Questions and Answers About Medicare "Dear Marci" - 2008 & 2007 Have a question for Marci?  Click here to e-mail your question.

Dear Marci,
I just qualified for a Medicare Savings Program, which will pay my Part B premium. Is it true that I can sign up for the Medicare drug benefit before November 15^th? - Jeff

Dear Jeff,
Yes. Most people with Medicare can only sign up for or change Medicare private drug plans (Part D) between November 15^th and December 31^st each year. If you qualify for a Medicare Savings Program (MSP) that helps pay for your out-of-pocket Medicare costs, you will get a Special Enrollment Period (SEP) to join, disenroll from or switch Part D plans the month you become eligible. Everyone who has an MSP automatically qualifies for Extra Help, a federal program that lowers Medicare prescription drug costs. If you have Extra Help, you are allowed to change Part D plans once a month. Call 800-MEDICARE, or Social Security at 800-772-1213, for more information. - Marci

September 2007

Dear Marci,
I’m about to turn 65 and become eligible for Medicare. I am healthy so I don’t think I’ll need Medicare Part B, which covers doctors’ services. I want to delay paying the monthly Part B premium. Can I wait to sign up for it?  - Lauren

Dear Lauren,

Unless you have insurance from your or your spouse’s current job, you should sign up for Medicare Part B. If you wait, you will be charged a monthly premium penalty of 10 percent for each 12-month period you delayed enrollment in Part B. Generally, this penalty will last as long as you have Medicare. - Marci

Dear Marci,
September is prostate cancer awareness month and this year I want to be screened. Will Medicare cover this?  - Chris

Dear Chris,
Medicare covers prostate cancer screenings for men age 50 and over. Every 12 months, Original Medicare will pay 80 percent of the cost of a digital rectal exam, after you pay your annual Part B deductible. Medicare will also cover 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 prostate cancer, the second most common form of cancer in American men, the greater your chance of a complete recovery. If you get your health coverage from a private Medicare health plan (like an HMO), you should call your plan to find out what you’ll pay for these services. - Marci

Dear Marci,
Last March, an insurance agent enrolled me in a private Medicare HMO. He said it would cover all of my doctors but I just found out that my primary care doctor is not in the plan’s network. What can I do? - Al

Dear Al,
You may qualify for a new “Exceptional Circumstances Special Enrollment Period” (SEP), which will allow you to change health plans before the next enrollment period begins on November 15. You qualify for this SEP if you were misled or received incorrect information from a health insurance employee, agent or broker. Call 800-MEDICARE and describe, in as much detail as possible, how you were misled to a Medicare agent.

If you qualify for the SEP, you can select either Original Medicare or a new Medicare private health plan. If you ran up medical debts while enrolled in the private Medicare HMO, you can switch coverage retroactively. This means that you can enroll in a new plan as of the date you enrolled in your current plan. There are also a number of other SEPs, which you can read about on the Medicare Rights Center’s website at http://www.medicarerights.org/help.html. - Marci

August 2007

Dear Marci,
I just learned that my Medicare HMO won’t let me see the specialist I would prefer to see. I want to switch back to Original Medicare but was told I have to wait. Is that true? - Jerome

Dear Jerome,
Most people have to wait until November 15th to disenroll from their Medicare HMO. Everyone with Medicare can change their choice of Medicare health and/or drug coverage once between November 15 and December 31 each year, with new coverage effective January 1. You can also drop or change your health plan one time between January 1 and March 31, with coverage effective the next month, though you cannot decide to add or drop Medicare drug coverage (Part D) during this time. Under certain circumstances you may qualify for a Special Enrollment Period outside of regular enrollment periods, for example if you were fraudulently enrolled in your Medicare health plan or moved out of the area that it covers. - Marci

Dear Marci,
I cut my finger on a rusty nail yesterday and had to get a tetanus shot. Will Medicare cover the shot?  - Jack

Dear Jack,
Yes. Medicare Part B will cover your tetanus shot. In fact, Part B will cover an immunization any time you are exposed to a disease or condition, like a rabies shot if you have been bitten by an animal. - Marci

Dear Marci,
My husband and I get about $1,400/month from Social Security combined. It’s hard to afford our health care, even though we have Medicare, but I think our assets are too high to qualify for government help. What can we do? - Claire

Dear Claire,
You and your husband might qualify for QI-1 (Qualified Individual Program), which is a Medicare Savings Program (MSP). MSPs help with the out-of-pocket costs of Medicare. QI-1 will pay your Part B premium. In many states QI-1 has an asset limit of $4,000 for an individual and $6,000 for a couple; in other states, like New York, there is no asset limit. Income limits for QI-1 also vary by state but can be no lower than $1,169/month for an individual and $1,560/month for a couple.

