medicare

What Is Covered – Part C “Medigap” (Supplemental Insurance)

What Is Covered – Part C “Medigap” (Supplemental Insurance)

A Medigap policy is private health insurance sold by private insurance companies specifically designed to supplement the Original Medicare Plan. It Offers:

· Added Coverage – Medigap policies cover certain things that Medicare doesn’t cover.

· Lowers Deductibles & Co-Pays – It helps pay some of the health care costs (”gaps”) that the Original Medicare Plan doesn’t cover.

· Standardized Plans – By law, insurance companies can offer only 12 standardized Medigap benefit packages, referred to as Plans A through L. That means that the only difference in any standardized plan, such as Plan J, from one insurance company to another is the price. The benefits are identical.

· Guaranteed Issue Rights – If you are in your Medigap open enrollment period, insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for or existing conditions, and can’t charge you more for a Medigap policy because of past or present health problems. You may also be able to buy a Medigap policy at other times, but the insurance company is allowed to deny you a Medigap policy based on your health. Also, in some cases it may be illegal for the insurance company to sell you a Medigap policy (such as if you already have Medicaid or a Medicare Advantage Plan).

· Guaranteed Renewable – Your insurance company must automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums.

· Medigap policy only covers one person – If you and your spouse both want Medigap coverage, you each must buy separate Medigap policies.

· Every insurance company must make Medigap Plan A available if they offer any other Medigap policy.

· Not all types of Medigap policies may be available in your state. (e.g Massachussets, Minnesota, or Wisconsin).

· Medigap plans A – J must offer the following basic benefits:
Co-insurance for hospital days 61-90 – ($267/day in 2009) and
– Co-insurance for the 60 lifetime reserve days ($534/day in 2009).
– 100% of the cost of hospital care beyond 150 days covered by Medicare, up to a maximum of 365 lifetime days.
– 20% Co-insurance for Medicare approved charges after the $135 annual Part B Medicare deductible has been met.
– The first 3 pints of blood in each calendar year.
– Plan A has only the basic benefits.

The following Chart recaps Medigap coverage.

· If a check mark appears in the column, this means that the Medigap policy covers 100% of the described benefit.

· If the column lists a percentage, this means the Medigap policy covers that percentage of the described benefit.

· If no percentage appears or if the column is blank, this means the Medigap policy doesn’t cover that benefit.

· The Medigap policy covers coinsurance only after you have paid the deductible (unless the policy also covers the deductible).

Click Here for Medigap Plan A thru L Benefits info

*Medigap Plans F and J also offer a high-deductible option. You must pay the first $2,000 (high-deductible in 2009) in Medigap-covered costs before the Medigap policy pays anything.

** You must also pay a separate deductible for foreign travel emergency ($250 per year).

*** After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($135 in 2008), the plan pays 100% of covered services for the rest of the calendar year.

Medicare Advantage Plans

These Plans provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) benefits and must cover at least all of the medically necessary services that the Original Medicare Plan provides. Medicare Advantage Plans, like HMOs and PPOs, are another way to get Medicare benefits. These plans are health plan options approved by Medicare and run by private companies.

Medicare Advantage Plans may offer extra benefits, such as vision, hearing, dental, and/or health and wellness programs, and most include Medicare prescription drug coverage (usually for an extra cost). Medicare Advantage Plans generally have provider networks. This means you probably have to see doctors who belong to the plan or go to certain hospitals to get covered services. You may need a referral to see specialists.

Medicare Advantage plans include:

· Medicare Preferred Provider Organization Plans (PPO)
A PPO is a specific group of doctors and/or hospitals that provides medical services. PPO members pay for services as they are rendered.

Are prescription drugs covered?
In most cases, yes. Ask the plan. If you want drug coverage, you must enroll in a PPO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?
No.

Can I get my health care from any doctor or hospital?
Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.

Do I have to see a primary care doctor to get a referral to see a specialist?
In most cases, no. What else do I need to know about this type of plan? You may be able to get extra benefits for an additional premium.

