For more Q&A on Medicare & Social Security - Click Here

December 2006

Dear Marci,
I want to sign up for a Medicare prescription drug plan, but am afraid that my drug costs will still be too high. Is there anything that can help me? - Cathy

Dear Cathy,
If you have Medicare, and meet certain income and asset limits, you might qualify for a federal assistance program called “Extra Help” which will lower the costs of the Medicare prescription drug benefit (Part D). If your monthly income is below $1,226 and your assets below $11,500 ($1,651/income and $23,000/assets for a couple), Extra Help will reduce your premiums, deductible, and copays. To get an application from the Social Security Administration, call 800-772-1213 or apply online at www.ssa.gov. - Marci

Dear Marci,
I don’t want to get sick with the flu this winter. Does Medicare cover flu shots? - Ryan

Dear Ryan,
Yes, Medicare will pay 100 percent for one flu shot every flu season, which is usually from November through April, as long as you go to a doctor or healthcare provider who accepts Medicare assignment (this means that your doctor or healthcare provider agrees not to charge more than Medicare will pay). You don’t even have to meet your Part B deductible before Medicare will pay for your flu shot. If you are in a Medicare private health plan, like an HMO or PPO, they might charge a copay for this service, so call your plan and ask. - Marci

Dear Marci,
My doctor just prescribed a medicine that is not covered by my Medicare drug plan. What should I do? - Denise

Dear Denise,
You can have your doctor ask for an “exception” to cover the medication you need if it is not on your plan’s list of covered drugs (formulary) or if your plan places restrictions, like quantity limits, on a medicine that your doctor prescribes.  To ask for an exception, your doctor must write a letter to your Medicare drug plan which states that this medicine is medically necessary for you to take and explains why.

The letter should include as many details as possible to increase the chance that your plan will cover the prescription. If your Medicare drug plan still refuses the exception request, you can appeal the decision at different levels. For more information about drug plan appeals or to get help appealing, call the Medicare Rights Center’s Drug Plan Appeals Hotline at 888-466-9050. This free service will put you in touch with counselors and attorneys who can help you through the appeals process. - Marci

November 2006

Dear Marci,
My father has cancer and his doctor said he will not live much longer. Can Medicare help? - Maria

Dear Maria,
Your father may qualify for hospice or “end- of-life” care, which helps to relieve the symptoms and pain related to a terminal illness but not to cure it. To qualify your father must have Medicare Part A and a terminal illness, and his doctor must certify that he will live less than six months.

Your father must also agree in writing that he does not want treatment to cure his terminal illness, though he can receive treatment to cure any other conditions. If he qualifies, Medicare will cover hospice care that is provided through a Medicare-certified hospice agency as long as the agency’s director or physician agrees that your father will live less than six months.

The hospice benefit includes a range of services such as skilled nursing, skilled therapy, and durable medical equipment. If your father lives longer than six months, and still meets the requirements for hospice care, he can continue to receive hospice benefits. Call 800-MEDICARE to find Medicare-certified hospice agencies in your area, what services are covered and how much you have to pay for them. - Marci

Dear Marci,
I was just diagnosed with diabetes and prescribed insulin that I inject with a needle. My Medicare drug plan covers insulin, but how do I get the needle? - Molly

Dear Molly,
In addition to insulin, your Medicare drug plan must cover the supplies you need to inject it yourself. These include needles, syringes, alcohol swabs and gauze. Some plans may also cover other diabetes medications that are used at home. Always check with your plan to make sure it covers the medications you need. - Marci

Dear Marci,
I did not sign up for a Medicare private drug plan (Part D) last year because I like the drug coverage that I already have. Is there any reason for me to join a Medicare drug plan for next year? - Roy

Dear Roy,
You should find out from whoever provides your current drug coverage (for example, your employer) whether it is considered “creditable,” or, as good as or better than the Medicare drug benefit. If it is not creditable, and you decide to sign up for a Medicare drug plan in the future, for as long as you have the Medicare drug benefit you will have to pay a premium penalty based on the amount of time you delay enrolling in a Medicare drug plan.

 If your current drug coverage is creditable you will not have to pay a penalty as long as you are not without  “creditable” drug coverage for more than 63 days before signing up for a Medicare private drug plan. You can call the insurer you get your drug coverage through to find out whether or not it is creditable. - Marci

October 2006

Dear Marci,
I didn’t sign up for a Medicare drug plan this year but am thinking about it for next year. Can I still sign up? - Scarlet

Dear Scarlet,
You can sign up for a Medicare drug plan between November 15th and December 31st each year. This is called the Annual Coordinated Election Period and your drug coverage begins January 1. When choosing a Medicare private drug plan, remember that different plans cover different drugs at different prices and have different monthly premiums. Make sure that the plan you sign up for will work with any other health coverage that you have, such as a Medicare Advantage plan or retiree coverage. If you want to stay in Original Medicare, you must choose a stand-alone drug plan (PDP). You may have to pay a premium penalty if you have not previously had drug coverage that is as good as the standard Medicare drug benefit (“creditable”). For more information you can call 800-MEDICARE. - Marci

Dear Marci,
Last year I signed up for a Medicare drug plan and it took a lot of time to find one that covered all of my prescriptions. Can I keep my plan next year or do I have to find one all over again? - Billy

Dear Billy,
As long as your plan is still in business next year you can keep it, but you should check to make sure it still covers the medications you need at a price you can afford. A plan can change its list of covered drugs (“formulary”). Your plan should send you information this fall telling you how its costs and coverage are changing.. Before you decide whether to stay with your Medicare drug plan, call the plan and make sure that it is still affordable and will continue to cover your prescriptions. Everyone who has a Medicare private drug plan has the opportunity to choose a new plan for next year between November 15th and December 31st. - Marci

Dear Marci,
Breast cancer runs in my family and, since this month is breast cancer awareness month, I’d like to get a mammogram. Will Medicare cover this? - Anne

Dear Anne,
Getting a mammogram is a good idea since breast cancer is the most common type of cancer in American women. Medicare will pay 80 percent of the cost for one screening mammogram every year if you are 40 or older ( 80 percent of the cost of one baseline mammogram if you are 35 to 39 years old). Medicare will cover this screening even if you haven’t yet reached your Part B deductible.  A mammogram can identify breast cancer while in its early stages when the most treatment options are still available. - Marci

September 2006

Dear Marci,
My drug costs are pretty high this year. I learned that my plan’s coverage is stopping until I spend more on my drugs without any help from my plan.  Could that be true? - Anne Marie

Dear Anne Marie,
Yes. Most Medicare drug plans have a big gap in drug coverage, called the “doughnut hole.”  In most plans the gap begins after you have been paying copayments for a while, when your total drug costs (what both you and your plan have paid) reach $2,250. It ends when you have spent $3,600 out of pocket, not including your drug plan’s monthly premiums.

You then get “catastrophic coverage” in which Medicare pays about 95 percent of your drug’s costs through the end of the calendar year. While in the gap, you are responsible for 100 percent of your drug costs. You can only buy drugs on your plan’s formulary and in your plan’s pharmacy network, if you want the cost to count toward the $3,600 you must spend to get “catastrophic coverage.”

