Category Archives: Medicare

Medicare’s Conditional Approval: Bariatric Surgery

Bariatric surgery is commonly referred to as either Lap-Band surgery or weight loss surgery. The premise behind this surgery is to help patients achieve positive weight loss by effectively reducing the size of their stomach. The smaller space means less food can comfortably be consumed in a single setting. The reduced caloric intake results in weight loss that the patient is better able to keep off.

Compelling Data
In 2004 the Journal of American Medical Association reported that of more than 22,000 diabetics who received bariatric surgery 76.8 percent of those patients found their diabetes, “Completely resolved.” Other studies seem to point to the possibility that this type of surgery remains a viable contender for management or reversal of diabetes.

Dr. Christine Ren is quoted as saying, “If you lose weight, your diabetes will go away, and when you regain the weight, the diabetes will come back. Diabetes is always lurking, and remission lasts as long as the weight loss lasts.”

Medicare’s Revised Decision
This idea may be why Medicare has revised policies dealing with this procedure. The Centers for Medicare & Medicaid Services (CMS) announced revisions to Medicare in mid February that essentially allow bariatric surgery to be considered for morbidly obese patients who are on Medicare.

HealthNewsDigest indicates, “The decision specifies type 2 diabetes as one of the co-morbidities CMS would consider in determining whether bariatric surgery would be covered for a Medicare beneficiary who is morbidly obese, as long as the surgery is furnished at a CMS-approved facility. An individual with a body-mass index (BMI) of at least 35 is considered morbidly obese. Normal body-mass index is considered to be between 18.5 and 25.”

In explaining the decision CMS Acting Administrator Charlene Frizzera said, “Today’s coverage decision assures that beneficiaries who are morbidly obese can access safe, effective weight loss options to help prevent complications.”

Not For Everyone?
To be clear this procedure can only be considered when Medicare patients have a BMI of 35 or higher. A BMI lower than 35 will not be considered for treatment using this type of surgery.

Surgery Types
This surgical procedure qualifies due to what is referred to as co-morbidity. This essentially means the combination of diabetes and obesity. They both need to be present to qualify. The Health and Human Services website states, “The evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) improve health outcomes in Medicare beneficiaries who have T2DM and a BMI > 35.”

You will notice there are three separate bariatric surgical procedures listed above that could be used to help qualified patients. You should also know that these surgeries need to take place in a Centers for Medicare and Medicaid Services approved facility.

Cost Effective and Diabetic Friendly
It is believed that this procedure may be more cost effective for health treatment among the morbidly obese. Diabetic treatments can be as high as $33,000 annually. If a bariatric surgery successfully reverses diabetes it will actually cost significantly less in the long run while providing a greater quality of life for the patient.

As of this report medical science is still unsure why this type of surgery works. The general consensus is that if they can learn why the procedure is successful there may come a time when they can duplicate the end result with non-surgical options.

Medicare Donut Holes and Nutrisystem’s Large Donation

Medicare Donut Holes and Nutrisystem’s Large DonationMedical care is an important consideration for most Americans, but when the costs rise to unmanageable levels there are difficult choices that must be made. In the case of some Medicare patients who also have diabetes it seems to mean a suspension of medication used to control the disease.

According to new research Medicare’s Part D prescription drug plan places a central gap in coverage that has resulted in many diabetics forfeiting medication in favor of using the funds to manage other financial obligations.

The cap on the plan is $2,250, but most diabetics go over that amount in medication for their personal care. The patient then must spend $3600 out of pocket before Medicare prescription coverage kicks in again for the calendar year. Some refer to this clause as a ‘donut hole’. There is coverage before and after, but nothing in the middle.

It is clear the primary reason the plan was designed this way was to appeal to prescription drug users to use only medication essential to their care. While this may have been the intent there appear to be more and more diabetics who are simply doing without when the Medicare funds are shut off.

Many of these individuals are living with decisions between diabetic medications and home heating, diabetic medication and transportation or even diabetic medication and food.

There are gap coverage policies and even prescription drug plans designed to lower overall medication costs. They are helping a little, but not as much as some patients need.

Many are hopeful that this disparity can be addressed and revised so that managed care among those on Medicare can result in a quality of life that is an improvement over current conditions.

Meanwhile Nutrisystem will donate up to $350,000 to the American Diabetes Association (ADA) to assist in the “Stop Diabetes” movement.

Nutrisystem is a weight loss company that uses food choices as a means of assisting in personal weight reduction. They have also developed a line of food specifically for diabetics called Nutrisystem-D. It is the potential proceeds from this product that the company will use to assist the ADA. The company has promised $250,000, but the actual amount could be higher based on the success of the Nutrisystem-D product line.

diabetic live is not necessarily endorsing the Nutrisystem-D product line. We are simply reporting what one company is doing to help foster understanding in diabetes and provide assistance in eliminating the disease.

These two stories do serve to indicate that the responsibility for diabetes care has become an important consideration for many. Drug manufacturers are working to provide lower costs, the ADA continues to look for answers and corporations are seeking to find ways to partner with organizations in an effort to eradicate the disease to the degree they can.

