JustCare

Category: Medicare

  • 7 questions you should answer before you turn 65

    7 questions you should answer before you turn 65

    Everyone has lots of questions about their health and financial security as they age. Here are seven questions you should answer before you turn 65 with links to simple information to help you decide what to do:

    1.     Do you need to sign up for Medicare?  Medicare provides health insurance for people 65 and over and people with disabilities, regardless of income.  Whether to enroll in Medicare depends on whether you have employer coverage and what kind you have. (If you have employer coverage through your job or your partner’s job, click here to learn more.) If you do need Medicare:

    • Enrollment in Medicare Part A, hospital insurance, and Part B, medical insurance, is generally automatic if you have signed up for Social Security. Part A is free if you or your spouse has paid into Medicare for at least 40 quarters. You pay the Part B premium unless you qualify for Medicaid. You need Medicare Part B if your employer coverage is no longer primary once you turn 65. (To avoid penalties for mistakenly turning down Part B, check with Social Security at 800-772-1213;  you can also contact your local area agency on aging at 800-677-1116.)
    • Understand your supplemental coverage options and how to choose among them. Medicare only covers about half of your health care costs. If you enroll in traditional Medicare (see below), you will want additional coverage, supplemental coverage, to fill gaps and limit your out-of-pocket costs. For an explanation of your options, click here.  If you enroll in a Medicare Advantage plan, you cannot buy insurance to cover your deductibles and copays and other out-of-pocket costs.

    2.   Should you enroll in traditional Medicare or a Medicare Advantage plan? It depends on the kind of coverage that’s important to you and whether you want as much choice of doctors and hospitals as possible. It also depends on how much you are willing and able to pay to get the coverage you need. Most people choose traditional Medicare because of the enormous choice of doctors and hospitals it offers anywhere in the country. (Note: Some insurers are involuntarily enrolling people in their Medicare Advantage plans when they turn 65. Make sure you’re not involuntarily enrolled.)

    3.    Should you sign up for a Medicare Part D prescription drug plan? In most cases, yes, if you need drug coverage. But, you should understand the limits to that coverage and when your drugs will be covered. Here are six tips for keeping your drug costs down.

    4.     What about Medicaid? Medicaid can pick up many of your health care costs that Medicare does not cover, including your Medicare premium, if your income is low.  Whether you qualify for Medicaid might depend on where you live. You can have both Medicare and Medicaid. Here’s how they work together. And, here’s what you need to know about the ways Medicaid can help you.  Even if you don’t qualify for Medicaid, here are five programs that lower your costs if you have Medicare.

    5.     When should you sign up for Social Security benefits (if you have not already done so) and what will your  Social Security benefits be when you retire?  You should understand the benefits and risks of claiming Social Security early.

    6.     Are you prepared if you need long-term services and supports? Today, two in five people with Medicare needing these services do not receive them.

    7.     Do you have a living will and medical power of attorney, Advance Directives? You should. Get help from Caring Connections.

  • How safe are outpatient surgery centers?

    How safe are outpatient surgery centers?

    Medicare now covers surgeries in some 5,500 outpatient surgical centers. Patients often like receiving care from these surgical centers because they say they are often more convenient than hospitals, they don’t have to wait as long for treatment and they get more personalized care. And, according to Consumer Reports, about 54 million surgeries are performed each year at these facilities. The question remains are they as safe as hospitals?

    Lisa McGiffert, who runs the Safe Patient Project at Consumer Reports questions their safety. Outpatient surgery centers like hospitals are breeding grounds for bacteria that can cause serious infections if the facilities are not kept clean. But, these centers tend not to be as tightly regulated or monitored to the same degree as hospitals. So, it’s not possible to know as much about what’s going on inside them.

    In addition, these centers may not have the safety equipment available at a hospital in case of an emergency such as a defibrillator and other lifesaving equipment. Moreover, they may not have staff with the level of training and skills to handle an emergency that are on hand in hospitals.

    Before getting care at an outpatient surgery center, do some research. Try to learn about the center’s infection rates. Make sure that the center is accredited, that your surgeon has experience with the procedure you are getting and that your anesthesiologist is board-certified.

    Right now, it may be hard to find good data on outpatient surgery centers. We should expect it over time. If you have a serious health condition, you may be better off getting your surgery in a hospital, because they are better equipped to address complications. (You should also choose your doctors carefully.)

    We are beginning to see more data rating hospitals, surgeons and doctors on a number of different metrics, including patient safety data from Consumer Reports.

    If you get treated in an ambulatory surgical center, be sure you understand what will happen after you leave. Leaving has its own set of risks if you are not prepared.

