Note: If you are age 65 or older and working for a small company (less than 20 employees), you should talk to your employee health benefits administrator before making any decision not to take Medicare Part B. If your employer has less than 20 employees, Medicare is the primary payer and your group health insurance would be the secondary payer.

For all others, the standard Medicare Part B monthly premium will be $110.50 in 2010, which is a 15% increase over the 2009 premium. The Medicare Part B premium is increasing in 2010 due to possible increases in Part B costs.  If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $110.50 per month.

New Part B beneficiaries will pay $110.50 (because they did not have the premium withheld from their Social Security benefit in the previous year).

Beneficiaries who do not currently have the Part B premium withheld from their Social Security benefit will pay $110.50.

Higher-income beneficiaries pay $110.50 plus an additional amount,  based on the income-related monthly adjustment amount (IRMAA).

Medicare Premiums and Coinsurance Rates for 2010

Medicare Part A

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. It also covers hospice care and some home health care. You must meet certain conditions.

Medicare Part A Helps Cover Your:

Hospital Stays: Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes care you get in critical access hospitals and inpatient mental health care. This does not include private duty nursing, or a television or telephone in your room. It also does not include a private room, unless medically necessary. ReadMedicare and Your Mental Health Benefits for more information on inpatient mental health benefits.

Skilled Nursing Facility Care: Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day hospital stay). Read Medicare Coverage of Skilled Nursing Facility Care for more information.

Home Health Care: Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services. Please visit the Home Health Compare section of our website for more information.

Hospice Care: Medical and support services from a Medicare-approved hospice for people with a terminal illness, drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. Hospice care is given in your home. However, short-term hospital and inpatient respite care (care given to a hospice patient by another caregiver so that the usual caregiver can rest) are covered when needed. Read Medicare Hospice Benefits for more information.

Blood: Pints of blood you get at a hospital or skilled nursing facility during a covered stay.

Medicare Part B

Medicare Part B (Medical Insurance) helps cover your doctors’ services, outpatient hospital care, and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. You pay the Medicare Part B premium.

Medicare Part B Helps Cover Your:

Medical and Other Services: Doctors’ services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Also covers second surgical opinions, outpatient mental health care, outpatient physical and occupational therapy, including speech-language therapy. ReadMedicare and Your Mental Health Benefits and Getting a Second Opinion Before Surgery for more information.

Clinical Laboratory Services: Blood tests, urinalysis, and more.

Home Health Care: Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services. Please visit the Home Health Compare section of our website for more information.

Outpatient Hospital Services: Hospital services and supplies received as an outpatient as part of a doctor’s care. Read Your Guide to the Outpatient Prospective Payment System for more information.

Blood: Pints of blood you get as an outpatient or as part of a Part B covered service.

Medicare Also Helps Cover:

• Ambulance services (when other transportation would endanger your health).
• Artificial eyes.
• Artificial limbs that are prosthetic devices, and their replacement parts.
• Braces – arm, leg, back, and neck.
• Chiropractic services (limited), for manipulation of the spine to correct a subluxation.
• Emergency care.
• Eyeglasses – one pair of standard frames after cataract surgery with an intraocular lens.
• Immunosuppressive drug therapy for transplant patients as long as you are covered by Medicare (transplant must have been paid for by Medicare).
• Kidney dialysis. Read Medicare Coverage of Kidney Dialysis and Kidney Transplant Services for more information.
• Macular degeneration of the eye (“wet” age-related) treatment, using ocular photodynamic therapy with verteporfin.
• Medical nutrition therapy services for people with diabetes or kidney disease with a doctor’s referral.
• Medical supplies – items such as ostomy bags, surgical dressings, splints, casts, and some diabetic supplies.
• Outpatient prescription drugs (very limited). For example, some oral drugs for cancer.
• Preventive services. Read Women with Medicare – Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam for more information.
• Prosthetic devices, including breast prosthesis after mastectomy.
• Second opinion by a doctor (in some cases). Read Getting a Second Opinion Before Surgery for more information.
• Services of practitioners such as clinical social workers, physician assistants, and nurse practitioners.
• Telemedicine services in some rural areas.
• Therapeutic shoes for people with diabetes (in some cases).
• Transplants – heart, lung, kidney, pancreas, intestine, bone marrow, cornea, and liver (under certain conditions and when performed at approved facilities).
• X-rays, MRIs, CAT scans, EKGs, and some other diagnostic tests.