During the gap, if your plan’s in-network pharmacy has a retail price lower than your plan’s price, you can buy it at the lower price and it will count toward “catastrophic coverage.” Some charities also offer assistance that can help towards the $3,600.
- Marci

Dear Marci,
My mother is not able to walk because she has multiple sclerosis but is not strong enough to use a manual wheelchair. Will Medicare help her to pay for a scooter? -Joe

Dear Joe,
Medicare may cover a power-operated vehicle or scooter for your mother to use in her home. She already meets one of the qualifications, which is that she cannot operate a manual wheelchair. She must be able to operate the controls of the power-operated wheelchair and safely get into it, out of it and ride in it. She also must need it to get around in her home. Medicare will not cover a power-operated wheelchair that is only needed outside of the home. To learn more call 1-800-MEDICARE.  
 - Marci

Dear Marci,
I am scheduled to have cataract surgery this month and will probably need eyeglasses afterwards. Does Medicare ever cover eyeglasses? - Kate

Dear Kate,
The only time that Medicare covers eyeglasses is after cataract surgery. If you have Medicare Part B, your optometrist can prescribe one pair of glasses for you. You should get the glasses through a supplier who works with Medicare so you will only have to pay a portion of the cost.

If your supplier works with Medicare and accepts “assignment,” Medicare’s price, Medicare will pay 80 percent of the cost. You will have to meet your Part B deductible, the amount that you have to pay by yourself before Medicare Part B will begin to cover services, if you haven’t this year. You can call 1-800-MEDICARE to learn how to find a supplier and more information about the eyeglasses Medicare covers. - Marci

August 2006

Dear Marci,
I just found out that my doctor left my HMO this summer. Can I go back to Original Medicare now and continue to see my doctor? - Brie

Dear Brie,
No. Starting this year, you are limited in when you can change your choice of how you get your Medicare health benefits. You will have the opportunity to return to Original Medicare or choose a different Medicare private health plan (such as an HMO or PPO) from November 15 to December 31, and your new coverage will be effective January 1, 2007.

You will have another chance to change health plans from January 1 to March 31, 2007 (although you cannot add or drop Medicare drug coverage during this period).  There are a few exceptions including if you move out of your private health plan’s service area. Call 800-MEDICARE for more information about what situations qualify you to change health plans.     
- Marci

Dear Marci,
My mom is about to get out of the hospital and will need to go to a health care facility while she recovers. Can Medicare help? - Karl

Dear Karl,
Your mother may qualify for a Medicare-certified, skilled nursing facility (SNF) while she recovers. To qualify, your mother must need skilled nursing care daily or skilled therapy at least five days a week, and have been in the hospital at least three days out of the 30 before entering the SNF. You can call the Eldercare Locator at 800-677-1116 or 800-MEDICARE for more information.
 - Marci

Dear Marci,
I just found out that my Medicare private drug plan does not cover one of the drugs that my doctor recently prescribed. What can I do? - Gabrielle

Dear Gabrielle,
Medicare private drug plans only cover drugs that are on their “formulary” (list of covered drugs). 

You can ask your doctor to switch your prescription to a covered drug. You also have the right to ask your private drug plan for an “exception” if your doctor believes that none of the drugs covered by your plan will work or that they may actually harm you.

Your doctor must call or write a letter to your drug plan stating this. Your plan must either agree to cover the drug for you or reject your request. If the “exception” is denied then you can appeal this decision. For more information on drug plan “exceptions” and “appeals,” call the Medicare Rights Center’s Drug Plan

Appeals Hotline at 888-466-9050.
 - Marci

July 2006

Dear Marci,
I have a Medicare private drug plan and usually just pay a copay for my prescriptions. Today when I went to the drug store I had to pay the full price. I’m still paying the plan’s premiums, so why isn’t the plan still covering my drugs? - Olivia

Dear Olivia,
It sounds like you have hit the “doughnut hole,” the gap in drug coverage that is built into most Medicare private drug plans. The coverage gap usually begins when the total cost of your drugs reaches $2,251 in a given year. During the gap you pay 100 percent of your drug costs and your drug plan’s monthly premiums. When your out-of-pocket drug costs reach $3,600, you qualify for “catastrophic coverage.” You will pay $2 for generics and $5 for brand name drugs, or 5 percent coinsurance, whichever is less, until the next calendar year begins.
- Marci

Dear Marci,
My wife and I are planning to go on a cruise through the U.S. Virgin Islands this month. Will Medicare cover us while on vacation? - Peter

Dear Peter,
Medicare will pay for any medical care you receive on the cruise ship if the ship is registered to the U.S., the doctor who cares for you is registered with the Coast Guard and you get the care while the ship is in U.S. territorial waters (this means the ship is within six miles of a U.S. port).

Medicare will also cover medical care received anywhere in the U.S. and its territories (which includes the U.S. Virgin Islands). If you will be outside of these areas at any point, you should consider buying supplemental insurance that will cover you while you travel. Speak with your travel agent about travel insurance or consider buying a Medigap plan that covers foreign travel.
- Marci

Dear Marci,
Is it true that there are new supplemental insurance options to help fill gaps in my Medicare coverage? - Jill

Dear Jill,
Private insurance companies now sell Medigap plans K and L. These plans work with Original Medicare, pay for part of your Medicare coinsurances and provide some additional benefits.

Medigap plans K and L are designed to have lower monthly premiums because they require you to pay some of the cost for most Medicare-covered services until you have spent a specified amount out of pocket. Once you reach your out-of-pocket limit, both plans will pay 100 percent of your Medicare coinsurance for covered services for the rest of the year.

These plans may save you money if you currently have low medical expenses. However, you may not be able to switch to another Medigap policy if you later need more medical services. For more information, call your State Health Insurance Assistance Program or visit www.medicare.gov.
- Marci

June 2006

Dear Marci,
I just found out that I was approved for “extra help,” the program that helps pay for the new Medicare drug benefit. Can I still sign up for a drug plan, even though it’s after the May 15th deadline? Will I have to pay a penalty? - Meredith

Dear Meredith,
Being approved for Extra Help entitles you to a Special Enrollment Period (SEP). You can sign up for a Medicare private drug plan through December 31st and will not have to pay a penalty. Extra Help is available to people whose monthly income in 2006 is below $1,226 and assets below $11,500 ($1,651/income and $23,000/assets for couples). To apply for Extra Help, get an application from the Social Security Administration or apply online at www.ssa.gov. People who do not have an SEP have to wait to sign up for a plan until the Annual Coordinated Election Period, which runs from November 15th  until December 31st of every year, with coverage beginning January 1 of the following year. A 7 percent penalty will be added to the monthly premium for delaying enrollment this year. - Marci

Dear Marci,
I have diabetes, which I recently read might be linked to glaucoma. Does Medicare cover glaucoma screening? -George

Dear George,
Medicare will cover an annual glaucoma screening because you have diabetes. Other risk factors that qualify you for glaucoma screening are high blood pressure, a family history of glaucoma, and being African American age 50 and older or Hispanic American age 65 and older. Medicare will pay 80 percent of its approved amount for the screening. It is a good idea to be screened because, while there is no way to prevent glaucoma, early treatment can slow the progress of the disease and could prevent blindness. - Marci

Dear Marci,
My Mother just had her knee replaced and will need a walker when she gets out of the hospital. Can she rent one through Medicare or will she have to buy one? - Miranda

Dear Miranda,
A walker will be covered by Medicare as a piece of durable medical equipment. Some types of durable medical equipment can only be rented, often the more expensive items. You get durable medical equipment through a supplier who can tell you whether your item needs to be bought or can be rented. To save money, choose a supplier who accepts Medicare’s reimbursement rate as full payment (this is called taking “assignment”). You can call 1-800-842-2052 to get a list of suppliers. - Marci

May 2006

Dear Marci,
My Medicare summary notice this month said I have reached the limit on outpatient physical therapy covered by Medicare, but my physical therapist says that I still need treatment. What should I do? - Summer

