eligibility and Medicare Enrollment is a challenge for every single one of them. That is why we are here to help. Here is how it works.

Medicare eligibility begins when you turn 65 years old if you are a U.S. citizen for at least five consecutive years. There are a few special situations where you can become eligible earlier with certain disabilities or health issues.

If you meet these eligibility requirements, then you qualify for Medicare Parts A and B, automatically available and managed by the federal government. The initial Medicare enrollment period is available three months before, the month of, and three months after your birthday when you turn 65.

What Does Medicare Cover?

Medicare Parts A and B are considered to be “original Medicare” offered as a federal health insurance program. However, Parts A and B do not cover all of your healthcare costs. This is where you have the option to buy Medicare Supplemental Insurance, Medicare Part D, or Medicare Advantage from private companies to help cover additional healthcare costs.

What is Medicare Part A?

Medicare Part A is provided by the federal government to pay for:

Inpatient hospital stays

Skilled nursing services

Hospice care

Certain blood transfusions

Inpatient mental health

Most people do not pay premiums with Part A because they have paid into Social Security for at least 10 years. If you have not made contributions to Social Security or if you enroll in Medicare Part A late, your monthly premiums will be high. There are certain costs that come with Part A, such as:

You pay a deductible before Part A starts paying costs for each hospital stay.

If you stay in a hospital for longer than 60 days, you will pay a daily copay. The copay rises after 90 days in a hospital.

If you stay in a skilled nursing facility for longer than 20 days, you pay a copay.

There is a copay for outpatient prescription drugs received in hospice care.

You pay coinsurance for inpatient respite care for hospice patients.

There is a possibility that multiple hospital stays mean multiple deductibles. There are other coverage limits for Medicare Part A, including:

Hospital care outside of the U.S. (usually)

Doctor services in the hospital

Personal in-hospital costs (ie: custodial care)

Prescription drug costs

Additional Medicare benefits, such as hearing, dental, and vision

Medicare enrollment in Part A cannot be denied based on medical history or pre-existing conditions. To sign up for Medicare Part A, enrollment is automatic if you have been paying into Social Security. If you have not paid into Social Security, you can sign up at your local Social Security office.

What is Medicare Part B?

Medicare Part B goes hand-in-hand with Medicare Part A and is provided by the federal government if you have been paying into Social Security at the time of Medicare eligibility. Medicare Part B pays for:

Necessary doctor visits and services

Outpatient hospital visits, mental health, physical therapy, occupational therapy, speech-language therapy

Ambulance

Laboratory services

Durable medical equipment including wheelchairs, oxygen tanks, etc.

Some preventive care, diagnostic screenings, and skilled nursing

Dental, vision, and hearing only in certain limited situations

For Medicare Part B, you will pay a monthly premium based on your yearly income. Joining after the initial enrollment period for Medicare Part B can make your monthly premium higher. If you receive Social Security, it will be deducted automatically from your Social Security benefits. Other costs associated with Medicare Part B include:

A deductible paid for the year before Medicare Part B starts paying a share of your costs.

A copay for outpatient hospital visits.

Coinsurance after a deductible is paid. Part B covers 80% of the Medicare-approved coinsurance and you pay 20%, generally speaking.

There is no maximum out of pocket for Medicare Part B. There are some coverage limits depending on each situation. Care outside the U.S. is not usually covered. Certain things, like the amount Part B will pay for occupational therapy or depending on when you get a screening, may not be covered. There are often excess charges that Part B will not cover.

To sign up for Medicare Part B, you can enroll as soon as you are eligible or certain times of the year during open enrollment. There may be a penalty if you do not enroll at the time of Medicare eligibility. Enrollment is usually automatic, or you can sign up at your local Social Security office. Medicare Part B cannot be denied because of your medical history or pre-existing conditions if you already have eligibility for Medicare.

Other Medicare Coverage Options from Private Companies

Medicare Parts A and B do not cover many things, including deductibles, coinsurance, premiums, and excess charges from Part B, prescription drug coverage, vision, hearing, and dental. This is where additional Medicare coverage plans offered by private Medicare providers come into play. You have two main options when it comes to additional Medicare plans for coverage.

Option 1: Medicare Supplemental Insurance which covers some or all of the costs that are not covered by Parts A& B and/or Medicare Part D which covers prescription drug costs.

Option 2: Medicare Advantage, also known as Medicare Part C, which combines Parts A& B to provide additional benefits. Most Part C plans cover prescription drug costs.

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Don't make these common, costly Medicare mistakes

If you are nearing retirement, you could fall prey to common misconceptions about Medicare. And that can lead to costly errors. "Medicare is very complicated and confusing," said Diane J. Omdahl, co-founder, and president of 65 Incorporated, a provider of Medicare software and consulting services. "The people who are turning 65 are at the biggest risk for making mistakes."

These issues are increasingly common as more people continue working past age 65. The labor force participation rate is expected to grow fastest for individuals ages 65 to 74 and 75 and older through the year 2024, according to the Bureau of Labor Statistics.

Age 65 generally marks a key decision point for Medicare coverage.

The first mistake people make is missing that deadline, said Katy Votava, president and founder of Goodcare.com, a health care consulting firm. That is because many people think their full retirement age according to the Social Security Administration is their Medicare deadline.