· Medicare Health Maintenance Organization Plans (HMO)

HMOs provide medical treatment on a prepaid basis regardless of how much medical care is needed. HMOs provide a wide variety of medical services, from office visits to hospitalization and surgery. With a few exceptions, HMO members must receive their medical treatment from physicians and facilities within the HMO network.

Are prescription drugs covered?
In most cases, yes. Ask the plan. If you want drug coverage, you must enroll in an HMO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?
Yes. You generally must see a primary care doctor to get a referral before you see any other health care provider.

Can I get my health care from any doctor or hospital?
No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). If the plan has a point-of-service option, you can go out-of-network, but it will cost more.

Do I have to see a primary care doctor to get a referral to see a specialist?
In most cases, yes. Exceptions include yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year), which don’t require a referral.

What else do I need to know about this type of plan?
– If your doctor leaves, your plan will notify you, You can choose another doctor in the plan.
– If you get health care outside the plan’s network, you may have to pay the full cost.
– It’s important that you follow the plan’s rules, like getting prior authorization when needed.
– You may be able to get extra benefits for an extra premium.

· Medicare Private Fee-for-Service Plans (PFFS)

PFFS is a Medicare Advantage health plan offered by a state licensed risk bearing entity, which has a yearly contract with the Centers for Medicare & Medicaid Services to provide beneficiaries with all their Medicare benefits plus any additional benefits the company decides to provide. In most cases, people who join a PFFS are not required to use a network of providers. Beneficiaries can see any provider who is eligible to receive payment from Medicare and agrees to accept payment from the PFFS MAO.

Are prescription drugs covered?
Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.

Do I need to choose a primary care doctor?
No.

Can I get my health care from any doctor or hospital?
In most cases, yes. You can go to any Medicare-approved doctor or hospital if they agree to the plan’s terms and conditions of payment before treating you. Not all providers will accept the plan’s payment terms or agree to treat you.

Do I have to see a primary care doctor to get a referral to see a specialist?
No.

What else do I need to know about this type of plan?
PFFS Plans aren’t the same as the Original Medicare Plan and they have different rules from other Medicare Advantage Plans.
– PFFS Plans are offered by private companies. The private company, not Medicare, decides how much the plan will pay and how much you pay for services.
– You may be able to get extra benefits for an extra premium.
– Before you join a PFFS Plan, make sure you find doctors, hospitals, and other types of providers willing to contact the plan for payment information and accept the plan’s payment terms.

· Medicare Special Needs Plans (SNP)

SNPs serve certain people with Medicare who are chronically ill with specific diseases or conditions (such as diabetes, congestive heart failure, mental illness, or HIV/AIDS), who live in institutions like nursing homes, or who have other special needs.

Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage. Formularies may be designed to cover the drugs members need most.

Do I need to choose a primary care doctor?
In some cases, yes, or you may need to have a care coordinator help you develop personal care plans and coordinate your care.

Can I get my health care from any doctor or hospital?
You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). Plans typically have specialists for the diseases or conditions that affect their members.

Do I have to see a primary care doctor to get a referral to see a specialist?
In most cases, yes. Yearly screening mammograms and an in-network Pap test and pelvic exam (at least every other year) don’t require a referral.

· Medicare Medical Savings Account Plans (MSA)

MSAs are two-part health insurance programs consisting of a high-deductible health insurance policy and a tax-free investment account set up to fund medical costs not covered by the policy.

Are prescription drugs covered?
No. You can join a Medicare Prescription Drug Plan to get drug coverage.

Do I need to choose a primary care doctor?
No.

Can I get my health care from any doctor or hospital?
Yes. Some plans may have network doctors and hospitals you could go to for a lower cost.

Do I have to see a primary care doctor to get a referral to see a specialist?
No.

