Medicare & ACA/ObamaCare Preventative Care
Trump Make America Healthy Again
Nearly half of the U.S. population is pre-diabetic or has type-2 diabetes. Every month, diabetes causes 13,000 new amputations, 5,000 new cases of kidney failure and up to 2,000 new cases of blindness in our country. In 1960, approximately 13 percent of American adults were obese. Now, more than 40 percent of Americans are obese, and more than 70 percent are either obese or overweight.
Even more shockingly, one-quarter of our teenagers today are pre-diabetic or have type-2 diabetes, and obesity is the leading medical reason that 71 percent of young Americans are disqualified from military service. Learn More >>> The Hill
#ACA / ObamaCare Preventative Care & Wellness Programs
- Here’s a Plain English List! from HealthCare.Gov of preventative services you can get with NO DEDUCTIBLE.
- However, if Preventive care is given during an Office Visit or as an outpatient or vice versa Covered CA it might not be covered under the Preventative Care section of your policy Check with your doctor. Preventative Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92
- If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016
- Ouch. That ‘Free’ Annual Checkup Might Cost You. Here’s Why
- Preventive care doctor visits are free, but if you bring up a health concern during the appointment, the visit may turn into a traditional doctor visit. That means you would have to pay a copay. The same could go for any tests that lead to more treatment or follow-up visits. Learn More Covered CA *
- If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016
- Health Care Reform hopes to save premium dollars as 20% of Employee Health Care Spending is on these common risk factors: health net pulse.com/
- stress
- depression
- high blood pressure
- high cholesterol
- obesity
- excessive alcohol use
- tobacco use
- US Preventative Services Task Force – Consumer Information for tons of different problems
Resources & Links
- A federal appeals court in Texas on 6.21.2024 (read courts actual ruling) found unconstitutional a key component of the Affordable Care Act that grants a health task force the effective authority to require that insurers both cover an array of preventive health interventions and screenings and refrain from imposing out-of-pocket costs for them. NBC News *
- Appeals Court Hears Appeal Over Obamacare’s Preventive Care Mandate KFF 3.5.2024
- The Texas ruling of March 30, 2023 (KFF Summary) * KFF update 4.7.2023 * doesn’t count in CA. Please don’t take blanket summaries & hype as gospel. Read the sources links
- California law that requires all health plans regulated by the State of California to cover the same necessary preventive services at no cost to the patient, consumers enrolled in plans offered through Covered California will continue to have access to these critical health care services without disruption. Covered CA Email dated 4.6.2023 * Joint Statement *
- FAQ finding doctors, labs and hospitals, when there’s confusion
All our plans are Guaranteed Issue with No Pre X Clause
Quote & Subsidy #Calculation
There is No charge for our complementary services
Watch our 10 minute VIDEO
that explains everything about getting a quote
- Our Quote Engine Takes all the complexity out of using pencil and paper to figure out the premiums per the Obamacare/ACA rules under CFR §1.36B-3 *
- Get more detail on the Individual & Family Carriers available in CA
Medicare Preventative Services
Medicare #Preventative Services & Wellness Visit Publication # 10110
Video's
- Preventative Benefits VIDEO
- Vaccines VIDEO
- Stroke Awareness Month VIDEO
- Heart Disease - Screenings under Part B
- Glaucoma explained on Medicare.Gov
- Silver Sneakers
- Review your potential risk for depression and your level of safety.
- Offer to talk with you about creating advance directives, legal documents that allow you to put in writing what kind of health care you would want if you were too ill to speak for yourself.
