Behavioral Therapy for Obesity.

The Centers for Medicare and Medicaid Services (CMS) has determined that intensive behavioral therapy for obesity is reasonable and necessary for the prevention or early detection of illness or disability.

Intensive behavioral therapy for obesity consists of the following:

1. Screening for obesity in adults.*
2. Dietary (nutritional) assessment.
3. Intensive behavioral counseling and therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

Benefits include:

• One face-to-face visit every week for the first month.
• One face-to-face visit every other week for months 2-6.
• One face-to-face visit every month for months 7-12, if the beneficiary meets the weight loss requirement of at least 3kg over the course of the first 6 months.

* Defined as a body mass index (BMI) of 30 kg/m² or more (weight in kilograms divided by the square of height in meters).

Medicare Benefits.com: Still No Relief in Sight for Long-Term Needs

Medicare Benefits.com: Still No Relief in Sight for Long-Term Needs

Still No Relief in Sight for Long-Term Needs

By GARDINER HARRIS and ROBERT PEAR

WASHINGTON — The law that many Americans had hoped would transform the nation’s dysfunctional system of long-term care for the swelling ranks of people with disabilities and dementia quietly died this month, a victim of its own weaknesses, a toxic political environment and President Obama’s re-election campaign focus on jobs.

Its demise came as an intense disappointment to people like Alison Briolat, a chemist for a pharmaceutical company, whose family is staggering under the burdens of caring for her bedridden parents.

“Everybody at work is very glib about how they’ll never be a burden to their children and how I’m such a saint,” she said. “But unless you have millions sitting in the bank, there’s no other way.”

Unlike the rich, who can afford to pay for services themselves, or the poor, who get help through Medicaid, the federal and state program for low-income people, many members of the middle class have to look after disabled relatives themselves, or pay someone to do it. Polls show that many people believe that Medicare, the federal health program for those 65 and older, pays for such care. Actually, Medicare stops paying nursing home bills after 100 days.

More than 10 million people in the United States already have long-term care needs, and two-thirds of the costs are paid for by government programs, mostly Medicaid. Studies estimate that unpaid family members deliver an even larger share of the care, and the cost of nursing home care averages $72,000 a year.

Ms. Briolat’s parents live in a downstairs bedroom in her home in Lebanon, Ohio. Her father’s decline began eight years ago when he broke his ankle, an injury that failed to heal even after four operations. His foot became infected and was amputated. He went into a nursing home.

Ms. Briolat’s mother, burdened by her husband’s growing needs, soon went into decline as well. By then, five months of nursing home care had already cost the family $60,000. Ms. Briolat moved them both into her home. She pays a home health aide while she and her husband work.

The Community Living Assistance Services and Support program, or the Class Act, was intended to provide a benefit that averaged at least $50 a day, or $18,000 a year. If such a law had been on the books in time for her parents, it would have paid for most of their care.

“We wouldn’t have had to sell their house in Michigan at a fire sale price,” she said.

But the Class Act’s ambitions were undercut by an impractical structure that doomed it from the start, experts and government actuaries say. Its failure harks back to an attempt by President Ronald Reagan and a Democratic Congress to protect the elderly from catastrophic medical expenses and provide a modest prescription drug benefit and somewhat improved nursing home care.

That law, the Medicare Catastrophic Coverage Act of 1988, was repealed within months of enactment after a furious response by elderly voters angry that they had to pay for the benefits themselves through a tax mostly paid by the wealthy. In a famous scene, Representative Dan Rostenkowski, an Illinois Democrat who was chairman of the powerful House Ways and Means Committee, was booed and chased down a Chicago street by a group of elderly people, one of whom draped herself over the hood of his car.

The repeal legislation created a commission to examine the issue of long-term care, but it ended the appetite of many in Congress to resolve the issue. The Clinton health plan made another attempt at improving long-term care, but the bill failed. And now the demise of the Class Act is repeating history.

Senator Edward M. Kennedy made passing the Class Act one of his last priorities, and his advocacy was an important reason that the program, despite its flaws, was included in the overhaul of the health law in 2010. But the Class Act was unusually sparse in its details — accounting for just 20 of the bill’s 900 pages. Senator Judd Gregg, Republican of New Hampshire, succeeded in adding an amendment requiring the administration to certify that the program would be self-sustaining for 75 years before enacting it. The administration concluded that it could not make that certification, killing the program.