What is not paid for by Medicare Part A and Part B:

The Original Medicare Plan does not cover everything. Health care costs not covered by Medicare will include, but are not limited to:

• Acupuncture.
• Deductibles, coinsurance, or copayments when you get health care services.
• Dental care and dentures (in most cases).
• Cosmetic surgery.
• Custodial care (help with bathing, dressing, using the bathroom,and eating) at home or in a nursing home.
• Health care you get while traveling outside of the United States (except in limited cases).
• Hearing aids and hearing exams.
• Orthopedic shoes.
• Outpatient prescription drugs (with only a few exceptions).
• Routine foot care (with only a few exceptions).
• Routine eye care and most eyeglasses (see exception above for one pair of standard frames after cataract surgery with an introcular lens).
• Routine or yearly physical exams.
• Certain screening tests
• Certain shots (vaccinations)

Medicare Advantage plans may include extra benefits such as prescription drugs, dental care, routine physical and vision services. You can learn more about whether Medicare Advantage plans are available in your area and any extra benefits offered by these plans by visiting the Medicare Personal Plan Finder. Please visit the Your Medicare Coverage section of our website for expanded information regarding your current Medicare Part A and Part B coverage under the Original Medicare Plan.

• Anytime you are still covered by the employer or union group health plan through your or your spouse’s current or active employment, or
• During the 8 months following the month the employer or union group health plan coverage ends, or when the employment ends (whichever is first).

If you are disabled and working (or you have coverage from a working family member), the Special Enrollment Period rules also apply.

Effective date if you sign up during a Special Enrollment Period

If you enroll in Medicare Part B while covered by the group health plan or during the first full month after coverage ends, your Medicare Part B coverage starts on the first day of the month you enroll. You also can delay the start date for Medicare Part B coverage until the first day of any of the following 3 months.

If you enroll during any of the 7 remaining months of the Special Enrollment Period, your Medicare Part B coverage begins the month after you enroll.

Remember: If you do not enroll in Medicare Part B during your Special Enrollment Period, you’ll have to wait until the next General Enrollment Period, which is January 1 through March 31 of each year. You may then have to pay a higher Medicare Part B premium because you could have had Medicare Part B and did not take it.

Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about “Coordination of Benefits” when assigning responsibility for first and second payment.)

The term “Medicare Secondary Payer” is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the “gaps” in Medicare’s coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program.

Precedence of Federal Law

Federal law takes precedence over State law and private contracts. Thus, for the categories of people described below, Medicare is the secondary payer regardless of state law or plan provisions. These Federal requirements are found in Section 1862(b) of the Social Security Act {42 USC Section 1395y(b)(5)}. Applicable regulations are found at 42 CFR Part 411 (1990).

More information on MSP laws and regulations is available through the CMS Laws and Regulations Portal.  The link to the CMS Laws and Regulations Portal is located below.

Responsibilities of Beneficiaries Under MSP

As a beneficiary, we advise you to:

• Respond to Initial Enrollment Questionnaire (IEQ) and MSP claims development letters in a timely manner to ensure correct payment of your Medicare claims,
• Be aware that changes in employment, including retirement and changes in health insurance companies may affect your claims payment,
• When you receive health care services, tell your doctor and other providers and the Coordination of Benefits (COB) Contractor about any changes in your health insurance due to you, your spouse, or a family member’s current employment or coverage changes,
• Contact the COB Contractor if you take legal action or an attorney takes legal action on your behalf for a medical claim,
• Contact the COB Contractor if you are involved in an automobile accident, and
• Contact the COB Contractor if you are involved in a workers’ compensation case.

Responsibilities of Providers Under MSP

As a Part A institutional provider (i.e. hospitals), you should:

• Obtain billing information prior to providing hospital services. It is recommended that you use the Centers for Medicare & Medicaid Services’ (CMS’) questionnaire, or a questionnaire that asks similar types of questions; and
• Submit any MSP information to the intermediary using condition and occurrence codes on the claim.

As a Part B provider (i.e. physicians and suppliers)

• Follow the proper claim rules to obtain MSP information such as group health coverage through employment or non-group health coverage resulting from an injury or illness;
• Inquire with the beneficiary at the time of the visit if he/she is taking legal action in conjunction with the services performed; and,
• Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process an MSP claim.

Responsibilities of Employers Under MSP

As an employer, you must:

• Assure that your plans identify those individuals to whom the MSP requirement applies;
• Assure that your plans provide for proper primary payments where by law Medicare is the secondary payer;
• Assure that your plans do not discriminate against employees and employees’ spouses age 65 or over, people who suffer from permanent kidney failure, and disabled Medicare beneficiaries for whom Medicare is secondary payer; and,
• Accurately complete and submit Data Match reports timely on identified employees.