    The Agency for Healthcare Research and Quality is currently funding a 12-month patient safety program in which outpatient surgical centers can participate. And in 2014, Medicare began asking these centers for reports on quality, providing payment increases for those centers that comply.

  • Benefits and risks of telemedicine

    Benefits and risks of telemedicine

    Telemedicine allows doctors to remotely assess the conditions of patients via telephone or video. Medicare covers some telemedicine services, both real-time audio and video, for some conditions in certain situations. If you don’t have Medicare, check with your commercial insurer about the coverage available through your plan.

    What are the benefits of telemedicine? There’s no denying that telemedicine is convenient, saves time and generally saves money. Through telemedicine, you can see a doctor and get a prescription with ease, even if you live in a rural community or a community with few doctors. Moreover, you don’t generally have to wait for an appointment. You also don’t have to leave your home or leave work to get a diagnosis.

    Does telemedicine improve health outcomes? According to Cochrane, based on the research to date, the jury’s still out on the benefits and risks of telemedicine. A series of studies show overall patient satisfaction. But, the evidence is still scant on the clinical benefits of telemedicine or the effects of telemedicine on health outcomes.

    One analysis of 80 reviews of telemedicine revealed that 21 reviews found telemedicine effective, 18 reviews found telemedicine “promising but incomplete,” and others still found that the evidence was still limited and not consistent.

    What are the risks of telemedicine? It can be difficult for doctors to evaluate patients remotely. Doctors get a better sense of patients’ conditions in person, through a physical evaluation. So, there is a real likelihood of misdiagnosis with telemedicine.

    While Medicare only covers limited home care services, it is now in the midst of a demonstration project that pays for doctors and nurse practitioners to make house calls. That could be a better option than telemedicine.

  • Pneumonia vaccine: Medicare covers it

    Pneumonia vaccine: Medicare covers it

    You should do what you can to avoid getting pneumonia, especially if you’re older. Pneumonia is a lung infection that can cause fever and chills;  it can make it hard to breathe, and it can be life-threatening. One way to avoid getting pneumonia is by getting a vaccine. Fortunately, Medicare covers the pneumonia vaccine without a deductible or coinsurance.

    • If you are enrolled in traditional Medicare, your costs are fully covered through Medicare Part B, so long as you use a doctor who takes assignment, accepts Medicare’s payment as payment in full.
    • If you are enrolled in a Medicare HMO, PPO or other Medicare Advantage plan, the plan should cover the full cost so long as you use an in-network doctor.

    Talk to your primary care doctor about getting the pneumonia vaccine. You should also discuss the flu shot, another important vaccine.  Medicare covers the flu shot, along with most of the preventive care you need. 

    Here are more ways to keep yourself and the people you love safe and healthy.

  • Three big differences between a private Medicare fee-for-service plan and traditional Medicare

    Three big differences between a private Medicare fee-for-service plan and traditional Medicare

    Today, just as 50 years ago, when President Johnson signed Medicare into law, traditional Medicare is a fee-for-service program that allows older adults and people with disabilities to use almost any doctor or hospital in America knowing that Medicare will cover their care. Medicare Advantage Plans, including private Medicare fee-for-service plans, are newer Medicare health insurance options. All of these private Medicare Advantage plans are required to offer all the benefits that traditional Medicare offers. But, even the private fee-for-service plans work very differently from traditional Medicare.

    Of note, people with complex and costly conditions rate traditional Medicare substantially higher than the private Medicare plans on access and quality.  Not surprisingly, the overwhelming majority of people newly eligible for Medicare enroll in traditional Medicare. Here are three big differences between traditional Medicare and private Medicare fee-for-service plans that help explain the higher ratings and overwhelming preference for traditional Medicare:

    1. Many doctors and hospitals, which take traditional Medicare, may refuse to accept your private fee-for-service coverage. So, while private fee-for-service plans must pay for care from any doctor or hospital you choose to see, you may find that your doctors and hospitals do not accept the private fee-for-service plan’s rates. To make sure your providers will accept the plan’s rates and to avoid huge doctor bills, you should either use network providers or ask your plan for an “advance coverage determination” before seeing the doctor.
    2. Each Medicare private fee-for-service plan may have different approved doctor and hospital rates. Whereas traditional Medicare’s rates are transparent and identical within a geographic area, private fee-for-service plans are not. It is therefore near impossible to know what your out-of-pocket costs will be or to budget for your health care if you’re in a private fee-for-service plan and need to use out-of-network providers.
    3. Unlike traditional Medicare, you cannot buy supplemental coverage to fill gaps in a private fee-for-service plan. Private Medicare fee-for-service plans require you to pay annual deductibles and coinsurance (or copays) out-of-pocket, exposing you to financial risk if you need a lot of costly services. The plan must have a yearly limit on out-of-pocket costs, but it can be very high.

