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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.
>> Click
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