Skip to content

Medicare Open Enrollment: October 15- December 7, 2012

In most cases, this may be the one chance you have to make a change to your health and prescription drug coverage for 2013. This is the second year the fall Open Enrollment Period dates are earlier. The dates have changed to give you more time if you want to chose and join a Medicare health or prescription drug plan.

Mark your calendar with these important dates!

October 1-15, 2012: Compare your coverage with other available options to see if there's a better choice for you.

October 15-December 7, 2012: Open Enrollment. You can change your Medicare health or prescription drug coverage for 2013.

January 1, 2013: New coverage begins if you switched or joined a new plan. New costs and benefit changes also begin if you kept your existing Medicare health or prescription drug coverage and your plan made changes.

Here are eight things to consider when choosing or changing your coverage:
1. Coverage: Does the plan cover all of the services you need?
2. Your other coverage: If you have other types of health or prescription drug coverage, make sure you understand how that coverage works with Medicare. If you have employment-related coverage or get your health care from an Indian Health or Tribal Health Program, talk to your benefits administrator or insurer before making any changes.
3. Costs: How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out-of-pocket for medical services? Make sure you understand any coverage rules that may affect your costs.
4. Doctor and hospital choice: Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?
5. Prescription drugs: Do you need to join a Medicare Prescription Drug Plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What will your prescription drugs cost under each plan? Are your drugs covered under the plan's formulary? Are there any coverage rules that apply to your prescriptions? Is the pharmacy you use in the plan's network?
6. Quality of care: Are you satisfied with your medical care? The quality of care and services given by plans and other health care providers can vary. Get help comparing plans and providers.
7. Convenience: Where are the doctor's offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records (EHRs) or E-prescribe?
8. Travel: Will the plan cover you if you travel to another state or outside the United States?

If you need help making your decision, you can contact Medicare toll free at 800.633.4277 or you can get personalized health insurance counseling from Med Care Navigators at 716.667.7600.
Pro2

Source: Medicare.gov The official U.S. Government Site for Medicare Retrieved September 17, 2012 from http://medicare.gov/

The Importance of Face-to-Face Clinical Evaluations

Physician or Nurse in scrubsAccording to DME MAC A, the Medicare Administrative Contractor for Durable Medical Equipment, more than two-thirds of all claims denied in their latest audit were denied because of issues with face-to-face clinical evaluation documentation.

DME MAC A reviewed claims processed between November 2011 and January 2012 for CPAP devices. Of claims that were denied, almost half (46.5%) were missing the required clinical documentation and medical records to support the medical necessity of the device.

"These claims had no Face to Face clinical evaluations from the beneficiaries' medical records. Included in these were no Face to Face evaluations conducted by the treating physicians where the beneficiaries were seeking PAP replacement following the 5 year RUL or when requiring coverage of a replacement PAP upon entering FFS Medicare."

About 20% of the claims that were denied had insufficient clinical documentation to support the medical necessity of the device, such as:
- No detailed narrative describing the presenting symptoms of sleep disordered breathing, daytime sleepiness/fatigue, observed apneas, choking/gasping during sleep; duration of symptoms; or Epworth Sleepiness Scale scores
- The face-to-face clinical re-evaluation failed to demonstrate an improvement in obstructive sleep apnea (OSA) symptoms and that the patient continued to benefit from PAP therapy
- Insufficient clinical documentation for face-to-face evaluations where the patient is seeking PAP replacement or when requesting coverage of a replacement PAP upon entering FFS Medicare

Finally, just over 6% of denied claims were missing the signature and/or date on the face-to-face evaluation and a handful had illegible documents.
Pro2

Source: Results of Widespread Prepayment Review of Claims for HCPCS E0601, (Continuous Positive Airway Pressure Devices). NHIC, Corp. Retrieved August 20, 2012 from http://www.medicarenhic.com/dme/medical_review/mr_bulletins/mr_bulletin_pca/042012_cpap.pdf