- Learn more than you ever wanted to know about HRA – Health Risk Assessments
- Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage READ MORE 42 CFR § 410.15
- Medicare Health Outcome Survey
- Medicare does not cover an annual physical exam – see 15 pages from Medicare to explain the difference. “It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’”An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure. CA Healthline.org *
- Medicare & You: Flu Prevention VIDEO
- Health Risk Assessment
- Our Webpage on Preventative Care – Wellness Visit – Medicare
- JFK Inaugural Address
- President Kennedy – Help our country – Not just get free benefits
Ask Not, what your country can do for you
What can you do for your country - Medicare’s Preventative Benefits
- Kaiser VIDEO Play List
- Kaiser Thrive Little Miss Sunshine
See also programs that might be offered by Medi Gap or Medicare Advantage Carriers
- Medi Gap – Supplement Plans
- Medicare Advantage Plans – Part C
#Medicare10050 and You 2025
Everything you want to know
- Steve's Video Seminar Introduction to Medicare & You
- 2025 Changes & Updates CA Health Care Advocates 78 page slide show pdf
- Clear View to Medicare Patient Advocate.org - 36 pages
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- Your Medicare #Benefits # 10116
- Inpatient ONLY - How Medicare Pays for your Surgery Part A vs Part B Very Well Health.com
- medicare.gov/coverage
- What's Covered App for Smartphones
- Medicare Coverage Database Search
- medicare.gov/procedure-price-lookup
- MLN Items & Services Not Covered Under Medicare
- An Overview-05-19-23 CA Health Care Advocates Hi Cap
- Original Medicare: An Overview CA Health Care Advocates Hi Cap
- 2024 Premiums, Coinsurance & Deductibles – 10-19-23 CA Health Care Advocates Hi Cap
- Supplementing Medicare: An Overview 10-30-20 CA Health Care Advocates Hi Cap
- Enroll in Blue Cross
- Learn about UHC United Health Care
- Enroll in Blue Shield
- SCAN
- Use our scheduler to Set a phone, Skype or Face to Face meeting
- #Intake Form - We can better prepare for the meeting (National Contracting Center)
- TITLE XVIII—HEALTH INSURANCE FOR THE AGED - Medicare AND DISABLE
-
- Welcome to Medicare 2022 Publication # 11095
- Our webpage on Enrolling ONLINE for Medicare Part A Hospital & B Doctor Visits
- Part A Hospital rules for zero premium
- Part B – Doctors – How to sign up – Benefits
- How to apply for Part B when you lose employer coverage - during your special enrollment period # 10012
- Fact Sheet Deciding Whether to Enroll in Medicare Part A and Part B When You Turn 65 CMS.gov 15 pages
- Medicare & You: Deciding to Sign Up for Medicare Part B VIDEO
- CMS form to fill out L 564 E to prove you had Employer Coverage and get a special enrollment period, when you retire. VIDEO
- HI CAP CA Health Care Advocates Medicare Enrollment Periods
FAQ's from Medicare.Gov
#Should I get Parts A & B?
Most people should enroll in Medicare Part A (Hospital Insurance) when they're first eligible, but certain people may choose to delay Medicare Part B (Medical Insurance). In most cases, #How
It depends on the type of health coverage you may have.
- Deciding to Sign Up for Medicare Part B VIDEO
- You must pay your Part B premium every month for as long as you have Part B (even if you don’t use it).
- If I'm low income - are there any breaks?
- Interactive Q & A from IRS on when to sign up for Medicare
- I have coverage through my spouse who is currently working.
- I have retiree coverage (from my former employer or my spouse’s former employer) or COBRA coverage.
- I have TRICARE, and I'm a retired service member.
- I have TRICARE, and I'm an active-duty service member.
- I have CHAMPVA.
- I have End-Stage Renal Disease (ESRD).
- I have Marketplace Covered CA or other private insurance.
- I don't have any of these.
- medicare.gov/should-i-get-parts-a-b
- How to apply for Part B during your special enrollment period # 10012
- Fact Sheet Deciding Whether to Enroll in Medicare Part A and Part B When You Turn 65 15 pages
- FAQ's that we did
Nutrition & Weight
#nutrition & weight control
I lost 20 pounds and 4″ off my waist in 2011 and while my gut might be a little bigger… in the years since, at least I fit into the smaller clothes. Here’s some of the tips and suggestions I found helpful.