You should call your local Medicaid office to find out the income and asset limits in your state. If you enroll in a Medicare Savings Program, you will also automatically be enrolled in Extra Help, a federal program that significantly lowers your Medicare Part D, prescription drug, costs.  – Marci

July 2007

Dear Marci,
I receive $800/month from Social Security and find it hard to pay for visits to the doctor, even with Medicare. Do I qualify for any help? - Wendy

Dear Wendy,
You may qualify for a government program called Qualified Medicare Beneficiary (QMB) which will pay your Medicare premiums and deductibles, and full co-insurance if you receive care from a Medicaid-certified doctor. The 2007 income limit for QMB, a Medicare Savings Program, is $871/month and the assets limit is $4,000 ($1,161/month income and $6,000 assets for a couple). You can apply for QMB and other Medicare Savings Programs with higher income limits, at your local Medicaid office. Call 800-MEDICARE for more information. - Marci

Dear Marci,
I was just diagnosed with diabetes and my doctor recommended medical nutrition therapy to teach me the best diet for my condition. Will Medicare cover this? - Jack

Dear Jack,
Yes. Medicare Part B will cover medical nutrition therapy, which may include diet counseling, if you have diabetes, chronic renal disease, or are a post-kidney transplant patient and follow certain guidelines. You need a referral from your doctor and must receive the medical nutrition therapy from a registered dietitian or other qualified nutrition professional. After you have paid the annual Part B deductible, Medicare will cover 80% of the medical nutrition therapy’s cost. Medicare generally covers three hours of medical nutrition therapy the first year and two hours every year after, although it may cover more if your doctor says you need it. - Marci

Dear Marci,
My doctor told me that I need knee replacement surgery but my Medicare HMO would not authorize it because they said it wasn’t medically necessary. What can I do? - Claire

Dear Claire,
You can appeal your HMOs decision. Ask the plan for a written denial notice. Write an appeal letter to your HMO which outlines why the surgery is medically necessary and attach a letter from your doctor which confirms this. You have 30 days to appeal a care decision by a Medicare private health plan (you would have 60 days if your plan was denying payment for a service you already received).

 If you do miss the deadline you can still file your appeal if you show “good cause” for why you did not file on time. Your HMO has 30 days to reconsider its decision but if your “life, health, or ability to regain maximum function” is in jeopardy you can ask for an expedited appeal, which means that your plan must respond in 72 hours. If your appeal is denied there are several levels at which you can continue to appeal. - Marci

June 2007

Dear Marci,
This summer my husband and I want to travel around the United States. Will Medicare cover us outside our state? - Susan

Dear Susan,
Original Medicare covers medical care you receive from nearly every doctor and hospital in the U.S. and its territories. However, if you and your husband have a Medicare private health plan, like an HMO or PPO, you have to follow your plan’s rules. Private plans generally restrict you to doctors and hospitals in their network. Most plans only cover a limited geographic area (however some will offer coverage out-of-state). You will have to pay more, sometimes the full cost, for non-emergency care received outside your plan’s network. Call your plan to ask what their rules are for out-of-network care. If you want to switch to Original Medicare you will have to wait. You can only sign up for a Medicare private health plan, or disenroll from one, between November 15 and March 31. - Marci

Dear Marci,
My wife has Medicare and was recently hospitalized after having a stroke. She is almost well enough to be discharged but I have no idea how to handle her follow-up care. - Robert

Dear Robert,
Every hospital that accepts Medicare is required by federal law to offer hospital discharge planning. When your wife is ready to leave the hospital, she should receive a written discharge plan to help her ease the transition to care in her home or a skilled nursing facility.  If she does not receive a written plan, request one.  Discharge planning services may include a discussion between your wife, her doctor and family about what services she will need after she leaves the hospital; planning for follow-up visits or treatments; arrangement for nursing care or other services; help finding a skilled nursing facility; or help finding resources in her community.  - Marci