What else do I need to know about this type of plan?
– if the year is added to your next deposit.
– Medicare MSA Plans have two parts: a high-deductible health plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account.
–You can use the money in your account to pay your health care costs. When you use account money for Medicare-covered Part A and Part B services, it counts toward your plan’s deductible. After you reach your deductible, your plan will cover your Medicare-covered services.

· If You Join a Medicare Advantage Plan:

You are still in the Medicare Program.You still have Medicare rights and protections, including the right to appeal.

You still get Part A and Part B coverage.

You generally still pay the monthly Part B premium. You also pay the Medicare Advantage Plan’s premium (if they charge one) that includes coverage for Part A and Part B benefits and prescription drug coverage (Part D, if offered), and any extra benefits (if offered).

You may have to use providers who belong to the plan. If you use providers who aren’t in the network, you may have to pay the entire cost of the covered service.

You must follow plan rules, like getting a referral to see a specialist or getting prior authorization for certain procedures. Check with the plan.

You usually will have to pay some other costs (such as copayments, deductibles, or coinsurance) for the services you get. Out-of-pocket costs in these plans cary by the services you get. Check with your plan before you get a service to find out what your costs may be.

You don’t need to (and can’t) buy a Medigap policy . It won’t cover your Medicare Advantage Plan deductibles, copayments, or coinsurance.

If you see a doctor who doesn’t belong to the plan, your services won’t be covered, or your costs could be higher.

The plan will send you an Evidence of Coverage each year. This document gives you details about what benefits the plan will cover, how much you pay, how to file an appeal, and more. Plan benefits may change each year. The plan will send you an Annual Notice of Change each fall. This notice has information about any changes in benefits, costs, or service area that will be effective in January. If the plan covers prescription drugs, the notice will include changes to the formulary. You should review this notice carefully to learn about changes for the upcoming year to decide if you want to look at other plans in your area.

Medicare offers prescription drug coverage for everyone with Medicare. This coverage is called “Part D”.

· To get Medicare drug coverage, you must either join a Medicare drug plan adding on to your Original Medicare Plan, or join a Medicare Advantage Plan that includes Part D.

· Medicare drug plans are run by insurance companies and other private companies approved by Medicare.

· Each plan can vary in cost and drugs covered.

· If you decide not to join a Medicare drug plan when you are first eligible, you may pay a late-enrollment penalty if you choose to join late.

· If you qualify for extra help and don’t choose a plan yourself, Medicare will enroll you in one.

All Medicare drug plans must generally cover at least two drugs in each category of drugs, but plans can choose which specific drugs are covered in each category. Plans are required to cover almost all drugs in six classes that include anti-psychotics, anti-depressants, anti-convulsants, immunosuppressants, cancer, and HIV/AIDS drugs.

There are certain drugs that Medicare drug plans aren’t required to cover, such as benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for erectile dysfunction. Some plans may choose to cover these drugs as an added benefit. In addition, drug plans generally aren’t allowed to cover over-the-counter drugs. Some states may cover these drugs if you have Medicaid.

Plans may also exclude certain drugs from coverage. Although your Medicare drug plan may not have a certain drug on its list of covered drugs (formulary), a different drug that is safe and effective for the same purpose will be covered. This may be a generic version of the drug, or it may be another brand-name drug that may provide the same benefit as the drug that isn’t on the plan’s formulary. All plans must have a process for you to ask them to pay for a drug you need that isn’t on their formulary. They may or may not agree to cover the drug.

What Is Not Covered

Items and services that Medicare doesn’t cover include, but are not limited to the following:

· Acupuncture,

· Chiropractic services (with some exceptions),

· Cosmetic surgery,

· Custodial care (such as help with bathing or using the bathroom), except when you also get skilled nursing care in a skilled nursing facility, at home, or in a hospice,

· Deductibles, co-insurance, or co-payments when you get certain health care services,

· Dental care and dentures (with only a few exceptions),

· Eye care (routine exam), eye refractions (exam that measures your ability to see at specific distances), and most eyeglasses (with some exceptions),