- Why is urine yellow CBS News
- Q&A: Food-as-medicine program increases engagement in preventive health care
- Best diet for 2024 goes to a science-backed style of eating
- Exercise & Diet more important than ever with virus at large! CA Health Line *
- A high BMI is not necessarily associated with a higher risk of death, study finds A body mass index in the range considered overweight is not linked to a higher mortality risk for many people — more evidence that BMI alone is not a reliable indicator of health. Read More CBS News *
- Rabbi Moses Ben Maimon, known as Maimonides – Rambam on Diet & Hygiene
- If you have suggestions or questions, please post in comments.
- HMR Calorie Chart Height & Weight Chart from healthy weight forum.org
- Choose My Plate.gov NEW USDA Food Plate (WebMD) 8 1/2 x 11 Printable
- Note that Health Care Reform – MANDATES Chain Restaurants to provide calories on the Menu. Deadline Extended 7.10.2015 CA Health Line 2014 Updates Page 455 Section 4205 HR 3590
- Emotional Eating ace fitness.org
- Maybe a Nap would help?
- Supreme Court Ruling – Nutrition labels will be more accurate and easier to read Food and beverage companies can be sued for false advertising if they put labels on products that would “mislead and trick consumers,” Until Thursday, many judges and food-industry lawyers maintained that sellers of beverages and food products could not be sued for false advertising so long as the product’s label accurately disclosed the ingredients in small print, as required by the Food and Drug Administration. Lanham Act. It forbids using “false or misleading descriptions” to sell a product latimes.com/
- What type of stool is the healthiest?
- LA Health Officials Launch Campaign To Combat Obesity As part of “Healthy Eating Out,” restaurants across the county will offer smaller portions to help fight the obesity epidemic. The organizers would like to grow the participating list of restaurants from 700, many of which are Subways, to 30,000. In other news, restaurants’ health inspections are falling behind because of a shortage of inspectors.
- Why Food Portions Matter For Children’s Health In L.A. County More than 700 restaurants across Los Angeles County have pledged to curb adult and childhood obesity by offering smaller portion sizes and healthier meals on their menus as part of a public health campaign, officials announced Thursday. (Abram, 2/11)
- Health Officials Want You To Eat Smaller Portions At Restaurants Now, in another attempt to reduce obesity rates, the Los Angeles County Public Health department is launching an advertising campaign to encourage parents and their kids to choose smaller portions and healthier foods the next time they eat out. Though California has the fifth-lowest adult obesity rate in the nation, it has the highest obesity rate among low-income kids ages 2 to 4, with nearly 17% who are obese. Approximately 15% of all California kids are obese, according to national data. (Karlamangla, 2/11)
- Restaurant Labor Woes Extend To Shortage Of Health Inspectors The growing number of restaurants, cafes and food trucks in San Francisco presents a labor challenge not just to the business owners in charge of staffing them. There aren’t enough health inspectors to conduct the routine inspections required by the city, industry leaders say. A search of the restaurant database on the San Francisco Health Department web site shows restaurants often have gone well over a year between inspections. (Sciacca, 2/11)
- kff health news.org new-weight-loss-treatment-is-marked-by-heavy-marketing-and-modest-results
- Exposure to any light during sleep linked to obesity – Serious Health Issues
Insurance Company Information
- myuhc.com_Health record flier_UnitedHealthcare.pdf
- Preventive care_Overview flier_UnitedHealthcare.pdf
- Real Appeal_Case study brochure_UnitedHealthcare.pdf
- Real Appeal_Overview Flier_UnitedHealthcare.pdf
- Unitedhealthcare Member Welcome_Brochure_UnitedHealthcare.pdf
Food & Nutrition Calculators
The online dietary assessment provides information on your diet quality, related nutrition messages, and links to nutrient information. After providing a day’s worth of dietary information, you will receive an overall evaluation by comparing the amounts of food you ate to current nutritional guidance. To give you a better understanding of your diet over time, you can track what you eat up to a year.
