Medicare Coverage for Gentle Cures

1. Introduction

Kidney failure should be considered a pandemic. Worldwide, over 1,000,000,000 people have reduced kidney function. In the United States, it is estimated that about 5,300,000 are receiving some type of treatment for kidney failure. 2010 USRDS data from 2010 states that 368,000 receive hemodialysis treatment. Approximately 200,000 have a functioning kidney transplant. A number of those patients will have recurrent or new onset kidney disease and will require a second or subsequent kidney transplant. Several hundred thousand patients are at various stages of chronic kidney disease (CKD). Economic costs of this care approach 40 billion USD per year, using 6.5% of Medicare’s total budget. CKD and its management are a significant issue for the Centers for Medicare and Medicaid Services (CMS). CKD has both direct and indirect effects on Special Needs Plan (SNP) enrollees. Disease management for early stage CKD can prevent progression to ESRD. Patients with kidney transplants or who have stable CKD may be enrolled in regular, chronic care plans but will be at risk for relapse to ESRD and require a change of plan type. As it stands now, Medicare coverage of kidney disease is complex and fragmented, often leading to confusion among both patients and providers in coverage eligibility and effective benefit access. Medicare’s current fee for service (FFS) payment structure does not create incentives for efficient and effective care of ESRD. CMS has acknowledged the issues of CKD and ESRD and is beginning to address them through various U.S. Government mandates and legislations over the last decade. This paper will focus on potential changes in Medicare ESRD reimbursement and how they can affect care outcomes to improve the lives of patients with ESRD – Equity in Access to Medicare and Medicaid Services, and what improvements, if any, have been made to Medicare’s coverage of CKD and ESRD since 2002.

2. Understanding Medicare Coverage for Gentle Cures

Established in 1984, Medicare provides an accessible and affordable health care system for all Australians. It is designed to manage health care costs through the payment of a rebate for a portion of the referred or listed health care services. Medicare Safety Net has two arms, the original Medicare Safety Net and Family and the enhanced Medicare Safety Net. Its aim is to protect all individuals and families from large gap payments for out-of-hospital Medicare services. By registering for the Medicare Safety Net, Australians can claim additional rebates for out-of-hospital medical services once they reach the relevant Medicare Safety Net threshold. With the availability of a range of programs for health care providers, the Chronic Disease Management (CDM) Medicare items enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions. EPC, DVA and CDM patients can receive varying levels of Medicare rebate for allied health services. Although this is not fully specified, the amount of rebate is determined by the service and the initiative that the patient is being referred under. With a range of CAM treatments relating to chronic health conditions, this form of Medicare subsidy of allied health services may be relevant when seeking CAM treatment. [1][2][3][4][5][6]

2.1 What is Medicare?

This section will provide the reader with information about Medicare and its implications in relation to CAM treatments. This information is crucial in that not only will it give the reader an insight into what Medicare is and what it covers, it will provide them with the knowledge they need to make informed decisions when seeking CAM treatment with consideration of their Medicare coverage. The current state of play with Medicare and the subsidizing of CAM treatments is outlined in the following.

2.1 What is Medicare?

The Medicare program was first established in 1965. Since then, it has undergone many changes and will be expected to have more changes in the future. Steps are currently being taken to make Medicare more effective and efficient. With the aging of the baby boomer population and the increase in average life expectancy, Medicare will become a significant factor in the healthcare business. Due to these factors, healthcare providers will require increased knowledge of the Medicare program, benefits, and limitations in order to provide the best and most cost-effective services to their patients.

You should know about Medicare, which is a federally funded health insurance program for people over 65 years old and certain disabled people. The Centers for Medicare and Medicaid Services (CMS) is the agency in charge of administering the Medicare program. This program provides Part A, which covers inpatient hospitalizations, skilled nursing facilities, home health care, and hospice care services. If the recipients are eligible for Social Security, usually they don’t need to pay for Part A. Medicare also provides Part B, which covers medical services that are reasonable and necessary to treat or diagnose a medical condition. There are monthly premiums to pay for this type of Medicare. Then there’s Part C, called Medicare Advantage Plan, that is available in many areas. This is a plan offered by a private company that combines Part A and Part B and sometimes other Medicare coverage. This plan usually offers more benefits at lower costs. Lastly, there’s Part D, which provides help covering the cost of prescription drugs and may help lower prescription drug costs and help protect against higher costs in the future.

2.2 Types of Medicare Coverage

Medicare Part B provides coverage for outpatient services in a physician’s office or hospital outpatient setting. Covered services include those that are deemed reasonable and necessary for the diagnosis or treatment of your medical condition. National coverage decisions are also made for Part B services; however, there is the additional possibility of seeking coverage for an item or service under Part B Medicare by asking your local carrier for reconsideration of their initial non-coverage decision. This is an important option for many gentler cures that might be considered to fit the Part B benefit category but have been denied national coverage. If the infusate was a specific item or drug to be given in the physician’s office, it may be possible to receive coverage under Part B, though national coverage decisions will greatly affect the likelihood of success for this option. Finally, many patients have supplemental insurance through Medicare Advantage plans. These plans are required to cover everything that is covered under traditional Medicare and may have additional coverage options for specific infusion therapies. Always check with the specific Medicare Advantage plan for details. [7][8][9][10][11][12][13][14][15]

Medicare has two primary coverage components that may be used to cover the infusion of gentler cures – Part A and B. Medicare Part A provides coverage to all patients who are eligible for Medicare benefits. It is used primarily for curative treatment in an inpatient setting. It’s difficult to determine if there is current coverage for a specific infusion under Medicare Part A. The decision to cover an item or service under Part A is a national one and is made by the Medicare Coverage Advisory Committee. It may be possible to seek coverage for an inpatient infusion under an investigative new National Coverage Decision. If the decision has been made to not cover the new infusion under Part A, it cannot be submitted under Part B to be covered as an outpatient service.