Group Health Plans (GHP)

An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual’s insurance company, the GHP policy is the primary payer to Medicare.

Responsibilities of Attorneys Under MSP

As an Attorney, you must:

• Immediately, upon taking a case, that involves a Medicare beneficiary, inform the COB Contractor about a potential liability lawsuit, and
• Contact the assigned lead contractor regarding Medicare’s interest in a liability, auto/no-fault, or workers’ compensation lawsuit.

Responsibilities of Insurers Under MSP

As a GHP insurer, you must:

• Report to the COB Contractor if you find that CMS has paid primary when you are primary to Medicare (i.e. 411.25).

As a Non-GHP Auto/Liability Insurer, you must:

• Contact the COB Contractor immediately when the individual you insure is a Medicare beneficiary.

-The individual or his/her spouse is currently employed/working and covered under an employer group health plan as a result of current employment.

The company has 20 or more employees or participates in a multiple-employer or multi-employer group health plan where at least one employer has 20 or more employees.

-Individual in question is entitled to Medicare as a result of a disability, the company has 100 or more employees, or participates in a multi-employer/multiple-employer group health plan where one employer has 100 or more employees.

-The individual in question is Medicare entitled due to end-stage renal disease. Medicare is the secondary payer to a group health plan until a 30-month coordination period has ended.

-For further explanation on how Medicare pays with other types of insurance, please read:
Medicare Coordination of Benefits, Welcome to the Medicare Secondary Payer and You Page page on http://www.cms.hhs.gov/COBGeneralInformation/.

By law, the Centers for Medicare & Medicaid Services (CMS) is required to announce the Part A deductibles and Part B premium amount – a notice that is published annually in the Federal Register.

Under the Medicare law, the standard premium is set to cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.   The remaining Part B costs are financed by Federal general revenues. This monthly premium paid by beneficiaries enrolled in Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items.

In calculating the monthly Part B premium each year, the CMS Office of the Actuary includes a contingency margin to provide for possible variation between actual and projected costs.  The size of the contingency margin estimated to be needed for 2010 is affected by two main factors.

First, the current law formula for physician fees, which will result in a reduction in physician fees of approximately 21 percent in 2010 and is projected to cause additional reductions in subsequent years, is one factor affecting the 2010 contingency margin.  For each year from 2003 through 2009, Congress has acted to prevent physician fee reductions from occurring.

In recognition of the strong possibility of increases in Part B expenditures that would result from similar legislation to override the decreases in physician fees in 2010 or later years, it is appropriate to maintain a significantly larger Part B contingency reserve than would otherwise be necessary.  The asset level projected for the end of 2009 is not adequate to accommodate this contingency.

Second, the Social Security Administration announced there would be no increase in Social Security benefits for 2010.   As a result of the hold-harmless provision, the increase in the Part B premium for 2010 will be paid by only a small percentage of Part B enrollees. Most Part B enrollees will pay the same monthly premium that they paid in 2009 ($96.40 was the 2009 standard monthly premium).

Approximately 27 percent of beneficiaries are not subject to the hold-harmless provision because they are new enrollees during the year (3 percent), they are subject to the income-related additional premium amount (5 percent), they do not have their Part B premiums withheld from social security benefit payments (19 percent), including those who qualify for both Medicare and Medicaid and have their Part B premiums paid on their behalf by Medicaid (17 percent).

As required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), beginning in 2007 the Part B premium a beneficiary pays each month is based on his or her annual income.  Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2010 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.  In addition to the standard 25 percent premium, such beneficiaries now pay an income-related monthly adjustment amount.  These income-related Part B premiums were phased-in over three years, beginning in 2007.  About 5 percent of current Part B enrollees are expected to be subject to the higher premium amounts

John Dempsey Hospital said Barrows was under “observation” during his stay, said his wife, Lee. Under Medicare rules, patients listed as under observation face 20 percent co-payments that wouldn’t be required if they were admitted, and expensive aftercare isn’t covered at all. Larry Barrows needed three months of rehabilitation that Medicare wouldn’t pay for because the hospital didn’t call him an inpatient, something his family didn’t learn until halfway through his hospital stay, said his wife.

“A hotshot doctor came down armed with a social worker and Larry’s doctor, and said, ‘Gee, I’m sorry, your husband’s never been admitted,’” Lee Barrows, 75, said in a telephone interview. “I said, ‘Who the hell have I been visiting?’”

Elderly patients caught between U.S. hospitals and Medicareauditors pushing to cut costs are increasingly facing tens of thousands of dollars in unexpected medical bills like the Barrowses, patient advocates say.