Education will always be a primary tool used to confront this disease and used to implement new strategies, reduce incidence of the disease and accessed to make better health decisions early in life.

Diabetes is a silent killer, but one that can be avoided or managed if taken seriously and responded to early.

diabetic live is a committed resource in information and news related to all aspects of diabetes. We are not focused only on one type of the disease and we will share information related to medical advances as well as more natural approaches that have proven successful.

Diabetes and Medicare: Donut Hole Elimination

In an effort to close the legendary ‘donut hole” gap in Medicare Part D coverage the government is sending out $250 checks to hundreds of thousands of Medicare recipients who require prescription medications. The intent is to close the gap in coverage by 2012.

In explaining the donut hole it is important to know there are strong benefits for Medicare users up to $2,830. There is also strong coverage once total prescription amount exceeds $6,440. It is the middle area for which the term “Donut Hole” applies.

There are nearly 28 million Americans enrolled in Medicare Part D coverage and have survived in gap coverage by either paying a substantial amount of out of pocket expenses related to prescription drugs or by simply refusing to refill prescriptions when the benefits ran out. The later can place the individual at risk and cause additional stress and health issues to develop.

Over a fourth of all Medicare Part D users reach the $2,830 prescription level and are left to consider how to fund the more than $3,500 it takes before any additional help is provided. That being said there are plans to effectively eliminate the donut hole. reports, “Beginning in 2011, Part D beneficiaries who reach the doughnut hole will get a 50 percent discount. This will be phased up to a 75 percent discount on brand name drugs by 2020 and a 7 percent discount on generic drugs—bringing costs to Part D beneficiaries back down to 25 percent (standard coverage level), thereby effectively closing the doughnut hole.”

In the meantime the government continues to send out checks worth $250 to Medicare Part D participants who reach the lower threshold of the ‘donut hole’ with a situational review every quarter. This means that if you reach the threshold in the 3rd quarter you would still be eligible to receive one $250 rebate once that threshold is exceeded.

Perhaps what is most troubling to those observing the program is the disconnect that occurs when Medicare patients reach the threshold and then determine they simply can’t afford to continue the treatment their primary health care provider recommends. By standardizing the subsidy the stress of that donut hole gap is reduced. The perceived end suggests a greater continuance of coverage and an overall improved health outlook for those using this Medicare plan.

For diabetics it is important to note that one in ten Medicare Part D participants will stop taking their diabetes medications once they reach the donut hole threshold. Interestingly 85% of all Medicare Part D participants exceeded the lower threshold, but did not reach the $6,440 level where assistance was once again provided. This means that living in the ‘donut hole’ requires enormous out of pocket expenses for participants.

Only 20% of Medicare Part D providers offer any kind of gap coverage. This leaves an incredibly large remainder to struggle with paying for their prescription needs.

The elimination of the gap is all part of the current Health Care Reform Act. President Obama has said that there will be approximately 4 million Part D beneficiaries that will receive the $250 rebate checks by years end.

While this doesn’t completely eliminate the disparity between the two thresholds many see it as a signal that Medicare will be helping more individuals cope as the Health Care overhaul comes into its own.

Medicare and the Diabetic: Part C

In this article we will review the comprehensive Medicare Advantage Plan known as Part C. This fee based service covers other Medicare Plans and may be preferred by some Medicare recipients.

According to Medicare, “Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are health plans offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan provides all your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage.

“Medicare Advantage plans always cover emergency and urgent care. Medicare Advantage Plans must cover all the services that Original Medicare covers, except hospice care. (Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan.)

“Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most plans also include Medicare prescription drug coverage.

“Medicare Advantage Plans must follow rules set by Medicare. However, each plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan).

“You usually pay one monthly premium to the Medicare Advantage plan, in addition to your Part B premium.

Different Types of Medicare Advantage Plans

  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Medical Savings Account (MSA) Plans
  • Special Needs Plans (SNP)

Other less common types of Medicare Advantage Plans include:

  • Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out-of-network for a higher cost.
  • Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.

What You Pay in a Medicare Advantage Plan
Your out-of-pocket costs in a Medicare Advantage Plan depend on:

  • Whether the plan charges a monthly premium in addition to your Part B premium.
  • Whether the plan pays any of the monthly Part B premium. Some plans offer this option, usually for an extra cost.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much you pay for each visit or service (co-payments).
  • The type of health care services you need and how often you get them.
  • Whether you follow the plan’s rules, like using network providers.
  • Whether you need extra coverage and what the plan charges for it.
  • Whether the plan has a yearly limit on your out-of-pocket costs for all medical services.

How to Join a Medicare Advantage Plan
Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs.

More about Medicare Advantage Plans

  • As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
  • Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
  • You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.
  • You can join a Medicare Advantage Plan even if you have a pre-existing condition, except for End-Stage Renal Disease.
  • You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
  • If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher.
  • If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare. (Source: Medicare)