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Medicare Part-D 2015: Donut Hole, Costs, Drug Plans, Deductible

<div dir="ltr" style="text-align: justify;" trbidi="on">The Medicare Modernization Act (MMA) requires to announce each year the Medicare Part D standard defined benefit and Retiree Drug Subsidy (RDS) amounts for the coming year. 
 
Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. 
 
<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/11/medicarepart-d2015donuthole-costsdrugplansdeductible.html"><img alt="Medicare Part-D 2015: Donut Hole, Costs, Drug Plans, Deductible" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBEDmG2p5ZdAHRl2EE5cBrysRDricrv6qrBfBEqcI5Y9KuiI0-zppSZ1P52fVp91cQHdY1RwryrjHiv1Mv-_0wH0yHVjuh-5Ddqrbhu6aR0MvKtq6p_1negXedUAlxKg3OnoKIETGFE8RV/s1600/medicare-part-d2015-donuthole-costs-drugplans-deductible.jpg" /></a></div> 
<h2>Medicare Part-D 2015: Donut Hole, Costs, Drug Plans, Deductible</h2>The Centers for Medicare & Medicaid Services (CMS) recently released information about the Medicare Part D stand-alone prescription drug plans (PDPs) that will be available in 2015. 
 
<h2>Medicare Part D Benefit Parameters Comparison 2015</h2>Medicare & Medicaid Services (CMS) on April 7, 2014, has announced the Medicare Part-D 2015 rates, deductible and out-of-pocket limit. Here are the Medicare Part-D Benefit Plan changes from 2014 to 2015. These are the Standard Benefit plan changes. This "Standard Benefit Plan" is the minimum allowable plan to be offered. 
<ul><li>Medicare Part-D Initial Deductible 2015: will be increased by $10 to $320 in 2015</li>
<li>Medicare Part-D Initial Coverage Limit 2015: will increase from $2,850 in 2014 to $2,960 in 2015</li>
<li>Medicare Part-D Initial Out-of-Pocket Threshold: will increase from $4,550 in 2014 to $4,700 in 2015</li>
<li>Medicare Part-D Initial Donut Hole (Coverage Gap) 2015: begins once you reach your Medicare Part D plan’s initial coverage limit ($2,960 in 2015) and ends when you spend a total of $4,700 in 2015. In 2015, Part-D enrollees will receive a 55% discount on the total cost of their brand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will still apply to getting out of the donut hole, however the additional 5% paid by your Medicare Part D plan will not count toward your TrOOP. Enrollees will pay a maximum of 65% co-pay on generic drugs purchased while in the coverage gap. </li>
<li>Minimum Cost-sharing in the Medicare Part-D Catastrophic Coverage Portion of the Benefit: will increase to greater of 5% or $2.65 for generic or preferred drug that is a multi-source drug and the greater of 5% or $6.60 for all other drugs in 2015</li>
<li>Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $2.65 for generic or preferred drug that is a multi-source drug and $6.60 for all other drugs in 2015</li>
</ul>For the defined standard Medicare Part-D plan, which will be higher than the 2014 amounts as shown in the Medicare Part D Benefit Parameters Comparison 2015 below: 
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<table cellpadding="1" cellspacing="0" bgcolor="#ffffff" border="0" class="tblData" valign="top"><tbody>
<tr class="tblhead"> <td align="left">Medicare Part-D Benefits</td> <td align="center">2015</td> <td align="center">2014</td> <td align="center">2013</td> <td align="center">2012</td> <td align="center">2011</td> </tr>
<tr> <td align="left"><h4>Medicare Part-D Deductible</h4>After the Medicare Part-D Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit.</td><td align="center">$320</td><td align="center">$310</td><td align="center">$325</td><td align="center">$320</td><td align="center">$310</td> </tr>
<tr> <td align="left"><h4>Medicare Part-D Donut Hole</h4>Initial Coverage Limit: Medicare Part-D Coverage Gap (Donut Hole) begins at this point. The Beneficiary pays 100% of their prescription costs up to the Out-of-Pocket Threshold.</td><td align="center">$2960</td><td align="center">$2850</td><td align="center">$2970</td><td align="center">$2930</td><td align="center">$2840</td></tr>
<tr><td align="left">Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - Catastrophic Coverage starts after this point. 
 
