About larrydgaddisfsg

I work in the Senior Market helping find the right Medicare Supplement or Advantage program as well as help solve Long Term Care needs, Safe Money and Income planning. I also help my customers find the right dental and vision programs that fits their needs. I work in Northern California.

Improving Medicare…Bulletin from Center for Medicare Services

Fixing America’s health care system means more than just guaranteeing that everyone has coverage.  To address the rising costs of health care, we must improve the way that health care is delivered, including coordinating care better and improving the safety of care.

The Affordable Care Act includes steps to improve the quality of health care and, in so doing, lowers costs for taxpayers and patients.  This means avoiding costly mistakes and readmissions, keeping patients healthy, rewarding quality instead of quantity, and creating the health information technology infrastructure that enables new payment and delivery models to work.   These reforms and investments will build a health care system that will ensure quality care for generations to come.

Already we have made significant progress:

Health care spending is slowing

According to the annual Report of National Health Expenditures, total U.S. health spending grew 3.9 percent in 2011.  That’s the same rate of growth as in 2009 and 2010, and in all three years spending grew more slowly than in any other year in the 51-year history of the report.  Medicare spending per beneficiary grew just 0.4 percent per capita in fiscal year 2012, continuing the pattern of very low growth in 2010 and 2011.  Medicaid spending per beneficiary also decreased 0.9 percent in 2011, compared to 0.6 percent growth in 2010. Average annual increases in family premiums for employer-sponsored insurance was 6.2 percent from 2004-2008, 5.6 percent from 2009-2012, and 4.5 percent in 2012 alone.  In 2011, the Affordable Care Act’s 80 / 20 rule (medical loss ratio policy) and strengthened rate review program resulted in an estimated $2.1 billion in savings to consumers of private health insurance.

Health outcomes are improving and adverse events are falling

This past year, we finalized several programs that tie Medicare reimbursement for hospitals to their readmission rates, when patients have to come back into the hospital within 30 days of being discharged. The 30-day, all-cause readmission rate is estimated to have dropped in the last half of 2012, to 17.8 percent, after averaging 19 percent for the past five years.  This translates to about 70,000 fewer readmissions in 2012. Additionally, as part of a new Affordable Care Act initiative, clinicians at some hospitals have reduced their early elective deliveries to close to zero, meaning fewer at-risk newborns and fewer admissions to the NICU.  Among 135 hospitals reporting common measures, early elective delivery rates have fallen (improved) by 48 percent.

Providers are engaged

In 2012, we debuted the Medicare Shared Savings Program and the Pioneer Accountable Care Organization Model.  These programs encourage providers to invest in redesigning care for higher quality and more efficient service delivery, without restricting patients’ freedom to go to the Medicare provider of their choice.

Over 250 organizations are participating in the Medicare Accountable Care Organizations (ACOs), serving approximately 4 million (eight percent of) Medicare beneficiaries.  As existing ACOs choose to add providers and more organizations join the program, participation in ACOs is expected to grow. ACOs are estimated to save up to $940 million in the first four years.

Medicare beneficiaries are shopping for coverage according to quality

The Affordable Care Act tied payment to private Medicare Advantage plans to the quality of coverage they offer.  Since those payment changes have been in effect, more seniors are able to choose from a broader range of higher quality Medicare Advantage plans, and more seniors have enrolled in these higher quality plans as well.  Since the health care law passed, enrollment has increased by 30 percent and premiums have fallen by 10 percent in Medicare Advantage.

Below are specific examples of the reforms and investments that we are making to build a health care delivery system that will better serve all Americans.


Hospitals.  Two important programs that reward hospitals based on the quality of care they provide to patients began last fall.  On October 1, 2012, the Hospital Value-Based Purchasing Program began, linking a portion of hospitals’ Medicare payments to performance on important quality measures.  Examples of measures include whether a patient received an antibiotic before surgery, or how well doctors and nurses communicate with patients.  The Hospital Readmissions Reduction Program reduces Medicare payments to hospitals with relatively high rates of potentially preventable readmissions, to financially encourage them to focus on this key indicator of patient safety and care quality.

Medicare Advantage Plans.  CMS strengthened the quality bonus incentives provided by the Affordable Care Act by providing additional payments for plans that improve the quality of care.  As a result, in 2013, the 14 million Medicare beneficiaries currently enrolled in Medicare Advantage have access to 127 five and four-star plans, which is 21 more high-quality plans than were available in the previous year.