· Foot care (routine) like cutting corns or calluses (with few exceptions), Hearing aids and exams for the purpose of fitting a hearing aid, Hearing tests that haven’t been ordered by your doctor,

· Laboratory tests for screening purposes (with some exceptions), Long-term care, for example, if you only need custodial care in a nursing home,

· Orthopedic shoes (with few exceptions),

· Physical exams (routine or yearly). Medicare will cover a one-time physical exam within the first 6 months of enrolling in Part B (co-insurance and Part B deductible applies),

· Prescription drugs. Most precription drugs aren’t covered by Part A or Part B, Shots to prevent illness (with some exceptions),

· Syringes or insulin, unless the insulin is used with an insulin pump, but it may be covered by Medicare Prescription Drug Coverage (Part D), and

· Travel (health care while you’re traveling outside the United States… with some exceptions).

Medigap policies don’t cover long-term care (like care in a nursing home),

Jim Bigelow 918-640-4657

www.jimbigelow.com jim@jimbigelow.com

Coldwell Banker Select

medicare

What Is Medicare ? Part 3

What Is Covered – Part B

· Abdominal Aortic Aneurysm Screening (Preventive Service): A one-time screening ultrasound for people at risk (like people who have smoked). Medicare only covers this screening if you get a referral for it as a result of your “Welcome to Medicare” physical exam. You pay coinsurance.

· Ambulance Services: When you need to be transported to a hospital or a skilled nursing facility for medically necessary services, and transportation in any other vehicle would endanger your health. You pay coinsurance, and Part B deductible applies.

· Ambulatory Surgery Center Fees: Facility fees for approved services at an Ambulatory Surgery Center (facility where surgical procedures are performed, and the patient is released the same day). You pay coinsurance, and Part B deductible applies.

· Blood: Pints of blood you get, starting with the 4th, as an outpatient or as part of a Part B-covered service. The first three pints aren’t covered. You pay coinsurance, and Part B deductible applies.

· Bone Mass Measurement (Preventive Service): To help see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically neccessary) for people who have certain medical conditions or meet certain criteria. You pay coinsurance, and Part B deductible applies.

· Cardiovascular Screenings (Preventive Service): To help prevent a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost.

· Chiropractic Services (Limited): To correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine. You pay coinsurance, and Part B deductible applies.

· Clinical Laboratory Services: Including certain blood tests, urinalysis, some screening tests, and more. No cost.

· Clinical Research Studies: To help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical research studies test new types of medical care, like how well a new cancer drug works. Usual patient care costs are covered if you take part in a qualifying clinical research study. If the item or services isn’t covered outside of a clinical research study, the cost of the investigational item or service may nor be covered. You pay coinsurance, and Part B deductible applies.

· Colorectal Cancer Screenings (Preventative Service): To help find precancerous growths and help prevent or find cancer early, when treatment is most effective. One or more tests may be covered…talk to your doctor.

· Diabetes Screenings (Preventive Service): To check for diabetes. These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a history of high blood sugar. Tests are also covered if you answer yes to two or more of the following questions: • Are you age 65 or older? • Are you overweight? • Do you have a family history of diabetes (parents, siblings)? • Do you have a history of gestational diabetes (diabetes during pregnancy) or did you deliver a baby weighing more than nine pounds? Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost.

· Diabetes Self-Management Training (Preventive): For people with diabetes. Your doctor or other health care people must provide a written order. You pay coinsurance, and Part B deductible applies.

· Diabetes Supplies: Including glucose testing monitors, blood glucose test strips, lancet devices and lancets, glucose control solutions, and therapeutic shoes (in some cases). Syringes and insulin are only covered if used with an insulin pump, but may be covered by Medicare prescription drug coverage (Part D). You pay coinsurance, and Part B deductible applies.

· Doctor Services: Services that are medically necessary or covered preventive services. Doesn’t cover routine physical except for the one-time “Welcome the Medicare” physical exam. You pay coinsurance, and Part B deductible applies.

