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Dear Marci at Senior Journal

Today's Answers About Medicare for Senior Citizens

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Questions and Answers About Medicare

"Dear Marci" - 2009 thru 2007

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July 2009

Dear Marci,
I get sunburned very easily and have been getting screened for skin cancer since I was young. I will be eligible for Medicare this summer, and I would like to know if Medicare will cover these screenings. - Olivia

Dear Olivia,
No, Medicare will not cover screenings for skin cancer. If, however, you see a suspicious-looking mole, you should make an appointment with your doctor as soon as possible. Medicare will cover a diagnostic doctor’s visit and any diagnostic tests your doctor considers medically necessary. You may be able to find a doctor who will give you a free skin cancer screening by visiting the American Academy of Dermatology’s website (www.aad.org/public/exams/screenings/index.html).  - Marci

Dear Marci,
When I see my doctor, must I pay first and then get Medicare to reimburse me?  --Harvey

Dear Harvey,
It depends on your doctor and on whether your doctor accepts Medicare’s payment as payment in full (this is known as “accepting assignment”).

If your doctor accepts assignment: he or she can ask you to pay only the 20% coinsurance (50% for mental health services) up front (and your Part B deductible if you have not yet reached it—$135 in 2009). Your doctor files the claims, and Medicare pays the doctor directly.

If your doctor does NOT accept assignment: your doctor may ask you to pay the full amount for services in advance and charge you up to 15% more than Medicare’s approved amount under federal law (balance billing). Some states have stricter limits on what your doctor can charge you.

Medicare will reimburse you directly for its part of the bill (80% of Medicare's approved amount for most medical services; 50% for mental health services).  - Marci

Dear Marci,
The hospital my father is staying in wants to discharge him. He feels that he is not ready to leave and that they want him to leave too soon. Is there anything we can do?  --Natalia

Dear Natalia, 
If your father feels he is being asked to leave the hospital before he is well enough to go, he can ask for an immediate (expedited) independent review of his case.

It is a good idea to ask a doctor (treating physician would be best) for support.

Before being discharged, your father should receive a notice called an “Important Message from Medicare” that describes his rights as a patient as well as how to request an immediate review. (If he was in the hospital for more than a couple of days, he should have received this same document within two days of being admitted to the hospital.)

If your father makes his formal request within the proper timeframe—by midnight on the day he is supposed to be discharged—the hospital cannot force him to leave before a decision has been reached. He should be able to stay in the hospital for a few extra days at no charge while his case is being reviewed.

Even if it is decided that your father does not need to stay in the hospital, he cannot be charged for any care he receives until noon of the next calendar day after he receives the review decision.  --Marci

May 2009

Dear Marci,
Does Medicare cover screenings for heart disease? - Luther

Dear Luther,
Yes. Medicare covers blood tests every five years to screen for cholesterol, for lipid and triglyceride levels, and for other signs of cardiovascular disease (or indications that you are at high risk for it).

Medicare will pay 100% of its approved amount for these tests, even before you have met the Part B deductible.

The American Heart Association estimates that over 80 million Americans have one or more forms of heart disease, including high blood pressure, coronary heart disease and stroke. Heart disease and stroke are the first and third leading causes of death in the US. Heart screening can save your life and improve your quality of life by treating the condition before it results in more severe health problems. - Marci

Dear Marci,
I received something
in the mail called a Medicare Summary Notice. Is this a bill? - Sam

Dear Sam,
No. The Medicare Summary Notice (MSN) is not a bill.

When Original Medicare processes a claim for health care services you received, the claim is detailed in a MSN. The MSN is a summary of claims for health care services Medicare processed for you during the previous three months. MSNs are mailed four times a year and contain information about submitted charges, the amount that Medicare paid, and the amount you are responsible for.

The most important fields on your MSN explain:

The total amount your doctor or other provider may bill you. The "You May Be Billed" field indicates the total amount that the provider is allowed to bill you (balance billing). It deducts the amount you already paid.

Non-covered charges, if any.

The "Non-Covered Charges" field shows the portion of charges for services that are denied or excluded (never covered) by Medicare. A $0.00 in this field means that there were no denied or excluded services. If you disagree with a non-covered charge you can appeal. The MSN will have instructions for how to appeal.

Try to save your MSNs for about seven years. You might need them in the future to prove that payment was made if a provider sends you a bill or that services were received if you claimed a medical deduction on your taxes.