Dear Marci,
My father already has Medicare and the social worker at his housing facility thinks that his income and assets are low enough to get Medicaid. Can he have both Medicare and Medicaid?  -Jenny

Dear Jenny,
Yes. If your father qualifies for Medicaid, Medicare will be his primary payer and Medicaid will pay second. This means he should pay very little or nothing. He should see doctors who accept Medicaid to ensure full coverage. In addition, Medicaid may pay for services that Medicare does not, like personal care at home or nursing home care. Generally, medical costs are lower with Original Medicare (not Medicare private health plans like HMOs) and Medicaid. If your father joins a Medicare private health plan, he may have to pay the premium, copayments and deductibles out of pocket. He should not join a Medicaid HMO. Call 800-MEDICARE for more information. - Marci 

May 2007

Dear Marci,
I was approved for disability because I have severe chronic back pain and can’t work anymore. I just received my first disability check. When do I get Medicare?  -Madeline

Dear Madeline,
You should qualify for Medicare 24 months after you receive your first Social Security Disability Insurance (SSDI) check, if you are a U.S. citizen, have your resident visa, or have lived in the U.S. for five years in a row. Generally, you receive this disability check five months after you are approved for SSDI. There are two exceptions. If you have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s Disease, you qualify for Medicare the month you get your first SSDI check. If you have end-stage renal disease (ESRD), you may become eligible for Medicare much sooner if you fit certain eligibility requirements. Call 800-MEDICARE if you have questions.  - Marci

Dear Marci,
I am feeling fine but my wife has been after me to be screened for heart disease. Will Medicare cover this? -Vince

Dear Vince,
Yes, Medicare does cover blood tests every five years that screen for signs of cardiovascular disease, like cholesterol and lipid and triglyceride levels, or indications that you may be at risk for it. Medicare will pay 100% of the Medicare-approved amount for these tests, even before you meet your annual Part B deductible. If you are in a Medicare private health plan, like a HMO or PPO, you have the right to receive these services but may have to pay for them. Heart disease is the leading cause of death in the U.S. so it is important to be screened.  - Marci

Dear Marci,
I have Original Medicare and never had trouble affording the Part B premium, until it was raised to $93.50 this year. Are there any programs that can help me? - Miranda

Dear Miranda,
If your income is below $1,169 and your assets are below $4,000 (income below $1,560 and assets below $6,000 for a couple) then you qualify for a government program called a Medicare Savings Program (MSP) that will pay your Part B premium. In some states you can qualify for an MSP no matter how high your assets. Some states allow you to have a higher income.

The income limits go up every year. If you think you might be eligible, go to your local Department of Social Services to apply. If you enroll in an MSP you will also automatically get Extra Help, a federal program that will lower your costs with Medicare drug coverage (Part D). If your income is very low, an MSP may pay for additional Medicare costs. Call 800-MEDICARE if you have questions or to locate the Department of Social Services office that is closest to you.  - Miranda 

April 2007

Dear Marci,
I was diagnosed with breast cancer and my doctor recommended a mastectomy. Before I schedule the surgery, I’d like to get another doctor’s opinion. Will Medicare cover this? - Claire

Dear Claire,
Yes, Original Medicare will cover a second opinion because your doctor recommended surgery.

In fact, Medicare will cover a second opinion after your doctor recommends just about any major procedure. If the second doctor disagrees with the first, Medicare will even cover a third opinion.

As with most Part B-covered services, Medicare will generally cover 80 percent of the appointment’s cost. If you have a Medicare private health plan, you might need a referral from your primary care doctor before a second opinion will be covered. Also, you may have to pay the appointment’s full cost if you see a doctor who is not in your plan’s network. Call your plan to find out whether a second opinion will be covered and at what cost, and whether you need to get a referral. - Marci

Dear Marci,
My dad had a stroke and now needs outpatient occupational therapy. Is it true that Medicare limits the amount he can get? - Ron

Dear Ron,
In many cases, but not all. In 2007, Medicare covers up to $1,780 for occupational therapy annually after the Part B deductible is paid. It also covers up to $1,780 of physical and speech therapy combined.  It will cover 80 percent of the cost of these types of therapy if they are medically necessary, your doctor or therapist sets up the plan of treatment and your doctor periodically reviews the plan.