For those who were born between 1943 and 1954, the full retirement age is 66, according to the Social Security Administration. But the age when you typically must sign up for Medicare is 65. You have up until you are age 65 and four months to make a decision. After that, you could face late enrollment penalties depending on your situation.

"Read the meter when you're 64," Votava said. "Do your homework, check, double-check, and sort it out so when you turn 65 you have a game plan." If you failed to sign up for Medicare when you should have, there is a general enrollment period every year when you can still get in, provided you are eligible.

The good news is that the general enrollment period, which runs from January to March, is happening now. If you sign up, your coverage begins in July. "Now is the time to stop the bleeding" if you do need to sign up, Votava said. "You will still have a penalty, but your penalty won't get any bigger."

Common errors

One of the biggest misconceptions for those who are 65 is that they have to take Medicare coverage, according to Omdahl.

If you are covered by an employer plan or a spouse's employer plan, for example, you must sign up for Medicare Part A but you can delay enrollment until you lose employer coverage or stop working. In that case, you would be eligible to fully enroll later during a special enrollment period without penalty.

Those who are 65 and who receive Social Security benefits must have Medicare Part A, which covers hospital insurance. If you are receiving Social Security benefits, you will be enrolled automatically.

But what to do about supplemental Medicare Part B coverage, which serves as medical insurance, is a key decision. Again, you must sign up for it, but you can delay enrollment under certain circumstances. A lot of the choice depends on your employer, provided that you are still working.

If you are 65 and employed at a company with fewer than 20 employees, the company has the right to exclude you from their health plan. As a result, you would have to enroll in Medicare Parts A and B, Omdahl said.

If you can stay on the employer group plan, Medicare then becomes the primary payer and the group plan is secondary.

This can become an issue if you are told you can stay on the plan and that changes, Omdahl said. At that point, there is no primary payer and you could be on the hook for unpaid medical bills. If your employer has 20 or more employees, they cannot exclude you from the plan or raise your premiums. Your firm will be the primary payer.

This is important to note, Omdahl said, as some employees receive erroneous information from their companies regarding their eligibility for coverage.

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Questions to Ask About Employee Benefit Packages

You have interviewed with a company where the position sounds great, the salary is more than you expected, and the job offer is on the table. Before you say "yes" though, it's important to consider the employee benefits package. Employment benefits can comprise 40%, or even more, of your total compensation package, so it's important to know exactly what benefits you will be provided with and to get enough benefit information to ensure that the coverage is what you need.

Investigate Benefits Coverage

It is much better to be fully informed before you accept a position than it is to have an unpleasant surprise later on. For example, if you're not married and want to cover your partner, will your health insurance plan insure him or her? Perhaps, if domestic partner coverage is provided. However, some plans only cover same-sex partners, not opposite-sex partners. Even though this sounds discriminatory, and it's certainly not fair, a federal court has ruled that it's legal.

Employer-provided insurance plans can have waiting periods of up to 90 days. So, if you or anyone in your family, have health issues, you will need to inquire about when coverage would go into effect. If you're leaving one job for another, you will need interim coverage, most likely through the Consolidated Omnibus Budget Reconciliation Act (COBRA).

When you have small children or elderly parents or are otherwise a caregiver, you will need to know how generous the sick time policy is. Some employers provide sick leave when either yourself or a family member is sick and allow time off for doctor's visits. Others aren't as flexible.

Some companies provide time-off for holidays, others expect you to work. If you are required to work on a holiday you may, or may not, be paid extra.Vacation leave also varies depending on the organization you work for. Some employers offer a generous amount of vacation or flex time off; others don't.

There are many different scenarios, as you can see, so it's important to review what benefit coverage is provided and to decide whether the employee benefits package is one that meets your needs. A great salary isn't always going to be enough to compensate for an employee benefit plan that doesn't offer what you need.

In general, there are employee benefits questions you should ask about to ensure that your overall compensation plan is right for you and for your family. Also, ask specific questions based on your needs and on the criteria that are important to you.

Questions to Ask

Does the employee pay for health insurance coverage? If so, how much for individual coverage and/or family coverage? Is the premium deducted from my paycheck? How much is the deductible?

Can I review a summary of the health insurance plan options? What restricts and limitations are there? What about pre-existing conditions? When does coverage begin?

How much sick time, vacation time, and holidays are provided. When do benefits start to accrue?

What type of pension plan is there? How much does the company contribute? Is life insurance provided?

Does the company offer short-term and long-term disability coverage?

Are there educational and training benefits? If so, are they are available for my family, as well as for me?

One important caveat is never to ask these questions during the interview. Wait until you have a job offer to discuss employee benefits, either with Human Resources or the person who is offering you the job.

Next, take some time to review the benefit plans so you can make an educated decision based on the benefits information provided by your prospective employer.

Making a Decision

Review the benefits offered. Are the programs what you need?

What benefit costs are you responsible for paying? How much will this cost on an annual basis?

If you have a family - is the workplace family-friendly?

Finally, make a decision on whether to accept the position based upon the entire compensation plan, including salary, fringe benefits, and additional perks that may be offered or negotiated.

That way, you're accepting, or rejecting, the job based on overall compensation rather than just one facet of it. And, most importantly, you won't have any unexpected costs or benefits issues when it might be too late to do anything about it.