Category: Your Coverage Options

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.
July 31, 2015
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.
July 26, 2015
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.”

July 22, 2015
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.
July 17, 2015
ER visits for dental care on the rise, but some states are finding ways to address the problem

Data from the American Dental Association reveals that emergency room visits for dental care more than doubled in the 12 years between 2000 and 2012, according to USA Today. Largely because neither Medicare nor standard private health insurance covers dental care, some 2.2 million people ended up in the emergency room because of tooth pain in 2012. But, some states have developed innovative solutions to reduce emergency room visits for dental care.

A report by the American Dental Association shows that in the majority of cases that people visit the emergency room for dental care, they should be visiting the dentist instead. Nearly 24 percent of emergency room visits for dental care are non-urgent and another 54.8 percent are semi-urgent.

People often avoid going to the dentist because they lack insurance coverage and don’t want to pay out of pocket for dental care, which can be very expensive. Most insurance does not cover dental care. Medicare never covers dental care. And the Affordable Care Act only covers dental care for children, not for adults. Medicaid pays for some dental services, but what Medicaid covers depends on what state you live in.

And, most states do not allow dental therapists to provide dental care, even though the data suggests that they can provide several services safely and well and at lower costs. The American Dental Association has blocked dental therapists from providing dental services in all states but Alaska.

Maine, Michigan and Virginia have developed innovative solutions to reduce the number of emergency room visits for dental care by as much as 72 percent. One Michigan county created a volunteer dental force for patients with low incomes. In Maine, several hospitals are piloting a program that gives patients a painkiller when they present at the emergency room and then refers them to a clinic for treatment. A Virginia pilot program developed an in-hospital urgent dental care clinic to treat patients and reduce costs.

Emergency rooms must treat anyone who visits, regardless of whether they have insurance or are able to pay for their care. But, they generally only treat the dental pain and do not deliver dental services. As a result, they often end up having repeat visits from people with dental pain. And, by some estimates, the cost for emergency room services is three times more than the cost of a dental visit. For sure, it’s important to choose your emergency room carefully ahead of time, if you have a choice of them, so you get the best care and keep your costs down.

Here are some ways to get free and low-cost dental care. Or, contact your local area agency on aging to find out about resources in your community.

July 7, 2015
Eight things you should know about the Affordable Care Act
Thanks to the Affordable Care Act (“ACA”), 16.4 million more people in the United States have health insurance, though 13.2 percent of the population is still uninsured. Here’s eight other interesting facts about the ACA in 2015, post King v. Burwell.
1. The ACA guarantees Americans and permanent legal residents the right to buy health insurance, regardless of whether they have a pre-existing condition; and it forbids insurers from cutting people’s coverage off if they get sick. Undocumented immigrants and legal immigrants in the US for 5 years or less are not eligible for coverage.
2. The ACA requires insurers to offer “minimum essential health insurance coverage” to everyone who they insure, including mental health care, prescription drugs, having a baby, as well as a range of preventive services with no copay or deductible.
3. The ACA requires insurers to charge everyone the same rate for the same policy based on their age, regardless of their health status. Also, your out-of-pocket costs must be capped. And, it limits the amount that insurers can profit off the premiums they charge.
4. The ACA requires everyone eligible for coverage to have coverage, although people can go without coverage if they pay a penalty (2% of income or $325, whichever is higher, 2015).
5. The ACA requires every state to have a health insurance exchange, a marketplace through which people without insurance from their jobs and small businesses can buy insurance. Either the state can establish the exchange itself or the federal government can establish the exchange for the state. The exchange, which can be accessed online, allows people to compare the costs and benefits of the health plans available to them.
6. The ACA provides a subsidy—help paying for coverage through a state’s health insurance exchange—for anyone with income up to 400 percent of the federal poverty level, $47,080 for an individual. If you’d like to know whether you’re eligible for a subsidy and the amount, click here. In the 30 states (including Washington DC) that opted to expand Medicaid, people with incomes under 138 percent of the federal poverty level are eligible for it, $16,242 for an individual and $27,724 for a family of three. About 3.7 million nonelderly adults in states that opted not to expand Medicaid fall into a coverage gap.
7. The ACA allows parents with health care coverage through their jobs to include coverage for their children until they turn 26.
8. The ACA requires chain restaurants to list calories on their menus.
If you still have questions, you can call the government at 1-800-318-2596.
July 3, 2015
Making medical decisions for someone you love: Your rights

You shouldn’t have to pull strings to be able to make medical decisions on behalf of the people you love if they are unable to make them for themselves. And, it should be easy if you’ve been named their health care proxy. But, without a written health care proxy, it could be hard to make medical decisions for the people you love or even to speak with their doctors about their medical conditions.

If there’s no legal document naming you as the health care proxy, sometimes called an “advance directive,” whether you have the right to act on behalf of someone you love depends on state law, even if you’re the caregiver. Some states allow next of kin to act on behalf of a patient who is unable to make medical decisions. However, if the next of kin disagree on the treatment, you might have to go to court to settle the matter.

If there is no health care proxy, in many cases the doctor and hospital staff end up responsible for making medical decisions. Click here to learn about advance care planning and how to get a free health care proxy document for you and the people you love. For sure, advance care planning is important for end-of-life care.

And, if you’d like to learn more about why you should have an advance directive, click here.

June 24, 2015
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.
June 15, 2015
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.

June 9, 2015
Two questions to ask before enrolling in Medicare if you have FEHB, federal employee health benefits
If you worked for the federal government, you may be entitled to federal employee health benefits (“FEHB”) even after you retire. People who qualify for FEHB receive the same benefits at the same price as people who are actively working. The question becomes should you enroll in Medicare?

Whether to enroll in Medicare depends upon the kind of health care coverage you want and the amount you are willing to spend for coverage. Here are three questions to ask:
1. Do you want access to care from most doctors and hospitals in the United States at little or no cost? If you’re enrolled in a fee-for-service FEHB plan and sign up for traditional Medicare, Medicare will pay first and the FEHB plan will wrap around Medicare, paying most out-of-pocket costs, including deductibles and coinsurance.
  - Can you afford to pay the premiums for both Medicare and your FEHB plan?
  - If you decide not to enroll in Medicare now but think you may want to enroll in Medicare at a later date, are you prepared to pay a premium penalty for late enrollment?
2. If you’re in a FEHB HMO, is it meeting your current health care needs? If so, you might choose not to enroll in Medicare and save money on the Medicare premiums.
  - Will the HMO meet your future health care needs, if you develop a costly and complex condition? If you enroll in Medicare Part B, you will have coverage for all out-of-network care.
  - Are you prepared to pay a premium penalty for late enrollment in Medicare if you decide to enroll later?
For more information on FEHB and Medicare, read this booklet from the federal government or contact the National Association of Retired Federal Employees (NARFE) at 800-627-3394.
June 3, 2015