If you have certain conditions, like Multiple Sclerosis the coverage limits do not apply. If your father reaches the coverage limit but does not have a condition that would automatically allow him to get more therapy covered, his therapist or doctor can ask Medicare to cover more outpatient therapy if it is medically necessary. You can learn more about how to request an extension by clicking here to Web page http://www.cms.hhs.gov/apps/media/press/release . as p?Counter=1782 or call 800-MEDICARE. - Marci

Dear Marci,
I used to have an employer health plan that covered all my prescriptions. Now I have a Medicare private drug plan, but it doesn’t cover one of my drugs. My doctor said that no other prescription will work for me. Is there anything I can do? - Wendy

Dear Wendy,
As long as the medication is not excluded from Medicare coverage by law, you can ask your drug plan to cover a drug not on its list of covered drugs (formulary) by asking for an exception.

Your doctor must send your drug plan a written statement that explains why the prescription is medically necessary and that other drugs covered by your plan will not work or may actually harm you. Your drug plan must respond within 72 hours of receiving your doctor’s statement, unless your health is in jeopardy. In this case, you can ask for an expedited request which your drug plan must respond to within 24 hours.

Every drug plan has its own exception process, so call your drug plan. If the plan denies your exception request, you can appeal. If you need help getting a drug covered, call the Medicare Rights Center’s Drug Plan Appeals Hotline at 888-466-9050. - Marci 

March 2007

Dear Marci,
Even though I had no other health insurance, I didn’t sign up for Medicare Part B when I turned 65 because I didn’t want to pay the premium. I’m now 68 and realize I need Medicare Part B to cover doctors’ visits and other services. Can I still sign up for it? - Walter

Dear Walter,
Yes. You can still enroll in Medicare Part B during the general enrollment period, which is between January 1 and March 31, and your Medicare coverage will begin in July. You will be charged a Part B premium penalty since you missed your Medicare initial enrollment period and if you do not have employer insurance through your or your spouse’s current job.

For each 12-month period you delayed enrollment in Medicare Part B, you will have to pay a 10 percent Part B premium penalty. In most cases you will have to pay that penalty every month for as long as you have Medicare. To enroll in Medicare Part B, either go to your local Social Security office or mail Social Security a dated letter that includes your name, signature, and Social Security number. Call 800-772-1213 to locate your local Social Security office. - Marci

Dear Marci,
Is it true that Medicare now covers the new shingles vaccine? - Peg

Dear Peg,
The shingles vaccine (Zostavax ®) will only be covered for you if you have a Medicare private drug plan (Part D) that covers this particular vaccine.  If you have a Medicare drug plan, call and ask whether it covers the shingles vaccine. If it does not, you can ask your drug plan to cover it for you.

This is called asking for an “exception” and your doctor will have to write a letter to the drug plan that states why the vaccine is medically necessary. If your drug plan covers the vaccine, ask whether your doctor can bill the drug plan directly for the drug. If not, you can pay for the vaccine and ask your plan for reimbursement. In 2007, Medicare Part B, and not your drug plan, will pay your doctor to give you the shot (administration). - Marci

Dear Marci,
I just learned that I was approved for “Extra Help” to pay for the Medicare drug benefit. Can I still sign up for a Medicare drug plan? - Wendy

Dear Wendy,
Being approved for Extra Help—federal assistance that helps pay for the costs of the Medicare drug benefit (Part D)—entitles you to a Special Enrollment Period (SEP) to sign up for a Medicare private drug plan. You will not face a penalty, even if you did not enroll in Part D when you first eligible, as long as you sign up for a Part D plan in 2007.

Extra Help is available to people whose monthly income in 2007 is below $1,276 per month and whose assets are below $11,710 ($1,711 monthly income and below $23,410 in assets for couples).

To apply for Extra Help, get an application from the Social Security Administration by calling 800-772-1213 or apply online at www.ssa.gov. Certain other situations may qualify you for an SEP, for example, if you lose other drug coverage that is at least as good as Part D (creditable) through not fault of your own. Generally, only the Extra Help SEP will help you avoid a late enrollment penalty.

People who do not have an SEP can only sign up for a drug plan between November 15 and December 31 each year (the Annual Coordinated Election Period). Their coverage will begin January 1 of the following year. - Marci 

February 2007

Dear Marci,
I’ll turn 65 in August, but my Social Security benefits do not begin until December. When and how do I sign up for Medicare? - Paul

Dear Paul,
You can sign up for Medicare during the three months before, the three months after, and the month that you turn 65. To enroll in Medicare, either go to your local Social Security office or mail Social Security a dated letter that includes your name, signature, Social Security number and the date you want to be enrolled in Medicare. Be sure to note who you spoke with and keep copies of any letters, so you can prove that you tried to enroll in Medicare when you were first eligible.

