Medicare Part A and Part B Coverage Limitations: What to Expect

Enrolling in Medicare is an excellent way to ensure you are able to receive the vital health care you may need.  However, not all medical supplies and services will be covered by your Medicare Parts A and B.  In order to best prepare for your future, it is essential to be aware of some important coverage limitations.

For instance, Medicare doesn’t cover acupuncture, cosmetic surgery, hearing aids, hearing aid-fitting exams, and hearing tests (unless ordered by your doctor).  Medicare also won’t cover custodial care, unless you are also receiving skilled nursing care in a nursing facility, in a hospice, or at home. The majority of chiropractic services also aren’t covered, other than for subluxation.  Aside from a few exceptions, most dental care, dentures, foot care, orthopedic shoes, and eye-glasses won’t be covered either.

Although Medicare does cover a “welcome to Medicare” physical exam when you first enroll, yearly or routine exams aren’t generally covered.  Additionally, many vaccines and prescription drugs, as well as syringes or insulin not used with an insulin pump, won’t be covered by Parts A and B. If you plan to travel, be aware that most medical care won’t be covered by Medicare if you’re traveling outside of the United States. 

There are, of course, many valuable services which are covered by your Medicare Parts A and B.  Even when services are covered, though, you may be responsible for paying deductibles, coinsurance, or copayments for a number of these services.  By being cognizant of coverage limitations in services and supplies, you will be better able to plan, financially and practically, for your health care needs.

New Sentinel Initiative to Improve Safety of Medical Products

The U.S. Food and Drug Administration is working with the Centers for Medicare & Medicaid Services to improve the safety of Prescription drugs, as well as other medical products.

The new initiative will make Medicare prescription drug data available in order to assist researchers and government agencies in ensuring and improving safety, quality, and care.  It will incorporate a new electronic system – the “Sentinel System” - that will allow the Food and Drug Administration to look at a wide variety of information in order to see potential concerns.  The system will utilize substantial databases – including information provided by Medicare – to carefully monitor effects of medical products and to provide prompt information about the performance of a drug or other medical product.

The use of Medicare claims information, like diagnoses, treatments, and hospitalizations is particularly helpful, since it is such a large database.  The Centers for Medicare & Medicaid Services has published a final rule which will allow them to use Medicare Part D claims data to aid research, care coordination, program oversight, and quality improvement and performance measurement initiatives. 

The Sentinel System will be good, in particular, for Medicare Part D beneficiaries.  A survey done by the Center for Medicare & Medicaid Services shows that Medicare beneficiaries use over twice the medications as other Americans.  Because this means that Medicare beneficiaries would therefore be at greater risk of negative medication effects, a system designed to protect people from these risks is of particular use to people enrolled in Medicare Plan D.

With the new Sentinel Initiative underway, we can look forward to both an improvement in safety and an increase of relevant, timely information. 

Missed Your Optimal Enrollment Period for Medicare Part B? When to Sign Up

If you are eligible for automatic enrollment in Medicare Part A, you will start getting it the first day of the month you turn 65, or, if you are disabled and under 65, after you have been receiving disability benefits from Social Security or Railroad Retirement Board for 24 months. If you are not eligible for automatic enrollment, you should sign up when you’re close to 65.  However, if you miss your initial enrollment period, there are some other times when you may be able to enroll.

Starting January 1^st and running until March 31^st each year, the General Enrollment Period is the next best thing.  When you sign up during the General Enrollment Period, your coverage will start on July 1^st. The drawback for waiting until the General Enrollment Period, of course, is that you may be responsible for paying a late-enrollment penalty.  Unfortunately, you might need to pay the late-enrollment penalty for as long as you have the plan. 

Another time you might be able to enroll is during a Special Enrollment Period.  You may be eligible for a Special Enrollment Period if your or your spouse have a group health plan based on your current work.  You can then sign up for Part B at any point during your workplace coverage or in the eight-month period that starts when the employment (or group health plan coverage) ends.  Finally, if you didn’t enroll in Medicare Part B during your initial enrollment period because you were volunteering in a foreign country and already had health insurance for that reason, you may qualify for a Special Enrollment Period For International Volunteers.  Usually, when you are enrolling during a Special Enrollment Period, you won’t need to worry about a late-enrollment penalty.

While there are, then, ways for you to enroll in Medicare Part B outside of your initial enrollment period, the optimal time is, of course, when you are first eligible.

Costs and Coverage of Medicare Part A

Medicare Part A is the component of your Medicare insurance that deals with Hospital Insurance.  For most people, there is no monthly premium for Medicare Part A, as long as you or your spouse have paid enough Medicare taxes while working.   However, while you usually don’t need to pay monthly premiums for Part A, many services will involve some out-of-pocket costs. 

