As a member of a Peoples Health Medicare health plan, you are our priority. Our commitment is to take care of your health. This means much more than ensuring you have access to healthcare providers. It’s about providing you with the resources and tools you need to manage and maintain a healthy lifestyle. Use the links on the left-hand side of this page to learn more about common topics. We also regularly update this page with important plan or general information that may affect you as a Peoples Health plan member.
Medicare has revised the coverage rules for some healthcare procedures. To be covered, procedures generally must be received through a provider in your plan’s provider network, and some services may require prior authorization from Peoples Health. You can learn more about these coverage changes by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. If you have received any of these treatments on or after the effective dates and would like to seek reimbursement, contact member services.
Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis
On Dec. 7, 2016, Medicare began covering percutaneous image-guided lumbar decompression (PILD) for members enrolled in certain CMS-approved clinical studies and who have lumbar spinal stenosis. PILD is a noninvasive procedure that uses specially designed instruments to relieve lower back pain from the condition. To be covered, the surgery must be performed on or after the date above.
Percutaneous Left Atrial Appendage Closures
The Centers for Medicare & Medicaid Services issued a mid-year benefit update covering percutaneous left atrial appendage closures when the procedure is done for patients with non-valvular atrial fibrillation and according to an FDA-approved indication for the procedure with an approved device. The coverage applies for services received on or after Feb. 8, 2016. Coverage requires that patients have:
- A CHADS2 score ≥ 2 or CHA2DS2-VASc score ≥ 3 (these scores are determined by a healthcare provider to help determine stroke risk)
- A formal shared decision-making interaction—documented in his or her medical record—with an independent non-interventional physician using an evidence-based decision tool for oral anticoagulation medication in patients with non-valvular atrial fibrillation prior to left atrial appendage closures
- A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation medication following the conclusion of the shared decision-making interaction
Cologuard™ Colorectal Cancer Screening
Effective October 9, 2014, Medicare will cover Cologuard™, a multi-target stool DNA test, as a colorectal cancer screening test once every three years for beneficiaries that meet all of the following criteria:
- Age 50 to 85
- Asymptomatic (no signs or symptoms of colorectal disease, such as lower gastrointestinal pain, blood in the stool, or a positive guaiac fecal occult blood test or positive fecal immunochemical test)
- At no more than average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; and no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer)
All other screening stool DNA tests not otherwise specified above remain nationally non-covered.
Medicare Coverage Change for Speech-Generating Devices
Effective July 29, 2015, Medicare will cover speech-generating devices as durable medical equipment. Speech-generating devices are covered for patients who suffer from severe speech impairment and have a medical condition that warrants use of the device. Speech is generated using one of the following methods:
- Digitized audible and verbal speech output using prerecorded messages
- Synthesized audible and verbal speech output that requires message formulation by spelling and device access by physical contact with the device’s selection options
- Synthesized audible and verbal speech output that permits multiple methods of message formulation and device access
- Software that allows a computer or other electronic device to generate audible and verbal speech
Other covered features of the device include the capability to generate email, text or phone messages to allow the patient to communicate remotely, as well as the capability to download manufacturer and supplier updates.
Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral
Effective January 1, 2015, Medicare now covers diagnostic digital breast tomosynthesis, unilateral or bilateral. Tomosynthesis is a more sophisticated mammogram that uses computers to reconstruct a more three-dimensional image of the breast.
Single-Chamber and Dual-Chamber Permanent Cardiac Pacemakers
Effective August 13, 2013, single-chamber and dual-chamber implanted permanent cardiac pacemakers are covered for the treatment of nonreversible symptomatic bradycardia due to sinus node dysfunction and second- and third-degree atrioventricular block.
Lung Cancer Screening
Effective February 5, 2015, Medicare has classified an annual lung cancer screening with low-dose computed tomography as an additional preventive service benefit under Medicare for those meeting the following criteria:
- 55-77 years of age
- Asymptomatic (no signs or symptoms of lung cancer)
- Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes)
- Current smoker or one who has quit smoking within the last 15 years
The initial screening must be ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist during a lung cancer screening counseling and shared decision-making visit. Subsequent screenings may be ordered during any appropriate visit.
Medicare has revised the coverage rules for screenings for hepatitis C virus (HCV). Effective June 2, 2014, Medicare covers:
- A screening for patients at high risk for hepatitis C infection (those with a current or past history of illicit injection drug use or who received a blood transfusion prior to 1992). Repeat screenings for these patients are covered annually only if there is continued illicit injection drug use since a prior negative screening test.