Less than 3 percent of Americans now buy private long-term care insurance. The government’s version of long-term care insurance shared a basic flaw with commercial options: It was voluntary, with benefits to be paid entirely by premiums.

The Class Act allowed anyone — even those with serious health problems — to sign up. Policy holders had to pay premiums for only five years and could then get benefits for life. The poor could pay just $5 a month. Both promises all but guaranteed that the program would have needed big government subsidies to avoid going broke, experts said. Internal documents from the Department of Health and Human Services show that officials had doubts about the viability of the Class program before it was signed into law by President Obama. Richard S. Foster, the chief actuary at the federal Centers for Medicare and Medicaid Services, wrote in July 2009 that “36 years of actuarial experience lead me to believe that this program would collapse in short order and require significant federal subsidies to continue.”

The Obama administration continued to insist that the proposed long-term care program would be solvent over 75 years. But even some prominent Democrats disagreed. As the Senate considered the health bill in December 2009, 11 Democrats, including the chairmen of the Finance and Budget Committees, supported efforts by Senator John Thune, Republican of South Dakota, to eliminate the long-term care insurance program.

Senator Charles E. Grassley, Republican of Iowa, said recently, “Everyone involved in the debate knew the proposal was impossible to deliver, and many of us said so.”

If the program had restricted enrollment to the healthy, limited payouts to five years and eliminated subsidies for the poor, it might have worked, said Joshua M. Wiener, a fellow at RTI International, a nonprofit research group. But advocates for the disabled were among the program’s biggest backers, and opposed the restrictions.

The program’s chief actuary, Robert Yee, said that limiting initial enrollment to workers at large companies or excluding benefits for 15 years also might have worked. But such fixes would have required new legislation, and the Obama administration concluded that such a bill had no chance of passing the present Congress, with Republicans, who control the House and can frustrate legislative efforts in the Senate, pushing for outright repeal of the entire health care law.

The president’s advisers decided that another fight over the health reform law would be a politically damaging distraction for his re-election prospects and ill timed, given the need to enact the broader health care law, itself under serious legal challenge

Advocates for the Class Act say they have not given up hope for the program. Connie Garner, who helped devise the long-term care program as an aide to Mr. Kennedy, declared: “We don’t see this program as dead. We will not let it die. “

The program’s end is a blow to middle-class hopes, though its modest benefit would have covered only about a quarter of nursing home care.

“This was designed to serve as a bridge between the affluent who can care for their own and the poor who get Medicaid,” said Diane Rowland, executive vice president of the Kaiser Family Foundation, a nonprofit group.

Raymond Eriksen of New Providence, N.J., thought he was safe. He moved his in-laws into an assisted living facility because both were suffering memory problems. Fortunately, both had private long-term care insurance that, along with the proceeds from the sale of their house, pays for their care. Then Mr. Eriksen’s wife, Linda, began to decline and was given a diagnosis of early-stage Alzheimer’s.

He kept her at home until August, when caring for her became so overwhelming that he moved her into the same facility with her parents. Although long-term care insurance was offered by his employer, Mr. Eriksen had not purchased it “because we had three kids we had to put through college.” Mr. Eriksen was an electrician for a major oil company but retired four years ago because of an injury.

“So we put it off until it was too late,” he said.

He is now paying $7,000 per month for his wife’s care, a bill that is likely to rise as her faculties decline. Mr. Eriksen, 61, said that he is unlikely to have any money left by the time he needs care himself.

“I was middle class, but I’ll be impoverished eventually,” he said.

How Medicare Fails the Elderly

By JANE GROSS

Jane Gross is a former New York Times reporter and the author of “A Bittersweet Season: Caring for Our Aging Parents — and Ourselves.”

HERE is the dirty little secret of health care in America for the elderly, the one group we all assume has universal coverage thanks to the 1965 Medicare law: what Medicare paid for then is no longer what recipients need or want today.

No one then envisioned the stunning advances in medicine that now keep people alive into advanced old age, often with unintended and unwelcome consequences. Indeed, scientific reports have showed the dangers, not merely the pointlessness and expense, of much of the care Medicare is providing.