· Durable Medical Equipment: Items such as oxygen, wheelchairs, walkers, and hospital beds needed for use in the home. For certain equipment, such as wheelchairs and hospital beds, Medicare pays rental fees for up to 13 months (36 months for oxygen). After this, you own the equipment, and Medicare pays for maintenance. For Medicare to cover your equipment, you must go to a supplier that is enrolled in Medicare. You pay coinsurance, and Part B deductible applies. In some cases, if you buy the equipment without renting it first, Medicare pays no part. New: In 2008, you may have to use certain Medicare-contract suppliers to get certain durable medical equipment in some geographic areas. Call 1-800-633-4227 for more information. TTY users should call 1-877-486-2048.

· Emergency Room Services: When you believe your health is in serious danger. You may have a bad injury, a sudden illness, or an illness that quickly gets much worse. You pay coinsurance, and Part B deductible applies.

· Eye Exams: For people with diabetes to check for diabetic retinopathy once every 12 months. You pay coinsurance, and Part B deductible applies.

· Eyeglasses (Limited): One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay coinsurance, and Part B deductible applies.

· Flu Shots (Preventive service): To help prevent influenza or flue virus. This is covered once a flu season in the fall or winter. The flu is a serious illness. You need a flu shot for the current virus each year. No cost.

· Foot Exams and Treatment: If you have diabetes-related nerve damage and/or meet certain conditions. You pay coinsurance, and Part B deductible applies.

· Glaucoma Tests (Preventive service): To help find the eye disease glaucoma. This is covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. Tests must be done by an eye doctor who is legally authorized by the state. You pay coinsurance, and Part B deductible applies.

· Hearing and Balance Exams: If your doctor orders it to see if you need medical treatment. Hearing aids and exams for fitting hearing aids aren’t covered. You pay coinsurance, and Part B deductible applies.

· Hepatitis B Shots (Preventive service): To help protect people from getting Hepatitis B. This is covered (three shots) for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (permannt kidney failure requiring dialysis or a kidney transplant), or a condition that lowers your resistance to infection. Other factors may increase your risk for Hepatitis B, so check with your doctor to see if you are at high or medium risk. You pay coinsurance, and Part B deductible applies.

· Home Health Services: Limited to reasonable and necessary part-time or intermittent skilled care or continuing need for physical therapy, occupational therapy, or speech-related pathology ordered by a doctor and provided by a Medicare-certified home health agency. Home health services may also include medical social services, home health aide services or other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies for use at home. No cost for home healh services. You pay coinsurance, and Part B deductible applies for dirable medical equipment.

· Kidney Dialysis Services and Supplies: Either in a facility or at home when your doctor orders it. You pay coinsurance, and Part B deductible applies.

· Mammograms (screening) (Preventive service): A type of x-ray to check women for breast cancer before they or their doctor may be able to feel it. Screening mammograms are covered once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between age 35 and 39. You pay coinsurance.

· Medical Nutrition Therapy Services (Preventive service): Medicare may cover medical nutrition therapy if you have diabetes or kidney disease and your doctor refers you for the service. You pay coinsurance, and Part B deductible applies.

· Mental Health care (outpatient): To get help with mental health issues such as depression or anxiety. Includes services generally given outside a hospital or in a hospital outpatient department, including visits with a doctor, clinical psychologist or clinical social worker, and lab tests. Certain limits and conditions apply. You pay coinsurance, and Part B deductible applies. Note: Talk to your doctor if you feel sad, have little interest in things you used to enjoy, or have thoughts about ending your life.

· Occupational Therapy: Services to help you return to usual activities (such as bathing) after an illness when your doctor orders them. You pay coinsurance, and Part B deductible applies.

· Outpatient Hospital Services: Services you get as an outpatient as part of a doctor’s care. You pay coinsurance, and Part B deductible applies.

