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Hospital Clinic and Office Visit Charges and Medicare Payments 2017

Find Hospital Clinic and Office Visit charges (average price) for 2017, and the payments that Medicare made. Find average charges for about 13,000 different codes (depending whether office or hospital facility-based).  National average prices are in the Procedure Summary file. Extremely difficult to use, even if somewhat familiar with using Excel files. File uses HCPCS codes. The most common codes were office visits 99213 (average charge about $134) and 99214 (average charge about $201). Medicare allowed about $71 for code 99213 and about $105 for 99214. Lab tests, x-ray, emergency department visits are in the file. Physician charges may be available in the Provider Summary Table. Calendar year 2017 data from CMS updated 2019.

Drug Coverage under Medicare

Learn the basics on prescription drug coverage under Medicare. Six-page Tip Sheet explains how prescription drugs, medicines and immunizations might be covered under Medicare Part B, Medicare Advantage plans (Part C) or Medicare Part D (the drug plan for seniors). Includes guidelines for cancer drugs, injectibles and IV drugs. Generally, Part A (hospital insurance) does not cover outpatient drugs. Publication 11315-P revised October 2018

Indiana Medicare Prescription Drug Plan Costs for 2020 (pdf)

Find out how much Medicare Prescription drug plans cost for 2020 in Indiana. Site shows monthly premium cost and annual deductibles for 2020 Medicare Prescription Drug Plans (Part D). Health insurance plans are listed in alphabetical order in a 2-page PDF called Complete list of Medicare Prescription Plans in Indiana. Monthly premiums for 2020 range from $13.20 (Humana Walmart) to $74.70 (United Healthcare’s AARP Medicare Rx Preferred, and Express Scripts Medicare Choice plans). Annual deductibles range from $0 to $435. From In.gov, updated October, 2019

Medicare Part B Premiums and Part A Deductibles for 2020

CMS announced the standard Medicare Part B monthly premium will be $144.60 (up $9.10) in 2020 for most recipients ($1,735 per year), with a $198 deductible (up $13). Both the premiums and deductible are up about 7%. High income seniors will pay between $202.40 and $491.60 per month. CMS says about 7% of Medicare beneficiaries pay the high-income premiums for Part B. Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and other items. The Medicare Part A hospital insurance deductible will rise $44 (about 3%) to $1,408. Released Nov. 8, 2019.

Medicare Part D Drug Premium Costs for 2020

Based on the bids submitted by Part D Medicare prescription drug plans, CMS estimates that the average monthly premium that beneficiaries will pay for standard Part D coverage in 2020 will be $30.00, a decline of $2.50 per month from 2019. Reported July 2019.

Medicare Personal Plan Finder (medicare.gov)

The Medicare Personal Plan Finder site at medicare.gov helps you locate supplemental health insurance plans, find out their prices (premiums), and link to a page to check Medicare Eligibility. Generally, one has to be age 65 or disabled to qualify for Medicare. Early retirement at age 62 does NOT by itself allow someone to receive Medicare benefits

Medicare Prescription Drug Plans – Learn how they work (Medicare.gov)

Learn how Medicare Prescription Drug Plans (Part D) work, from medicare.gov. Medicare’s help line for selecting a prescription drug plan (Medicare Part D) is 1-800-633-4227 (1-800-MEDICARE), or click on how to get prescription drug coverage

MEDICARE TRUSTEES 2020 Report – hospital fund runs out of money in 2026

The Medicare hospital insurance fund (Part A) runs out of money in 2026, according to the latest report from the Medicare Trustees. The April 2020 report by CMS discusses the state of each of the Medicare Trust funds – a $796 billion program for 61.2 million people in 2019. Medicare expenditures alone are estimated at 3.7% of gross domestic product (2019), same as last year. Part B (outpatient) and Part D (drug) have “sufficient financing” – i.e., they are in decent shape. However, the hospital trust fund is projected to be depleted by 2026 (the same as projected in  the last two years). As a caveat, the picture could actually be worse in light of the COVID-19 pandemic. The Medicare Board of Trustees was unable to adjust the estimates accurately at this time for the effects of the new coronavirus. The Trustees noted that the real picture could be worse than projected. Next year’s report could be more dire, with less time to fix the fund. In 2019, the average total Medicare benefit per enrollee was $13,879, up 4.7% from the prior year.

