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Marci's Medicare Answers
Dear Marci is a service of the Medicare Rights Center (MRC) (www.medicarerights.org), the largest independent source of Medicare information and assistance in the United States. Founded in 1989, MRC helps older adults and people with disabilities get good, affordable health care.
Dear Marci,
My husband was just diagnosed as diabetic, and his doctor prescribed medical nutrition therapy. Does Medicare cover this?
--Polly
Dear Polly,
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 after they pay 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. Medicare will only cover these services if you receive them from a registered dietitian or other qualified nutrition professional.
--Marci
Dear Marci,
I fell and broke my arm two months ago, and my son says I should install safety rails in my bathroom. Will Medicare pay for it?
--Otto
Dear Otto,
No, Medicare will never cover home modifications (such as the installation of grab bars near the toilet or tub) or assistive devices (such as large-button telephones or flashing doorbell signals for the hard-of-hearing). Medicare will, however, cover durable medical equipment (DME)—equipment that is medically necessary, able to withstand repeated use, and is generally not useful to someone in the absence of illness or injury. DME includes items like wheelchairs, walkers, scooters and hospitals beds.
--Marci
Dear Marci,
I’m on Medicaid and am about to turn 65 in a few months. Will my drugs be covered by Medicaid or Medicare?
--Meredith
Dear Meredith,
Once you have both Medicaid and Medicare, you must get your drugs covered by the Medicare prescription drug benefit (Part D). You will be automatically enrolled in a Medicare private drug plan if you do not choose one yourself. You will also automatically get “Extra Help,” federal assistance that pays for most of the costs of Medicare drug coverage. You do not need to apply for this assistance.
When you get the letter from Medicare telling you what plan you have been enrolled in, you should call 800-MEDICARE or visit www.medicare.gov to make sure your assigned plan covers the drugs you need and that the pharmacies you use regularly are part of that plan's network. If not, ask the counselor to help you enroll in a different plan that meets your needs. People who have Medicaid are allowed to change Medicare private drug plans once a month.
--Marci
Dear Marci,
I have been more forgetful than usual these past few months, and would like to go see my doctor. Does Medicare cover screenings for dementia or Alzheimer’s disease?
--Eliot
Dear Eliot,
Yes, Medicare will cover medically necessary visits to the doctor and laboratory tests needed to diagnose any suspected disease or condition, including dementia or Alzheimer’s disease. Methods to diagnose these conditions include a consultation with a primary care physician and/or with a neurologist or other specialist, a mental status evaluation, a physical examination, a brain scan and a psychiatric evaluation. Medicare will cover 80 percent for your initial mental health visit, 80 percent for medication management and 50 percent for ongoing mental health treatment like psychotherapy. If a full diagnostic evaluation fails to clearly show whether your symptoms are the result of Alzheimer’s disease or frontal-temporal lobe dementia, Medicare will pay for a PET scan to clarify the diagnosis.
--Marci
Dear Marci,
My family has a history of osteoporosis, and I had a bone density test last year. My doctor says I need to have another bone density test soon. Will Medicare pay for it?
--Yvonne
Dear Yvonne,
If your doctor believes you are at risk for osteoporosis and orders the test, Medicare will cover 80 percent of the cost of one bone density test (also known as bone mass measurement) every two years (24 months), after you pay your annual Part B deductible. Medicare will also cover follow-up measurements or more frequent screenings if your doctor prescribes them. Those at high risk for osteoporosis include people who have a family history of the disease, spinal abnormalities, particular conditions (such as thyroid disorders) or have taken certain medications for a prolonged period of time (such as a steroidal anti-inflammatory drugs).
--Marci
Dear Marci,
I just heard that some states have programs to help people with drug costs. How do these work?
--Tim
Dear Tim,
Most states offer a state pharmaceutical assistance program (SPAP) for their residents. Each state can design their program differently, but many states coordinate their drug assistance programs with Medicare’s drug benefit (Part D) and require members to join a Medicare private drug plan. Call your State Health Insurance Assistance Program (SHIP) office to find out if your state has an SPAP and how it works with the Medicare drug benefit. You can get the number for your SHIP by calling 800-MEDICARE.
If your state’s SPAP works with Part D, it may help pay for a drug plan in a number of ways. You may get assistance paying for your monthly premium and copays. You may get help paying for your deductible (the amount you pay out of pocket before your drug coverage begins). In most cases, what the SPAP helps pay for your prescriptions will count toward reaching your “catastrophic coverage limit”, the amount you must pay out of pocket in your plan before your costs go down substantially. The out-of-pocket limit in all Part D plans in 2008 is $4,050. You should always check with the SPAP directly to see if and how it will work with Part D.
--Marci
Dear Marci,
Does Medicare cover the cost of screenings for cancer?