- A single screening test is covered for patients who are not high risk as defined above, but who were born between 1945 and 1965.
The screening must be ordered by a patient’s primary care physician or a practitioner within a primary care setting and performed by an eligible Medicare provider.
Screening Fecal-Occult Blood Tests (FOBT)
Effective January 27, 2014, an FOBT is covered if a written order is provided by the patient’s attending physician or by a physician assistant, nurse practitioner or clinical nurse specialist, every 12 months for patients 50 years of age and older. Previously, Medicare would only cover the FOBT if the order was written by the patient’s physician.
Ultrasound Screening for Abdominal Aortic Aneurism
Effective January 27, 2014, an abdominal aortic aneurism screening is covered for eligible patients without requiring them to receive a referral as part of the initial preventive physical examination (commonly known as the “Welcome to Medicare Preventive Visit”). Patients only need to obtain a referral from their physician, physician assistant, nurse practitioner or clinical nurse specialist, and to meet other coverage requirements.
Intensive Cardiac Rehabilitation and Cardiac Rehabilitation
Effective, May 16, 2014, Medicare has expanded the intensive cardiac rehabilitation (ICR) benefit to include the Benson-Henry Institute Cardiac Wellness Program, which meets the intensive cardiac rehabilitation (ICR) program requirements set forth by Congress and is now included on the list of medicare-approved ICR programs. The Cardiac Wellness Program is a multi-component intervention program that includes supervised exercise, behavioral interventions and counseling, and is designed to reduce cardiovascular risk and improve health outcomes.
Medicare has retroactively revised the coverage rules for two healthcare benefits related to cancer treatment. Previously, Medicare required the gathering of specific information before covering any fluorodeoxyglucose positron emission tomography scans for cancer treatment. Effective June 11, 2013, however, Medicare no longer requires the data collection in order to cover three scans for use in guiding anti-tumor treatment after initial anti-cancer therapy. Drugs for Vomiting and Nausea Medicare previously covered the oral three-drug combination of aprepitant, a 5HT3 antagonist and dexamethasone during or after treatment with a defined list of chemotherapy agents considered “highly” likely to cause vomiting and nausea. Effective May 29, 2013, Medicare expanded coverage to include the following chemotherapy agents, which are only “moderately” likely to cause nausea and vomiting:
Do Your Part to Prevent Fraud
Each year, Medicare loses billions of dollars to fraud, which raises costs for everyone. So check out these tips on how to keep from becoming a victim, and share the information with your friends. Question Free Medical Supplies Medicare does not sell or mail medical supplies. If you receive medical supplies that you or your doctor did not order, you might be the target of a fraud scheme. Take action to protect your Medicare benefits:
- Refuse medical supplies you did not order
- Return unordered medical supplies that are shipped to your home
- Call us to report companies that send you these items
Report Services Not Provided You are one of the first lines of defense against Medicare fraud. Do your part and report services or items that you have been billed for, but did not receive. Review your plan statement and be on the lookout for this scheme:
- Make sure you received the services or items billed
- Check the number of services billed
- Ensure the same service has not been billed more than once
Prevent Identity Theft Identity theft can lead to higher healthcare costs for everyone enrolled in Medicare. Current fraud schemes to be on the lookout for include:
- People using your Medicare or health plan member number for reimbursements of services you never received
- People calling you to ask for your Medicare or health plan numbers
- People trying to bribe you to use a doctor you don’t know to get services you may not need
Protect Medicare for Future Generations Did you know that reducing Medicare fraud is one step toward making sure your grandchildren will have Medicare when they need it? You can do your part by being on the lookout for fraudulent schemes such as:
- People going door to door to sell you healthcare items or services (only your doctor knows what you need)
- People calling you to ask for your Medicare or health plan numbers
- People offering you money or other incentives
Protect Your Identity and Your Benefits Never give out your Social Security, Medicare, health plan, or banking information to someone you don’t know. Carefully review your Explanation of Benefits to ensure all the information is correct. Know that free services do not require you to give your plan or Medicare number to anyone. Compliance and Fraud, Waste and Abuse Hotline To report potential violations of the law, call the toll-free Peoples Health Compliance Hotline at 1-877-662-5894. You may choose to remain anonymous. We have a nonretaliation policy toward all callers.