Receiving blood in the Original Medicare Plan, for example, will require you to pay for the first 3 pints you get as an inpatient.  After that, you will be responsible for 20% of the Medicare-approved amount.  An exception to this cost is if you or someone else donates enough blood to replace the blood you received. 

For home health care, you pay nothing for the home health care services and 20% of the Medicare-approved amount for necessary durable medical equipment.  For hospice care, you will need to cover a copayment of up to $5.00 per prescription for outpatient prescription drugs, as well as 5% of the Medicare-approved amount for inpatient respite care.  Also, if you receive hospice care somewhere other than for short-term general inpatient/respite care, you might be responsible for the cost of room and board.

In the case of hospital stays, you will need to pay a $1024 deductible and $0 coinsurance for 1 – 60 days each benefit period.  For days 61 – 90 each benefit period, you will cover $256.  Following day 90 for each benefit period (for up to 60 days over your lifetime), you will pay $512 per lifetime reserve day.

For skilled nursing facility stays, you will pay nothing for the first 20 days each benefit period, and $128 per day for days 21 – 100.  After that, you will be responsible for all costs incurred. 

Medicare Advantage Plans will cover the same benefits as your Original Medicare, but costs won’t necessarily be the same.  For details on specific out-of-pocket costs, contact your plan directly.

 

New to Medicare? Things to Think About

If you’re new to Medicare, you can look forward to a number of benefits.  However, there are a variety of things to consider as you start your program. 

The first thing you should do is, if you already have insurance, look into how it works with Medicare.  For instance, if you have veterans’ benefits, military benefits, federal employee health benefits, or employer or union health coverage, you should make yourself aware of how these will work with your Medicare plan. 

You will also need to choose the Medicare health plan you want, whether it is the Original Medicare Plan or a Medicare Advantage Plan, and if you want both parts A and B.  You’ll need to decide if you want part D as well, which is your prescription drug coverage.  If you do want prescription drug coverage, you’ll need to look at your various options and choose the prescription drug plan which will best meet your needs.  In addition to your hospital, medical, and prescription coverage, you’ll need to decide if you want a Medigap Policy. 

Another important thing to do within the first 6 months of joining Medicare is to go for your “Welcome to Medicare” physical exam.  You should also talk to your doctor about what other preventive services you may need. 

Finally, you’ll need to look at the basic information you need to make the most of your Medicare policy.  Make sure you’re aware of enrollment dates, and use the password and instructions mailed to you by Medicare in order to access your personalized information online.  If you need further assistance with your Medicare, contact your State Health Insurance Assistance Program.

New Print Advertising Campaign Highlights Hospital Compare Website

A new advertising campaign, created to increase awareness and informed decision making about health care choices, is being released by the U.S. Department of Health and Human Services.  Placed by the Centers for Medicare & Medicare Services in the May 21 edition of 58 newspapers, the ads will focus on health care information and quality by promoting the HHS’ Hospital Compare website.  The Hospital Compare site, found at www.hospitalcompare.hhs.gov, allows users to compare hospitals in terms of patient experiences and quality of care.  The site deals with ten specific components, using 26 quality measures, of patient experience, like communication, promptness of help, and an overall rating. 

The advertising campaign will highlight the scores of two specific measures of quality and patient satisfaction from the Hospital Compare site, in newspaper area-specific hospitals.  The ads should encourage people to use the technology available to them, in order to help them make more informed choices in their own health care decisions.  

The campaign includes information about the percentage of patients at each hospital who report receiving help when first requested, the percentage of patients at each hospital given antibiotics an hour before surgery (according to the hospitals), and the state average for both measures.  The ads, in combination with the website being promoted, should not only help people increase their access to clear health care information, but also, at the same time, urge hospitals to improve their patient care. 

Medicare and Renal Disease: How to Enroll and What Will It Cover

After being diagnosed with a renal disease or permanent kidney failure, you know that your whole life will change. You may become sad, frustrated and there are some people who becomes confused about the whole thing. However, you have to consider that you will still be able to take control your life and live a comfortable and meaningful life even with renal disease.

With Medicare, you will be able to see that it will be able to cover treatments for renal disease or for permanent kidney failure. Basically, you will become eligible for Medicare if you are over the age of 65, if you are under 65 with certain disabilities, and you will also be able to get Medicare if you have end stage renal disease, which requires kidney transplant, or dialysis.

You will also be eligible for Medicare Part A no matter how old you are if your kidneys no longer work and that you need regular dialysis treatment or in need of a kidney transplant. If you have renal disease, you may want to get covered for both Medicare Part A and Part B. So, even if you are already covered by Medicare Part A, you need to enroll in Medicare Part B in order to cover certain treatments for your renal disease.