Dear Summer,
Medicare will cover $1,740 worth of outpatient physical therapy each calendar year, after which you must get an exception to extend coverage. Certain conditions and situations qualify you to get an automatic exception (such as if you have Parkinson’s disease or require treatment to retain independent status), which means that your therapist can use a special code to bill Medicare for as much therapy as you need. If you do not have one of these conditions, your therapist can ask for an exception for you. To do this you or your therapist should fax necessary forms and a letter explaining why you need additional therapy to your regional Part B carrier. For more information call 1-800-MEDICARE. - Marci

Dear Marci,
I know that Medicare helps pay for medical treatment in a hospital, but what about care at a psychiatric hospital? - Ryan

Dear Ryan,
Medicare will cover 190 days of inpatient care at a psychiatric hospital during your life, and then might cover mental health care at a general hospital. For the psychiatric hospital you will only have to pay the deductible for each benefit period that you are there and coinsurance for each day, after the first 60. - Marci

Dear Marci,
Is it true that you can get help paying for prescription drugs, even if you own your house? - Marissa

Dear Marissa,
Yes, certain types of income and assets, such as your home, are not counted on the application for Extra Help, the federal program that helps pay the Medicare Part D premiums, deductible, and copays. This means you should apply even if your income is slightly above the $14,700 income and $11,500 asset limits ($19,800/income and $23,000/asset for couples).  To apply, get an application from the Social Security Administration or go online to www.ssa.gov. - Marci 

April 2006

Dear Marci,
I want to sign up for a prescription drug plan, but am afraid that my drug costs will still be too high. Is there anything that can help me? - Susan

Dear Susan,
If you have Medicare and meet certain income and asset limits a government assistance program called “Extra Help” can lower your prescription drug costs. In 2006, if your income is below $14,700 and your assets below $11,500 ($19,800/income and $23,000/assets for a couple), "Extra Help" will reduce your premiums, deductible, and copays.

To apply, get an application from the Social Security Administration or go online to www.ssa.gov. - Marci

Dear Marci,
I recently read in an article that osteoporosis causes “brittle bones” in many older adults. Will Medicare pay for me to be tested for it? - Jean

Dear Jean,
Osteoporosis affects over 9 million women in America and a bone mass measurement, or bone density test, is used to screen for it. Medicare will cover 80 percent of the cost of this test once every 24 months, after your annual Part B deductible is paid, if your doctor prescribes it.

Medicare will also cover follow-up measurements and more frequent screening if your doctor orders them.  - Marci

Dear Marci,
My father had a stroke and is not ready to come home from the hospital.  Is there a place for him to recover that Medicare will pay for? - Tom

Dear Tom,
Medicare may pay for some or the total cost of a Medicare-certified skilled nursing facility (SNF) where your father can receive skilled nursing care such as injections; skilled physical, speech and occupational therapy; and medical social services like counseling.

Your father must be in the hospital at least three days in the 30 before entering the SNF and either need skilled nursing care seven days a week or skilled therapy at least five days a week. Your father’s doctor or hospital discharge planner can help you find a SNF near you that meets your father’s needs. - Marci 

March 2006

Dear Marci,
I’m thinking about joining a Medicare HMO because its drug plan has no premium. Will this affect the doctors and specialists that I see? - Brooke

Dear Brooke,
A Medicare HMO is a private health plan and joining one will have a great impact on how you get your health care. Generally you are only covered for care you get from doctors in your HMO’s network and you need a referral from your primary doctor to see a specialist. Except in emergencies or urgent care situations, if you use other doctors and facilities you will pay the full cost of the care you receive. Keep in mind that doctors may leave the HMO at any time, but you can only change plans during specific enrollment periods. - Marci

Dear Marci,
I just learned that men who are over 50 should be screened for prostate cancer. Will Medicare pay for this? - Jay

Dear Jay,
There are two forms of prostate cancer screening that Medicare covers for men age 50 and over. Every 12 months Medicare will pay 80 percent of the cost of a digital rectal exam. Medicare will also pay for the complete cost of a prostate specific antigen (PSA) test, even if you have not met your Part B deductible. Remember, the sooner you catch and treat a problem, the greater your chance of a complete recovery. - Marci

Dear Marci,
My doctor just prescribed a drug that my private Medicare drug plan does not cover. I cannot afford to pay the full cost of the drug, but my doctor said it is the only one that will work for me. What should I do? - Liselle

Dear Liselle,
You can ask your drug plan to cover a drug that is not on its list of covered drugs (formulary). Your doctor must tell the plan that no other drug on their formulary will work for you. This is called asking for an exception. Your plan must respond within 72 hours. If your life, health or ability to regain maximum function is at risk, you can ask for an expedited decision and the plan must respond within 24 hours. If your plan denies your exception request, you have the right to file an appeal. - Marci

February 2006

Dear Marci,
My Part D coverage started on January 1, but I’m having trouble affording the copays. Is there anything I can do? - Mary

Dear Mary,
There is no way to completely avoid your copays, but here’s a little tip to get more for your money. Many of the plans will allow you to mail order a three-month supply of each of your prescriptions, but pay the copay only once for each three-month order. Call your plan and ask about this option. - Marci

Dear Marci,
Medicare’s home health benefit pays for my physical therapist to treat me at home. Will the new limits on therapy coverage affect me? - Jonathan

Dear Jonathan,
The new limits will not affect you since you receive this therapy through the home health benefit, which covers physical, speech, and occupational therapy. As of January 1, there is a cap on these therapies if they are received through outpatient services, for example, at a physician’s office or an outpatient rehabilitation facility. - Marci

Dear Marci,
I signed up for Medicare’s new prescription drug benefit, but now my pharmacist says my drug plan will not cover one of my prescriptions without preauthorization. What should I do? - Catherine

Dear Catherine,
Preauthorization means that you will have to get permission from the plan before it will cover the drug. Usually your doctor must send the plan a letter certifying that the drug is medically necessary and cannot be substituted with another prescription. Call your plan since the specific procedures may differ. Plans must respond to your request within 72 hours. If your life, health, or ability to recover is at risk, your request can be expedited and your plan must answer within 24 hours. If your plan denies your exception request you can appeal. - Marci 

January 2006

I like the drug coverage I have through my retiree plan, but have heard a lot about the new Medicare drug benefit. Do I have to get it? - Jane

Dear Jane,
You do not have to enroll in Medicare’s new drug benefit. If you do enroll in the drug benefit, and it does not work with your retiree coverage, you actually risk being dropped by your retiree plan. You should ask your plan whether their coverage is creditable (equal to or better than Medicare’s basic drug benefit). If it is creditable and you decide to enroll in Medicare’s drug benefit later, you will not be penalized as long as you are not without coverage for more than 63 days. - Marci

Dear Marci,
I have diabetes. Will Medicare be able to help me pay for diabetes services and supplies? - Ralph

Dear Ralph,
Medicare will pay 80% of the Medicare-approved amount of all covered diabetes supplies and services after you have paid the yearly Part B deductible.  Medicare will also cover up to 10 hours of self-management training your first year and two hours every year after that if your doctor deems it necessary.