If you have lost your MSN or you need a duplicate copy, call 800-MEDICARE.
 - Marci

Dear Marci,
I have Original Medicare. Over the last year I have been feeling more and more depressed, so I started seeing a psychiatrist a few weeks ago. I just received my Medicare Summary Notice and I'm confused.

For the first visit, Medicare paid the normal 80% of the cost, but after that, it looks like Medicare paid only 50%. Doesn’t Medicare pay 80% for all doctor visits?
 - Lindsay

Dear Lindsay,
Medicare covers outpatient mental health services differently than it covers other types of doctor services.

Medicare will pay 80% for your initial outpatient mental health visit so that your doctor can determine your diagnosis. However, Medicare will pay only 50% of its approved amount for future visits.

The same payment rate applies to other mental health providers that you see as an outpatient, such as psychologists and social workers.

There are a few other outpatient mental health services that are covered at 80% by Medicare. These include brief office visits used to monitor or change your prescription and psychological testing to establish a diagnosis.
 - Marci

April 2009

Dear Marci,
Does Medicare cover the cost of screenings for cancer? - Lance

Dear Lance,
Yes. Medicare covers screenings for several types of cancer—breast, cervical, vaginal, colorectal and prostate.

Talk to your doctor about which screenings you should get. Early detection of cancer can increase the chances that treatment will be successful, and in some cases, can identify precancerous conditions that can be treated and cured before cancer develops.

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 1-800-ACS-2345 (1-800-227-2345). To learn how Medicare covers cancer screenings and other preventive care services, click here. - Marci

Dear Marci,
I am retired and about to turn 65. Should I keep my retiree coverage once I have Medicare? - Sheryl

Dear Sheryl,
It depends. Retiree coverage can be very expensive but, if you can afford it, it may still be worth the price. It acts as supplemental insurance, and may fill many of the gaps in Original Medicare's coverage, such as deductibles and coinsurance. It may also pay for some health care Medicare does not cover.

If your retiree plan gives you good vision and dental coverage and fills many of the gaps in your Medicare coverage, you should think hard before dropping it. You should also find out whether the drug coverage through your retiree insurance is considered as good or better than Medicare's ("creditable coverage"). If it is, you can join a Medicare private drug plan later without penalty if you need it.

To find out exactly what your retiree insurance covers and whether its drug coverage is considered "creditable," contact the Human Resources Department of the company through which you have retiree coverage.

Some employers sponsor Medicare private health plans (Medicare Advantage), such as Medicare HMOs and PFFS plans, for retirees who are eligible for Medicare. If you worked for one of these employers, you can get both your Medicare benefits and your retiree health benefits from a Medicare private health plan that has a contract with your former employer.

Some employers require that you join a Medicare private health plan to continue getting retiree health benefits. You can always choose not to take your employer's coverage. However, keep in mind that you may not be able to get that retiree coverage back if you want it at a later date. - Marci

Dear Marci,
I just heard that some states have programs to help people with drug costs. How do these work? - Keith

Dear Keith,
Many states offer state pharmaceutical assistance programs (SPAP) to help their residents pay for prescription drugs. Each program works differently.

Many states coordinate their SPAPs with Medicare’s drug benefit (Part D). If you do not have Part D but qualify for your state’s SPAP, you will have the chance to sign up for Part D, and may be required to enroll in a Part D plan.

If a drug is covered by both your SPAP and your Part D plan, both what you pay for your prescriptions plus what the SPAP pays will count toward the out-of-pocket maximum you have to reach before your Medicare drug costs go down significantly.

Your SPAP may also help pay for your Part D plan’s premium, deductible, copayments, and/or coverage gap. (Many SPAPs give you coverage during your part D plan’s “coverage gap” or “doughnut hole.”)

Be aware that only official SPAPs can provide assistance that counts toward your Part D plan’s out-of-pocket maximum. Some states sponsor other programs that are not official SPAPs.

To find out if your state has an official SPAP, whether you are eligible and how the SPAP works with Part D, click here. - Marci

March 2009

Dear Marci,
I recently had a kidney transplant. My doctor said I will need diet counseling so that I can learn to eat the right foods. Does Medicare cover this counseling? - Tonya

Dear Tonya,
Medical nutritional therapy, which may include diet counseling, is designed to help you learn to eat right so you can better manage your illness. With a doctor’s referral, Medicare will cover 80 percent of the cost of medical nutritional therapy for people with diabetes, chronic renal disease, or who are post-kidney transplant patients, after they have met their annual Part B deductible.