· Outpatient Medical and Surgical Services and Supplies: For approved procedures. You pay coinsurance, and Part B deductible applies. Pap Test and Pelvic Exam (includes clinical breast exam) (Preventive service): To check for cervical and vaginal cancers. Medicare covers these screening tests once every 24 months for women at low risk, and once every 12 months for women at high risk and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past three years. No cost for the Pap lab test. You pay coinsurance for Pap test collection, and pelvic and breast exams.

· Physical Exam (One-time “Welcome to Medicare” Physical Exam) (Preventive service): A one-time review of your health, and education and counseling about preventive services, including certain screenings and shots and referrals for other care if needed. Important: You must have the physical exam within the first 6 months you have Part B for it to be covered by Medicare. You pay coinsurance, and Part B deductible applies.

· Physical Therapy: Evaluation and treatment of injuries and disease using various procedures, such as exercises and testing, when your doctor orders it. It may also include heat, light, and ultrasound therapy. You pay coinsurance, and Part B deductible applies.

· Pneumococcal Shot (Preventive service): To help prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive service once in their lifetime. Talk with your doctor. No cost.

· Practitioner Services: Such as services provided by clinical social workers, physician assistants, and nurse practitioners. You pay coinsurance, and Part B deductible applies.

· Prescription Drugs (limited): Includes certain injectable cancer drugs or immunosuppressive drugs. You pay coinsurance, and Part B deductible applies. Note: See Part D for additional Medicare prescription drug coverage.

· Prostate Cancer Screening (Preventive service): These tests help detect prostate cancer. Medicare covers a digital rectal exam (You pay coinsurance, and Part B deductible applies for the exam) and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50. No cost for the PSA test.

· Prosthetic/Orthotic Items: Including arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); breast prostheses (after mastectomy); prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and prenteral and enteral nutrition therapy). For Medicare to cover your prosthetic or orthotic, you must go to a supplier that is enrolled in Medicare. You pay coinsurance, and Part B deductible applies.

· Rural Health Clinic and Federally-Qualified Health Center Services: A broad range of primary care services usually provided on an outpatient basis. You pay coinsurance, and Part B deductible applies for rural health clinic services.

· Second Surgical Opinions: Covered in some cases for surgery that isn’t an emergency. in some cases, Medicare covers third surgical opinions. You pay coinsurance, and Part B deductible applies.

· Smoking Cessation (counseling to stop smoking) (Preventive service): Covered if your doctor orders it. Includes counseling for 2 cessation attempts within a 12 month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Counseling for each cessation attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies.

· Speech-Language Pathology Services: Treatment given to regain and strengthen speech skills when your doctor orders it. You pay coinsurance, and Part B deductible applies.

· Surgical Dressings: For treatment of a surgical or surgically-treated wound. You pay coinsurance, and Part B deductible applies.

· Telemedicine: In some rural areas, under certain conditions and only in a provider’s office, a hospital, or a federally-qualified health center. You pay coinsurance, and Part B deductible applies.

· Tests: Including X-Rays, MRIs, CT scans, EKGs, and some other diagnostic tests. You pay coinsurance, and Part B deductible applies.

· Transplants: Including doctor services for heart, lung, kindey, pancreas, intestine, and liver transplants under certain conditions and only in a Medicare-certified facility. Bone marrow and cornea transplants are covered (under certain conditons. Immunosuppressive drugs are covered if Medicare paid for the transplant, or and employer or union group health plan that was required to pay before Medicare paid for it. You must have been entitled to Part A at the time of the transplant and Part B at the time you get immunosuppressive drugs, and the transplant must have been performed in a Medicare-certified facility. If you join a Medicare Advantage Plan, check with the plan for information on transplant coverage. You pay coinsurance, and Part B deductible applies. Note: Medicare drug plans may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant.

· Travel (health care needed when traveling outside the United States): Limited to medical services provided in Canada when you travel on the most direct route through Canada between Alaska and another state. Medicare also covers hospital, ambulance, and doctor services if you are in the U.S., but the nearest hospital that can treat you isn’t in the U.S. (The “U.S.” includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). In some limired cases, Medicare may pay for services you get while on board a ship within the territorial waters adjoining the land areas of the U.S. You pay coinsurance, and Part B deductible applies.