Medicare will be able to cover initial dialysis. It will also cover outpatient dialysis treatments under the Part B coverage. Training for self-dialysis will also be covered by Medicare as well as home dialysis equipments and supplies. Other factors can also be covered by Medicare such as certain drugs for home dialysis and laboratory tests that are part of the dialysis treatment.

As you can see, Medicare will be able to cover dialysis treatments. So, if you have renal disease, you can be sure that Medicare will be able to cover most of the treatments you need in order to live a comfortable life.

325 Bidding Suppliers Contracted to Supply Medicare Medical Equipment and Supplies

The competitive bidding program, intended to lower costs of various of durable medical equipment, prosthetics, orthotics, and supplies, is well on its way to achieving its projected goals. The program should see a reduction of costs both to the Medicare system and to beneficiaries (since beneficiaries are responsible for a 20 % coinsurance on these items).

Ten communities will start the competitive bidding program on July 1 of this year. According to the bids submitted by the winning suppliers, Medicare will see an average savings of 26%. These 325 winning suppliers were announced on May 19, 2008, and all met Medicare’s specific standards. They all also must be enrolled in Medicare based on their products and services, be financially reliable, fill orders from their own inventory (or have contracts with other companies), ensure beneficiaries can get necessary items, and offer quality customer service by promptly delivering products and resolving complaints efficiently and effectively.

Out of all the suppliers who bid, CMS offered contracts to 23%, who were asking the desired price and met financial and disclosure expectations. 61% of bids asked too high a price, and over half of those were disqualified because they didn’t meet other requirements. 16% of bids were in the winning price range, but they were also disqualified.

Consumers and provides can obtain a list of Medicare contract suppliers at www.medicare.gov, by using the search tool and selecting “find suppliers of medical equipment in your area”.

Medicare Costs in 2008

In the Original Medicare Plan, your specific costs will include premiums, deductibles, and coinsurance amounts.  Part A and Part B differ in cost requirements, and your amounts will vary from year to year. 

Usually, Part A doesn’t call for a monthly premium if you or your spouse paid enough Medicare taxes while you were working.  In this case, you will most likely be automatically enrolled when you turn 65.  However, if you don’t qualify for premium-free Part A, your monthly premium for this component of your Medicare coverage can be up to $423.00.  If you have 30 – 39 quarters of Medicare-covered employment, your Part A monthly premium will be $233.00

Your Part A deductible, per benefit period, will most likely be $1,024.00, and your coinsurance amount will be $256.00 a day for the 61^st – 90^th day each benefit period.  For each lifetime reserve day, coinsurance will be $512.00 for the 91^st – 150^th day. 

For your Part B, your monthly premium will likely be $96.40.  However, some people will pay more, depending on their modified adjusted gross income.  For your Part B deductible, you will need to pay $135.00 for the year, and then 20% of the Medicare approved amount for services after this deductible. 

To find out more, visit www.medicare.gov. 

Drug Coverage: Some Important Rules You Should Know

All Medicare Prescription Drug plans have a number of rules, created to meet the needs of beneficiaries and, at the same time, to protect plan providers.  

 One of the rules for most Medicare drug plans is that they need to cover two drugs, minimally, in each drug category. They also need to cover almost all drugs in the anit-psychotics, anit-depressants, anti-convulsants, immunosuppressants, cancer, and HIV/AIDS classes.  Additionally, even when a Medicare drug plan doesn’t have a certain drug on its formulary, another drug with a comparable function which is equally effective will likely be covered.

The plans are usually able to choose which of the drugs in each category they will cover.  There are also a number of drugs your plan probably won’t cover, like barbiturates, benzodiazepines, and weight control drugs, although some plans may.  Most often, your drug plan won’t cover over-the-counter medication.  There are, of course, exceptions, like if your state allows people with Medicaid to receive coverage for these over-the-counter drugs.

Plans must, regardless of which Medicare Prescription Drug plan you are enrolled in, have some sort of a process which allows you to request coverage for a necessary drug not included in their formulary.

Drug plans also have some stipulations to ensure correct coverage use, such as you and/or your doctor needing to contact the plan prior to prescription coverage, demonstration of the medical necessity of the drug, a limit on how many drugs you can get at once, and “step therapy”, which is trying one or more similar, low-cost drug before moving on to a more expensive brand-name version. 

Because formularies vary according to plan and because they may change, each plan will have the required up-to-date information you need.  To find out what drugs are covered by your Medicare Drug Plan, contact your plan directly. 

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