Dialysis Facilities.  An End-Stage Renal Disease (ESRD) Quality Incentive Program, started in 2012, ties CMS payments directly to facility performance on quality measures, resulting in better care at lower cost for nearly 500,000 Americans with kidney disease.  In addition, a new comprehensive care model announced in January 2013 tests a new payment and service delivery approach to improve care for ESRD beneficiaries, by coordinating primary care with care for their special health needs.


Electronic Health Records (EHRs).  Adoption of electronic health records is making it easier for physicians, hospitals, and others serving Medicare and Medicaid beneficiaries to evaluate patients’ medical status, coordinate care, eliminate redundant procedures, and provide high-quality care.  Approximately 36 percent of health care professionals, and as many as 70 percent of hospitals, have already qualified for incentive payments for EHR systems that meet the standards and objectives established by the program. Electronic health records will help speed the adoption of many other delivery system reforms, by making it easier for hospitals and doctors to better coordinate care and achieve improvements in quality.

Partnership for Patients.  The nationwide Partnership for Patients initiative aims to save 60,000 lives by averting millions of hospital acquired conditions over three years, and save up to $35 billion in health care costs by reducing complications and readmissions, and improving the transition from one care setting to another.  At the core of this initiative are 26 Hospital Engagement Networks, which work with 3,700 hospitals, working with healthcare providers and institutions, to identify best practices and solutions to reducing hospital acquired conditions and readmissions.  These Hospital Engagement Networks have been actively involved in the effort to reduce the rate of early elective deliveries, in conjunction with the   Strong Start for Mothers and Newborns Initiative (described later).

Healthy infants.  The Strong Start for Mothers and Newborns initiative aims to reduce early elective deliveries as well as test models to decrease preterm births among high-risk pregnant women in Medicaid and the Children’s Health Insurance Program (CHIP). The Strong Start initiative builds on the work of the Partnership for Patients, testing test ways to support providers in reducing early elective deliveries.  It also offers funds to states to test models lowering the risk of preterm birth among pregnant women with Medicaid or CHIP.

Hospital-acquired conditions.  Along with other data available on Hospital Compare, beneficiaries can now find information on the incidence of serious hospital-acquired conditions (HACs) in individual hospitals.  In FY 2015, hospitals with high rates of HACs will see their payments reduced.

Community-Based Care. As part of the Partnership for Patients, the Community-Based Care Transition Program supports 82 community-based organizations, many of them partnered with multiple hospitals in 35 states to help patients make more successful transitions from hospital to home or to another post-hospital setting. $500 million in total funding has been appropriated for the program for 2011 through 2015.


Integrating care for patients enrolled in Medicare and Medicaid.  Many of the nine million Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions.  Total annual spending for their care exceeds $300 billion. Four states (Massachusetts, Ohio, Washington and Illinois) have received approval for demonstrations using managed care or health homes to coordinate care for Medicare-Medicaid beneficiaries.  Coordination strategies include more flexibility for home and community-based services and improving health IT systems.

Greater independence for Americans with disabilities and long-term care needs.  The Affordable Care Act includes a number of policies to promote non-institutional long-term care programs that will help keep people at home and out of institutions:
o Twelve additional states have joined the Money Follows the Person Program to help rebalance their long-term care systems to transition Medicaid beneficiaries from institutions to the community.  Forty-three states are now participating in Money Follows the Person.
o Nine states are participating in the Balancing Incentive Program, which gives states incentives to increase access to non-institutional long-term services and supports and provides new ways to serve more Medicaid beneficiaries in home and community-based settings.
o Ten states have approved Health Home State Plan Amendments to integrate and coordinate primary, acute, behavioral health, and long term services and supports for Medicaid beneficiaries.

Promoting care at home. A new Affordable Care Act demonstration, Independence at Home, tests whether providing chronically ill beneficiaries with primary care in the home will help them stay healthy and out of the hospital.  Fifteen physician practices and three consortia of physician practices, including the Cleveland Clinic, are participating in the Independence at Home Demonstration.


Center for Medicare and Medicaid Innovation. The Innovation Center is charged with testing innovative payment and service delivery models to reduce expenditures in Medicare, Medicaid, and CHIP, and at the same time, preserving and enhancing quality of care.  Already the Innovation Center is engaged in projects with more than 50,000 health care providers to improve care.