- Dessert Wizard
- Calorie Counter
- healthy weight forum.org
- Breakfast Calculator
- health care partners.com
- croatia.bmi
- 20 Reasons Japanese Women Stay Slim and Don’t Look Old
Resources
- Healthy Eating & Diet (Web MD)
- Food Frauds that can wreck your Diet (WebMD)
- Fast Food Choices Table of Condiments Healthy Refrigerator The Sweet Truth About Food and Diabetes Nutrition Quiz
- Health Line.com lose weight asap
- 14 ways to lower insulin levels
- beckers payer.com/payers-are-mostly-denying-coverage-for-weight-loss-drugs-but-a-loophole-exists
Our other pages on Preventative & Wellness Benefits & Tips
- Employer Insurance Company pages – Then find Administrative or Wellness
- Individual & Family Insurance Companies
Try this so your host or the waiter or host knows your full
Dining Etiquette Seminar – Eating Styles
See also Huff Post.com
Etiquette scholar.com
Wellness and Prevention Programs from #Kaiser
Employers have an opportunity to improve the health of your employees every day. Making small changes to your workplace and company policies is a great way to start, and it’s where you can make the biggest impact. On these pages, you’ll find the tools and support to build a culture of health at work — and see how the right partner can help guide you along the way.
reduce absences caused by the flu set up on-site flu clinics. There’s a 6-week lead time to set up a clinic and clinics are available from mid-September to mid-December depending on your location.
Benefits of Employee Wellness Programs for Small Business
6 Low-Cost Wellness Ideas for Small Businesses
- Workforce Health Resource Center
- A better way to invest in employee health
- Starting a workforce health program
- Tools for building a culture of health
- Small business workforce health guide (PDF)
- Small business workforce health iPad® presentation (PPT)
- Chronic condition management (PDF)
Kaiser’s Website on why workforce health Matters
Mental Health
myStrength_for_Employers_Brochure
myStrength_Flyer_National
Calm_Promotional_Flyer
Controlling Presenteeism
It’s Monday morning, and all your employees are at their desks working—to some degree. Bill is having a mild asthma attack that’s making it hard for him to concentrate, Anne is dealing with depression, and Dana is still worn out from the flu. They’re at work, but not really all there. This is called “Presenteeism,” and we want to help you find a way to make sure your employees are at their best.
Quality Dividend CalculatorTM 2011, gives you a simple way to estimate how your choice of health plan will affect the productivity and absenteeism of your workforce.
When employees get higher quality care, they stay healthier, absenteeism drops, and productivity improves
Fewer Days Lost with Better Medical Coverage
Give yourself the winning edge with a customized online program from Kaiser Permanente in collaboration with Health Media®. You’ll get the clear steps and ongoing encouragement it takes to reach your health goals.
Presenteeism refers to attending work while ill.
why premiums are increasing
Insomnia – Proper Rest & Sleep
Get a Return on your Investment of your Health Insurance Premiums
Premiums are only 24 percent of your total health care costs. The other 76 percent are indirect costs associated with:
• Presenteeism—people showing up for work but not being as productive as they could be—63%
• Absenteeism and short-term disability—12%
• Long-term disability—1% For example, overweight and obese employees take more sick leave than nonobese employees and are twice as likely to have high-level absenteeism.
The average annual cost of medical expenses and absenteeism related to obesity can range from $460 to $2,500 per employee.
Mammogram, Bone Density & Osteoporosis
#Mammogram coverage under Medicare
Breast cancer screening (mammograms)
Breast cancer is the most common non-skin cancer in women and the second leading cause of cancer death in women in the U. S. Every woman is at risk, and this risk increases with age. Breast cancer usually can be treated successfully when found early. Medicare covers screening mammograms and digital technologies to check for breast cancer before you or a doctor may be able to find it manually.
Who’s covered?
Women 40 and older are eligible for a screening mammogram every 12 months. Medicare also covers one baseline mammogram for women between 35–39.
How often is it covered?
Once every 12 months.
Your costs if you have Original Medicare
You pay nothing for the test if the doctor accepts assignment.
Am I at high risk for breast cancer?
Your risk of developing breast cancer increases if any of these are true:
• You had breast cancer in the past.
• You have a family history of breast cancer (like a mother, sister, daughter, or 2 or more close relatives who’ve had breast cancer).
• You had your first baby after age 30.