    Note that just because private fee-for-service plans must cover the same benefits as traditional Medicare does not mean that they will always cover the same services.  Private fee-for-service plans will apply their own rules for deciding whether a service is medically reasonable and necessary from traditional Medicare. For example, they might decide that a different number of trips to the doctor for a particular service is appropriate. That said, private fee-for-service plans might offer additional benefits such as eyeglasses or a vision test, benefits that traditional Medicare does not cover.

    For more information on the differences between traditional Medicare and private Medicare Advantage plans more generally, click here.

  • If your Medicare drug plan refuses to cover your medications, take these five simple steps

    If your Medicare drug plan refuses to cover your medications, take these five simple steps

    Too often, pharmacists are unable to fill prescriptions for people with Medicare because their Part D plan says the drugs are not covered. If you need the medications, you should appeal. The drug plan may improperly believe that a less costly medication will meet your needs.  Or, the drug plan might apply inappropriate limits on your medication or not implement proper Medicare policy. Here are three things to think about when choosing a Medicare Part D drug plan.

    Almost four out of five people who appeal get their drugs covered. To file an appeal, you will need to follow a five-step process, whether you have a stand-alone Part D plan or you get your drug coverage through a private Medicare Advantage plan. Along the way, the drug plan might agree to cover your drug.

    1. If your pharmacist tells you that your Medicare Part D drug plan will not cover a drug you need, you will get a “Medicare Prescription Drug Coverage and Your Rights Notice.”
    2. Call the Part D plan and find out the reason for the denial. Unfortunately, the pharmacy cannot tell you the reason for denial. If it’s because the drug prescribed is not on the drug plan’s list of covered drugs, its “formulary,” ask your doctor if there’s another drug you can take that is on the formulary. If it’s because you must first try another drug or meet some other requirement, speak with your doctor.
    3. If you need the drug prescribed, you will need a denial letter from the drug plan. You can only appeal the drug plan’s refusal to cover a prescription if you have this letter. To get the letter, file a request for drug coverage, an “exception request” (or an expedited exception request if you need the drug urgently), along with the letter from your doctor explaining the need for the drug, with your Part D plan. Your Part D plan will let you know how to file this request. And, the drug plan might decide to cover your drug after it receives your exception request.
    4. If your Part D plan denies your exception request, it will send you a Notice of Denial of Medicare Prescription Drug Coverage. The Part D drug plan’s denial letter should explain the reason for denial. Get your doctor to explain in writing why the drug prescribed is medically reasonable and necessary and why no other drug will meet your needs. In a 2013 audit, CMS found that more than half of the health plans audited had issued inappropriate denials.
    5. If necessary, file an appeal with the Part D plan, including the letter from your doctor; file an expedited appeal if you need your drug immediately.

    So long as your drug is medically necessary, you are very likely to win the appeal. The delay you might face in getting needed medications is a problem that the Center for Medicare and Medicaid Services is now looking to address.

    Of course, even with drug coverage your out-of-pocket costs can be sky high since Congress allows the drug companies to charge whatever they want and they often have the power to set prices. And the health plans simply raise copays to offset rising costs.  They have no ability to rein in prices. It’s no surprise that 576,000 Americans had drug bills over $50,000 in 2014.

    For more information on Medicare Part D appeals, visit Medicare Interactive.

  • Medicare proposes to pay for advance care planning

    Medicare proposes to pay for advance care planning

    In a newly released proposed rule, Medicare is proposing to pay for individuals to talk to their doctors and care teams about their health care wishes as part of their advance care planning. Medicare already pays for advance care planning under people’s Welcome to Medicare visit. But, the agency wants to give people additional opportunities and greater flexibility to have a conversation about end-of-life decisions with their doctors.

    For their peace of mind and for the comfort of their family, an increasing number of people are planning ahead for their care and creating advance directives even before they enroll in Medicare.  Some are ready to discuss end-of-life planning with their doctors when they first enroll in Medicare, and others would prefer to wait.  People also might want to start the conversation at the onset of a serious illness or as an illness progresses.

    Making decisions about the kind of care you would want when you cannot speak for yourself takes some serious thinking.  There are a number of factors to consider, including Medicare coverage options and who you would want to make decisions on your behalf.  The proposed rule would allow Medicare to cover patient conversations with providers about the kind of care patients desire—from every treatment possible to minimal intervention–along with a range of other issues, when the patient wishes to have them.