Certain diabetic supplies such as a glucose monitor and foot care every 6 months, if you have not seen a foot-care specialist for another reason between visits and have peripheral neuropathy, are also covered. Beginning in 2006 the new Medicare drug benefit will cover the cost of insulin. - Marci

Dear Marci,
My Medicare managed care plan has refused to pay for the emergency surgery I had after a car accident while out of town. What should I do? - Celia

Dear Celia,
You should tell your Medicare private health plan to send their denial to you in writing. This denial notice will include instructions on appealing and an address to which you can send the appeal. You must include the reason you needed the surgery and if possible a letter from a doctor supporting this. You must appeal within 60 days of receiving the denial. - Marci

December 2005

Dear Marci,
My mother just had a stroke and will need outpatient physical and speech therapy. I heard that there will be new limitations on these services. Will they affect her? - Will

Dear Will,
Yes, starting January 1, 2006 there will be new limits on the amount of outpatient, rehabilitative therapy that she can get.  She will be restricted to about $1,750 worth of outpatient physical and speech therapy combined.  There will also be a new limit of about $1,750 on occupational therapy, beginning in the New Year. - Marci

Dear Marci,
I have no idea how to pick a Medicare prescription drug plan. What should I do? - Michael

Dear Michael,
If you have decided the Medicare drug benefit is right for you, find the drug plans that cover the medications you take and check whether you have to get special permission before the plan will cover a drug (i.e., pre-authorization, step therapy).  Next, consider the costs of the drug plans’ premiums, annual deductibles and copayments for each drug. Finally, make sure that the plans’ pharmacy networks include the drug stores where you regularly fill your prescriptions. You can compare drug plan information online at www.medicare.gov . - Marci

Dear Marci,
I don’t want to be sick this winter. Will Medicare pay for me to get a flu shot? - Maria

Dear Maria,
Yes, Medicare will pay 100% of one flu shot every flu season as long as you go to a doctor or health care provider who accepts assignment. You do not need to meet your Part B deductible first.  If you are in a Medicare private health plan you must call them and find out whether you will be charged a co-pay. - Marci

October 2005

Dear Marci,
I’ve read about the new Medicare drug benefit set to start January 1, 2006 but I’m not sure I want to sign up. I think it will cost too much money. Am I required to sign up? - Beth

Dear Beth,
No, the Medicare drug benefit is voluntary. One thing you should consider is your current drug coverage. If you have drug coverage now, you should receive a notice from your current provider about whether or not your coverage is “creditable” – at least as good or better than the Medicare drug benefit. If it isn’t and you do not enroll before May 15, 2006, you will have to pay a premium penalty if you decide to enroll later. In considering the Medicare drug benefit weigh the benefit of having insurance in case you suddenly get sick and your drug costs increase dramatically against your ability to pay the monthly premium, which is expected to rise every year.  - Marci

Dear Marci,
My doctor told me I needed to have a medical procedure done, but before she did it, she wanted me to sign a form agreeing to pay the full cost of the test if Medicare didn’t. What should I do?  - Michael

Dear Michael,
You should ask your doctor why you need to sign this form if he believes you need the services he is giving you. Medicare should pay for all medical services you need except those specifically excluded from coverage. If your doctor believes the services are medically necessary ask why he doesn’t think Medicare will cover them and ask him to write a letter explaining your medical need so you can appeal if Medicare denies coverage. If he will not write the letter, you may want to get a second opinion. - Marci

Dear Marci,
I see that November 2005 is American Diabetes Month. I was just diagnosed with diabetes and need more test strips. What will Medicare cover? - Bill

Dear Bill,
Medicare will pay 80 percent of the Medicare-approved amount of all covered diabetes supplies and services, after you have paid the yearly Part B deductible. - Marci

September 2005

Dear Marci,
I am considering signing up for the new Medicare drug benefit set to start January 1, 2006. My concern is that the drug plans are allowed to change the drugs they cover, and the plan I sign up for will drop drugs I need. Would I be able to switch plans if that happened? - Geraldine

Dear Anne,
No, while drug plans can change the drugs they cover as long as they give 60-day notice, that does not give you the right to change plans. You can only change your plan once a year between November 15 and December 31. There are a few exceptions such as if you move out of your plan’s service area. If you have Medicaid, or a Medicare Savings Program, you can change your Medicare drug plan once a month. And if you live in a nursing home, you can change your plan once a month as well. - Marci

Dear Marci,
I am 63-years-old and I have Medicare because I’m disabled. My wife has employer insurance, but the employer insurance told me they aren’t “primary.” I’m confused. - George

Dear Eddie,
If are younger than 65 years of age and there are fewer than 100 employees in your wife’s company, Medicare is your primary insurer. This means Medicare pays the bill first. If there are more than 100 employees, the employer insurance is your primary coverage. Medicare would act as secondary insurance, meaning it pays some of the balance after the primary payer. - Marci

Dear Marci,
I see that October 2005 is National Breast Cancer Month. Does Medicare pay if I want to get a mammogram? - Laura

Dear Laura,
Medicare pays 80 percent of the cost for one mammogram a year for women older than 40. Your Part B deductible doesn’t need to have been paid. - Marci

Aug. 2005

Dear Marci,
I am currently getting my health care coverage through Medicaid. I’ve been told that will change on January 1, 2006, when the new Medicare drug benefit begins. Is it true? What should I do? - Anne

Dear Anne,
Yes, your Medicaid prescription drug coverage will end on December 31, 2005. Your other Medicaid benefits will stay the same. You will have to choose a Medicare drug plan by December 31 or a drug plan will be randomly assigned to you.  Because you have Medicaid, you will automatically get extra help to pay for the drug benefit. Your only cost will be a small co pay for each prescription: $1 or $2 for generics and $3 or $5 for brand-name drugs depending on your income.

— Marci

Dear Marci,
I just turned 65-years-old and retired. I no longer get employee benefits and I’m beginning to receive Medicare. My wife is 62-years-old and was receiving health coverage under my employee health plan.  Will she be able to get Medicare too?  - Eddie

Dear Eddie,
Your wife will not be covered under your Medicare plan; she will have to wait until 65 for coverage from Medicare. There are some options though: you could extend her benefits under your employer coverage via COBRA (make sure you do it before the deadline) or she could receive care at Federally Qualified Health Centers, which try to give price breaks to people without health coverage. You can find a center in your area by visiting the U.S. Health and Human Services Department website at www.hhs.gov.

— Marci

Dear Marci,
I see that September 2005 is National Cholesterol Education Month. Does Medicare pay if I want to get my cholesterol level checked?  - Laura

Dear Laura,
Medicare pays 100 percent of the cost for a cholesterol, lipid and triglyceride level screening once every five years. You do not have to meet the Part B deductible first. If your doctor says the test is medically necessary, the test will always be covered for diagnostic or treatment purposes.

— Marci

July 2005

Dear Marci,

I received a letter saying that because I have Medicaid, I am automatically eligible for “extra help” paying for my prescription drugs under the new Medicare drug benefit.  How will this change my current coverage? - Sue

Dear Sue,

Your Medicaid drug coverage will end on December 31, 2005. In the fall you will be automatically enrolled in the Medicare prescription drug benefit and randomly assigned a plan through which to receive the benefit. You should receive a letter detailing which plan you will be enrolled. You should call 800-MEDICARE before December 31, 2005 to make sure the plan you have been assigned covers the drugs you need and works at the pharmacies you use regularly.  If not, ask the counselor to help you enroll in a plan that does. You must start using your new Medicare prescription drug card on January 1, 2006 to get drug coverage. Your only cost will be a small co pay for each prescription: $1 for generics and $3 for brand-name drugs. (Note: your Medicaid coverage for other services will not change.)

— Marci

Dear Marci,

What types of chiropractic services does Medicare cover? - Stella

Dear Stella,

Medicare only covers manual procedures – those done by a chiropractor that includes the use of hands or the use of a hand-held machine. 