(Please see note 1 below)</td><td align="center">$6680.00 
 
plus a 55% brand discount</td><td align="center">$6455.00 
 
plus a 52.50% brand discount</td><td align="center">$6733.75 
 
plus a 52.50% brand discount</td><td align="center">$6657.50 
 
plus a 50% brand discount</td><td align="center">$6447.50 
 
plus a 50% brand discount</td></tr>
<tr><td align="left">Out-of-Pocket Threshold - This is the Total Out-of-Pocket Costs including the Donut Hole. 
2015 Example: 
$320 (Deductible) 
+(($2960-$320)**25%) (Initial Coverage) 
+(($6680.00-$2960)*100%) (Cov. Gap) 
= $4700 (Maximum Out-Of-Pocket Cost prior to Catastrophic Coverage - excluding plan premium)</td><td align="center">$4700 
 
 
 
$320.00 
$660.00 
 
$3720.00 
 
$4700.00 
 
 
</td><td align="center">$4550 
 
 
 
$310.00 
$635.00 
 
$3605.00 
 
$4550.00 
 
 
</td><td align="center">$4750 
 
 
 
$325.00 
$661.25 
 
$3763.75 
 
$4750.00 
 
 
</td><td align="center">$4700 
 
 
 
$320.00 
$652.50 
 
$3727.50 
 
$4700.00 
 
 
</td><td align="center">$4550 
 
 
 