--Carol
Dear Carol,
Yes. Medicare covers screenings for several types of cancer—breast, cervical, vaginal, colon 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.
--Marci
Dear Marci,
Are there any hospitals or health care facilities that will treat patients at a reduced cost?
--Klaus
Dear Klaus,
People with Medicare can receive services from Federally Qualified Health Centers (FQHC), which are also known as Primary Health Care Service Delivery Sites. FQHCs are health care facilities located in what is defined as “medically underserved areas” and provide Medicare-covered medical services as well as some preventive services that are not covered by Medicare. FQHCs waive the Medicare Part B annual deductible, and clinics may waive the 20 percent coinsurance for Medicare-covered benefits for people with an annual income at or below the federal poverty level ($10,400 a year for individuals and $14,000 a year for couples). To find the FQHC nearest you, call 888-ASK-HRSA or go to http://ask.hrsa.gov/pc/.
--Marci
Dear Marci,
After I retired last year, my income decreased significantly, and I’m now having trouble paying for my Part D drug plan—both the copays and the premium. I heard there are programs that might help me, but could I be ineligible because I own a home?
--Sarah
Dear Sarah,
No. If your monthly income is below $1,301 for singles ($1,751 for couples) and your assets are below $11,990 ($23,970 for couples), you may be eligible for Extra Help, a federal program that helps you pay for some or most of the costs of Medicare prescription drug coverage (Part D). You may still qualify even if your income or assets are above the limit, because certain types of income and assets may not be counted. For example, you do not need to state the value of your home or your car when you apply.
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). If you are enrolled in Medicaid, Supplemental Security Income (SSI) or a Medicare Savings Program (MSP), you automatically qualify for Extra Help, so you do not have to apply for it.
You may also be able to get some help from a State Pharmaceutical Assistance Program if one is available in your state. Call your State Health Insurance Assistance Program to find out. You can get the number by calling 800-MEDICARE.
--Marci
Marci,
I just got a bill from my physical therapist that is much higher than usual. What’s going on?
--Bernard
Dear Bernard,
If you receive your physical therapy as an outpatient, you may have reached Medicare’s limit on outpatient therapy. In 2008, Medicare will cover up to $1,810 worth of outpatient physical and speech therapy combined, and another $1,810 for occupational therapy. The therapy limits only apply in certain outpatient facilities, such as therapists’ or physicians’ offices or at home (if you are not receiving them as part of Medicare’s home health benefit). They do not apply if you are receiving outpatient therapy at a hospital’s outpatient department. If you need more therapy, ask your provider. If she agrees, she should provide the service and bill Medicare, using a special code.
--Marci
Dear Marci,
My doctor says I need a colonoscopy to screen for colon cancer. Will Medicare cover the cost?
--Janice
Dear Janice,
If you are not at high risk for colorectal cancer, Medicare will cover 80% of the colonoscopy cost every 10 years. If you are at high risk (have had colorectal cancer or have a family history of it, or have had colorectal polyps or inflammatory bowel disease), Medicare will cover 80% of the cost every two years. If the procedure is done in an ambulatory surgical center or hospital outpatient department, Medicare will cover 75% of the cost. You do not have to meet the Part B deductible before Medicare will cover this service. There is no minimum age requirement for a Medicare-covered colonoscopy unlike other colon cancer screenings,
--Marci
Dear Marci,
I am having trouble paying for my Medicare out-of-pocket costs. Are there any programs that can help?
--Hugh
Dear Hugh,
If your monthly income is below $1,190 and your assets are below $4,000 (below $1,560 income/ $6,000 assets for a couple), then you qualify for a Medicare Savings Program (MSP), a government program that will help you pay your Medicare premiums, deductibles and copays. In some states you can qualify for an MSP no matter how high your assets, and some states allow you a higher income. There are several kinds of MSPs, and each has different income eligibility limits and provides different levels of assistance. If you enroll in an MSP you will also automatically get Extra Help, a federal program that helps pay most of your Medicare prescription drug costs. If you think you might be eligible, go to your local Department of Social Services to apply.
--Marci
Dear Marci,
They want to discharge my mother from the hospital, but she says she’s not ready to go home. Is there anything she can do?
--Amy
Dear Amy,
If your mother feels she is being asked to leave the hospital before she is well enough to go, she can ask for an immediate (expedited) independent review of her case. It is a good idea to ask a doctor (treating physician would be best) for support. Before being discharged, your mother should receive a notice called an “Important Message from Medicare” that describes her rights as a patient as well as how to request an immediate review. (If she was in the hospital for more than a couple of days, she should have received this same document within two days of being admitted to the hospital.) If your mother makes her formal request within the proper timeframe—by midnight on the day she is supposed to be discharged—the hospital cannot force her to leave before a decision has been reached. She should be able to stay in the hospital for a few extra days at no charge while her case is being reviewed. Even if it is decided that your mother does not need to stay in the hospital, she cannot be charged for any care she receives until noon of the next calendar day after she receives the review decision.