    In May 2015, 66 organizations sent a letter to Sylvia Burwell, head of the Department of Health and Human Services, urging that Medicare pay for advance care planning discussions with medical providers. “Published, peer‐reviewed research shows that ACP [advance care planning] leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity.”

    And, there is a bi-partisan Senate bill, the Care Planning Act of 2015, from June 11, 2015, that would authorize Medicare to pay physicians to counsel patients on end-of-life decisions.

    A proposal to cover advance care planning was taken out of the Affordable Care Act before it was passed, after Sarah Palin called these voluntary discussions to plan for end-of-life care “death panels.”

  • Respite care: Medicare may pay for you to take a break when caring for a loved one

    Respite care: Medicare may pay for you to take a break when caring for a loved one

    It can be very stressful as well as physically demanding to take care of anyone, particularly someone you love. In some cases, Medicare will cover the cost of a loved one’s care so that caregivers can take a break. To qualify for Medicare respite care, the person you are caring for must:

    1. Have a life-threatening illness
    2. Be enrolled in the Medicare hospice program.  (Here are three things to consider about hospice care)

    If your loved one qualifies, Medicare will pay for him or her to stay in a Medicare-certified skilled nursing facility or a Medicare-approved hospital for up to five days at a time. For more information, visit MedicareInteractive.org.  

    If your loved one does not have a life-threatening illness or is not enrolled in the Medicare hospice program, there still may be community services available to allow you to take a rest from caregiving. Contact your local area agency on aging to learn about community resources, including adult day services. Visit www.eldercare.gov for the agency nearest you and click Get Help to learn about free and low-cost services available to older adults.

  • Three things to think about if you’re traveling and have Medicare

    Three things to think about if you’re traveling and have Medicare

    If you leave your home to visit friends and family outside of your community or simply go on an adventure, you should understand your Medicare coverage when you travel and make sure you have the health care coverage you need.
    • Travel within the United States: Whether you have coverage when you travel outside your community depends on whether you’re enrolled in traditional Medicare or a Medicare Advantage plan.  With traditional Medicare, you’ll have the same comprehensive coverage anywhere in America, including Puerto Rico, American Samoa, Guam, the Northern Mariana Islands and the Virgin Islands.  If you’re enrolled in a Medicare Advantage plan, you may only have coverage for emergency and urgent care outside your area.
    • Travel outside the United States: As a general rule, Medicare will not cover your care.  There are only limited exceptions.  However, if you have traditional Medicare and one of four Medicare supplemental policies (“Medigap”)—Plans C, G, M or N—you will have lifetime coverage for 80 percent of your care during the first two months of your trip, up to $50,000. And, if you need prescription drugs, there’s a great chance that you’ll be able to buy them abroad at a fraction of the cost you pay in the United States. Virtually every other country negotiates low drug prices on behalf of their citizens.
    • Medical travel insurance: There are lots of policies out there.  Some will reimburse you for the cost of your trip if you end up needing to cancel. Some will cover your care if you get sick abroad, or will refund you if you need to cut your trip short, or will cover the cost of an emergency plane trip home.  Click here to see travel insurance options from a range of different companies.
  • Medicare coverage for people with diabetes

    Medicare coverage for people with diabetes

    More than nine million people over 65 have diabetes. Whether you are enrolled in traditional Medicare or a Medicare Advantage plan, Medicare covers a range of services and supplies for people with diabetes. It also covers annual and sometimes twice annual diabetes screenings for people with a variety of conditions who are likely to develop diabetes.

    If you think you might need a diabetes screening, speak with your doctor. Medicare will likely cover the full cost of an annual diabetes screening if you have hypertension, high cholesterol, low glucose tolerance, have a family history of diabetes, or are overweight. And if you have a pre-diabetes diagnosis—higher than normal blood sugar levels—Medicare will cover the full cost of a diabetes screening twice a year so long as you see a doctor who takes assignment, accepts Medicare’s payment as payment in full.

    If you have diabetes, Medicare will cover a range of supplies, including a glucose monitor, lancets and test strips, as well as an insulin pump and insulin if you need it. Call Medicare at 1-800-633-4227 for more information. If you are enrolled in a Medicare HMO or other private Medicare plan, call the plan.

    Medicare will also sometimes cover foot care and therapeutic shoes for people with diabetes. And, for some people, Medicare covers diabetic self-training and education. Talk to your doctor about these services and supplies. For more details on Medicare coverage of diabetes services and supplies, check out this fact sheet from Medicare Rights Center.

    For more information on Medicare coverage of preventive care services, click here.  And, if you have a chance, read this post on foods with added sugar.  And, this post on one little known way to get free help losing weight.