From: "Dr. D. Kossove" <doctordee@telkomsa.net>
To: <alaskafox99@YAHOO.COM>
Subject: Medicare and Payment Schedules and other info
Date: Thursday, December 18, 2003 2:31 PM

Date:    Wed, 17 Dec 2003 19:57:33 -0800
From:    MaryJane Biddle <alaskafox99@YAHOO.COM>
Subject: Medicare and Payment Schedules and other info

To start off.  Indiana does not cover GEM/TAX for
LMS,to date I have found out that MI, TX, and KY do so
we now have an appointment in KY for Mary Jane on the
24th

It would appear that the oncology nurse I talked to
was misinformed to some extent with regard to how
Medicare is structured.  After doing some research I
think I discovered out how it is structured.  It
appears that each state is a Medicare intity but must
follow certain federal guide lines. Each state has a
panel of medical experts that determine which
treatments will be funded for which illnesses that are
not covered by federal mandate.

CMS now administers Medicare and it is broken up into
10 regions.  Billing and Summary Statements are
regional but not exactly along the CMS regional
boundaries.  It appears, if I am reading the data
corectly, that there ae more than 10 different
"private" agencies that handle fiscal side and send
out the Summary Statements.

I logged onto the Medicare web site, which falls under
the CMS web site.
Additional information regarding CMS and its programs
is available at http://cms.hhs.gov/about/default.asp.
The CMS site has a map of the states.  By clicking on
a specific state you are provided with the regional
office info that handles that state.
http://cms.hhs.gov/about/regions/professionals.asp
The regional office site lists the items they deal
with.
I reviewed 1228 FAQ at the CMS site and have extracted
some I thought may be informative.
Q:  What is CMS?
A:  CMS is the Centers for Medicare & Medicaid
Services. Formerly known as the Health Care Financing
Administration (HCFA), we are the federal agency
responsible for administering the Medicare, Medicaid,
SCHIP
Q:  How does Medicare determine place of service for
physician services?
A:  For physician services paid under the physician
fee schedule, it is the physical location of the
physician providing the service that determines the
place of service. For example, if a patient had a
x-ray performed by a facility in Pennsylvania, and the
x-ray was read by a physician sitting in Florida,
Medicare would consider the service to have been
furnished in Florida. Moreover, if the patient was in
Pennsylvania and the x-ray was read in Israel,
Medicare would consider the service to have been
furnished in Israel.
Q:  Where can I find out if Medicare covers a service
or supply that I need?
A:  Answers about what Medicare covers can be found in
the Your Medicare Coverage section on
http://www.medicare.gov. This section of the web site
provides information about your health care benefits
in the Original Medicare plan (sometimes referred to
as fee-for-service). By searching this database
you will find:
h Some of the services and supplies the Original
Medicare Plan covers;
h The conditions that must be met for some services
or supplies to be covered;
h How often services or supplies are covered
(limits);
h How much you pay;
h Who you can contact if you have additional
questions;
h Some of the services and supplies the Original
Medicare Plan does not currently cover.
Please note some service and supplies are statutorily
excluded from Medicare coverage. Congress would be
needed to change the Medicare in order for current
excluded services and supplies to be covered.
Q:  Where can I find information about how my claim is
being processed?
A:  For questions regarding a claim or claims
processing, please contact your local Fiscal
Intermediary (for Part A claims), Medicare Carrier
(for Part B claims), or Durable Medical Equipment
Regional Carrier (for Durable Medical Equipment or
Supplies). You can use the Helpful Contacts database
to get the phone number for your area.
Q:  How does the 2003 Medicare Modernization Act
change Medicare?
A:  Medicare is an essential health insurance program
for people age 65 and older, some people with
disabilities and with permanent kidney failure.
Congress and the Administration worked together to
modernize Medicare to bring people with Medicare more
choices in health care coverage and better health care
benefits. This new law strengthens the current
Medicare program, adds important new coverage for
prescriptions and preventive benefits and brings in
features of more modern insurance plans.
These new choices and benefits include:
h Prescription Drug Improvement
h Replacing Medicare+Choice with Medicare Advantage
h Changes to Fee for Service Payments
h Expanding Preventive Benefits coverage
h Adding new Medigap plans
In 2007, the Part B premium will increase for people
with Medicare whose income exceeds $80,000 as an
individual or $160,000 as a couple. Actual Part B
premium amounts for 2007 will not be available until
the end of 2006.
Q:  Im interested in participating in the Medicare
Prescription Drug Discount Card and Transitional
Assistance A:  A:  Program. Where can I find more
information?
Information including the interim final rule, notice
of solicitation, upcoming events, and how to ask
questions can be found at
http://www.cms.hhs.gov/discountdrugs/.
 (State Childrens Health Insurance), HIPAA (Health
Insurance Portability and
Accountability Act), CLIA (Clinical Laboratory
Improvement Amendments), and several other
health-related programs.

Sorry for any misunderstandings.  I have sent CMS a
specific inquiry regarding exactly how they are
structured and how treatments are determined.  So far
I have not recieved a reply.  The 1228 FAQs are from a
wide mix of people from the normal citizen to
providers to insurance cos to researchers.  THe
category appears next to the question.

If I find out any more info that is of interest to the
group in this regard I will post it.

John, Mary Jane's care giver.
LMS 3/78
resected 7/78
reappeared in liver and lungs 12/03
 