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How Good Is Your Medicare Health Insurance Coverage?

Medicare health insurance is generally designed to offer some coverage for hospitalization and routine health care, but it does not offer complete coverage for most services. In some cases, health care services you may need or want might not be covered at all, or may be covered only in limited circumstances.

Another consideration for Medicare beneficiaries is that not every health care provider accepts Medicare insurance. There is no requirement that doctors or hospitals accept Medicare. Many do, however based on recent and proposed changes in Medicare payment to providers, some doctors and hospitals are limiting the number of Medicare patients they’re accepting, and some providers have said that they will no longer accept Medicare.

When you enroll in Medicare, it’s important to decide how much you want to stay with your current doctor(s), hospital and/or pharmacy. Don’t make assumptions about your health care providers. You may need to ask each provider you see whether or not s/he accepts Medicare. If your provider does not accept Medicare, you may need to ask for a referral to another provider who does accept Medicare, or cover your health care costs from that provider out-of-pocket.

If you’re enrolled in traditional Medicare Part A and Part B, you can choose your health provider. Assuming your provider accepts Medicare, you can see the doctor(s) you want to see and receive services at your choice of hospitals that participate in the Medicare insurance program.

If you’re enrolled in a Medicare Advantage plan, you may have to choose your doctor(s), hospital(s) and pharmacies based on a list of participating providers who have been approved by your Medicare Advantage plan provider. In this way, Medicare Advantage plans are much like a health maintenance organization (HMO). If you choose to go out of your Medicare Advantage provider network, you could end up paying most or all of the costs associated with your care by yourself.

In short, not all health care providers accept Medicare, and not all services are covered. With traditional Medicare Part A and Part B coverage, you can purchase additional Medicare Supplemental Insurance to fill in some of the coverage gaps. With Medicare Advantage plans, some of these gaps are already filled in, but you may pay extra premiums with these plans, or you may find a limited network of health care providers whose services are covered by your Medicare Advantage plan.

Doctor Survey Shows More Than 10 Percent May Close In 2011

Arizona Medicare DoctorA survey conducted by the American Academy of Family Physicians (AAFP) shows that about 13% of family physicians who have an ownership stake in their practices may close their practices if Congress does not halt planned drastic cuts in reimbursements in January 2011.  Congress has announced planned cuts of 30% in the Medicare reimbursement rate beginning January 1, 2011.  Initially the cutbacks were set to take effect December 1, but Congress recently voted to delay implementation by one month.

Nearly two-thirds of survey respondents said they would have to stop accepting new Medicare patients and nearly three-fourths said they would have to reduce the number of appointments available to Medicare patients if the cuts are enacted. According to the AAFP, more than one-quarter of rural family physicians depend on Medicare reimbursements to keep their practices open, and the closure of a medical practice would affect not only Medicare recipients, but also healthy adults and children who require routine healthcare services.

The proposed cuts are the result of the application of the sustainable growth rate (SGR), which ties Medicare reimbursements to economic growth. In periods of negative economic growth, the SGR formula calls for payment reductions.  Since its inception in 2002, the SGR has indicated reimbursement reductions, but Congress has voted to override the SGR in favor of modest increases in reimbursements.  Without continued Congressional intervention, the accumulated reductions, which now total nearly 30%, will take effect January 1.

In the past, Congress has briefly allowed the SGR to take effect. During the brief lapses, CMS withheld Medicare and Medicaid reimbursements while waiting for Congress to act. The resulting reductions of as much as 20% required practices to take loans to make their payroll and continue providing services to patients.

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