Of course, some may actually want everything medical science has to offer. But overwhelmingly, I’ve concluded in a decade of studying America’s elderly, it is fee-for-service doctors and Big Pharma who stand to gain the most, and adult children, with too much emotion and too little information, driving those decisions.

In the last year alone, and this list is far from complete, here is what researchers have found both useless and harmful, according to leading medical journals:

• Feeding tubes, which can cause infections, nausea and vomiting, rarely prolong life. People with dementia often react with agitation, including pulling out the tubes, and then are either sedated or restrained.

• Abdominal and gall bladder surgery and joint replacements, for those who rank poorly on a scale that measures frailty, lead to complications, repeat hospital stays and placement in nursing homes.

• Tight glycemic control for Type 2 diabetes, present in 1 of 4 people over 65, often requires 8 to 10 years before it helps prevent blindness, kidney disease or amputations. Without enough time to reap the benefits, the elderly endure needless dietary limits and needle sticks.

Yet Medicare, which pays for all of the above, does not, except in rare instances, pay for long-term care in a supervised, safe place for frail or demented old people, or for home aides to help with shopping, transportation, bathing and using the toilet.

Nationwide, the median annual cost of a nursing home in 2010 was $75,000; room and board in an assisted living facility, with no additional help, was $37,500; and the most basic category of home health aide, who can perform no medical tasks, like the dispensing of medication, was $19 an hour. These expenses are left to the elderly (and their adult children) to pay for out of pocket until their pockets are all but empty.

Then they are eligible for Medicaid, the state-run safety net for the poor. While Medicare, a federal program, is financed by payroll taxes, and thus is an “earned” benefit, Medicaid is “charity,” in the minds of the formerly middle class who worked their whole lives and never imagined themselves destitute.

In the case of my mother, who died at 88 in 2003, room and board in various assisted living communities, at $2,000 to $3,500 a month for seven years, was not paid for by Medicare. Yet neurosurgery, which I later learned was not expected to be effective in her case, was fully reimbursed, along with two weeks of in-patient care. Her stay of two years at a nursing home, at $14,000 a month (yes, $14,000) was also not paid for by Medicare. Nor were the additional home health aides she needed because of staffing issues. Or the electric wheelchair after strokes had paralyzed all but the finger that operated the joy stick. Or the gizmo with voice commands so she could tell the staff what she needed after her speech was gone.

She paid for the room. My brother and I paid for the private aides and bought her the chair and the “talking board.” What would her life have been like without the skilled care she required and the ability to get around her floor and communicate her needs? I shudder to think. But none of this was Medicare’s responsibility.

Yet Medicare would pay for “heroic” care for a woman who was dying of old age, not a disease that could be treated: Diagnostic tests. All manner of surgery. Expensive medications. Trips to the emergency room or the hospital — had she not refused all of them, in the last year of her life. So, in less than a decade, by my low-ball estimate, my mother spent $500,000 of her own money and uncalculated sums from her two children before winding up what she considered, with shame, “a welfare queen.”

A recent state-by-state study of long-term care, the first of its kind, by a consortium of researchers, has found that this kind of essential help costs anywhere from 166 percent to 393 percent of the average annual income of America’s elderly.

BY now, you may be wondering if your parents have a half million dollars for old age. Or if you or your children do. You may be counting on quick and easy deaths. Shoot me, so many people say. Alas, 70 percent of the elderly will need extended care before they die. Denial is powerful but doesn’t pay the bills.

This mismatch between what is covered and what is actually useful is the central flaw in Medicare today, a shock to families who have no clue, until they’re smack in the middle of it, about how this system works.

This mismatch tortures our elderly, drains the Medicare trust fund and leaves adult children with depleted retirement reserves. Yet in all the debate about the national debt, medical inflation and the need to pare Medicare costs by such means as raising the eligibility age, why is nobody, outside the insular community of long-term care providers, even mentioning the difference between acute and chronic care and how each is paid for (or not)?