--Marci
Dear Marci,
My family has a history of heart disease. Will Medicare cover the costs of screening tests?
--Howard
Dear Howard,
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.
--Marci
Dear Marci,
It’s getting very hard for me to afford the monthly Medicare Part B premium. Is there a program that can help me?
Laura
Dear Laura,
Yes, you may be eligible for a Medicare Savings Program if your 2007 income was less than $1,169 a month ($1,560 for a couple) and your assets are $4,000 or less ($6,000 or less for a couple). These are government programs that help pay your Medicare costs. If your income is above the limit, you may still qualify for these programs because of certain allowed income deductions, such as the amount you pay for private health insurance, such as a Medigap. Also, be aware that the income limits will go up in February or March (they are based on the Federal Poverty Level, which changes at that time). To find out how to apply for Medicare Savings Programs in your area, call your local Medicaid office.
--Marci
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
Dear Marci,
I have a Medicare drug plan, and it worked very well for me this year. Can I just keep it next year?
--Frances
Dear Frances,
Most Medicare private drug plans (“Part D”) change their costs and benefits every year, so don’t assume that your plan will work the same way in 2008. It’s important to review your drug plan options now, because after January 1, most people will be locked into the plan they chose until 2009. Before deciding on a drug plan, review all of your options for 2008 by visiting Medicare’s “Prescription Drug Plan Finder” at www.medicare.gov or by calling 800-MEDICARE. It’s also important to call the plan and confirm all details. People with low incomes and few assets may be eligible for Extra Help, a federal program that helps pay for some or most of the costs of Medicare prescription 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).
--Marci
Dear Marci,
I recently went to see a psychiatrist to be treated for depression. Medicare covered the usual 80 percent of the cost of my first visit, but after that, they covered only 50 percent. Why?
--Albert
Dear Albert,
Original Medicare covers mental health services differently than other types of doctor services. Medicare will pay 80 percent for your initial mental health visit so that your doctor can determine your diagnosis. However, Medicare will pay only 50 percent of its approved amount for future visits. The same payment rate applies to other mental health providers, such as psychologists and social workers. If you have supplemental insurance, such as a Medigap plan, it will cover your coinsurance as it does with your other medical services. People who get their health care coverage through a Medicare private health plan, such as an HMO or PPO, should check the coverage rules and costs of their plan.
--Marci
Dear Marci,
I will be eligible for Medicare soon, and was thinking of trying a Medicare HMO. A friend told me that some plans have expensive copays for inpatient hospital care. Is that true?
--Paula
Dear Paula,
Medicare HMOs are run by private insurance companies, and vary widely in their costs and benefits. But your friend is right to warn you that some private health plans charge high copays for inpatient hospital care. The best place to get up-to-date information on Medicare private health plans is from the plans themselves. Confirm the details before signing up, because you will have limited opportunities to switch plans. Also, keep in mind that you could get your benefits from Original Medicare—the traditional fee-for-service program run by the federal government. Original Medicare will often cover a shorter hospital stay—or the first part of a long hospital stay—for free after you’ve met your deductible. If you have Original Medicare you may want to get a supplemental insurance plan (Medigap) to help with your out-of-pocket costs.
--Marci
Dear Marci,
I’m interested in getting a Medicare drug plan, but don’t think I can afford it. What can I do?
--Bruce
Dear Bruce,
If you are single and your monthly income is below $1,276 ($1,711 for couples) and your assets are below $11,710 ($23,410 for couples), you may be eligible for Extra Help, a federal program that helps you pay for some or most of the costs of your Medicare prescription drug coverage. Even if your income or assets are above the limit you may still qualify, because certain types of income and assets may not be counted.
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). You can also apply at your local Medicaid Office. If you are enrolled in Medicaid, Supplemental Security Income (SSI) or a Medicare Savings Program (MSP), you automatically qualify for Extra Help, so you do not have to apply for it.
--Marci
Dear Marci,
My doctor says I should get a flu shot this winter. Does Medicare cover flu shots?
--Cynthia
Dear Cynthia,
Yes, Medicare covers 100 percent of the cost of a flu shot once every flu season, which is usually from November through April, with no Part B deductible required. Medicare will pay for the shot no matter where you get it, as long as the health care provider “takes assignment” (agrees to accept the Medicare-approved amount as payment in full). If you are in a Medicare private health plan, like an HMO or PPO, you may be required to go to a provider in their network and pay a copay for this service, so call your plan and ask. If you pay for the shot yourself, get a receipt and Medicare will pay you back for some of the cost (which could be less than what the provider charges you). Call 800-MEDICARE (800-633-4227) to find out where to send your receipt.