Other Helpful Listings

Fact Sheet: Underpayment by Medicare & Medicaid (2019)

Analysis by the American Hospital Association shows that Medicare and Medicaid under-pay the true cost of hospital care by about $77 billion. This cost ends up being borne by other payors and commercial insurance. Using 2017 data, it is estimated Medicare pays 87 cents on the dollar, and Medicaid also pays 87. January 2019 report

Healthcare Expenses for Seniors (MEPS)

Healthcare expenses for seniors are outlined in this MEPS report on Health Care Expenditures for the Elderly Age 65 and over. Median annual expenditures were $4,206 per person. Average annual expenses for those with expense were $9,863 in 2011. Using medical inflation rates, $9,863 was about $12,194 in 2019 dollars. Medicare paid over 62% (up considerably from 10 years earlier); private insurance paid 16%; out-of-pocket amount declined to 12%. 96% of seniors had some healthcare expense, most often office-based care and prescribed medicines. Medications took up 22% of the total, averaging $76 per purchase. For seniors, the inpatient room rate averaged $3,199 per day (sticker shock, and nearly $4,000 in 2019 dollars); ER visit was $884 on average; office visit was $228. MEPS Statistical Brief #429 uses 2011 data, published Jan. 2014.

Medicare Coverage for Colonoscopy or other Colon Cancer Screens

Learn what Medicare covers for colonoscopy or other screens for colon cancer. Annual fecal occult blood tests (FOBTs) are free under Medicare. Other more expensive colon cancer screening tests such as colonoscopy and sigmoidoscopy are covered periodically, without cost to the patient if your doctor accepts Medicare assignment as full payment. Medicare also covers at-home multi-target stool DNA lab test (e.g. Cologuard) once every 3 years for certain people ages 50 to 85. Cologuard identifies altered DNA and/or blood in stool, which are associated with the possibility of colon cancer or precancer. Find out Medicare’s details. Unfortunately, Medicare does not provide cost estimates for the public at this site

Medicare Part D Prescription Drug Plan Ratings 2020

Theoretically, consumers should be able to compare the 2020 star ratings for nearly 750 health insurance plans that are part of the Medicare Part D Prescription Drug program at this site. But the files linked here are darn near impossible to use, even if you know Excel. Best bet is to review the overall summary file at the bottom of the zipped file download. Other files show performance scores including member ratings. But you will have to phone a friend with a PhD to help. From CMS, updated fall, 2019

Medicare Prescription Drug Plans – Premiums and Quality Ratings Editor's Pick

Compare the prices (monthly premium average cost) for prescription drug coverage through Medicare (medicare.gov) and see which plans have higher ratings. Uses a 5-star quality rating system that includes member satisfaction survey reports. Part D plans.

Medicare Value-Based Programs

Outline of Medicare’s five original value-based programs: End-Stage Renal Disease (ESRD) Quality Incentive Program, Hospital Value-Based Purchasing, Hospital Readmission Reduction, Physician Value-Based Modifier program, and Hospital Acquired Conditions Program. Also Skilled Nursing Facility and Home Health Value-based programs.

Physician Payments: Average Medicare payment for 25 Common Office visits

Find out what Medicare paid for certain types of office visits and procedures in 2012. Average doctor’s price is NOT SHOWN, but only the allowed amount determined by Medicare, and how much Medicare paid on average (for every state). Must know how to use Excel files and billing code knowledge would also be helpful. Medicare paid $49 for a 99213 office code (15 minute office visit for an established patient) and $73 for a 25-minute office visit, and just $101 for a 60-minute visit (est. patients). If the patient was new, Medicare paid $73 on average for a 30 minute visit, and $116 for 45 minutes. Medicare’s annual wellness visit was paid at $165 for new enrollees, then $111 for subsequent annual visits. The most common EKG was paid at $14, ear wax removal at $36, pneumonia or annual flu shot at $23. Difficult file to use. Terribly dated; last updated Sept. 2013

Physician: Average Cost for 25 Common Ambulatory Surgery Center Procedures

Find the Allowed Medicare amounts (rather than prices) in the Ambulatory Surgery file for 25 Common high volume outpatient surgical procedures in an Ambulatory Surgery Center (not hospital-based). File shows what Medicare paid during 2012 for cataract surgery, different types of endoscopy, spinal injections, some hernia repairs, carpal tunnel release, kidney stone crushing, prostate biopsy (avg $530 paid on $670 allowable charge; full charge is not shown), correction of bunion, and more. Uses CPT codes, and all states are listed. Difficult file for consumers to use unless familiar with Excel. Terribly dated; last updated Sept. 2013. Federal government could show its commitment to price transparency by updating this file, and showing full sticker prices.

Previously Uninsured Have Higher Medicare Expenses – 2009

Research study shows that people who were previously uninsured, have higher Medicare expenses.  Pubmed abstract in December 2009 Annals of Internal Medicine. Study of 4567 adults who didn’t have insurance prior to enrolling in Medicare. Once acquiring coverage, those with diabetes, heart disease or joint replacements had 21% higher medical expenditures through Medicare, than those who were previously insured. Article by McWilliams, Meara et al.

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