· Urgently Needed Care: To treat a sudden illness or injury that isn’t a medical emergency. You pay coinsurance, and Part B deductible applies.

Jim Bigelow 918-640-4657

www.jimbigelow.com jim@jimbigelow.com

Coldwell Banker Select

medicare

What is Medicare? Part 2

What is Medicare?

What Is Covered – Part A

This and succeeding sections outline the coverage for “Original Medicare” Part A (Hospital Insurance), Part B (Medical Insurance); Part C (”Medigap”/Supplemental Insurance); Part D (Prescription Drugs); and common Medicare Advantage Plans.

Since the topic includes many details and options we have presented the basics to help you understand the coverage. Please research all the details applicable to your location, in more depth, before selecting and enrolling in a specific Plan.

Part A (Hospital Insurance) Covered Services

·         Blood: Starting with the 4th pint of blood you get at a hospital or skilled nursing facility during a covered stay. The first three pints are not covered.
 

·         Home Health Services: Limited to reasonable and necessary part time or intermittent skilled care or continuing need for physical therapy, or speech-related pathology, ordered by the doctor and provided by a Medicare-certified home health agency. Home health services may also include medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home.
 

·         Hospice Care: For people with a terminal illness who are expected to live 6 months or less if the disease runs its normal course. Coverage includes drugs, medicinal and support services from a Medicare approved hospice, and other services not otherwise covered by Medicare (such as grief counseling) for terminal and related conditions. Hospice care is usually given in your home (or other facility where you may live). Medicare covers some short-term inpatient stays (for pain and symptom management) and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
 

·         Hospital Stays: Semi-private room, meals, general nursing, and other hospital services and supplies. This includes inpatient you get in acute care hospitals, critical access hospitals, inpatient care as part of a clinical research study, and mental health care. This doesn’t include private-duty nursing or a television or telephone in your room. It also doesn’t include a private room unless medically necessary. Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
 

·         Skilled Nursing Facility Care: Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. To get care in a skilled nursing facility, you must need skilled care like intravenous injections or physical therapy. Medicare doesn’t cover long-term care or custodial care in this setting. 

 

Jim Bigelow    918-640-4657

www.jimbigelow.com                jim@jimbigelow.com

Coldwell Banker Select

medicare

What is Medicare? PArt 1

What is Medicare?

Medicare is a United States Government-sponsored health insurance program available to people in the following categories:

·         age 65 or older; OR

·         under age 65 with certain disabilities; OR

·         any age with End-Stage Renal Disease
     (permanent kidney failure requiring dialysis or a kidney transplant).

Most people get their coverage through the ORIGINAL MEDICARE PLAN. (Unless you choose otherwise, this is the plan you will be enrolled in.)

 

How It Works

Sign Up for Either Original Medicare  OR  A Medicare Advantage Plan

Original Medicare Plan has four (4) Parts:

Part A: Hospital Insurance helps cover the following:

·         Inpatient Care In Hospitals,

·         Includes Critical Access Hospitals and In-patient Rehabilitation Facilities,

·         Inpatient Stays In A Skilled Nursing Facility
     (not custodial or long-term care),

·         Hospice Care Services,

·         Home Health Care Services,

·         Inpatient Care In A Religious Non-Medical Health Care Institution
     (coverage is related to non-medical, non-religious parts of care).

Part B: Medical Insurance helps cover medically necessary services like:

·         Doctors’ Services,

·         Outpatient Care,

·         Other Medical Services That Part A Doesn’t Cover
      (such as Physical and Occupational Therapists),

·         Some Home Health Care,

·         Some Preventative Services

Part C: Medigap -or- Supplemental Insurance Plans, and

Part D: Prescription Drugs.

Medicare Advantage Plans are a package providing the same services as the Original with added services and options.