The observation classification is designed to be used when there isn’t an immediate diagnosis, or if it is determined the condition isn’t normally treated within an inpatient setting, such as setting broken bones.

Challenging Admissions

Hospitals, though, sometimes extend the use of observation status to avoid being challenged byMedicare auditors on patient admissions when cases fall in a gray area between inpatient and outpatient. Inpatients are more costly to Medicare, said Robert Corrato of Executive Health Resources, a consultant for hospitals on how to classify patients. Medicare watches admissions closely, and if an admission is ruled inappropriate, the hospital doesn’t get paid.

“There’s fear they will be brought under scrutiny for making a false claim,” Corrato, whose closely held company is in Newton Square, Pennsylvania, said in a telephone interview.

That shouldn’t be happening, said Marilyn Tavenner, acting administrator of the Centers for Medicare and Medicaid Services. In most instances, observation shouldn’t last for more than 48 hours, she said in a July 2 telephone interview.

“Patients staying three, four, five, six days is not the intent of observation,” Tavenner said. “Observation is designed for the first 24 to 48 hours. Beyond that, hospitals should make a decision about whether to admit.”

Medicare Letters

Medicare has begun looking into how hospitals use the observation classification. In letters sent July 7 to the American Hospital Association, the Federation of American Hospitals, and the Association of American Medical Colleges, Tavenner asked the trade associations why use of observation cases lasting more than two days had doubled from 2006 to 2008.

“Observation care of more than 24 hours can have tremendous impact on Medicare beneficiaries,” Tavenner wrote. “Only in rare and exceptional circumstances would it be reasonable and necessary for outpatient observation services to span more than 48 hours.”

Anecdotal reports indicate that use of observation may have grown since 2008. In December 2008, Medicare expanded a pilot auditing program nationwide to cut fraud. Since then, the number of patients in long-term observation has increased, said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, in Washington. Lee Barrows isn’t alone in her frustration, Edelman said.

‘Calls From All Over’

“We’re getting calls from all over the place about this,” said Edelman, citing complaints from 18 states since 2008. “They’re told when they’re being discharged, that ‘By the way, Medicare won’t pay for your nursing home care because you weren’t an inpatient.’”

The hospital audit program began in 2005 in the three states with the biggest Medicare markets, New York, California and Florida. Medicare expanded it in 2006 on the way to a national rollout. Contractors who run Medicare claims processes have also upped enforcement, and Democrats added $350 million to fight fraud in the 2010 health-care law.

Mike Summerer, director of John Dempsey Hospital, where Larry Barrows stayed, said the hospital is feeling pressure from auditors. “It’s not unusual to have an inpatient admission denied that we then have to correct to outpatient, or observation,” he said in a telephone interview.

Dempsey Hospital’s average time for observation is 24 hours, he said, though there are exceptions when patients don’t have an available next step of care. He declined to discuss Barrows’ case, citing privacy law concerns.

‘A Few Extra Days’

“We use observation status, as defined in our policy, to observe patients and decide what their status will be,” Summerer said. Sometimes, “they might stay in outpatient status for a few extra days.”

Hospital associations and patient advocates interviewed said they’ve been getting the same type of feedback from patients as the advocacy center’s Edelman about increasing numbers of long-term observation stays.

“We certainly have been aware of an increased trend in observation and have been monitoring it in southeast Pennsylvania for the past year or so,” said Pam Clarke, vice president of health-care finance at the Hospital & Healthsystem Association of Pennsylvania, based in Harrisburg.

Health Overhaul

The issues surrounding hospital classifications are likely to become more prominent as a result of a provision in the health overhaul signed into law by President Barack Obama in March. The new program aims to retrieve about $1 billion a year from hospitals that re-admit too many patients, according to a Congressional Budget Office analysis.

“Certainly, hospitals will have an incentive not to admit people if they’re going to be penalized if they re-admit them,” said Nora Super, director of government relations with AARP, the lobby for people ages 50 and older.

Hospitals need to make sure patients receive the kind of treatment they require based on their condition and not “on how to generate the most revenue,” AARP, based in Washington, said today in an e-mail.

“AARP expects Medicare and hospitals to work together to address this disturbing trend,” said Executive Vice President John Rother in the statement. He said the observation classification may lead to higher costs and lower quality for Medicare patients and may deprive them of necessary follow-up care, such as stays in a skilled nursing home.

Observation Only

Dot Kirby, 90, of Saratoga, California, said she didn’t know the consequences of the observation status after she fell in her garage in January, fracturing her hip in two places. She was taken toEl Camino Hospital in Mountain View, California, where she has worked as a volunteer for 30 years, before stopping a decade ago.