— Marci

Dear Marci,

I’m going on vacation to Mexico next month; will Medicare cover my Hepatitis B vaccine? Will Medicare cover me in Mexico if I get sick? - Fred

Dear Fred,

Medicare covers 80 percent of the cost of the Hepatitis B vaccine for people who are at medium to high risk for the disease—this includes people who travel to countries with high rates of Hepatitis B.  

Medicare will not cover any care you get abroad, but some supplemental insurance policies (C—J) offer some coverage for emergency care outside the U.S.  If you do not have one of these supplemental policies, or any other form of health insurance, you might want to look into travel insurance.

— Marci

May 2005

Dear Marci,

I currently have retiree prescription drug coverage.  How will I know whether to sign up for the new Medicare drug benefit in November?  - Tom

Dear Tom,

If your former employer continues to offer retiree drug coverage, there are three possibilities to consider:

   (1) If you can afford your current plan and your former employer informs you that it is considered at least as good as Medicare’s (“creditable coverage”), you can keep it and not enroll in the new drug benefit.  In this case, if you later lose your retiree coverage, you can enroll in the Medicare drug benefit without a penalty (as long as you are not without drug coverage for more than 63 days). 

   (2) If your retiree plan coordinates to fill the gaps in Medicare’s drug benefit and you can afford both, you should keep it and also enroll in the Medicare prescription drug benefit. 

   (3) If your retiree plan is too expensive, or if you find that it covers less than Medicare’s drug benefit does (not creditable), you can drop it and enroll in a Medicare prescription drug plan.  (If you keep the plan and later decide to enroll in a Medicare drug plan, you will have to pay a premium penalty.) 

Talk to your former employer to find out whether your drug coverage is at least as good as Medicare’s.  If you decide to enroll in the Medicare prescription drug benefit, remember to sign up during the open enrollment period between November 15, 2005 and May 15, 2006. 

— Marci

Dear Marci,

My mother is in a nursing home and has been getting her prescriptions through Medicaid.  How will the new Medicare drug benefit affect her?  — Molly

Dear Molly,

Starting January 1, 2006, your mother will get her prescription coverage through Medicare instead of through Medicaid.  She will automatically receive extra help paying for her Medicare drug costs.  Since she has Medicaid and is in a nursing home, she qualifies for the most extra help and will not have any out-of-pocket costs: no premiums, deductibles or coinsurance.  To get Medicare drug coverage, she will have to enroll in a Medicare drug plan. Each drug plan will have its own list of covered drugs (formulary) and network of pharmacies.  She can compare plans by calling 800-MEDICARE or visiting ww.medicare.gov.  If she does not choose a plan by December 31, 2005, she will be automatically enrolled in a randomly selected plan that may not cover the drugs she needs or work in her nursing home’s pharmacy.  She can, however, switch plans every month (only people with Medicaid can do so).

— Marci

April 2005

Dear Marci,

I’m in a Medicare HMO.  What happens if I need medical care when visiting my son’s family out of state? — Tammie

Dear Tammie,

Although your Medicare HMO does generally restrict you to a network of doctors and hospitals, it is required by law to pay for emergency and urgent care outside of this network.  Even if the emergency service provider charges more than the HMO will reimburse, you cannot be billed for this difference.  If you visit your son’s family for extended periods of time, however, you may want to consider Original Medicare with a Medigap supplement so that you can receive regular care wherever you happen to be. 

 — Marci

Dear Marci,

Medicare paid the usual 80 percent when I first went to my therapist, but now I’m being charged more.  Does supplemental insurance cover this? — Jeff

Dear Jeff,

Medicare pays 80 percent of the approved amount for an initial visit to a mental health professional to determine a diagnosis.  After this it will only pay 50 percent of the approved amount for your visits.  The good news is that a Medigap supplemental insurance policy will cover the full 50 percent that you would otherwise be responsible for, not just the 20 percent that it covers for most Medicare Part B services.

— Marci

Dear Marci,

I plan on working past age 65.  Should I take Medicare Part B when I first become eligible?  — Ruth

Dear Ruth,

If your employer has 20 or fewer employees, you must take Part B at this point since Medicare becomes your primary insurer and your employer group health plan becomes secondary.  You will not have complete coverage without Part B.  If, however, your employer has 20 or more employees, you may choose to delay enrollment in Part B since your employer plan remains primary.  You will have eight months to enroll in Part B without penalty once you lose your employer insurance.  Keep in mind that unlike insurance plans from current employers, retiree plans are always secondary to Medicare.   

— Marci

March 2005

Dear Marci,

What is the Medicare Replacement Drug Demonstration Project? --Amy (Kansas City, MO)

Dear Amy,

The Medicare Replacement Drug Demonstration Project is a temporary program that provides limited prescription drug coverage in 2005 to people with the following diseases or conditions:

* Cancer
* CMV Retinitis
* Hemorrhagic Cystitis
* Hepatitis C
* Multiple Sclerosis
* Osteoporosis
* Paget’s Disease
* Psoriasis
* Psoriatic Arthritis
* Pulmonary Hypertension
* Rheumatoid Arthritis
* Secondary Hyperparathyroidism

Many of the drugs covered under this demonstration project are drugs that are currently covered under Part B if administered by your doctor. Under this project, Medicare will pay for a specific set of drugs that you can take at home.

To qualify for the Medicare Replacement Drug Demonstration Project, you must meet the following requirements:

* You must have Medicare Part A and Part B;
* Medicare must be your primary insurance (pays first for your health care services);
* You must not have comprehensive outpatient drug coverage from any other source including Medicaid, TRICARE, or an employer group health plan (drug coverage from a Medicare HMO, PPO or PFFS, or a Medigap policy is not considered comprehensive);
* You must live in the United States (U.S. territories not included);
* You must have one of the covered diseases or conditions, and your doctor must certify that you need at least one of the drugs covered under this program for a covered condition.

If your annual income falls below $13,965 a year for singles ($18,735 for couples), you will have very small out-of-pocket costs.

If you currently have supplemental insurance (such as a retiree plan or Medigap plan), you will likely have lower out-of-pocket costs if you do not enroll in the demonstration project because your supplemental insurance generally pays your deductible and coinsurance for drugs currently covered by Medicare Part B. 

Because the Medicare Replacement Drug Demonstration Project is modeled on the new Medicare drug benefit (Part D), you will have to pay a $250 deductible and 25 percent coinsurance yourself since supplemental insurance cannot wrap around this benefit. (If you qualify for the low-income benefit, this may not be a problem.) The only way to reduce your out-of-pocket costs is through charitable programs such as the Patient Advocate Foundation.

To determine if you should apply for the demonstration, consider the following issues and discuss them with your doctor:

* Will your out-of-pocket costs go up? If so, how much?
* Is there a medical or quality-of-life benefit to being able to use the replacement drugs covered under the program? If so, does it outweigh any increase in your out-of-pocket costs?

If you join the demonstration project, you can drop out at any time and continue to get any or all of your currently covered drugs through Medicare Part B.

You can send in your application at any time. Fifty thousand applicants will be accepted. They are still accepting applications.

The demonstration will end on December 31, 2005. You then have the option of enrolling in the full Medicare prescription drug benefit (Part D), which begins January 1, 2006.

--Marci

Dear Marci,

My mother heard that her neighbor is getting $600 from Medicare to spend on medication.  Could my mother be eligible to receive that assistance?  She lives off of her Social Security check and needs to take medication for her osteoporosis.

--Louis (Jacksonville, FL)

Dear Louis,

If your mother’s annual income in 2005 is less than $12,919 ($17,320 for couples), she may be eligible for a Medicare drug discount card with low-income assistance (also called “transitional assistance”).  With transitional assistance, the government will pay the card's annual fee and 90 to 95 percent of your mother’s drug costs, up to a maximum of $600 in 2005.  If she waits until April to apply for a card, the benefit will be reduced to $450.  (The benefit will be reduced by $150 every quarter of 2005.)