$310.00 
$632.50 
 
$3607.50 
 
$4550.00 
 
 
</td></tr>
<tr><td align="left">Total Estimated Covered Part D Drug Out-of-Pocket Spending, including the Coverage Gap Discount (NON-LIS). See note 2 below.</td><td align="center">$7061.76</td><td align="center">$6690.77</td><td align="center">$6954.52</td><td align="center">$6730.39</td><td align="center">$6483.72</td></tr>
<tr><td align="center" colspan="6" valign="top"><h3>Medicare Part D Catastrophic Coverage Benefits</h3></td></tr>
<tr><td align="left">Generic/Preferred 
Multi-Source Drug</td><td align="center">$2.65</td><td align="center">$2.55</td><td align="center">$2.65</td><td align="center">$2.60</td><td align="center">$2.50</td></tr>
<tr><td align="left">Other Drugs</td><td align="center">$6.60</td><td align="center">$6.35</td><td align="center">$6.60</td><td align="center">$6.50</td><td align="center">$6.30</td></tr>
<tr class="tblhead"><td align="left">Full Benefit Dual Eligible (FBDE)</td><td align="center">2015</td><td align="center">2014</td><td align="center">2013</td><td align="center">2012</td><td align="center">2011</td></tr>
<tr><td align="left">Deductible</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td></tr>
<tr><td align="left">Copayments for 
Institutionalized 
Beneficiaries</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td></tr>
<tr> <td align="center" colspan="6" valign="top"><h3>Maximum Copay for Non-Institutionalized Beneficiaries</h3></td></tr>
<tr><td align="left" colspan="6" valign="top">Up to or at 100% FPL:</td></tr>
<tr><td align="left" colspan="6" valign="top">Up to Out-of-Pocket Threshold</td></tr>
<tr><td align="left">Generic/Preferred 
Multi-Source Drug</td><td align="center">$1.20</td><td align="center">$1.20</td><td align="center">$1.15</td><td align="center">$1.10</td><td align="center">$1.10</td></tr>
<tr><td align="left">Other</td><td align="center">$3.60</td><td align="center">$3.60</td><td align="center">$3.50</td><td align="center">$3.30</td><td align="center">$3.30</td></tr>
<tr><td align="left">Above Out-of-Pocket 
Threshold</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td></tr>
<tr><td align="left" colspan="6" valign="top">Over 100% FPL:</td></tr>
<tr><td align="left" colspan="6" valign="top">Up to Out-of-Pocket Threshold</td></tr>
<tr><td align="left">Generic/Preferred 
Multi-Source Drug</td><td align="center">$2.65</td><td align="center">$2.55</td><td align="center">$2.65</td><td align="center">$2.60</td><td align="center">$2.50</td></tr>
<tr><td align="left">Other</td><td align="center">$6.60</td><td align="center">$6.35</td><td align="center">$6.60</td><td align="center">$6.50</td><td align="center">$6.30</td></tr>
<tr><td align="left">Above Out-of-Pocket 
Threshold</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td></tr>
<tr class="tblhead"><td align="left">Part-D Non FBDE Full Subsidy</td><td align="center">2015</td><td align="center">2014</td><td align="center">2013</td><td align="center">2012</td><td align="center">2011</td></tr>
<tr><td align="left" colspan="6" valign="top">Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources < $7160 (individuals) or < $10750 (couples)</td></tr>
<tr><td align="left">Deductible</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td></tr>
<tr><td align="left" colspan="6" valign="top">Maximum Copayments up to Out-of-Pocket Threshold</td></tr>
<tr><td align="left">Generic/Preferred 
Multi-Source Drug</td><td align="center">$2.60</td><td align="center">$2.55</td><td align="center">$2.65</td><td align="center">$2.60</td><td align="center">$2.50</td></tr>
<tr><td align="left">Other</td><td align="center">$6.60</td><td align="center">$6.35</td><td align="center">$6.60</td><td align="center">$6.50</td><td align="center">$6.30</td></tr>
<tr><td align="left">Maximum Copay above 
Out-of-Pocket 
Threshold</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td><td align="center">$0.00</td></tr>
<tr class="tblhead"><td align="left">Medicare Part-D Partial Subsidy</td><td align="center">2015</td><td align="center">2014</td><td align="center">2013</td><td align="center">2012</td><td align="center">2011</td></tr>
<tr><td align="left" colspan="6" valign="top">Applied and income below 150% FPL and resources between $7161-$13440 (individuals) or $10751-$26860 (couples) (category code 4)</td></tr>
<tr><td align="left">Deductible</td><td align="center">$66.00</td><td align="center">$63.00</td><td align="center">$66.00</td><td align="center">$65.00</td><td align="center">$63.00</td></tr>
<tr><td align="left">Coinsurance up to 
Out-of-Pocket 
Threshold</td><td align="center">15%</td><td align="center">15%</td><td align="center">15%</td><td align="center">15%</td><td align="center">15%</td></tr>
<tr><td align="left" colspan="6" valign="top">Maximum Copayments above Out-of-Pocket Threshold</td></tr>
<tr><td align="left">Generic/Preferred 
Multi-Source Drug</td><td align="center">$2.65</td><td align="center">$2.55</td><td align="center">$2.65</td><td align="center">$2.60</td><td align="center">$2.50</td></tr>
<tr><td align="left">Other</td><td align="center">$6.60</td><td align="center">$6.35</td><td align="center">$6.60</td><td align="center">$6.50</td><td align="center">$6.30</td></tr>
</tbody></table><ol><li>Total Covered Part D Spending at Out-of-Pocket Threshold for Non-Applicable Beneficiaries - Beneficiaries who ARE entitled to an income-related subsidy under section 1860D-14(a) (LIS) 
 
</li>
<li>Total Covered Part D Spending at Out-of-Pocket Threshold for Applicable Beneficiaries - Beneficiaries who are NOT entitled to an income-related subsidy under section 1860D-14(a) (NON-LIS) and do receive the coverage gap discount. For 2015, the weighted gap coinsurance factor is 90.693%. This is based on the 2013 PDEs (85.9% Brands & 14.1% Generics) 
 
</li>
<li>The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2014, beneficiaries would be charged $2.60 for those generic or preferred multisource drugs with a retail price under $52 and 5% for those with a retail price greater than $52. As to Brand drugs, beneficiaries would pay $6.60 for those drugs with a retail price under $132 and 5% for those with a retail price over $132. 
 
</li>
<li>The actual amount of resources allowable may be updated for contract year 2015</li>
</ol></div>

Medicare Part-D 2015: Donut Hole, Costs, Drug Plans, Deductible

The Medicare Modernization Act (MMA) requires to announce each year the Medicare Part D standard defined benefit and Retiree Drug Subsidy (RDS) amounts for the coming year. Most Medicare Prescription …

Colon Cancer Screening Medicare Coverage Guidelines and Codes

<div dir="ltr" style="text-align: justify;" trbidi="on">Medicare does cover Colon Cancer also referred as Colorectal Cancer, Rectal Cancer or Bowel cancer. Which is the development of cancer in the colon or rectum in the lower part of the large intestine. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. 
 