--Marci
Dear Marci,
I signed up for a Medicare HMO this year. Do I need to review my choices for next year (2008)?
--Agnes
Dear Agnes,
Yes, it is very important that you review your health plan options, because most Medicare private health plans change their costs and benefits from year to year. A plan that works well for you now may not do so next year. Everyone who has Original Medicare, a Medicare private health plan such as an HMO, or a Medicare private drug plan can choose a new plan between November 15 and December 31. Your plan should have sent you a letter by the end of October to explain how its costs and coverage are changing for 2008. Before you make any decision, call the plan and make sure that it is affordable and your doctors are still in the plan’s network. If your plan includes drug coverage, find out if it will continue to cover your prescriptions and at what cost. You should always call the plan to verify the information you have before you sign up. The new plan’s coverage will begin January 1.
--Marc
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.
-Marc
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
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
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
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
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 at 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
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?
—WalterDear 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.
—MarciDear Marci,
Is it true that Medicare now covers the new shingles vaccine?
—PegDear 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).
—MarciDear 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?
—WendyDear 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
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?
—PaulDear 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.
—MarciDear 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?
—MaryDear 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.
—MarciDear 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?
—EddyDear 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
Dear Marci,
Every year my Medicare Part B premium is higher. What will it be this year?
—ScottDear 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.
—MarciDear Marci,
I plan to spend the winter in Florida. Will Medicare cover my health care there?
—MaryDear 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).
—MarciDear 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.
—EddyDear 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.
—MarciDear Marci,
I want to sign up for a Medicare prescription drug plan, but am afraid that my drug costs will still be too high. Is there anything that can help me?
—CathyDear Cathy,
If you have Medicare, and meet certain income and asset limits, you might qualify for a federal assistance program called "Extra Help" which will lower the costs of the Medicare prescription drug benefit (Part D). If your monthly income is below $1,226 and your assets below $11,500 ($1,651/income and $23,000/assets for a couple), Extra Help will reduce your premiums, deductible, and copays. To get an application from the Social Security Administration, call 800-772-1213 or apply online at www.ssa.gov.
—MarciDear Marci,
I don't want to get sick with the flu this winter. Does Medicare cover flu shots?
—RyanDear Ryan,
Yes, Medicare will pay 100 percent for one flu shot every flu season, which is usually from November through April, as long as you go to a doctor or healthcare provider who accepts Medicare assignment (this means that your doctor or healthcare provider agrees not to charge more than Medicare will pay). You don't even have to meet your Part B deductible before Medicare will pay for your flu shot. If you are in a Medicare private health plan, like an HMO or PPO, they might charge a copay for this service, so call your plan and ask.
—MarciDear Marci,
My doctor just prescribed a medicine that is not covered by my Medicare drug plan. What should I do?
—DeniseDear Denise,
You can have your doctor ask for an "exception" to cover the medication you need if it is not on your plan's list of covered drugs (formulary) or if your plan places restrictions, like quantity limits, on a medicine that your doctor prescribes. To ask for an exception, your doctor must write a letter to your Medicare drug plan which states that this medicine is medically necessary for you to take and explains why. The letter should include as many details as possible to increase the chance that your plan will cover the prescription. If your Medicare drug plan still refuses the exception request, you can appeal the decision at different levels. For more information about drug plan appeals or to get help appealing, call the Medicare Rights Center's Drug Plan Appeals Hotline at 888-466-9050. This free service will put you in touch with counselors and attorneys who can help you through the appeals process.
—Marci
Dear Marci,
My father has cancer and his doctor said he will not live much longer. Can Medicare help?
—MariaDear Maria,
Your father may qualify for hospice or "end- of-life" care, which helps to relieve the symptoms and pain related to a terminal illness but not to cure it. To qualify your father must have Medicare Part A and a terminal illness, and his doctor must certify that he will live less than six months. Your father must also agree in writing that he does not want treatment to cure his terminal illness, though he can receive treatment to cure any other conditions. If he qualifies, Medicare will cover hospice care that is provided through a Medicare-certified hospice agency as long as the agency's director or physician agrees that your father will live less than six months. The hospice benefit includes a range of services such as skilled nursing, skilled therapy, and durable medical equipment. If your father lives longer than six months, and still meets the requirements for hospice care, he can continue to receive hospice benefits. Call 800-MEDICARE to find Medicare-certified hospice agencies in your area, what services are covered and how much you have to pay for them.
—MarciDear Marci,
I was just diagnosed with diabetes and prescribed insulin that I inject with a needle. My Medicare drug plan covers insulin, but how do I get the needle?
—MollyDear Molly,
In addition to insulin, your Medicare drug plan must cover the supplies you need to inject it yourself. These include needles, syringes, alcohol swabs and gauze. Some plans may also cover other diabetes medications that are used at home. Always check with your plan to make sure it covers the medications you need.