2.3 Limitations of Medicare Coverage

In certain circumstances, signing an Advance Beneficiary Notice (ABN) may be necessary for a provider to charge a beneficiary for a service that is not covered due to a Medicare limitation. An ABN is a written notice that a doctor or supplier should give you before you receive a service, item, or treatment that is not covered because Medicare will not pay for it. The notice helps you make an informed consumer decision about whether to get the service or item.

Take, for example, a limitation on the number of inpatient days covered under Part A. If a beneficiary receives hospital services and uses up the lifetime reserve days but still needs inpatient hospital care, the beneficiary must pay all costs for such care.

What is the effect of a restriction? When coverage is limited for a particular service, the beneficiary must pay the full cost of the service if he or she wishes to obtain it. In other words, Medicare will only pay for the service in the circumstances specified by the limitation, and the beneficiary has a financial liability if he or she chooses to obtain the service in a different setting or to a greater extent.

Limitations of Medicare coverage include restrictions and exclusions. A restriction is a condition that limits coverage for a procedure, treatment, or item. An exclusion is a service, treatment, or item that is not covered by the Medicare program, even if a doctor or other healthcare provider deems it medically necessary to diagnose or treat a condition.

3. Exploring Gentle Cures Covered by Medicare

Gentle cures refer to those treatments which are seen by some as many medical treatments that are covered by Medicare can be both gentle and aggressive. A treatment is only termed gentle when it does not bring harm to the patient. This could include treatments such as osteopathy, chiropractic, acupuncture, and counseling, which will be discussed in the sections to follow. Cognitive behavioral therapy has been described as a gentle treatment when the patient has been counseled. Individually, the patient has sought to make changes to the way they think and behave, and this is also classed as a gentle cure. Groups as being non-forceful and which do not involve breaking the skin are effective. They are the simplest possible interventions and therefore most appropriate in circumstances and do not bring harm.

3.1 Definition of Gentle Cures

Gentle cures that are beneficial and are covered by Medicare therapy in the treatment of somatic dysfunction for G4 coding (using OMT in the global diagnostic process) when there is a local, somatic dysfunction amenable to OMT, dealing with soft tissue non-drug non-surgical in which there is improvement in medical condition as determined by the regular follow-up with the patient’s primary complaint, in an outpatient setting. This means that the patient has to benefit from the OMT that deals with soft tissue, the patient’s condition must improve, and it must be related to an effective treatment on the condition. An example may be a patient with lower back pain due to a postural change because of pulmonary restrictions caused by a recent medication change to treat an exacerbation of a chronic condition, an attack of bronchitis, or a bout of viral upper respiratory infection. The G4 coding and diagnosis is the postural change, the back pain is a symptom from the postural change. OMT would be effective for the treatment of the symptoms of this condition. [16][17][18][19][20][21][22][23]

Gentle cures allow patients to achieve pain relief, stability, and optimum health, often avoiding the need for surgery or drugs. This is accomplished by a number of hands-on methods in which DOs use their hands to diagnose illness and injury and to encourage your body’s natural tendency toward good health. The goal of these cures is to help restore normal functioning to the area of the body affected by illness, injury, or to help compensate for the changes the body has made in order to deal with other illnesses or medical conditions. Given the effectiveness of these cures in helping patients avoid high-risk, high-cost surgery and drug therapy, it is unfortunate that many people do not know what these cures involve and/or state that it is not covered by Medicare despite Medicare policy to the contrary.

3.2 Examples of Gentle Cures Covered by Medicare

– Cardiovascular screening Again, Medicare covers this for people at risk. The benefit is a one-time screening EKG. Medicare also covers up to two ultrasound screenings for AAA for those at risk. People who qualify must be referred by their doctor, and those with Part B, Medicare’s medical insurance, can expect to pay 20% of the Medicare-approved amount after the yearly Part B deductible. AAAs are more common in men ages 65-75 who have smoked at least once in their life. With the increased risks, Medicare covers these useful screenings.

– Glaucoma screening Medicare covers glaucoma exams for individuals in high-risk groups. Those in this category include: • People with diabetes • Anyone with a family history of glaucoma • African Americans aged 50 and older The exams are covered once every 12 months.

4. Conclusion

Perhaps the best coverage that is offered under the Medicare plan for 2004 can be found in the category of home health care as it provides a wide range of services and even covers medical supplies and durable equipment. Nevertheless, this does not mean that it covers services provided in an alternative setting such as adult day care or supportive services. All in all, it is a common understanding when using Medicare insurance that it does cover a wide range of health care services, yet it does not apply the same coverage for each and every service.

Overall, the conclusion can be made that Medicare insurance is an extremely selective insurance that only covers care in which it deems medically necessary. Despite all the categories of service that were previously mentioned in which the coverage differed from service to service, one thing held true among the board and that is the fact that Medicare only covers a service in which it deems medical necessity. Medicare insurance is not very beneficial for those seeking to use it to cover costs for alternative medicine and other drugs that have not been proven truly effective on a national level.

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