Colon Cancer Symptoms and Signs include blood in the stool, a change in bowel movements, weight loss, and feeling tired all the time. 
 
<h3>Colon Cancer Screening</h3>Colon Cancer Screening can be done by obtaining a sample of the colon during a sigmoidoscopy or colonoscopy. This is then followed by medical imaging to determine disease spread, colon cancer staging and prognosis. 
 
In US, Colon Cancer Screening is found effective to decrease colon cancer related deaths. Colon Cancer Screening is recommended starting at the age of 50 and continuing until the age of 75 in United States. 
 
<h2>Colon Cancer Screening Medicare Coverage Guidelines and Codes</h2>You can checkout the <a href="http://www.medicalbillingcodings.org/2014/10/Colorectal-cancer-screening-icd9cpt-codes.html">Colorectal Cancer Screening ICD 9 and CPT Codes</a> under which Medicare does cover colorectal (colon) cancer screenings. 
 
<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/11/coloncancerscreening-medicarecoverageguidelines.html"><img alt="Colon Cancer Screening Medicare Coverage Guidelines and Codes" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgplTpGTiq6cMEoo8E6BcugpGCTydTOr3mVrhvMbP0DT5YQDh_9f5fz2ZGzHgFrW3R1iVUan_3z_wi1gj4D2stYRopkRMxEznlwaH7T8fhmyTYSApP8yM-jB0oYHqmDbceI5_F0A9C5Rjv6/s1600/Colorectal-cancer-screening-icd9cpt-codes.jpg" /></a></div> 
<h3>Medicare Colon Cancer Screening Coverage Guidelines</h3>With Medicare, a patient must be 50 age or older to be eligible for Medicare Colon Cancer Screening Coverage for most of the colon cancer types. 
 
However, there is an exception to this. For colonoscopy procedure (which can also diagnose colon cancer) there is no minimum age requirement. 
 
Below are the medicare colon cancer screening coverage eligibility guidelines: 
<ul><li>Fecal occult blood test - once a year (every 12 months) for persons age 50 or older. 
 
</li><li>Flexible sigmoidoscopy - once every four years (48 months) for persons at high risk and less frequently for other persons. 
 
</li><li>Colonoscopy - once every two years (24 months) if you are at high risk for colorectal cancer (Have a family history of the disease or have had colorectal polyps or colorectal cancer, or have had inflammatory bowel disease). 
 
</li><li>Medicare covers colonoscopies every 10 years (but not within 48 months of a screening flexible sigmoidoscopy) if you are not at high-risk. 
 
</li><li>Barium enema – once every two years for persons at high risk and once every four year for others (but not within 48 months of a screening flexible sigmoidoscopy).</li>
</ul>From 2011, if you have original Medicare, no coinsurance or deductible applies to the fecal occult blood test, flexible sigmiodoscopy or colonoscopy if you see doctors who take assignment. Doctors and other health care providers who take assignment cannot charge you more than the Medicare approved amount. 
 
From 2012, Medicare Advantage Plans will cover all preventive services the same as Original Medicare. This means Medicare Advantage (MA) plans will not be allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that Original Medicare does not charge for as long as you see in-network providers. If you see providers that are not in your plan’s network, charges will typically apply. Therefore, if you are in a Medicare Advantage plan, contact your plan to find out what rules and costs apply. 
 
For Barium Enema, patient will pay 80 percent of the Medicare approved amount if the doctor takes assignment. The Medicare Part-B deductible does not apply. 
 
For Diagnostic Colon Cancer Screening, if a patient undergoes colonoscopy and the provider finds and removes a polyp, the costs will apply. Patient would have to pay the coinsurance for the colonoscopy and the polyp removal because the Colon Cancer Screening became diagnostic. However, no deductible will apply. 
</div>

Colon Cancer Screening Medicare Coverage Guidelines and Codes

Medicare does cover Colon Cancer also referred as Colorectal Cancer, Rectal Cancer or Bowel cancer. Which is the development of cancer in the colon or rectum in the lower part of the large intestine. …

AR Analyst Role in Medical Billing Claims Review Process

<div dir="ltr" style="text-align: justify;" trbidi="on">Account Receivables (AR) in Medical Billing and Coding are defined as amounts due and expected to be collected by Medical billing / provider office for the services provided to individuals. 
 