—MarciDear Marci,
I did not sign up for a Medicare private drug plan (Part D) last year because I like the drug coverage that I already have. Is there any reason for me to join a Medicare drug plan for next year?
—RoyDear Roy,
You should find out from whoever provides your current drug coverage (for example, your employer) whether it is considered "creditable," or, as good as or better than the Medicare drug benefit. If it is not creditable, and you decide to sign up for a Medicare drug plan in the future, for as long as you have the Medicare drug benefit you will have to pay a premium penalty based on the amount of time you delay enrolling in a Medicare drug plan. If your current drug coverage is creditable you will not have to pay a penalty as long as you are not without "creditable" drug coverage for more than 63 days before signing up for a Medicare private drug plan. You can call the insurer you get your drug coverage through to find out whether or not it is creditable.
—Marci
Dear Marci,
I didn't sign up for a Medicare drug plan this year but am thinking about it for next year. Can I still sign up?
—ScarletDear Scarlet,
You can sign up for a Medicare drug plan between November 15th and December 31st each year. This is called the Annual Coordinated Election Period and your drug coverage begins January 1. When choosing a Medicare private drug plan, remember that different plans cover different drugs at different prices and have different monthly premiums. Make sure that the plan you sign up for will work with any other health coverage that you have, such as a Medicare Advantage plan or retiree coverage. If you want to stay in Original Medicare, you must choose a stand-alone drug plan (PDP). You may have to pay a premium penalty if you have not previously had drug coverage that is as good as the standard Medicare drug benefit ("creditable"). For more information you can call 800-MEDICARE.
—MarciDear Marci,
Last year I signed up for a Medicare drug plan and it took a lot of time to find one that covered all of my prescriptions. Can I keep my plan next year or do I have to find one all over again?
—BillyDear Billy,
As long as your plan is still in business next year you can keep it, but you should check to make sure it still covers the medications you need at a price you can afford. A plan can change its list of covered drugs ("formulary"). Your plan should send you information this fall telling you how its costs and coverage are changing. Before you decide whether to stay with your Medicare drug plan, call the plan and make sure that it is still affordable and will continue to cover your prescriptions. Everyone who has a Medicare private drug plan has the opportunity to choose a new plan for next year between November 15th and December 31st.
—MarciDear Marci,
Breast cancer runs in my family and, since this month is breast cancer awareness month, I'd like to get a mammogram. Will Medicare cover this?
—AnneDear Anne,
Getting a mammogram is a good idea since breast cancer is the most common type of cancer in American women. Medicare will pay 80 percent of the cost for one screening mammogram every year if you are 40 or older (80 percent of the cost of one baseline mammogram if you are 35 to 39 years old). Medicare will cover this screening even if you haven't yet reached your Part B deductible. A mammogram can identify breast cancer while in its early stages when the most treatment options are still available.
—Marci
Dear Marci,
My drug costs are pretty high this year. I learned that my plan's coverage is stopping until I spend more on my drugs without any help from my plan. Could that be true?
—Anne MarieDear Anne Marie,
Yes. Most Medicare drug plans have a big gap in drug coverage, called the "doughnut hole." In most plans the gap begins after you have been paying copayments for a while, when your total drug costs (what both you and your plan have paid) reach $2,250. It ends when you have spent $3,600 out of pocket, not including your drug plan's monthly premiums. You then get "catastrophic coverage" in which Medicare pays about 95 percent of your drug's costs through the end of the calendar year. While in the gap, you are responsible for 100 percent of your drug costs. You can only buy drugs on your plan's formulary and in your plan's pharmacy network, if you want the cost to count toward the $3,600 you must spend to get "catastrophic coverage." During the gap, if your plan's in-network pharmacy has a retail price lower than your plan's price, you can buy it at the lower price and it will count toward "catastrophic coverage." Some charities also offer assistance that can help towards the $3,600
—MarciDear Marci,
My mother is not able to walk because she has multiple sclerosis but is not strong enough to use a manual wheelchair. Will Medicare help her to pay for a scooter?
—JoeDear Joe,
Medicare may cover a power-operated vehicle or scooter for your mother to use in her home. She already meets one of the qualifications, which is that she cannot operate a manual wheelchair. She must be able to operate the controls of the power-operated wheelchair and safely get into it, out of it and ride in it. She also must need it to get around in her home. Medicare will not cover a power-operated wheelchair that is only needed outside of the home. To learn more call 1-800-MEDICARE.
—MarciDear Marci,
I am scheduled to have cataract surgery this month and will probably need eyeglasses afterwards. Does Medicare ever cover eyeglasses?