Medicare will generally cover three hours of medical nutritional therapy for the first year and two hours every year thereafter, although it will cover more hours if your doctor says you need them. In order to have Medicare cover these therapy sessions, you must get these services from a registered dietitian or other qualified nutrition professional. Talk to your doctor if you think you qualify for this benefit.

--Marci

Dear Marci,
Can I have both Medicare and VA (Veterans Affairs) benefits? - John

Dear John,
Yes, you can have both, but Medicare and VA benefits do not work together. To receive VA benefits, you must get care at a VA facility. Medicare does not pay for any care provided at a VA facility.

Many veterans use their VA health benefits to get coverage for services not covered by Medicare. For example, some veterans use VA services to obtain prescription drugs that are excluded from Medicare drug coverage (benzodiazepines and barbiturates, for example), but rely on Medicare for their other prescriptions and medical care.

 -- Marci

Dear Marci,
I have health insurance coverage through my spouse’s current job. Which is my primary insurer: Medicare or the employer insurance? - Mary Beth

Dear Mary Beth,
If you are 65 or older and you have health insurance coverage through your or your spouse's current job with an employer that has 20 or more employees, your employer coverage is primary.

If you are under 65 and have a disability or are diagnosed with ALS (Lou Gehrig’s disease) and you have health insurance coverage through your or your family member's current job with an employer that has 100 or more employees, your employer coverage is primary.

--Marci

October 2008

Dear Marci,
I am unhappy with my current Medicare private health plan because it does not cover my medicines. When I tried to change plans, I was told that I could not change until November 15th. Why is this? -- Idina

Dear Idina,
You are generally limited in when you can change your Medicare health and drug coverage during the year (this is known as lock-in).

All people with Medicare can make any change to their health or drug coverage from November 15 through December 31 (a period known as the Annual Coordinated Election Period). During this time you can change to another Medicare private health plan or to Original Medicare, and add, drop or change Medicare drug coverage (Part D). Your new coverage starts January 1.

From January 1 to March 31 (the “Open Enrollment Period”), you can change your choice of Medicare health coverage, but not add or drop Medicare drug coverage. During that period you could potentially change your choice of drug coverage through a health plan switch.

(In some circumstances, for example, if you were to move out of your plan’s coverage area, you would get a Special Enrollment to enroll in a new health or drug plan outside of annual enrollment periods.)

To switch plans, you should enroll in your new plan without disenrolling from your old plan. Enroll early during an enrollment period to make sure that your new coverage starts when it should. It is best to enroll in your new plan by calling 800-MEDICARE, rather than through the plan itself. You will be automatically disenrolled from your old plan when your new coverage starts. If you are considering changing your health coverage as well as your drug coverage, review full benefits packages carefully to make sure you choose a plan that addresses your prescription and general health needs. -- Marci

Dear Marci,
My father is very ill, and his doctor says he is eligible for Medicare-covered hospice care because he has less than six months to live. How long will Medicare cover this service? -- Natalie

Dear Natalie,
Your father can get hospice care for as long as his doctor and the medical director or physician employed by a Medicare-certified hospice agency certify that he is terminally ill (has fewer than six months to live). Even if he lives past the six months, he can continue to get hospice care as long as his doctor and the hospice's medical director or physician recertify that he is terminally ill. -- Marci

Dear Marci,
I have been trying for years to quit smoking, but I have not been successful. A friend told me that he quit by attending hypnosis sessions. Will Medicare pay for these sessions? -- Shaun

Dear Shaun,
Medicare will not pay for hypnosis sessions to help you quit smoking. Medicare will, however, pay for one initial evaluation and up to eight counseling sessions in a 12-month period to help you quit smoking if you receive services from a qualified Medicare-certified provider and (1) you are taking a prescription drug that interacts with tobacco; or (2) you have a disease or condition that is caused by smoking (such as cancer, cardiovascular disease or pneumonia). -- Marci

September 2008

Dear Marci,

I have had diabetes for many years and will be eligible for Medicare in September. Does Medicare pay for my monitoring supplies?

--Ed

Dear Ed,

Yes, Medicare will cover certain diabetic supplies, such as glucose monitors and control solutions, lancets, and test strips. You can get these benefits even if you don’t use insulin.

If you use an insulin pump, the insulin and the pump may be covered as durable medical equipment under Medicare Part B. Contact your Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for more information.