System-wide reforms going on now.  Critical reforms already underway include reducing adverse drug events; improving cardiac care and outcomes; reducing health disparities; using health IT and data analytics to improve population health, and engaging patients in decisions about their care.


Lower cost health care equipment and supplies. In 100 metropolitan areas, a stronger Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) competitive bidding program is setting new, lower payment rates for medical equipment and supplies.  Because of this program, CMS estimates that Medicare beneficiaries will save an average of 45 percent on certain equipment and supplies in the 91 MSAs launching this year.  Overall, the initiative is expected to save the Medicare program an estimated $25.7 billion, and beneficiaries an estimated $17.1 billion, over the next 10 years.

Fighting fraud. The Affordable Care Act’s landmark steps to improve and enhance the Administration’s ongoing efforts to prevent and detect fraud and crack down on individuals who attempt to defraud Medicare, Medicaid, and CHIP has resulted in a record level of recoveries—$4.2 billion in fiscal year 2012—and a record return on investment— $7.90 for every dollar invested.  Total recoveries over the past four years were $14.9 billion compared to $6.7 billion over the prior four years. Efforts include tough new rules and sentences for criminals; enhanced screening and enrollment requirements; increased coordination of fraud-fighting efforts; sharing data across federal agencies to fight fraud; and new tools to target high-risk providers and suppliers.




Vision care under Medicare is very limited, and often misunderstood!  Under most circumstances Medicare does not pay for your eye care.

Medicare does cover medically necessary eye care and office visits, it does not pay for routine eye exams.

Medicare will not cover routine vision exams, period. Medicare is designed similar to other health insurance policies in that they pay for eye examinations when the patient’s complaint or previous diagnosis is medical in nature. “Routine” suggests a simple screening. Although Medicare is starting to develop more and more procedures and exams that are indeed health screenings, for the most part, it does not cover exams when the chief complaint is, “I need new trifocals” or “I need a vision exam.” For example, let’s say that at the end of the examination, your doctor diagnoses you with three different eye conditions or diseases. If you had gone into the exam room that day for a “routine” eye exam and stated that you were not having any problems with your eyes, Medicare will not pay for that exam. (Medicare will, however, cover subsequent examinations and tests to follow those previous eye conditions or diseases that were detected.)

Is Any Eye Care Covered by Medicare?

You may be wondering what eye and vision care is covered by Medicare and your supplemental policy. Well, let’s say you move to a new city and find a new eye doctor. The reason for the visit? A couple of years ago, your last eye doctor diagnosed you with mild cataracts and found a little spot on your retina. Those are medical diagnoses and medically necessary reasons for having another eye examination. However, your glasses are now a bit old and falling apart. You need to have your prescription checked and you want to invest in a new pair of no-line, progressive bifocal eyeglasses. To you, you are scheduling a simple eye exam. To your doctor, however, it looks something like this:

  • 92004 – Comprehensive eye examination
  • 92015 – Refraction

“92004” is a code used by doctors to indicate to insurance companies and Medicare that a comprehensive eye exam was performed. “92015” is a code for refraction. Refraction is the determination of your refractive error, or your prescription for glasses.

Assuming the Medicare allowable fee for an exam is $135.00, Medicare will cover 80% of $135.00, which is $108.00. Your supplemental “medigap” insurance, such as Physicans Mutual will cover the remaining 20%, or $27.00. If you have no medigap or Medicare supplemental insurance, then you will be responsible for the $27.00. Medicare and most insurance plans consider the refraction a non-covered service. (For this exam, let’s say the doctor is charging $25 for the refraction, the part of the exam in which the doctor or technician asks “Which one is better, one or two?”) So, you also must pay the refraction fee of $25. As a result, your total out of pocket expense for the eye examination is $25 if you have a supplement, or $52 if you don’t.

Does Medicare Cover Eyeglasses?

Unfortunately, Medicare only covers basic frames and lenses directly following cataract surgery, and only once per lifetime. (Medicare will sometimes pay twice if the cataract surgery between the two eyes is separated by some extended length of time.)

To help with the cost of your eyeglasses, it never hurts to ask your optician for a discount on the glasses. Some will offer a discount for AAA, senior citizens. Also, most opticians will be happy to offer you a 10-20% discount if you intend to pay for the glasses in full on the day of the exam.