—KateDear Kate,
The only time that Medicare covers eyeglasses is after cataract surgery. If you have Medicare Part B, your optometrist can prescribe one pair of glasses for you. You should get the glasses through a supplier who works with Medicare so you will only have to pay a portion of the cost. If your supplier works with Medicare and accepts "assignment," Medicare's price, Medicare will pay 80 percent of the cost. You will have to meet your Part B deductible, the amount that you have to pay by yourself before Medicare Part B will begin to cover services, if you haven't this year. You can call 1-800-MEDICARE to learn how to find a supplier and more information about the eyeglasses Medicare covers.
—Marci
Dear Marci,
I just found out that my doctor left my HMO this summer. Can I go back to Original Medicare now and continue to see my doctor?
—BrieDear Brie,
No. Starting this year, you are limited in when you can change your choice of how you get your Medicare health benefits. You will have the opportunity to return to Original Medicare or choose a different Medicare private health plan (such as an HMO or PPO) from November 15 to December 31, and your new coverage will be effective January 1, 2007. You will have another chance to change health plans from January 1 to March 31, 2007 (although you cannot add or drop Medicare drug coverage during this period). There are a few exceptions including if you move out of your private health plan's service area. Call 800-MEDICARE for more information about what situations qualify you to change health plans.
—MarciDear Marci,
My mom is about to get out of the hospital and will need to go to a health care facility while she recovers. Can Medicare help?
—KarlDear Karl
Your mother may qualify for a Medicare-certified, skilled nursing facility (SNF) while she recovers. To qualify, your mother must need skilled nursing care daily or skilled therapy at least five days a week, and have been in the hospital at least three days out of the 30 before entering the SNF. You can call the Eldercare Locator at 800-677-1116 or 800-MEDICARE for more information.
—MarciDear Marci,
I just found out that my Medicare private drug plan does not cover one of the drugs that my doctor recently prescribed. What can I do?
—GabrielleDear Gabrielle,
Medicare private drug plans only cover drugs that are on their "formulary" (list of covered drugs). You can ask your doctor to switch your prescription to a covered drug. You also have the right to ask your private drug plan for an "exception" if your doctor believes that none of the drugs covered by your plan will work or that they may actually harm you. Your doctor must call or write a letter to your drug plan stating this. Your plan must either agree to cover the drug for you or reject your request. If the "exception" is denied then you can appeal this decision. For more information on drug plan "exceptions" and "appeals," call the Medicare Rights Center's Drug Plan Appeals Hotline at 888-466-9050.
—Marci
Dear Marci,
I have a Medicare private drug plan and usually just pay a copay for my prescriptions. Today when I went to the drug store I had to pay the full price. I'm still paying the plan's premiums, so why isn't the plan still covering my drugs?
—OliviaDear Olivia,
It sounds like you have hit the "doughnut hole," the gap in drug coverage that is built into most Medicare private drug plans. The coverage gap usually begins when the total cost of your drugs reaches $2,251 in a given year. During the gap you pay 100 percent of your drug costs and your drug plan's monthly premiums. When your out-of-pocket drug costs reach $3,600, you qualify for "catastrophic coverage." You will pay $2 for generics and $5 for brand name drugs, or 5 percent coinsurance, whichever is less, until the next calendar year begins.
—MarciDear Marci,
My wife and I are planning to go on a cruise through the U.S. Virgin Islands this month. Will Medicare cover us while on vacation?
—PeterDear Peter,
Medicare will pay for any medical care you receive on the cruise ship if the ship is registered to the U.S., the doctor who cares for you is registered with the Coast Guard and you get the care while the ship is in U.S. territorial waters (this means the ship is within six miles of a U.S. port). Medicare will also cover medical care received anywhere in the U.S. and its territories (which includes the U.S. Virgin Islands). If you will be outside of these areas at any point, you should consider buying supplemental insurance that will cover you while you travel. Speak with your travel agent about travel insurance or consider buying a Medigap plan that covers foreign travel.
—MarciDear Marci,
Is it true that there are new supplemental insurance options to help fill gaps in my Medicare coverage?
—Dear Jill,
Private insurance companies now sell Medigap plans K and L. These plans work with Original Medicare, pay for part of your Medicare coinsurances and provide some additional benefits. Medigap plans K and L are designed to have lower monthly premiums because they require you to pay some of the cost for most Medicare-covered services until you have spent a specified amount out of pocket. Once you reach your out-of-pocket limit, both plans will pay 100 percent of your Medicare coinsurance for covered services for the rest of the year. These plans may save you money if you currently have low medical expenses. However, you may not be able to switch to another Medigap policy if you later need more medical services. For more information, call your State Health Insurance Assistance Program or visit www.medicare.gov.
—Marci
Dear Marci,
I just found out that I was approved for "extra help," the program that helps pay for the new Medicare drug benefit. Can I still sign up for a drug plan, even though it's after the May 15th deadline? Will I have to pay a penalty?