To find the number of your local DME MAC, call 1-800-MEDICARE. If you inject your insulin with a needle (syringe), the Medicare drug benefit (Part D) covers the cost of insulin and the supplies necessary to inject the insulin, including syringes, needles, alcohol swabs and gauze.

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. (If you are in a Medicare private health plan-HMO or PPO-you may have a copay for these services. Call your plan to find out what you will have to pay.) --Marci

Dear Marci,

I have had Pap smears every year, but last month when I went for my exam, I was told that Medicare won’t pay for my exam this year. Why might this be? --Helen

Dear Helen,

Original Medicare covers 100 percent of the cost of one Pap smear every two years for all women with Medicare (if you are in a Medicare private health plan you may pay a copay).

If you are in your second year with Original Medicare, and had a Pap smear last year, and you are generally healthy, you will not have another one covered until next year.

However, if you are considered at high risk for cervical or vaginal cancer (e.g. have had a sexually transmitted disease or your mother was given the drug diethylstilbestrol (DES) during pregnancy), or are of child-bearing age and have had an abnormal Pap smear in the past 36 months, Medicare covers the cost of one Pap smear a year (every 12 months).

Medicare will cover the full cost of your Pap lab test, 80 percent of the cost of the Pap test collection, a pelvic exam (used to help find fibroids or ovarian cancers) and a clinical breast exam. Medicare will cover all of these services with no Part B deductible required. --Marci

Dear Marci,

I applied for Extra Help paying for Medicare drug coverage (Part D) and was denied. Is there anything I can do? --Vincent

Dear Vincent,

If it is before you receive the final decision—you get a notice from the Social Security Administration (SSA) saying you may be denied because your application is incomplete—you can correct your application.

If you received a “Notice of Denial” from SSA saying that you do not qualify for Extra Help, and if you disagree with that  decision, you can appeal. It is best not to reapply for Extra Help and appeal instead, because if you win, your Extra Help will be effective from the first day of the month that you originally submitted your application.

To appeal you should request a review of your case (a hearing) within 60 days of receiving SSA’s decision. If you do not want a hearing, you can just ask for a “case review,” where an SSA agent will review your application and any additional information you send in. --Marci

August 2008

Dear Marci,

I heard that Medicare covers the cost of a routine physical just once. What exactly is included in this physical? --Doris

Dear Doris,

Yes, Medicare covers 80 percent of the Medicare-approved amount (after meeting the Part B deductible) of a one-time routine physical examination during the first six months after you enroll in Medicare Part B regardless of your age.

The exam includes measurement of height, weight and blood pressure, an electrocardiogram (EKG), ultrasound screening for abdominal aortic aneurysms (AAA) if you are at risk, as well as education, counseling and referral related to other preventive services covered by Medicare.

Payment for clinical laboratory tests, however, are not included in this physical exam benefit. Some Medicare private health plans (such as HMOs or PPOs) may cover routine physicals. --Marci

Dear Marci,

I am going to have cataract surgery next month, but my friend just told me that Medicare does not cover eye care. Is this true? --Paulo

Dear Paulo,

Medicare will not generally pay for routine eye care, but it will cover surgery to remove the cataract and replace your eye’s lens with a man-made intraocular lens. Medicare will also cover the dark glasses you must wear immediately after surgery to protect your eyes, and a standard pair of untinted prescription eyeglasses or contacts if you need them after surgery. If it is medically necessary, Medicare may pay for customized eyeglasses or contact lenses. --Marci

Dear Marci,

I applied for a Medicare Savings Program a few months ago, and was told that I did not qualify because I had too much in my savings account. My sister applied for one recently, and was told she qualified. But she has a little more savings than I do. Was I given wrong information? --Beatrice

Dear Beatrice,

Does your sister live in a different state? Eligibility for Medicare Savings Programs (MSPs)—programs that help pay for the out-of-pocket costs of Medicare—is based on your income and assets. However, income and asset limits can vary by state.

Most states deny MSP coverage to individuals with incomes above $1,190 per month ($1,595 for a couple) in 2008. But in some states, there is no asset limit eligibility requirement for some or all MSPs. 