Why is nobody enraged that our taxes are paying for hip replacements, for example, for people with advanced Alzheimer’s disease, who are incapable of physical therapy? Why is nobody saying out loud, like it or not, that one of our great challenges is figuring out what to do about our elderly people, our fastest growing-population cohort, which will grow exponentially when 76 million baby boomers join the ranks?

The current system is unsustainable, but the alternative is the third rail of health care policy. President Obama’s original legislation included Medicare reimbursement to doctors for discussion of end-of-life issues. These are what Sarah Palin called “death panels”; days later, they were cut from the legislation. An Independent Payment Advisory Board will make recommendations to Medicare about what works and what doesn’t, beginning in 2015, but its proposals are not binding, as intended. A long-term-care insurance provision — with an average daily benefit of a mere $50 — is under siege.

Reading the history of the Medicare law, which was not intended for long-term care because today’s technology and demographics were unimaginable then, one is struck by the battles and ultimate compromises between President Lyndon B. Johnson and Wilbur Mills, the head of the House Ways and Means Committee, who originally opposed Medicare.

That the crafting of that legislation was so difficult leaves one despairing that this pillar of the Great Society could now be rewritten, given our partisan incivility. But right now, according to the health economist Marilyn Moon, there are 47 million Medicare beneficiaries, costing a half trillion dollars a year, or one-fifth of the nation’s health spending. In 2050, the population on Medicare will number 89 million. How scary is that?

Eye Treatment Medications

By ANDREW POLLACK

Dr. Robert Feig, a retina specialist in Brooklyn and the Bronx, says he wants to save patients and Medicare money by treating eye diseases with a drug that costs $50 a dose, rather than one that costs $2,000 a dose.

But three recent incidents around the country in which a total of 21 patients lost some or all vision in the affected eye after injections of the less expensive drug have made him fearful of a malpractice lawsuit, should something similar happen at his practice.

“Why would I want to risk my family to save America $1,950 a dose?” asked Dr. Feig. So even though he laments it, he is starting to use more of the expensive product, Lucentis, instead of the cheaper one, Avastin.

Similar trade-offs of cost versus perceived risk are being weighed across the country.

The Department of Veterans Affairs has temporarily halted use of Avastin for eye conditions while it reviews the situation. In Los Angeles, the pharmacy company that was supplying Avastin to Harbor-U.C.L.A. Medical Center decided to get out of that business, leaving the hospital without supplies and forcing it to cancel patient appointments.

But many eye doctors say the problems occur in fewer than one in 1,000 injections. The recent incidents, they say, were isolated and apparently stemmed from easily correctable sloppy procedures at pharmacies, not from anything wrong with Avastin itself.

“Are you going to stop eating hamburgers because there was some tainted meat in Texas?” said Dr. Randy Dhaliwal, a retina specialist in August, Ga. “I’m not aware of anyone previously using Avastin in private practice making a switch because of this.”

Moreover, such problems can occur with Lucentis as well, and some studies suggest the rate of such problems for the two drugs is similar.

If all doctors switched to Lucentis, “You are going to tremendously jack up the cost to the country and achieve absolutely nothing,” said Dr. Jon Adleberg, a retina specialist in Chesapeake, Va.

Avastin and Lucentis work in similar ways and both are made by Genentech. Lucentis has regulatory approval as a treatment for the wet form of age-related macular degeneration, the leading cause of severe vision loss in the elderly, and for another eye condition.

Avastin, by contrast, is a cancer drug. But many eye doctors say Avastin, used off-label, works roughly as well while costing one-fortieth as much.

A report last month from the inspector general of the Department of Health and Human Services estimated that in 2008 and 2009, Medicare paid $1.1 billion for 696,927 Lucentis injections but only $40 million for a greater number — 936,382 — of injections of Avastin. Patients get an injection as often as once a month.

If Lucentis had been used for all the injections, Medicare would have paid an extra $1.5 billion over those two years, the report said. And patients would have had to pay an extra $370 million because the co-payment for Lucentis was $406, compared to only $11 for Avastin.

However, dividing a vial of Avastin meant for a single cancer patient into many tiny doses for the eye introduces the risk of microbial contamination. That job is usually done under sterile conditions by compounding pharmacies.

A clue to how much the recent incidents are changing practice might come when Roche, Genentech’s parent company, reports third-quarter sales on Oct. 13. Despite being undercut by its own drug, Genentech sold about $1.5 billion worth of Lucentis in the United States last year.