As an alternative to the Original Medicare Program, Medicare Advantage Plans are a package providing the same services as the Original with added services and options.

 

Jim Bigelow    918-640-4657

www.jimbigelow.com                jim@jimbigelow.com

Coldwell Banker Select

 

 

 

medicare

TRICARE HELP

TRICARE HELP

 

HOW MUCH WILL YOU HAVE TO PAY ON A CLAIM?

 

 

Tricare claims require proof that the provider meets certain standards for education, training, States Licensure, or certification, and is qualified to provide the services on the beneficiary’s claim. A provider that meets Tricare’s criteria becomes an authorized provider and is assigned a Tricare Provider Number to be used all claims.

 

These providers sometime will indicate on the claim form that he agrees to accept the amount Tricare allows as full payment for the services on that claim.  In return, Tricare will send its share to the provider.

 

When the beneficiary pays the cost share to the provider, the claim and the provider’s bill will be paid in full under terms of their contract with Tricare.  A provider always participates on claims under Tricare Prime and Extra.

 

If an authorized provider chooses not to participate on a claim he is allowed by federal law to charge the patient fifteen (15) percent over the amount Tricare allows.  This applies to Tricare Standard claims only.

 

Tricare will send its usual share of the amount allowed to the patient, not the provider.  The patient is responsible for paying the provider the amount Tricare allowed plus the additional fifteen (15) percent.

 

Doctors that see Medicare patients are aware that the “Limiting Charge Law” applies to Medicare claims and it also applies to Tricare claims.

 

It is unfortunate that the law does not allow Tricare to do more than write to the doctor and explain the Federal Laws.  Beyond that Tricare can threaten to discontinue his status as a Tricare authorized provider and threaten to cancel his ability to participate in other Federal Programs such as Medicare.

 

The doctor may not be aware what his billing clerk is doing.  Consider writing or talking to them about your situation.

 

As a military retiree, dedicated to the military personnel and their families, I urge you to contact Coleman White@Jimbigelow.com for all your real estate needs.

 

Coleman White 918-760-1317

coleman@jimbigelow.com  www.jimbigelow.com

 

Jim Bigelow    918-640-4657

www.jimbigelow.com                jim@jimbigelow.com

Coldwell Banker Select

 

 

 

medicare

Who is required to accept Tricare?

Who is required to accept Tricare?

 

If your Physician has severed their relationship with Tricare and is no longer a Tricare-authorized provider, Tricare will not pay for any services regardless of who files the claim.  If your doctor remains a Tricare authorized provider, but no longer participates in Tricare on the claims, you may use his services and file the claim yourself.

 

In this case the Doctor is not required to accept the amount Tricare allows as full payment for his services.  There is a law that limits the amount you pay for doctor services.  This provision of the law governing Medicare is called: “The Limiting Charge.”

 

In 1983, Congress made the law apply to Tricare as well as to Medicare.

 

This Limiting Charge allows a non participating doctor to charge Tricare or Medicare beneficiary up to 15 percent over the amount Tricare allows on a claim.  Tricare will pay its usual amount directly to you.

 

Your out of pocket expense is 25 percent cost share, plus 15 percent surcharge.  Tell the office manager that Medicare and Tricare are required by law to use the same method and database to calculate the amount allowable on claims.

 

Tricare allows slightly more than Medicare due to a younger, healthier beneficiaries. 

 

If your claim is denied it is very important to state the denial reason in Tricare terminology, not what you think the words mean.  If you don’t understand what to do call Tricare for help.

 

The four official sources for Tricare information is: the health benefits adviser/healthcare finder at a military hospital, Tricare contractor, and military health system home page at www.tricare.mil.

 

Please email all comments to Coleman White @Jimbigelow.com.  Your Time Real Estate Sales Executive.

 

Coleman White 918-760-1317

coleman@jimbigelow.com  www.jimbigelow.com

 

Jim Bigelow    918-640-4657

www.jimbigelow.com                jim@jimbigelow.com

Coldwell Banker Select