After her fall, “I couldn’t walk, I couldn’t do anything,” she said. When she entered the hospital, a staff person had her sign a form saying she was in observation, Kirby said in a telephone interview.

“I didn’t know anything about it and she didn’t explain it to me,” Kirby said. The hospital took X-rays of her hip and, according to a record of the hospital charges provided by Kirby, performed $25,498.73 of care and services.

When she left the hospital, she needed five weeks of physical therapy at a nursing facility to walk again. Medicare refused to pay the $11,180.93 bill, she said.

Lost Benefits

Under the agency’s rules, Medicare would have covered Kirby’s bill had she been a hospital inpatient for three days or more.

While a patient’s doctor decides whether someone is admitted, hospitals review those decisions. The status of patients can be changed as a result of these reviews, said Corrato, the hospital consultant.

“In the past, the reality was that hospitals and physicians were on their honor,” he said. “No more.”

Medicare’s Tavenner disputed the idea that pressure from the audits, which are contracted to private companies, were causing hospitals to put more patients in observation longer.

In her July 7 letter to hospital groups, Tavenner wrote that “Some have speculated that the recent increase in the duration of observation care is due to hospitals’ concern about post-payment review of inpatient claims. We wish to emphasize that that there has been no change in CMS policy for how hospitals should approach such cases.”

Medicare Monitoring

Corrato disagreed. He said auditors in the Medicare program are increasingly looking at whether a patient should have been admitted. The agency has “made it very clear that they were going to be looking very closely at medical utilization,” Corrato said.

A 2008 Medicare report on the audit program supports his statement. It says that 41 percent of the overpayments found by the auditors “was due to the service being rendered in a medically unnecessary setting … These are situations where the beneficiary needed care but did not need to be admitted to the hospital to receive that care.”

Edelman and the Center for Medicare Advocacy have demanded that Medicare, which pays hospitals almost $200 billion a year, stop them from using “observation services” for long periods.

“Congress needs to make clear that anyone who is in a hospital for 24 hours or more is considered an inpatient,” Edelman wrote in an e-mail. “Medicare beneficiaries either forego nursing home care entirely or pay tens of thousands of dollars privately for care that Medicare should have covered.”

WILL THE LEGISLATION CUT MEDICARE BENEFITS?

There are no cuts to the traditional Medicare benefit. The lion’s share of spending cuts are in Medicare Advantage — a program that uses private firms such as Humana and UnitedHealth Group to deliver Medicare benefits. Many of these providers offer extra coverage and some of those extras could be dropped as Medicare Advantage subsidies are bought more in line with the cost of traditional Medicare benefits. Medicare Advantage payment rates will be frozen in 2011 and then gradually reduced giving companies time to adjust to the changes.

ARE THERE ANY MEDICARE BENEFIT CHANGES IN THE BILL?

Yes. Medicare will begin paying for annual wellness visits and increase reimbursements for primary care physicians. Currently Medicare only pays for a general checkup when someone first enters the program and many health analysts believe regular check ups would help improve the overall health of elderly people and provide for better coordination of care.

Also the bill provides for an improvement in the Medicare prescription drug program. The current program includes a significant coverage gap that the legislation will eventually close. Currently people fall into this so-called doughnut hole falls after a total $2,700 is spent on drugs. Coverage begins again after $6,154 is spent.

In 2010, people who fall into the doughnut hole will get a $250 rebate. In 2011, they will get a 50 percent discount on brand-name drugs. By 2020, the doughnut hole will have been closed and 75 percent of drug costs will be covered.

HOW DOES MEDICARE ACHIEVE OTHER SAVINGS?

The legislation aims to capture productivity savings in the health system to save Medicare money.

Studies have shown huge cost variations in different parts of the country with little difference in health outcomes. The legislation provides for Medicare to test payment systems that are thought to promote better coordination and efficiency of care while maintaining or improving the quality of care.

Lawmakers hope the program will save billions of dollars by avoiding duplication of services and by providing better coordination of care for people with chronic conditions. The main aim of these delivery system reforms is to reward a quality of care rather than a quantity of services.

The bill also establishes an independent payment advisory board that will make recommendations on how to save money in Medicare and extend the financial solvency of the program.

The bill also provides more money to fight Medicare fraud.

WHAT HAPPENS ON THE MEDICARE PAYROLL TAX?

Most taxpayers will not pay the higher Medicare payroll tax. The bill calls for raising the tax to 2.35 percent from the current 1.45 percent for individuals earning $200,000 or more and for couples earning $250,000 or more. The legislation would also apply the tax to some investment income for those high-income groups.

Source: Reuters