The incidents could also help Regeneron Pharmaceuticals, which hopes to win approval in November of a new drug for macular degeneration that is expected to cost at least as much as Lucentis.

One of the three incidents occurred in Miami, where 12 patients suffered eye infections from Streptococcus bacteria in July after receiving Avastin injections that came from the same compounding pharmacy.

Four patients got Streptococcus infections at the Veterans Affairs hospital in Nashville earlier this year, the hospital has acknowledged.

And five patients treated in August at a V.A. hospital in Los Angeles lost all or most vision in the injected eye. No infectious agent has been identified, prompting speculation that the patients were injected with some drug other than Avastin.

Yet there is also a risk of infection from Lucentis. That drug comes in a vial meant for a single patient. But a doctor or a nurse still must put a syringe into the vial and draw out the medicine. And this is usually done in the doctor’s office, not under the sterile conditions of a compounding pharmacy.

Dr. Colin A. McCannel, an expert at the University of California, Los Angeles, said a source of infection appeared to be droplets from the mouths of doctors who talk while handling the syringe.

Biren Amin, an analyst at Jefferies & Company, tallied the data from clinical trials involving 140,000 injections of either Avastin or Lucentis. The rate of endophthalmitis, an inflammation of the eye presumably caused by infection, was identical for the two drugs — about one in 2,000 injections.

Another study, published this month in the journal Ophthalmology, followed 27,736 consecutive injections over 17 months at a 16-physician retinal practice in Philadelphia. Endophthalmitis occurred in about 1.1 of every 1,000 Avastin injections compared to 0.66 of every 1,000 Lucentis injections, a difference that is not statistically significant.

The incidents have focused attention on compounding pharmacies, whose standards vary from state to state. Both the American Society of Retina Specialists and the International Academy of Compounding Pharmacists are surveying members and trying to compile recommended best practices for the pharmacies.

Dr. Yu-Guang He of the University of Texas Southwestern Medical Center in Dallas visited the compounding pharmacy that supplies his Avastin. He said he was reassured that the pharmacy was testing Avastin syringes for bacterial contamination.

“Right now, everyone is scared,” said Dr. He, who has slightly increased his use of Lucentis. “But over time people will gradually come back, because the price differential is so great.”

Surgery Rate Late in Life Surprises Researchers

By GINA KOLATA

Surgery is surprisingly common in older people during the last year, month and even week of life, researchers reported Wednesday, a finding that is likely to stoke, but not resolve, the debate over whether medical care is overused and needlessly driving up medical costs.

The most comprehensive examination of operations performed on Medicare recipients in the final year of life found that nationally in 2008, nearly one recipient in three had surgery in the last year of life. Nearly one in five had surgery in the last month of life. Nearly one in 10 had surgery in the last week of life.

The very oldest patients were less likely to have surgery. Those who were 65 had a 38.4 percent chance of having surgery in the last year of life. For 80-year-olds, the chance was 35.3 percent, but the rates fell off more sharply from there, declining by a third by age 90.

But such analyses are controversial. By looking only at people who died, researchers can get a skewed picture of what is taking place, critics say.

“Because the patient died, you can’t assume that the treatment and therapies were not of value,” said Dr. Peter B. Bach of Memorial Sloan-Kettering Cancer Center. “Although in that individual, things may not have worked out, you have no insight into whether the decision to operate was appropriate.” Nor is it known how many similar patients who had that same surgery did not die.

But the sheer number of operations at the end of life was unexpected, said the researchers, at Harvard School of Public Health. They added that they did not know why the operations had been done. Some undoubtedly were necessary to relieve pain and suffering or to prolong life. But, they said, they know from experience that doctors often operate to repair something that can be fixed but that will not save a dying patient, avoiding the difficult discussions with patients about their prognosis and whether the surgery will improve or compromise their quality of life.

In their study, published Wednesday in The Lancet, the investigators analyzed data for all the 1,802,029 Medicare recipients 65 and older who died in 2008. In addition to the number of operations nationally, they reported marked regional variations in the use of surgery at the end of life. For example, the rate of surgery in Honolulu was a third of that in Gary, Ind.