You cannot get this extra assistance if you have prescription drug coverage from Medicaid or a current or former employer, including TRICARE and the Federal Employees Health Benefits Program.  You can still get the assistance if you have drug coverage from a state drug assistance program (other than Medicaid) or from the Department of Veterans Affairs.

If you are enrolled in a state-sponsored pharmaceutical assistance program, it may affect which Medicare discount drug card you can get.
You can get the Medicare drug card with low-income assistance no matter what your assets (what you own or how much you have in savings). Rules for low-income assistance are different in Puerto Rico and the U.S. territories. Call 800-MEDICARE (800-633-4227) or visit www.medicare.gov for more on transitional assistance.

Visit www.medicarerights.org/rxframeset.html to find out whether your mother qualifies for a state assistance program that could provide her with ongoing assistance to pay for her medications or other programs that could provide deep discounts once the $600 runs out.

--Marci

Dear Marci,
How does Medicare work with Medicaid? --Margaret (Indianapolis, IN)

Dear Margaret,

Medicare is a federal health insurance program for people 65 and older and people with disabilities.  Medicaid is a joint federal and state health insurance program for people with low incomes and few assets. Medicaid pays for many medical expenses not covered by Medicare, such as prescription drugs and custodial care at home or in a nursing home.

When you have both Medicare and Medicaid coverage, Medicare is the primary payer and Medicaid pays second.

When you use Medicaid and Medicare and see doctors who accept Medicaid, you should not have to pay anything. You must see doctors who accept Medicaid to get full coverage. If you go to a doctor who does not take Medicaid, you may have to pay all out-of-pocket costs, including deductibles and coinsurance, yourself.

If you are eligible for Medicaid, the government will also pay your Medicare Part B premium for you, but you may need to enroll in the Qualified Medicare Beneficiary (QMB) Program in addition to Medicare.

When you have Medicare and Medicaid, you have two options to keep your costs down:

* Original Medicare and Medicaid.   As long as you see doctors who accept Medicaid, you should not have to pay anything.
* A Medicare private plan that coordinates with Medicaid, which has a network of doctors and facilities from which you can get care. (If you join a Medicare private plan that does not coordinate with Medicaid, Medicaid may not pick up out-of-pocket costs [copayments, deductibles, etc.], leaving you with potentially hefty out-of-pocket expenses.) 

--Marci

Dear Marci,

I’m 72 and just found out that I have diabetes.  Can Medicare help me manage my condition? — Larry

Dear Larry,

People with diabetes can live longer, healthier lives if they actively monitor their condition, and Medicare can help. Depending on your condition, Medicare may cover the following:

*Diabetic supplies, such as glucose monitors and control solutions, lancets, and test strips. Medicare generally will not cover the cost of insulin or syringes. However, if you use an insulin pump, the insulin and the pump may be covered as durable medical equipment.

*Diabetes self-management training and education

*Nutritional therapy

*Foot care and therapeutic shoes (if you also have peripheral neuropathy and/or severe foot disease).

Medicare will pay 80 percent of the Medicare-approved amount of all covered diabetes supplies and services, after you have paid the yearly Part B deductible.

For more information on when Medicare covers these services and supplies, call 800-MEDICARE (800-633-4227) or visit www.medicarerights.org/diabetescoverageframeset.html.

 — Marci

Dear Marci,

I recently read that cancer is now the number one killer in America.  Does Medicare cover screenings? — Nancy

Dear Nancy,

Yes, Medicare covers screenings for the following types of cancers: breast, cervical, vaginal, colon and prostate. Talk to your doctor today about getting your screenings.  Early detection of cancer can increase the success of treatment and, in some cases, screenings can identify precancerous conditions that can be treated and cured before cancer even develops. For more information, visit www.medicarerights.org/preventivecareframeset.html or call 800-MEDICARE (800-633-4227).  To learn more about risks, screenings and coping with cancer, visit the American Cancer Society’s web site at www.cancer.org or call its hotline at 800-227-2345.

— Marci

Dear Marci,

How do Medicare and Medicaid work together? — Lucia

Dear Lucia,

Medicare is a federal health insurance program for people 65 and older, and people with disabilities, who have worked long enough to qualify.  Medicaid is a federal and state health insurance program for people with low incomes and few assets. Medicaid pays for many medical expenses not covered by Medicare, such as prescription drugs and custodial care at home or in a nursing home.

When you have both, Medicare is the primary payer and Medicaid pays second. You must see doctors who accept Medicaid to get full coverage.

If you are eligible for Medicaid, the government will also pay your Medicare Part B premium for you (through a Medicare Savings Program for which you must apply at the Medicaid office). 

For more information, call 800-MEDICARE to get the number of your State Health Insurance Assistance Program and the nearest Medicaid office. — Marci

Dear Marci,

Does Medicare cover acupuncture? — Elaine

Dear Elaine,

Medicare does not cover acupuncture or other forms of alternative medicine. — Marci

Dear Marci,

My doctor prescribed me medicine for my heart.  It’s pricey and I don’t make much money. Is there any way I can get help paying for it? — Frank

Dear Frank,

If your annual income is below $12,569 ($16,862 for a couple) and you don’t have other drug coverage, you should rush to get a Medicare drug discount card.  The government will pay for your card and you will get $600 to put toward your drug costs.  If you wait until April, you will only get $450 in assistance.  For more information on low-income “transitional assistance,” call 800-MEDICARE or visit www.medicare.gov. You also should find out if your state has a prescription drug assistance program. 

You can explore all your options at www.medicarerights.org/rxframeset.html or by calling your State Health Insurance Assistance Program; call 800-MEDICARE to get the number.  — Marci

Dear Marci,

When I enrolled in Medicare last year, I mistakenly turned down Part B thinking my retiree plan would be my primary insurance.  What should I do? — Irwin

Dear Irwin,

Perfect timing.  The Medicare General Enrollment Period runs from January 1 to March 31 every year.  If you missed your initial enrollment period and need health insurance from Medicare, you should contact your local Social Security office (800-772-1213) right away.  You’ll have to pay a premium penalty of 10 percent for every 12 months you delayed enrolling in Medicare Part B.  Once enrolled, you’ll want to think about

How to fill gaps in your Medicare coverage;

Whether you might be eligible for assistance to pay your Medicare Part B premium;

How to pay for your prescription drugs; and

Whether you want to enroll in a Medicare Advantage plan.

For help understanding your options, call your State Health Insurance Assistance Program (SHIP). Call 800-MEDICARE to get the number of your SHIP.  If you have access to the internet, you can get helpful information online at www.medicarerights.org. — Marci

Dear Marci,

I sometimes can't afford the 20 percent coinsurance when I see my doctor, but I can’t afford supplemental insurance.  Any advice? — Ursula

Dear Ursula,

Federally Qualified Health Centers (FQHCs) provide health services at reduced cost.  These centers will waive the Medicare Part B deductible for Medicare services, including preventive care. They may also waive the 20 percent coinsurance for Medicare-covered benefits for people with an annual income at or below the federal poverty level. To find the FQHC nearest you, call 888-ASK-HRSA (888-275-4772).

If your monthly income is below $1,068 (or $1,426 for couples), you may be eligible for a Medicare Savings Program, which helps you pay for your Medicare premiums, deductibles and coinsurance.  Even if your income is slightly higher, you should look into it because some states allow you to make certain deductions when calculating your income. 