—MeredithDear Meredith,
Being approved for Extra Help entitles you to a Special Enrollment Period (SEP). You can sign up for a Medicare private drug plan through December 31st and will not have to pay a penalty. Extra Help is available to people whose monthly income in 2006 is below $1,226 and assets below $11,500 ($1,651/income and $23,000/assets for couples). To apply for Extra Help, get an application from the Social Security Administration or apply online at www.ssa.gov. People who do not have an SEP have to wait to sign up for a plan until the Annual Coordinated Election Period, which runs from November 15th until December 31st of every year, with coverage beginning January 1 of the following year. A 7 percent penalty will be added to the monthly premium for delaying enrollment this year.
—MarciDear Marci,
I have diabetes, which I recently read might be linked to glaucoma. Does Medicare cover glaucoma screening?
—GeorgeDear George
Medicare will cover an annual glaucoma screening because you have diabetes. Other risk factors that qualify you for glaucoma screening are high blood pressure, a family history of glaucoma, and being African American age 50 and older or Hispanic American age 65 and older. Medicare will pay 80 percent of its approved amount for the screening. It is a good idea to be screened because, while there is no way to prevent glaucoma, early treatment can slow the progress of the disease and could prevent blindness.
—MarciDear Marci,
My Mother just had her knee replaced and will need a walker when she gets out of the hospital. Can she rent one through Medicare or will she have to buy one?
—MirandaDear Miranda,
A walker will be covered by Medicare as a piece of durable medical equipment. Some types of durable medical equipment can only be rented, often the more expensive items. You get durable medical equipment through a supplier who can tell you whether your item needs to be bought or can be rented. To save money, choose a supplier who accepts Medicare's reimbursement rate as full payment (this is called taking "assignment"). You can call 1-800-842-2052 to get a list of suppliers.
—Marci
Dear Marci,
My Medicare summary notice this month said I have reached the limit on outpatient physical therapy covered by Medicare, but my physical therapist says that I still need treatment. What should I do?
—SummerDear Summer,
Medicare will cover $1,740 worth of outpatient physical therapy each calendar year, after which you must get an exception to extend coverage. Certain conditions and situations qualify you to get an automatic exception (such as if you have Parkinson's disease or require treatment to retain independent status), which means that your therapist can use a special code to bill Medicare for as much therapy as you need. If you do not have one of these conditions, your therapist can ask for an exception for you. To do this you or your therapist should fax necessary forms and a letter explaining why you need additional therapy to your regional Part B carrier. For more information call 1-800-MEDICARE.
—MarciDear Marci,
I know that Medicare helps pay for medical treatment in a hospital, but what about care at a psychiatric hospital?
—RyanDear Ryan,
Medicare will cover 190 days of inpatient care at a psychiatric hospital during your life, and then might cover mental health care at a general hospital. For the psychiatric hospital you will only have to pay the deductible for each benefit period that you are there and coinsurance for each day, after the first 60.
—MarciDear Marci,
Is it true that you can get help paying for prescription drugs, even if you own your house?
—MarissaDear Marissa,
Dear Marissa, Yes, certain types of income and assets, such as your home, are not counted on the application for Extra Help, the federal program that helps pay the Medicare Part D premiums, deductible, and copays. This means you should apply even if your income is slightly above the $14,700 income and $11,500 asset limits ($19,800/income and $23,000/asset for couples). To apply, get an application from the Social Security Administration or go online to www.ssa.gov.
—Marci
Dear Marci,
I want to sign up for a prescription drug plan, but am afraid that my drug costs will still be too high. Is there anything that can help me?
—SusanDear Susan,
If you have Medicare and meet certain income and asset limits a government assistance program called "Extra Help" can lower your prescription drug costs. In 2006, if your income is below $14,700 and your assets below $11,500 ($19,800/income and $23,000/assets for a couple), Extra Help will reduce your premiums, deductible, and copays. To apply, get an application from the Social Security Administration or go online to www.ssa.gov.
—MarciDear Marci,
I recently read in an article that osteoporosis causes "brittle bones" in many older adults. Will Medicare pay for me to be tested for it?
—JeanDear Jean,
Osteoporosis affects over 9 million women in America and a bone mass measurement, or bone density test, is used to screen for it. Medicare will cover 80 percent of the cost of this test once every 24 months, after your annual Part B deductible is paid, if your doctor prescribes it. Medicare will also cover follow-up measurements and more frequent screening if your doctor orders them.
—MarciDear Marci,
My father had a stroke and is not ready to come home from the hospital. Is there a place for him to recover that Medicare will pay for?
—TomDear Tom,
Medicare may pay for some or the total cost of a Medicare-certified skilled nursing facility (SNF) where your father can receive skilled nursing care such as injections; skilled physical, speech and occupational therapy; and medical social services like counseling. Your father must be in the hospital at least three days in the 30 before entering the SNF and either need skilled nursing care seven days a week or skilled therapy at least five days a week. Your father's doctor or hospital discharge planner can help you find a SNF near you that meets your father's needs.