“Honolulu and Gary, Ind., can’t both be doing it right,” said Dr. Ashish Jha, an associate professor of health policy at Harvard and the lead author of the study.

But regional variations in health care have been controversial because it is not clear whether they reflect true differences in patient needs or in health care practices or regional differences in health care payment rules, Dr. Bach said.

Dr. Scott Ramsey, an economist and a physician who is director of cancer outcomes research at the Fred Hutchinson Cancer Research Center in Seattle, faulted the researchers for citing regional differences but then suggesting a long list of factors that might be causing them, including the health of the population, the patterns of medical practice, and the availability of hospice care and other end-of-life services.

Their list of potential explanations “covers about everything and says absolutely nothing,” Dr. Ramsey said.

But the researchers said their study — done from public records and with no financing — probably pointed to a real problem in American medicine: surgery, which can be painful, expensive and debilitating, is tempting for doctors and patients alike.

“I will admit to being guilty of this,” Dr. Jha said. “Often we say, ‘If you have this intervention, we will be able to fix that problem. You have an intestinal blockage. Surgery will fix it.’ But will it let you walk out of the hospital alive? Will it let you return to your old life?”

Dr. Mark McClellan, a former commissioner of the Centers for Medicare and Medicaid Services, who directs the Engelberg Center for Health Care Reform at the Brookings Institution, said, “Evidence like this — and a lot of previous evidence, directly from patients and their families — shows that we need much better support for patients and their families when they have serious illnesses and may need intensive treatments.”

Dr. Jha said he and his colleagues were continuing to study the causes and consequences of surgery at the end of life, adding, “It is hard to take these data and make clear policy recommendations about what is appropriate and what is not.”

But he said he had no doubt that the difficult conversations that should precede a decision to operate all too often never occurred.

“As clinicians, we often end up focusing on something narrow and small that we think we can fix,” Dr. Jha said. “That leads us down the path of surgical intervention. But what the patient cares about is not going to get fixed.”

Dr. Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

“No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.”

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”

Instead, Dr. Jha said, “we sent him to the O.R.”

What Boomers Need to Know About Medicare Open Enrollment Season

September 29, 2011
FOXBusiness

The Medicare open enrollment period is upon us once again, and now is the time for Medicare recipients to review their options and make unrestricted changes to their coverage options. The period, which runs from Oct. 15 to Dec. 7, is a good time to assess current coverage and shop around for other plans that might better meet your needs and financial situation.

In order to make the most-informed decision, Medicare consumers need to be aware of the changes coming to the system.

Joe Baker, president of the Medicare Rights Center, a non-for-profit counseling organization in New York, discussed the following changes and updates for 2012 that boomers need to know:

Boomer: What changes and updates have been made to Medicare for 2012?

Baker: The first change is when you can make a change to your current plan. It now starts earlier, on Oct. 15th and it ends earlier on Dec. 7. In the past the enrollment period started in November and extend through the holidays and the end of the year. Folks in Medicare Advantage plans will be getting an annual notice of change about what might be changing in their plan, Part D plan or prescription drug coverage, by the end of this month.

When it comes to benefits and other costs, there’s some good news this year. If you are in a Medicare Advantage plan and have Part D as a separate prescription drug plan, or part of Medicare Advantage, premiums are not going up this year. The federal government announced that on average, Medicare Advantage premiums would probably decrease by 4%, and Part D prescription drug premiums would stay about the same.

This is good news if you are not looking to change plans, prices and benefits are remaining stable despite the volatility in the marketplace. With that said, you should still research your own individual plan, any notices that detail plan changes will be more general and won't be individualized for you. If you are taking a particular drug, or getting a specific type of treatment, be sure to check there are no changes that might impact them.

Boomer: What impact has health-care reform had on Medicare if any?

Baker: The Affordable Care Act had a lot less of a negative impact than what was predicted, along with some expected good changes.

Negative first: Part of the reform significantly scaled back (starting this year) the level of subsidies or payments that Medicare Advantage plans received from the federal government. Many of the reform’s critics expected to see big premium increases, plans leaving the market and reduced benefits—all of which would be bad for consumers. The good news: those disaster scenarios did not occur. Some of the additional benefits the law enacted to Medicare will further enhanced this year. For example, in the coverage gap (also known as the doughnut hole), you are still going to have a 50% discount for brand name drugs and the discount on generic drugs will increase to 14% from 7%, giving a little more relief on out-of-pocket costs.

