JustCare

Tag: Medicare Advantage

  • 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.

  • What will big health insurer mergers mean for our health care choices and costs?

    What will big health insurer mergers mean for our health care choices and costs?

    On Friday, July 3, Aetna, the third largest health insurer, paid $34.1 billion for Humana, the fourth largest insurer, merging two of the biggest health insurers in America.  And, the mergers don’t stop there. There’s talk of UnitedHealth Group, the largest insurer, merging with Aetna. There’s also talk of Anthem, the second largest insurer, merging with Cigna, the fifth largest insurer.

    We should be extremely concerned about these mergers. They could very well mean less choice and higher costs for millions of Americans.

    While it’s hard to make a compelling case that there is much meaningful competition in the health insurance marketplace today (the kind of competition that brings down costs and improves quality, delivering value), millions of people with Medicare, in the health insurance exchanges, and with employer group coverage, do have some health plan choices. With insurer mergers, we could have less ability to find an affordable health plan or to choose a plan with in-network doctors whom we know and trust.

    To be sure, more power for insurers means that they arguably would have more leverage over hospital and doctor rates. But, they are enormous today and still have been unable or unwilling to use their leverage. And, some would argue that the insurers will have a financial incentive to pay providers more, because that’s one way for them to generate more revenue. They can charge higher premiums if they are spending more on health care. (The Affordable Care Act limits insurer administrative costs and profits to 15-20 percent of premium dollars.)

    More power for insurers also means more power for them to charge their members more without fear of losing business since members may not have a good lower-cost alternative. There are many examples of insurers merging and increasing rates significantly post merger.

    To make matters worse, according to David Lansky, head of the Pacific Business Group on Health, the bigger the insurers are, the less accountable they may be willing to be regarding prices, quality and outcomes.

    To the extent regulators in the states have power to shape these mergers, there is precious little evidence that all but a few of them will consider wielding that power on our behalf. (California and New York may be two exceptions.) Even when they’d like to, most lack the resources to do battle with health insurers. Remember that before the Affordable Care Act was passed, virtually every state allowed insurers to deny coverage to people with preexisting conditions, to sell policies with inadequate coverage, and to hike up rates excessively. Most also saw no need for transparency of prices or quality in the marketplace.

    The U.S. Justice Department could intervene to stop these mergers.  But, even if it does, that is likely to be a short-term solution at best if Congress and our next president want to support big business interests.

    At the end of the day, Medicare does a better job of controlling costs than the largest private health insurers and, as Robert Reich explains in this video, we should be giving everyone in America a Medicare option.

  • 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.

     

  • Four tips for keeping your health plan costs down

    Four tips for keeping your health plan costs down

    There are a bunch of reasons why you should not think you can choose a health plan “that’s right” for you. If you have Medicare, you can budget for your care with traditional Medicare, though you will need supplemental coverage to protect yourself from financial risk. And, if you are not yet eligible for Medicare, you can do some homework to keep your health plan costs down.
    1. Choice of doctors and hospitals: Each health plan has different networks of doctors and hospitals. Many people choose plans with narrow networks, which tend to have lower premiums. Ask your doctors about which health plan’s network they are in and then call the health plan to confirm. (Sometimes, the same insurance company will offer different plans, with different doctors in their networks.) Also, find out if the hospital you want to use is in the network.
    2. Costs: Before enrolling, understand all of your costs. On top of your monthly premium, some health plans charge a deductible, the amount you must pay before the plan begins covering your care. And, you will likely have a copay, a fixed amount you pay every time you see an in-network doctor, or coinsurance, a percentage of the cost you must pay. If you see out-of-network providers, you’re likely to be stuck with huge doctor and hospital bills.  Most health plans will pay only a tiny portion of those bills, and many won’t pay anything. 
    3. Access: Before receiving services, make sure you understand the health plan’s rules. Even if you use in-network doctors and hospitals, the health plan might require you to get a referral from your primary care doctor or prior authorization from the plan before it will cover your care.  If the plan denies your care, be aware that you have appeal rights.
    4. Coverage: Each health plan has different rules about what it covers and under what conditions.  Different health plans may offer different benefits. If you travel or live in another area during parts of the year, make sure your plan covers your care while you are away and what it will pay.

    Here’s more from Just Care:

  • A crash course in 5 important health insurance terms

    A crash course in 5 important health insurance terms

    As if you didn’t already have enough to think about, you need to understand a sea of insurance concepts to keep your health care costs down. Here are five terms you should definitely know.