• You’ve never had a baby.
Other pages on our website dealing with cancer and how Insurance and Rx Prescription coverage might pay for it
Blue Shield of California Authorized Agent - Broker
Medicare Coverage of #Cancer Treatment # 11931
- Our FAQ Cancer Experimental Rx
- Chemotherapy covered under Part B and not Part D Forbes *
- FAQ on cancer coverage in ACA/Obamacare plans
- Kaiser Health News - Cancer & Medical Debt
- Our webpage on Medical Necessity
- ESMO Clinical Practice Guideline for the diagnosis, staging and treatment of patients with metastatic breast cancer
- Chemotherapy (Medicare.Gov)
- Mammograms
- Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service
- Cancer Care.org
- How Cancer Treatment Is Improving for People Living in Rural Areas Healthline.com 5.19.2022
- Medicare Dental Care
- Why Are So Many Young People Getting Cancer? It’s Complicated Time.com
- Mental Health Toll cancer takes Kaiser Permanante.org
- Professor Longo’s New Book: “Fasting Cancer”
Preventative Care
Bone Density Osteoporosis
Medicare covers bone mass measurements to see if you’re at risk for broken bones due to osteoporosis. Osteoporosis is a disease in which your bones become weak and brittle. In general, the lower your bone density, the higher your risk for a fracture.
Resources & Links
MLN Medicare Preventive Services for Professionals
- Medline Plus Trusted Health Information
- Merck Manual – Home Edition
- health.gov/my health finder
Vision
How often are Eye exams covered?
Medicare doesn’t cover routine eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses. Medicare Part B (Medical Insurance) covers some preventive and diagnostic eye exams:
- Yearly eye exam
- Glaucoma tests
- Macular degeneration
- Medicare Part B (Medical Insurance) covers a yearly eye exam for diabetic retinopathy
- ICD 10
- Web MD
by an eye doctor who’s legally allowed to do the test in your state.
Who’s eligible?
All people with Part B who have diabetes are covered.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
Note
To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service. medicare.gov yearly-eye-exam
- cms.gov/VisionServices_FactSheet
- FAQs / Ask Us a Question
- ICD billing codes
- 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
- 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).
- 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).
Dental For #Everyone,
has an excellent website with full brochures, Instant online quoting and enrollment
- One of our colleagues on how Dental for Everyone Works.
- Some of our webpages on dental
- VSP Vision
Child & Related Pages – Site Map
Medi-Cal Share of Cost
If you are low income you might check out LIS – Low Income Subsidy – Extra Help to pay the Rx costs that are not covered. LIS may also pay your Part D and Part B premiums and you might also qualify for Medi-Cal.
https://time.com/7014466/what-to-say-when-people-comment-on-your-weight/
https://www.webmd.com/healthy-aging/ss/slideshow-guide-to-sex-after-60
https://www.insurancebusinessmag.com/us/news/breaking-news/why-employers-preventive-care-approach-needs-to-be-way-way-better-512286.aspx
https://kffhealthnews.org/morning-breakout/viewpoints-ultra-processed-foods-require-better-fda-research-how-will-rfk-jr-perform-in-new-role/
https://www.withings.com/us/en/body
https://www.webmd.com/sex-relationships/ss/slideshow-have-sex-now
How is Vitamin D – 3 level 82306 GA paid?
What is Local Coverage Determination LCK http://www.CMS.gov/medicare-coverage-database
Vitamin D Assay Testing: Medical Necessity and Documentation Requirements
82306-Vitamin D, 25 HYDROXY, includes fraction(s), if performed
Vitamin D lab assay is only reimbursable under Medicare when it meets the indications under the applicable LCD and not as a routine screening according to 42 CFR 410.32(a) source
§ 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
(a) Ordering diagnostic tests. Except as otherwise provided in this section, all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary (see § 411.15(k)(1) of this chapter).
Our webpage on Medicare Appeals
How is the PSA Prostate Specific Antigen Measurement 84153 GA paid under Medicare A or B?
cms.gov/
quest diagnostics.com/Prostate_Specific_Antigen