Call your SHIP or 800-MEDICARE to learn more. — Marci

Dear Marci,

My 93-year-old father is homebound, very frail and needs help going to the doctor. Does Medicare cover non-emergency ambulance services? — Bill

Dear Bill,

Generally, Medicare only covers emergency ambulance services. However, Medicare may cover non-emergency ambulance services if any other means of transportation is inadvisable, and your father has a written statement from his doctor certifying in advance the medical necessity of the ambulance transportation.

Medicare Part B covers ambulance services for emergencies when the transportation is from your home to the nearest hospital or skilled nursing facility (SNF) that can provide the necessary services, or from a hospital or SNF to your home, or from one facility to another, when any other type of transportation would endanger your health. Medicare Part B also covers paramedic intercept services in rural areas and regularly scheduled non-emergency transport when your doctor certifies the need for it.

Medicare pays 80 percent for ambulance services and you or your supplemental insurance will have to pick up the 20 percent coinsurance. (Ambulance services must accept the Medicare-approved amount as payment in full.) — Marci

Dear Marci,

I’m retiring and will have insurance from my job. Do I need to enroll in Medicare? — May

Dear May,

Yes; even if you have health insurance from your or your spouse’s former employer, Medicare becomes your primary insurance when you retire so you need both Medicare Parts A and B.  You have the option to decline Medicare Part B coverage, but if you do, neither Medicare nor your retiree insurance will pay for your doctors’ services and other medical care—and you will pay a lifetime Part B premium penalty of 10 percent for each year you delay enrollment. For information about enrolling in Medicare, contact Social Security at 800-772-1213. — Marci

Dear Marci,

Will I be enrolled in Medicare automatically when I get my Social Security retirement benefits next year (2005)? — Harold

Dear Harold,

You should not wait until you get your retirement benefits to enroll in Medicare if you will be turning 65 next year and will need health insurance. Waiting could result in not getting Medicare for over a year.  Next year, Social Security’s retirement age will fall six months after a person’s 65th birthday, which is past the Medicare initial enrollment period. That’s the seven-month period, including the three months before, the month of, and the three months following a person’s 65th birthday, when he can enroll in Medicare Part B without incurring a premium penalty.  Don’t wait: call 800-772-1213 and make an appointment with your local Social Security office to sign up for Medicare during your initial enrollment period. 

Within the first six months of your enrollment in Part B, be sure to take advantage of the newly covered “Welcome to Medicare Physical.”  The exam will include measurement of height, weight and blood pressure, an electrocardiogram, education, and counseling.  Talk to your doctor and call 800-MEDICARE for more information. — Marci

Dear Marci,

What will my costs be for Medicare be in 2005? — June

Dear June,

The Medicare Part B premium will be going up to $78.20/month.  In addition, the Part B annual deductible will be going up (for the first time in years) to $110.  The Medicare hospital deductible is set to increase to $912.  For information on 2005 Medicare costs, call 800-MEDICARE or visit www.medicarerights.org/newmedicarecosts.html.

Note that if you have a low income and limited assets and are struggling to afford these costs, you may be eligible for assistance.  Contact your Medicaid office to ask about Medicare Savings Programs, which help pay for Medicare Part B premiums, deductibles and coinsurance.  — Marci

Dear Marci,
I just bought a computer and am taking classes on how to use the internet.  Can you recommend some good sites for Medicare information? — Paula

Dear Paula,

The internet is a wonderful and dangerous thing!  With so much info it can be hard to find what you’re looking for. Below are the sites I find most useful for information on:

Medicare benefits, rights and option: www.medicareinteractive.org/aarp.  This site was developed by the Medicare Rights Center and is made available to the public through AARP.

Doctors who accept assignment, Medicare private plans and drug discount cards available to you: www.medicare.gov.

Medicare supplemental insurance in your area: www.naic.org.   Click on the U.S. map for contact info for your State Department of Insurance.

Health matters: www.mayoclinic.com and www.medlineplus.gov.

Happy surfing!  — Marci

Dear Marci,
I bought a Medicare drug card in the spring, not realizing that some cards only work at certain pharmacies.  As a result, I have to drive to a farther pharmacy.  It’s a pain.  I was told I could switch at the end of 2004.  Can you tell me more? — Cynthia

Dear Cynthia,

Yes, you have the right to switch cards—which can cost as much as $30 and offer 10-25 percent discount on some prescriptions—between November 15 and December 31, 2004.  (You’ll want to find out which pharmacies are in the card’s network, which drugs are covered and what happens if you travel.) You may find deeper discounts using other programs; for a list, visit www.medicarerights.org/rxframeset.html.

If your income is below $12,569 (or $16,862 for a couple), you should rush to get a Medicare drug discount card since the government will pay for your card and you will get $600 in 2004 and another $600 in 2005 to put toward your drug costs.  Whatever you do not use in 2004 will roll over into 2005.  For more information on low-income “transitional assistance,” call 800-MEDICARE or visit www.medicare.gov.  — Marci

Dear Marci,
I am homebound and receiving therapy to recover from an injury.  I am told that I can get personal care but not custodial care covered by Medicare.  What does this mean? — Barbara

Dear Barbara,

If you get skilled nursing care or skilled physical, occupational, or speech therapy at home, Medicare may also pay for home health aide services if your doctor includes them in your plan of care. Home health aides might help you with personal care, such as bathing, dressing, eating, getting around your home, or getting in and out of bed.  Medicare does not pay home health aides to help you with grocery shopping, cleaning, laundry, and cooking—these services are often referred to as “custodial care.” — Marci

Dear Marci,
I just read about the new premiums for 2005. Can you tell me a bit more?  I’m on a fixed income and am not sure how long I will be able to make ends meet.  — Linden

Dear Linden,

In 2005, Medicare premiums will increase to $78.20 a month.  If you have a low income (below $1,068/month if single, $1,426 if married) and limited assets, you may qualify for a Medicare Savings Program that helps pay for your Part B premiums, deductibles, and coinsurance.  Visit www.medicarerights.org/helppayingformedicareframeset.html for more information and then contact your State Medicaid office to make an appointment.  For the number, visit www.cms.gov/medicaid or call 800-MEDICARE.

If you qualify, you can also get $600 in prescription drug assistance through the new Medicare drug discount card program.  For more on the drug discount cards, call 800-MEDICARE (800-633-4227)  — Marci

Dear Marci,
Who do I call if I have a question about a claim? — Ed

Dear Ed,

Medicare contracts with companies called “carriers” to handle its billing.  If you have a question about a claim, call 800-MEDICARE to be relayed to the carrier that handles claims for your medical service in your area. — Marci

Dear Marci,
My mother is about to be released from the hospital after open-heart surgery.  She is in a Medicare HMO.  What does she need to do to make sure her HMO covers her rehabilitation care?   —Willis (Chicago, IL)

Dear Willis,
Because your mother is in a Medicare HMO, she must follow the HMO’s rules to get coverage for her care.  To ensure your mother gets the care she needs from her HMO and is not stuck with high out-of-pocket costs, she should

1)     Get the HMO’s approval for her post-hospital care before her discharge from the hospital;

2)     Select providers in her HMO’s network, whether she needs to get inpatient care in a skilled nursing facility or rehabilitation hospital, or outpatient therapy or skilled care in her home; and

3)     Find out what she will have to pay for different types of convalescent care.  She may be charged copayments for certain types of care.   — Marci

Dear Marci,
I plan on taking a cruise at the end of summer.  Will Medicare cover me?  — Wilma

Dear Wilma,

If you have Original Medicare, it will pay for medical care you get on a cruise ship if:

 - The ship is registered to the U.S.;

 - The doctor is registered with the Coast Guard; and

 - You get the care while the ship is in U.S. territorial waters. This means the ship is in a U.S. port or within six hours of arrival at or departure from a U.S. port.

