Medicare & Medicaid Regulations

by Mahala Church

The Affordable Care Act of 2010 probably generated more press than any other item during 2011. A hot topic within many states, more than thirty lawsuits have been filed nationwide sending the healthcare debate to the Supreme Court. The Court will hear arguments and make decisions on the constitutionality of the regulations by June of 2012.  In the meantime, here are the basic changes to Medicare and Medicaid beginning January 1, 2012.

Preventive Care


As part of the Medicare reform package, there is an increase in free wellness and preventive care exams. The exams include a yearly wellness visit to a physician for a risk assessment. Medicare Part B recipients are eligible for free immunizations, mammograms, and screenings for diabetes and cancers such as colon.

Medicare Part D – The Doughnut Hole

People with Medicare Part D often find themselves falling into the drug coverage gap known as the doughnut hole. Now a 50% discount on the majority of brand name and biologic medications will help to decrease that problem. Discounts on generic medications will continue. The generic discount in 2012 doubled to 14% from 2011. By 2020, the gap is supposed to close completely.

Nursing Home Care and Medicare

The new nursing home regulations increase access to facility information. This assists families in choosing a facility and monitoring the quality of care. Information includes facility ownership and management, amounts spent in resident care compared to administrative costs, hours of actual nursing care per resident, staff turnover, complaints, and regulatory violations. Much of the oversight remains with individual states, including a new requirement for each state to have a nursing home website with regulatory compliance data. Medicare’s Nursing Home Compare website will continue. Most state requirements for notifications and other information will stay the same. There is some improvement in assessing the backgrounds of nursing home workers, but participation in the national program remains optional.

Find contact information for your state’s department that handles elder care issues, here.

Medicaid Coverage for Low-Income Families

By 2014, people with an income of less than $15,000 annually ($29,000 for family of four) can enroll in the federal public health insurance program for low-income persons.

Prevent Medicaid Fraud

New programs to reduce Medicare fraud and keep the program viable are now in place. The Senior Medicare Patrol has a division in every state and encourages active support to identify and report fraudulent activity. Medicare beneficiaries should routinely check receipts from care providers against Medicare statements to ensure the services match. The Department of Justice works with the Department of Health and Human Services’ Medicare Fraud Strike Force, a coalition of federal, state, and local law enforcement to prevent waste and abuse. Their goal is to save $2.7 billion from 2012 – 2016.

Comparing Physicians

Medicare reform is enhancing the Physician Compare website to include patient outcomes, quality and safety of care, effectiveness and timeliness of care, and patient experience data. An interesting side note is the proposal to establish a demonstration program by 2019 that will give “financial incentives” to Medicare patients who get high-quality physician services.

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Mahala Church is an editor and writer with extensive experience in healthcare management and nursing. Specializing in oncology nursing, she is a strong patient advocate. Her writing couples her degrees in liberal arts and nursing with her experience in business and healthcare to foster support for patient and family education.