Medicare and Medical Eye Problems

Even though Medicare does not pay for annual, routine eye exams, medical office visits and eye exams are covered. If you are having a medical eye problem such as blepharitis or dry eye syndrome.  Medicare will pay for any and all necessary medical visits to treat the problem.

Medicare and Glaucoma Screenings

Although Medicare does not cover regular vision screenings or routine eye exams, it does pay for health screenings for glaucoma. In the year 2000, Medicare developed an office visit code for glaucoma screenings. A glaucoma screening can be performed for patients once every year for individuals with diabetes, a family history of glaucoma, who are African American over age 50, and who are Hispanics aged 65 and older. Glaucoma screenings consist of a dilated examination with interocular pressure measurement and a slit lamp examination.

One of the best and most cost effective vision plans I have found is VSP vision care for life.  The site where you can find more information on this plan and sign up for it if you are interested is…Dental for Everyone  There are several dental plans here also but the best I have found is Physicans Mutual and you can find more information about that at my web page… larrydgaddisfsg.com


Centers for Medicare and Medicaid Services. Medicare Coverages. Department of Health and Human Services, 2009.

Suggested Reading

F.D.A. Delays Approval of New Diabetes Drug

F.D.A. Delays Approval of New Diabetes Drug


The Food and Drug Administration has decided not to approve the first of a new class of diabetes drugs, saying that more information was needed to assess the medicine’s safety and effectiveness.

The agency’s decision was announced Thursday morning by the developers of the drug, AstraZeneca and Bristol-Myers Squibb.

The companies said the F.D.A. wanted more data from continuing trials and might also require new clinical trials.

The decision is not a surprise, given that an advisory committee to the F.D.A. voted 9 to 6 in July against recommending approval. The committee cited a possible increased risk of bladder and breast cancers and of liver injury.

The drug, called dapagliflozin, has generated some interest among diabetes specialists because it has a novel mechanism of action that does not depend on influencing the production or use of insulin. Rather, it reduces blood sugar by causing more of the sugar to be excreted in the urine.

Numerous other companies have also been developing drugs of this type, which are called SGLT2 inhibitors.The drugs are aimed initially at Type 2 diabetes.

AstraZeneca and Bristol-Myers said they remained committed to developing dapagliflozin. While the companies did not estimate how long it could take to win approval, it could be years if new trials were required. European regulators have yet to decide whether to approve the drug.

In December, AstraZeneca suffered setbacks in the development of a drug for cancer and one for depression, while Bristol-Myers reported the failure of a liver cancer drug in a clinical trial. But Bristol-Myers has been showing some progress in drugs for treating hepatitis C.

The F.D.A. has become more cautious about diabetes drugs in part because of studies linking Avandia, a widely used diabetes drug from GlaxoSmithKline, to a possible increased risk of heart attacks.

34th annual Barrel Tasting

Members of the Wine Road would like to welcome you to our wineries and lodgings for an exciting weekend of wine tasting. This is your chance to sample wines from the barrel, talk to winemakers and explore the beautiful Alexander, Dry Creek and Russian River Valleys.

Barrel Tasting is not a food pairing or themed event. It’s all about the WINE…many wineries offer “futures” on their barrel samples. This is a chance to purchase wine now, often at a discount, then come back to the winery when the wine is bottled, typically 12-18 months from now. Many wines are so limited, buying futures is your only chance to purchase them.

Attendees are encouraged to pack a picnic as most wineries will not have food for this event. The ticket price includes the opportunity to sample wine from the barrel and in most cases also trying a limited number of current release wines.

Crab Feed in Healdsburg Weekend of March 17 and 18! Been to this and it is an event not to miss!

As many have come to know him, Wayne “The Crab Man” will be trucking in two hundred and fifty of the biggest, freshest, most delectable shellfish into White Oak Vineyard & Winery’s scenic Alexander Valley estate on March 17th & 18th. Straight from the clean, cold water of Del Norte County, Wayne & his crew prepare the crab onsite along with his famous albacore tuna appetizers (smoked & grilled with Asian style marinade) and homemade olives to be enjoyed with White Oak’s  Russian River Valley Sauvignon Blanc. New this year, Wayne has added stir fry crab & smoked salmon hors d’oeuvre to the menu! Local artisan breads and fresh salads will accompany the platters of heavenly Dungeness crab, which will be paired with White Oak’s  Russian River Valley Chardonnay. Saturday, March 17th: $75 for Wine Club Members & their guests /$90 to the public