—Marci
Dear Marci,
I'm thinking about joining a Medicare HMO because its drug plan has no premium. Will this affect the doctors and specialists that I see?
—BrookeDear Brooke,
A Medicare HMO is a private health plan and joining one will have a great impact on how you get your health care. Generally you are only covered for care you get from doctors in your HMO's network and you need a referral from your primary doctor to see a specialist. Except in emergencies or urgent care situations, if you use other doctors and facilities you will pay the full cost of the care you receive. Keep in mind that doctors may leave the HMO at any time, but you can only change plans during specific enrollment periods.
—MarciDear Marci,
I just learned that men who are over 50 should be screened for prostate cancer. Will Medicare pay for this?
—JayDear Jay,
There are two forms of prostate cancer screening that Medicare covers for men age 50 and over. Every 12 months Medicare will pay 80 percent of the cost of a digital rectal exam. Medicare will also pay for the complete cost of a prostate specific antigen (PSA) test, even if you have not met your Part B deductible. Remember, the sooner you catch and treat a problem, the greater your chance of a complete recovery.
—MarciDear Marci,
My doctor just prescribed a drug that my private Medicare drug plan does not cover. I cannot afford to pay the full cost of the drug, but my doctor said it is the only one that will work for me. What should I do?
—LiselleDear Liselle,
You can ask your drug plan to cover a drug that is not on its list of covered drugs (formulary). Your doctor must tell the plan that no other drug on their formulary will work for you. This is called asking for an exception. Your plan must respond within 72 hours. If your life, health or ability to regain maximum function is at risk, you can ask for an expedited decision and the plan must respond within 24 hours. If your plan denies your exception request, you have the right to file an appeal.
—Marci
Dear Marci,
My Part D coverage started on January 1, but I'm having trouble affording the copays. Is there anything I can do?
—MaryDear Mary,
There is no way to completely avoid your copays, but here's a little tip to get more for your money. Many of the plans will allow you to mail order a three-month supply of each of your prescriptions, but pay the copay only once for each three-month order. Call your plan and ask about this option.
—MarciDear Marci,
Medicare's home health benefit pays for my physical therapist to treat me at home. Will the new limits on therapy coverage affect me?
—JonathanDear Jonathan,
The new limits will not affect you since you receive this therapy through the home health benefit, which covers physical, speech, and occupational therapy. As of January 1, there is a cap on these therapies if they are received through outpatient services, for example, at a physician's office or an outpatient rehabilitation facility.
—MarciDear Marci,
I signed up for Medicare's new prescription drug benefit, but now my pharmacist says my drug plan will not cover one of my prescriptions without preauthorization. What should I do?
—CatherineDear Catherine,
Preauthorization means that you will have to get permission from the plan before it will cover the drug. Usually your doctor must send the plan a letter certifying that the drug is medically necessary and cannot be substituted with another prescription. Call your plan since the specific procedures may differ. Plans must respond to your request within 72 hours. If your life, health, or ability to recover is at risk, your request can be expedited and your plan must answer within 24 hours. If your plan denies your exception request you can appeal.
—Marci
January 2006
Dear Marci,
I like the drug coverage I have through my retiree plan, but have heard a lot about the new Medicare drug benefit. Do I have to get it?
—Jane
Dear Jane,
You do not have to enroll in Medicare's new drug benefit. If you do enroll in the drug benefit, and it does not work with your retiree coverage, you actually risk being dropped by your retiree plan. You should ask your plan whether their coverage is creditable (equal to or better than Medicare's basic drug benefit). If it is creditable and you decide to enroll in Medicare's drug benefit later, you will not be penalized as long as you are not without coverage for more than 63 days.
—MarciDear Marci,
I have diabetes. Will Medicare be able to help me pay for diabetes services and supplies?
—RalphDear Ralph,
Medicare will pay 80% of the Medicare-approved amount of all covered diabetes supplies and services after you have paid the yearly Part B deductible. Medicare will also cover up to 10 hours of self-management training your first year and two hours every year after that if your doctor deems it necessary. Certain diabetic supplies such as a glucose monitor and foot care every 6 months, if you have not seen a foot-care specialist for another reason between visits and have peripheral neuropathy, are also covered. Beginning in 2006 the new Medicare drug benefit will cover the cost of insulin.
—MarciDear Marci,
My Medicare managed care plan has refused to pay for the emergency surgery I had after a car accident while out of town. What should I do?
—CeliaDear Celia,
You should tell your Medicare private health plan to send their denial to you in writing. This denial notice will include instructions on appealing and an address to which you can send the appeal. You must include the reason you needed the surgery and if possible a letter from a doctor supporting this. You must appeal within 60 days of receiving the denial.
—Marci