For programs that have no asset test, savings will not be counted. Call your local Medicaid office or SHIP (State Health Insurance Assistance Program) for more information about eligibility requirements. --Marci

January 2008

Dear Marci,
I don’t have Part D and didn’t sign up for a Medicare private drug plan during this year’s November-December enrollment period, because I was afraid I couldn’t afford one. But now I wonder if I should. Is it too late? - Joe

Dear Joe,
Most people who didn’t sign up for a Medicare private drug plan (Part D) by December 31 will find that it’s too late now, but there are exceptions. If you are approved for Extra Help, a federal program for people with low incomes and few assets, you can enroll in a Medicare private drug plan and coverage will begin the month you became eligible.

Extra Help helps pay for some or most of the costs of Medicare drug coverage. You can apply for Extra Help through the Social Security Administration, using either the agency’s print or online application (available at www.ssa.gov). 

Even if you are enrolling in Part D after you were first eligible for the benefit, if you get Extra Help, you will not have to pay a late-enrollment penalty, as long as you enroll in a Medicare private drug plan in 2008. - Marci

Dear Marci,
Does Medicare cover glaucoma screenings? - Linda

Dear Linda,
Medicare generally does not pay for routine eye care, but will cover 80 percent of the cost of an eye exam by a state-licensed eye doctor if you are at high risk for glaucoma. You must first meet your annual Part B deductible.

You are considered to be at high risk if you have diabetes or high blood pressure, have a family history of glaucoma; are African American and age 50 or older; or are Hispanic American and age 65 or older. Medicare will pay for the eye exam for people at high-risk once every 12 months. - Marci

Dear Marci,
I didn’t enroll in Medicare Part B when I first became eligible, because I didn’t want to pay the monthly premium. Now I realize that I need it. Can I still enroll? - Gail

Dear Gail,
You can, but if you have not had health coverage from your or your spouse’s current employer, you will most likely have to pay a Part B premium penalty: 10 percent of the premium for each 12-month period that you delayed signing up. You will have to pay this penalty for as long as you have Medicare. You can apply for Part B from January 1 to March 31, and your coverage will start July 1

Medicare Part B generally covers outpatient care like doctors’ and laboratory services. To enroll in Part B go to your local Social Security office or send a signed and dated letter to Social Security that includes your name and Social Security number.

Call the National Social Security hotline at 800-772-1213 for the office nearest you. You may not have to pay the penalty if you have low income and are accepted into a Medicare Savings Program (MSP) that helps pay for Medicare’s out-of-pocket costs. Call your local Medicaid office to find out how to apply for an MSP in your state. - Marci

October 2007

Dear Marci,
I like Original Medicare because it allows me to see nearly every doctor in the country. Since I don’t have retiree coverage, how can I supplement Medicare? - Anne

Dear Anne,
You can buy a Medigap plan. Unlike private health plans, that may offer additional services but require that you follow the plan’s rules, Medigap plans simply supplement Original Medicare.

There are 12 Medigap plans (A-L) that each cover health costs that Medicare does not cover, like the hospital inpatient deductible, coinsurance for doctors’ visits and coinsurance for a Medicare-certified skilled nursing facility. Insurance companies can charge different premiums for the same Medigap plans, so shop around to find the least expensive plan. You can call 800-MEDICARE to learn more about Medigap plans. - Marci

Dear Marci,
My Mom has pancreatic cancer and her doctor said she will not live much longer. Can Medicare help? - Eren

Dear Eren,
Your mother may qualify for hospice, or “end-of-life,” care. The hospice benefit covers services to help people live as comfortably as possible (palliative care), but does not cover treatment. These benefits range from home health care and skilled nursing care, to pain medications and counseling for your mother and family. To qualify for hospice care, your mother must have Medicare Part A, her doctor must certify that she will live less than six months, and she must agree that she wants Medicare to pay for palliative care rather than treatments to try to cure her illness (she can receive treatment for other conditions). Medicare will only cover care that a Medicare-certified hospice agency provides. To learn more about hospice care, call 800-MEDICARE or the Eldercare Locator at 800-677-1116. - Marci

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 15th? - Jeff

Dear Jeff,
Yes. Most people with Medicare can only sign up for or change Medicare private drug plans (Part D) between November 15th and December 31st 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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Dear Marci’s Medicare Answers is a service of the Medicare Rights Center, the nation’s largest independent source of information and assistance for people with Medicare. To subscribe to “Dear Marci,” MRC’s free educational e-newsletter, simply click below:

Dear Marci

 

Dear Marci’s Medicare Answers is a service of the Medicare Rights Center, the nation’s largest independent source of information and assistance for people with Medicare. To subscribe to “Dear Marci,” MRC’s free educational e-newsletter, simply click below:

Dear Marci

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