You will be charged a premium penalty if you delay enrolling in Medicare Part B, unless you have employer health insurance through your or your spouse’s job at a company that employs at least 20 people. Call 800-772-1213 to locate your local Social Security office, or 800-MEDICARE if you have questions about your Medicare coverage. - Marci

Dear Marci,
My mother broke her hip and was in the hospital for four days. Now her doctor recommends that she enter a skilled nursing facility. Will Medicare cover this? - Mary

Dear Mary,
Medicare will cover your mother’s care in a Medicare-certified skilled nursing facility (SNF) if she was in the hospital for at least three days during the 30 before being admitted in to the SNF, needs either skilled nursing care seven days a week (like injections) or skilled therapy (like physical or speech therapy) at least five days a week, and became eligible for Medicare before she was discharged from the hospital.

If your mother meets these requirements, Medicare will pay the full cost of her first 20 days in a Medicare-certified SNF, and part of the next 80 days each benefit period. A benefit period begins the day she enters the SNF and ends when she no longer receives SNF care for 60 days in a row.  

To learn more about SNFs, or to find a Medicare-certified one for your mother, speak with her doctor and the hospital discharge planner, or call the Eldercare Locator at 800-677-1116. - Marci

Dear Marci,
I’ve been in the same Medicare HMO for years, but now my doctor has left the plan’s network. Can I drop the HMO? - Eddy

Dear Eddy,
You have until March 31 to drop your Medicare HMO and switch to Original Medicare or another Medicare private health plan (such as an HMO or PPO). Every year, everyone with Medicare can drop or change their health plan one time between January 1 and March 31 during the Open Enrollment Period, with coverage effective the next month. You can also change your choice of Medicare health coverage between November 15 and December 31, with new coverage effective on January 1. You cannot decide to add or drop Medicare drug coverage (Part D) during the Open Enrollment Period.  - Marci

January 2007

Dear Marci,
Every year my Medicare Part B premium is higher. What will it be this year? - Scott

Dear Scott,

In 2007, most people’s Medicare Part B premium will be $93.50. For the first time ever, the Part B premium is based on income. If your annual income is above $80,000 ($160,000 for couples) your Part B premium will be higher than $93.50. To find out what you will pay, call Social Security at 1-800-772-1213 or check http://www.medicarerights.org/newmedicarecosts.html. - Marci

Dear Marci,
I plan to spend the winter in Florida. Will Medicare cover my health care there? - Mary

Dear Mary,
It depends on which Medicare health plan you have. If you have Original Medicare, you will be covered to go to any doctor or hospital in any state or U.S. territory. If you are enrolled in a Medicare private health plan, like an HMO or PPO, you have to follow your plan’s rules.

These private plans generally restrict you to seeing doctors and hospitals in your plan’s network. You will pay more—sometimes the full cost—for non-emergency care received outside of your private plan’s network. Call your plan and ask what the rules are for out-of-network care. If you want to switch to Original Medicare, you can do so from November 15 to December 31 every year. You can also change your choice of health coverage between January 1 and March 31 (but you can not choose to add or drop Medicare drug coverage—Part D—during this period). - Marci

Dear Marci,
I signed up for a new Medicare drug plan this year. Last year some friends had trouble filling their prescriptions, and I am worried about what I will do if this happens to me. - Eddy

Dear Eddy,
Medicare drug plans are required to offer their new members a “transition policy.” You can use this to immediately fill at least one 30-day supply of every prescription you were taking before your new drug coverage began. You can tell your pharmacist to fill the prescription using your drug plan’s “transition” or “temporary” first-fill policy, regardless of whether the drug plan covers the prescription or has placed restrictions on it.

While you are getting this supply, ask your doctor to either switch you to a covered drug or to ask your plan for an “exception” to cover the drug you need.  You can only use your drug plan’s transition policy during the first 90 days after joining.

If you have trouble getting your prescriptions filled, call the Medicare Rights Center’s Medicare Drug Appeals hotline at 888-466-9050.  

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