In <a href="http://www.medicalbillingcodings.org/2012/09/how-to-start-medical-billing-home-business.html">Medical Billing Business</a> receivables are handled by Account Receivables (AR) Department. Thus, Account Receivables (AR) Analyst's role is crucial in identifying and resolving issues which helps to reduce or clear receivables. 
 
<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/11/aranalystrolemedicalbillingclaimsreviewprocess.html"><img alt="AR Analyst Role in Medical Billing Claims Review Process" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjt50cSS4FZOuYa5yckevJdyy3Y7drpT0v31BsowOLz1gGrzBOzNAmXGzaoT5hf4OLrMbJYfpO-zDoH-j65OjoxDQWP_i6MgkHjS4EZFttjK0mZZwg3gEidfwW0Isp46ARa0oKavM4On4/s1600/ar-analyst-role-medicalbilling-claims-review-process.jpg" /></a></div> 
<h2>AR Analyst Role in Medical Billing Claims Review Process</h2>AR Analyst Role and Responsibilities in Medical Billing Claims review process are based on ensuring timely, accurate and final settlement of medical insurance claims and patient bills by insurers or patients as appropriate. 
 
The purpose of Medical Billing Claim Analysis is to identify and resolve medical claims billing and reimbursement issues aimed at maximizing collections and minimizing accounts receivables. 
 
The scope of AR Claim Analysis is applicable to all health insurance claims and patient bills that have not been fully and finally settled by liable party or parties comprising health insurers, patients and others. It is the responsibility of the Accounts Receivables Analyst to ensure that AR is under control and acceptable by industry standards. 
 
<h3>What is AR Department Role in Medical Billing?</h3>An AR analyst as a part of Account Receivables (AR) Department has to ensure steady inflow of money from the medical insurances to the provider and in turn medical billing company. 
 
The main motive of this department is to collect money for all the treatments taken by the patients in a timely fashion. Usually the turn around period for the payment by the medical insurance companies is 30 to 45 days. Once the limit is exceeded AR department has to make an inquiry for the delay. There could be various reasons for the delay like: 
<ol><li>Correct details may not have been provided to the insurance companies. 
 
</li><li>Claims were sent correctly but Insurance Company may not have received the claims. 
 
</li><li>The checks issued might have been sent to the wrong address. 
 
</li><li>The insurance company may delay the payments if they have a backlog and they would inform us by a letter that they have received the claims and would be making the payments shortly.</li>
</ol><h3>AR Analyst and Medical Billing Softwares</h3>In a medical billing business, AR department acts as a hub around which other departments revolve. This department can gather and update lot of billing information which is required to settle a claim. Account analyst uses various reports available in billing software to identify claims which have not been settled. 
 
<a href="http://www.medicalbillingcodings.org/2013/07/best-medical-billing-coding-softwares-review.html">Medical Billing Softwares</a> are capable of running reports that pull out claims that are unpaid for greater than 30 days. These are called aging reports and these reports show pending payments in slots such as 0–30 days, 31-60 days and 61-90 days. 
 
Medical billing Claims filed within the last 30 days will find themselves in the first slot (0-30days). Claims that are more than 30 days but less than 60 days old will be found in the 31-60 days slot. 
 
A glance at this report will show the AR personnel the claims that need to be followed up on with the insurance company. 
 
<h3>AR Follow up in Medical Billing</h3>In Medical Billing, AR analyst follow up the claims over the telephone, email or by written correspondence. It's his duty to find out why the claims are yet to be paid and what needs to be done to have these claims paid. 
 
The delay and denials in claim reimbursement will be corrected by the billing office in coordination with the physician’s office and the insurance carriers. 
 
The same applies when patient billing statements are sent out. The patient is given 3-4 weeks to pay the bill and if the payment is not received with in that time, the billing office will follow up with the patient. 
</div>

AR Analyst Role in Medical Billing Claims Review Process

Account Receivables (AR) in Medical Billing and Coding are defined as amounts due and expected to be collected by Medical billing / provider office for the services provided to individuals. In Medica…

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