In the government program, preventative care is going to be free of charge along with your annual wellness visit, mammograms and colonoscopies. That is also going to be in place for Medicare Advantage plans.

It is going to be a fairly stable year for folks in both the original Medicare and Medicare Advantage plans. Some of the improvements include in the health-care law will continue to be rolled out and enhanced over the year as well.

Boomer: What basic coverage is offered with Medicare?

Baker: Usually if you are in original Medicare you need supplemental coverage to pay coinsurance and deductible amounts. If you go to the doctor on original Medicare you pay 20% of the doctor’s approved fee, and most people get what is called Medi gap or supplemental coverage to pay that 20% coinsurance or they have retiree insurance from their former employer that might cover those costs.

Most people also purchase prescription drug coverage under Part D. About 70 to 75% of people have the original Medicare, retiree insurance or Medi gap insurance. The other 25% of people are in the Medicare Advantage, which includes a variety of plans. Most people are in what we call HMOs or Medicare health maintenance organizations that are run by private companies like UnitedHealthcare or Humana. When you sign up with a Medicare Advantage plan, you normally don't need supplemental coverage because the plan usually combines with extra benefits to cover some of what Medi gap would and your Part D coverage.

It’s important to know that under a Medicare HMO, you can only use the doctors and hospitals that are in that plan’s network. With original Medicare you can go to any doctor and you may have out-of-pocket costs like deductibles and co-insurance and that can add up if you are sick. Be careful when choosing a Medicare Advantage plan: If you travel a lot or like the freedom of your doctor want, original Medicare may be the better option. If you don't mind having a more limited network of doctors you could save some money with a Medicare Advantage plan.

Boomer: What questions should consumers ask before enrolling in a supplemental Medicare health plan?

Baker: Medicare supplements are Medi gap policies and you want to make sure you are dealing with a reputable company. These supplements are standard plans that are offered across the country and are highly regulated usually work well with Medicare. When choosing the right plan, make sure to consider price and services offered.

With a Medicare Advantage plan you have a much more complicated decision-making process. You want to make sure your doctor and hospitals are in the network. It’s a good idea to get your doctor’s opinions on the different offerings to see if they are a good fit, particularly if you have an ongoing medical condition. A lot of people just look at the price and that is not always a good idea, especially for those in need of medical care or currently in treatment. A cheaper premium may be attractive, but you may have higher costs of copayments, deductibles and co- insurance or less coverage, and those costs could be enormous.

You can call your state’s Department of Insurance and request a list of the Medi gap insurers in your state as well as consumer satisfaction information.

Boomer: For people turning 65 next year, what steps should they take to get my Medicare?

Baker: Three months before your 65th birthday, either check out the medicare.gov website, visit your local Social Security office or can call 1-800 Medicare and enroll in Medicare. If you are still working or your spouse is still working and you have insurance through that spouse, you may be able to put off your enrollment, but you need to know the rules. It’s always a good idea to know the system early. If you are of age and not working, you will want to enroll in Medicare because it is the only show in town for you. Your coverage starts on the first of the month on your 65th birthday.

Boomer: Are there any programs available to help pay Medicare costs?

Baker: The Medicaid program helps people with very low income cover health-care costs, and consumers can find information about this program from their state’s Department of Health or the Medicare agency in their state.

Medicare savings programs also help people with higher levels of income cover their costs. These programs pay for your Medicare Part B premiums. The Part B premium is deducted from your Social Security check--and we still don’t know what the premium will be in 2012, but it will be higher than the current $115.

There is another program called Low-Income Subsidy for Part D that will cover most of that premium if you fall under a certain income level (usually between $12,000 and $20,000). The plan also has a lower cost sharing or copay when you go to pick up your medication at the pharmacy.

Read more: http://www.foxbusiness.com/personal-finance/2011/09/29/what-boomers-need-to-know-about-medicare-open-enrollment-season/print#ixzz1ZYO7ByWE