    1. Premium—what you have to pay each month for your health insurance.
      • If you have Medicare and are receiving Social Security benefits, the government will take your Part B premium out of your Social Security check—nothing to think about there.  But, if you have Part D drug coverage, you’ll likely have to pay that premium by check directly to the insurance company.  And, if you’re buying your own supplemental insurance, you’ll need to pay that premium as well.
      • If you’re in a Medicare Advantage plan, you’ll probably need to pay an additional premium to the insurance company offering that plan.
      • If you have coverage through the Affordable Care Act (ACA), you’ll have to pay that premium but may be eligible for a government subsidy based on your income.  Use this tool from the Kaiser Family Foundation to calculate the amount of your premium that the government will pay for.
    2. Deductible—what you have to pay out-of-pocket for your care before the insurance starts paying. 
      • If you have traditional Medicare, there is a small deductible for your Part B coverage for medical services and a large hospital deductible as well, both of which you’ll have to pay unless your supplemental coverage picks those up.
      • If you’re in a Medicare Advantage plan, an ACA plan, or an employer HMO or PPO, you’ll need to check on deductibles.  Often, insurers charge a deductible for in-network care and a separate deductible for out-of-network care.  And, if you’re premium is very low, your deductibles could be very high.
    3. Copay—a fixed fee that you pay for a particular service.
      • If you’re in a Medicare Advantage plan or an ACA or employer plan and seeing an in-network doctor, your copay will be a set amount of money that represents your share of the doctor’s charge.
    4. Coinsurance—a fixed percentage that you pay, based on the amount your insurer pays. 
      • If you have traditional Medicare and supplemental insurance, the supplemental insurer will pick up the coinsurance for all the services it covers.
      • If you are in a Medicare Advantage plan or an ACA or employer plan and seeing an  out-of-network doctor, your coinsurance will be a percentage of the doctor’s bill.
    5. Covered services: Insurers only pay for the services they cover.  Before you see a doctor, go to a hospital or use an ambulance, check to make sure that the insurer covers services from those providers and under what conditions.
      • Traditional Medicare covers services from most doctors and hospitals anywhere in America.
      • But, if you are in a Medicare Advantage plan or an ACA HMO or PPO, your coverage for routine care may be limited to your providers in your community. Sometimes, you will need prior approval from the insurer or a referral from your doctor in order for your services to be covered.
    If you like this, you might like these:
    Many Americans do not have a good understanding of how their health insurance works 
    How to keep your out-of-pocket costs down if your income is low and you have Medicare
    How to choose between traditional Medicare and a private Medicare Advantage plan
    What’s your Medicare Part B premium and deductible?
    What’s your Medicare Part A deductible?
  • Medicare Advantage plan “prior approval” rules could stick you with huge medical bills

    Medicare Advantage plan “prior approval” rules could stick you with huge medical bills

    The Medicare Rights Center just released a report illustrating how people with Medicare who are enrolled in Medicare Advantage plans can get stuck with huge bills even when they use in-network doctors. They didn’t understand Medicare Advantage plan “prior approval” rules.

    Medicare Rights Center’s client thought he was following his health plan’s rules when he received surgery from an in-network doctor. The health plan had told him he did not need a referral from his primary care doctor to be covered.  But, because his health plan requires “prior approval” for surgery–an OK from the health plan to go ahead with the procedure, which is different from a referral–and he had not secured it–he was stuck with a $12,000 bill.

    People with Medicare have appeal rights, and most people who know how to appeal win. Had the client understood how to appeal the denial properly, he most likely would have won on appeal because the health plan did not tell him he needed prior approval, and the in-network doctor did not secure prior approval as he should have known to do.

    If you like this post, you might also like this:
    A crash course in five important insurance terms

  • Two questions you should answer during the Medicare Open Enrollment Period

    Two questions you should answer during the Medicare Open Enrollment Period

    For anyone on Medicare and many caregivers, Medicare’s Open Enrollment Period is a time to reconsider coverage options. The open enrollment period runs between October 15th and December 7th this year. Here are two questions you should answer during the Medicare Open Enrollment Period:
    1. Is your Medicare doctor and hospital coverage meeting your needs?
    • If you’re in traditional Medicare and have supplemental coverage, you might be paying a little more than if you are in a private Medicare Advantage plan, but you have the widest choice of hospitals and doctors. And, you have good protection against health and financial risk.
    • If you’re in a private Medicare plan, you might save some money upfront, but you have a limited group of doctors and hospitals you can use. If you end up needing a lot of health care, it’s hard to know whether the doctors or hospitals in the health plan’s network will meet your needs. If you use out-of-network doctors and hospitals, you will likely spend a lot out of pocket for that care, more than your costs in traditional Medicare with a Medicare supplemental plan. Also, if you will be traveling out of area and you need care, it’s not likely your care will be covered, except in emergencies or urgent care situations.

    2. Is your Medicare (Part D) drug coverage meeting your needs? If you have Part D drug coverage, you should consider your options and not assume that the plan you have is still the one that you want or will cover the same drugs with the same cost sharing next year. The Part D plans often change the drugs they cover and the terms under which they cover drugs from one year to the next, as well as midyear sometimes. What makes sense this year may not make much sense at all next year. In 2015, the average monthly premium nationally is $32.

    To compare Medicare plan benefits and cost, visit the Open Enrollment Center page on the Medicare website.
  • Three things to know about cardiac care

    Three things to know about cardiac care

    More than 2 million people in America experience a heart attack or heart failure each year. Often they need cardiac care, specifically rehab services.  Here’s what you should know:
    1. Coverage: Medicare will cover most of the cost of your cardiac rehab care if you meet the qualifying criteria, which differs depending upon whether you receive the care as an outpatient or as an inpatient, after a hospitalization. The amount of care you receive will depend upon your condition.
    2. Access: Your doctor is responsible for prescribing the services you need and should be able to help you decide where to receive them. If you qualify for cardiac care in a Medicare-certified facility, make sure that the facility has a good cardiac rehab program.
    3. Cost: If you have traditional Medicare and supplemental insurance that fills gaps in coverage, your cardiac care costs should be covered once you’ve met the deductible.  If you are in a Medicare HMO or other private plan, you are likely to have a copay.  You should ask about it.