However, very few ships are registered in the U.S. so you may have trouble getting your care covered. Some supplemental insurance plans provide coverage for foreign travel. Medicare supplemental insurance (“Medigaps”) plans C through J cover 80 percent of the cost of emergency care abroad during the first two months of a trip with a $250 deductible and a $50,000 lifetime cap.  If you are in a Medicare HMO or PPO plan, you should find out from your plan if it will cover routine or emergency care on a ship. You may want to consider buying travel insurance. - Marci

Dear Marci,
Can a home health agency refuse to accept me as a patient, even if I qualify for the Medicare home health benefit? — Alvin

Dear Alvin,

Yes. A home health agency (HHA) can limit the kinds of services it provides and the types of patient health needs that it will meet. If you need services that the HHA does not provide, the HHA may refuse to accept you as a patient. However, HHAs must use the same criteria for refusing to accept people with Medicare as they do for all other people seeking care and treatment. A HHA can also refuse to accept you as a patient if it does not believe that it can ensure your safety.

Sometimes it can be difficult to get home health care under Medicare. If the first HHA you contact is unable to take you as a patient, call another one. If you cannot find an HHA able to take you as a patient, talk with your doctor about other options that may be available to you in your area or call the Eldercare Locator at 1-800-677-1116 or your local State Health Insurance Assistance Program (call 800-MEDICARE for the number) for referrals to other care options in your area.  — Marci

Dear Marci,
I think I’m eligible for the $600 credit on the Medicare drug discount cards.  Can you tell me more?  — Joyce

Dear Joyce,

If your income in 2004 is less than $12,569 a year ($16,862 for couples) and you do not have drug coverage from Medicaid, or a current or former employer, you may be eligible for low-income assistance. If you qualify, the federal government will pay the fee for the Medicare-approved drug discount card of your choice, as well as 90 percent to 95 percent of your costs for virtually any drug, up to $1,200 ($600 in 2004 and $600 in 2005). Once the $600 has been exhausted, you must follow the rules of that particular card and will receive discounts only on the drugs it discounts.  Note that some of the card sponsors are working with pharmaceutical company assistance programs to offer individuals with incomes below $18,620 (or $24,980 for couples) deep discounts on their brand name drugs.  Call 800-MEDICARE or visit www.medicare.gov for more information. - Marci

Dear Marci,
I signed up for Medicare Part B when I turned 65, but then my wife got group health coverage through her employer. Can I drop Part B and re-enroll without a penalty later? — David

Dear David,

If your wife's employer has 20 or more employees and you are covered under her policy, the employer group health plan would be your primary insurance so you could drop your Part B coverage.  You can regain it without penalty during your Special Enrollment Period (SEP), an eight-month period after you lose your group health coverage or your spouse stops working, whichever comes first.  If your wife's employer has fewer than 20 employees, the employer group health plan would be your secondary insurance and Medicare would be primary. You would need to keep Part B to get full coverage.  Call your wife's benefits administrator to find out how many employees work for the company and be sure to stay on top of any changes from one year to the next to avoid problems.  For more information contact the Coordination of Benefits Contractor at 800-999-1118.  — Marci

Dear Marci,
Why do I have to pay more when I go to my therapist than when I go see my family doctor?  — Carol

Dear Carol,

Medicare reimburses mental health services at a different rate than other Medicare Part B medical services.  If you get care from a psychologist and other licensed therapists such as social workers, psychiatrists, nurse practitioners and nurse specialists, Medicare will cover 50 percent of the Medicare-approved amount rather than the customary 20 percent for other Part B services.  Here are a few tips to help you get the care you need at a price you can afford:

See therapists who accept assignment to keep your costs down.  These providers agree to accept the Medicare rates so you’re only responsible for the 50 percent coinsurance.

Use supplemental coverage to pick up the tab.  If you have supplemental insurance (a Medigap policy or retiree insurance, for example) it may pay for all or part of the remaining 50 percent. 

Speak up for “mental health parity.”  Let your representatives in Congress know that you believe Medicare should cover mental health services the same way it covers physical health services—by paying 80 percent of the Medicare-approved amount. - Marci

Dear Marci,
Will Medicare cover my hearing aid?  — Bob

Dear Bob,

Though Medicare covers a variety of medical equipment, such as oxygen and wheelchairs, Medicare does not cover hearing aids.  For more information on what equipment Medicare covers, call your durable medical equipment regional carrier (for the number, call 800-MEDICARE). - Marci

Dear Marci,
I’m going on vacation; will Medicare cover me abroad? — Jenny

Dear Jenny,

Medicare will not cover you abroad, but if you have a supplemental insurance policy C-J, you will have some coverage for emergency care outside the US.  If you do not have one of these supplemental policies, or any other form of health insurance, you might want to look into travel insurance.  — Marci

Dear Marci,
I just read an article saying that women with Medicare were not getting screened for breast cancer.  I didn’t know Medicare even covered mammograms.  Can you tell me more? — Vanessa

Dear Vanessa,

Medicare actually covers a small but essential range of preventive care services, such as cancer screenings (including breast, cervical, prostate and colon cancer screenings).  I encourage you to take advantage of them, especially if you are at high risk for any health conditions.  Be sure to check out the guidelines for coverage (visit www.medicarerights.org or call 1-800-MEDICARE) because some screenings are covered only if you meet specific age or health criteria and once every couple of years. - Marci

Dear Marci,
When and how will I know how much my drugs cost under the different discount drug cards?  — Jill

Dear Jill,

As of April 29, the Centers for Medicare & Medicaid Services (www.medicare.gov, 1-800-MEDICARE) lists drug prices under the different Medicare-approved drug discount cards. Note that drug prices and the drugs a card discounts can change at any time.  Remember to explore all your options, not just the Medicare cards: visit www.medicarerights.org or send $5 to Discount RX /MRC/1460 Broadway/ NYC, NY 10036. - Marci

Dear Marci,
Is it true that Medicare will one day cover physicals? — Ben

Dear Ben,

Yes and no.  As of January 1, 2005, Medicare will cover one preventive physical examination in the first six months after a person enrolls in Part B. The exam will include measurement of height, weight and blood pressure, an electrocardiogram, education, and counseling.  Medicare will cover this one physical for new Medicare Part B enrollees, but will not cover routine physicals. — Marci

Dear Marci,
Will I be enrolled in Medicare automatically when I get my Social Security retirement benefits this year?   — Joan

Dear Joan,
You should not wait until you get your retirement benefits to enroll in Medicare if you are turning 65 and need health insurance, because it could result in not getting Medicare for over a year.  This year, Social Security’s retirement age is four months after a person’s 65^th birthday, which is past the Medicare initial enrollment period.  This is the seven-month period, which includes the three months before, the month of, and the three months following a person’s 65th birthday.  Don’t wait; call 1-800-772-1213 and make an appointment with your local Social Security office to sign up for Medicare during your initial enrollment period.  — Marci

Dear Marci,
I need new glasses—will Medicare pay?   — Roger

Dear Roger,
Unless you need these glasses because you just had cataract surgery, Medicare will not pay for your glasses.  Medicare does not pay for routine eye care or glasses, but it does pay for an annual glaucoma screening for people at high risk for the disease (people with diabetes or high blood pressure, people with a family history of glaucoma, and African Americans age 50 and older.)   — Marci</