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Medicare Information

Medicare, Medicare coverage, Meciare benefits, Meciare B, Medicare benefits for seniorsAccording to the American Society of Consulting Pharmacists, on average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year.   Medications alone may take a big chunk of living expenses for those not enrolled in Medicare programs, as well as those whose medications exceed the threshold paid by Medicare or private health insurance expenditures.  And the new Medicare bidding process hits home medical equipment providers with arbitrary reimbursement rates which is likely to cause a rise in durable medical equipment (DME) costs.  And starting Jul 1, 2014, reimbursements for a wide range of home medical equipment will drop on average by 45 percent.

While many DME products are covered by Medicare, beneficiaries are still required to pay 20% coinsurance for the cost of some DME equipment.  So as provider costs rise, so too will the coinsurance.  Another negative impact on Medicare is the inclusion of many across-the-board Medicare spending cuts in the Affordable Care Act.  The Medicare Trustees predict 15 percent of hospitals, hospices, nursing homes, and home health agencies would go red within five years causing a potential mass closing of necessary health care facilities.  But there are some representatives attempting to modify the Act which could minimize the impact on Medicare.  Time will tell. To obtain details on the physician’s Medicare fee schedule, go to Centers for Medicare and Medicaid Services.  Senior Strategy, Resources, information and Guides divides Medicare Information into medical equipment, home health care, mobility aids, hot water therapy/tubs, hospice, and skilled nursing care.

Medicare Coverage of Medical Expenses

Medicare coverage of medical expenses, medicare coverage of medical equipment, what does medicare cover, medicare coverageIf you want to get the most from your Medicare coverage, make sure your doctor or supplier is enrolled in Medicare! Doctors and other suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctor or other health provider is not enrolled, Medicare coverage of medical expenses will be denied even if submitted by your doctor or provider. This is true whether your supplier is a large chain or department store. Size simply does not matter. They must be enrolled in Medicare.

As of 2011, YOU pay 20% of the Medicare-approved amount. Medicare coverage of medical expenses varies for different kinds of durable medical equipment (DME): some equipment must be rented, other equipment may be purchased, and you may choose to rent or buy some equipment.

Ask if your doctor or supplier is a participating supplier in the Medicare Program before purchasing durable medical equipment. If the supplier is participating, it must accept assignment. This means they always accept Medicare-allowed amounts as payment in full. If the supplier is enrolled in Medicare but isn’t “participating,” there is no limit how much they can charge you. You may also have to pay the entire bill at the time you purchase the DME after which you can seek reimbursement. To find suppliers who accept assignment, visit http://www.medicare.gov, and select, “Medical Equipment Suppliers” from the Resource Locator. You can also call 1-800-MEDICARE (1-800-633-4227). If you are interested in reading the Medicare enrollment terms for Physicians, non-physician practitioners and other health care suppliers, go to

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/Suppliers.pdf.

Medicare is phasing in a new program called “competitive bidding” to help save money, ensure you have access quality equipment, supplies, and services, and to limit the potential for fraud and abuse. In some areas, if you need certain items, you must use specific suppliers, or Medicare coverage of medical expenses will be denied and you will likely have to pay full price out of pocket. It is important to check whether you are affected by this new program to ensure Medicare coverage and avoid any disruption of service. To find out whether the program has been implemented in your state, go to Medicare.gov.

If competitive bidding and requirements to use designated suppliers has been implemented in your area, Medicare coverage of medical expenses for the below items may be affected.

  • Oxygen supplies and equipment
  • Standard power wheelchairs, scooters, and related accessories
  • Certain complex rehabilitative power wheelchairs and related accessories
  • Mail-order diabetes supplies
  • Enteral nutrients, equipment, and supplies
  • Hospital beds and related accessories
  • Continuous Positive Airway Pressure (CPAP) devices, Respiratory Assist Devices (RADs), and related supplies and accessories
  • Walkers and related accessories
  • Support surfaces including certain mattresses and overlays (Miami, Fort Lauderdale, and Pompano Beach, Florida only)

Medicare Home Health Care Coverage

Home health care, home care, senior care, senior care at home, independent living, Medicare coverage of home health carYou may have long term care insurance that coverage home health care. Look at your policy for specific requirements and applicable wait times. It may be time to activate your benefit. But it is smart to consider all of your options before doing so. Both long term care insurance and hospice may provide more attractive benefits for home care. This is completely dependent on your health and other qualification triggers. Medicare may provide the coverage you need if you have no long term insurance and no terminal illness. You can use home health care benefits under Medicare Part A and/or Part B if you meet all the following conditions:

  • You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
  • You must need, and a doctor must certify that you need, one or more of the following:
  • Intermittent skilled nursing care (other than just drawing blood)
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational therapy
  • The home health agency caring for you must be Medicare-certified.
  • You must be homebound, and a doctor must certify that you’re homebound. To be homebound means the following:
  • Leaving your home isn’t recommended because of your condition.
  • Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).
  • Leaving home takes a considerable and taxing effort.

A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. You can still get home health care if you attend adult day care. Home health services may also include medical social services, part-time or intermittent home health aide services, medical supplies for use at home, durable medical equipment and an injectable osteoporosis drug. In 2011, YOU pay $0 for all covered home health visits. You pay 20% of the Medicare-approved amount for Medicare-covered medical equipment. YOU also pay 20% of the Medicare-approved amount, except for certain preventive services and certain outpatient mental health treatment services . The Part B deductible does apply.

Preventive Services

Medicare Part B covers the following preventive and screening services:

  • Abdominal Aortic Aneurysm Screening
  • Bone Mass Measurement
  • Cardiovascular Disease Screenings
  • Colorectal Cancer Screening
  • Diabetes Screenings
  • Diabetes Self-Management Training
  • Glaucoma Tests
  • HIV Screening
  • Mammogram (screening)
  • Medical Nutrition Therapy Services
  • One-time “Welcome to Medicare” physical exam
  • Pap Test/Pelvic Exam (screening)
  • Prostate Cancer Screening
  • Shots including the following:
  • Flu Shots
  • Hepatitis B Shots
  • Pneumococcal Shot
  • Smoking Cessation Counseling
  • Yearly “Wellness” Exam

Osteoporosis Drugs for Women

  • preventive care can help reduce the severity of osteoperosisMedicare Part A and Part B help pay for an injectable drug for osteoporosis in women who are eligible for Medicare Part B, meet the criteria for Medicare home health services, and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. You must also be certified by a doctor as unable to learn or unable to give yourself the drug by injection, and that family and/or caregivers are unable or unwilling to give the drug by injection. Medicare covers the visit by a home health nurse to give the drug.

In 2011, YOU pay 20% of the Medicare-approved amount for the cost of the drug. You pay $0 for the home health nurse visit to give the drug.

Non-Doctor Services

Medicare Part B covers certain services provided by certain health care professionals who aren’t doctors, such as clinical social workers, nurse practitioners, and physician assistants.

As noted previously, Medicare coverage changes from time to time. Be sure the above reflects the most current coverage by going to Medicare.gov.

Medigap

There are certain situations when insurance companies are required by law to sell or offer you a Medigap policy even if you have pre-existing conditions.

In these situations, an insurance company must sell you a Medigap policy, must cover all your pre-existing and cannot charge you more for a Medigap policy because of past or present health issues.

You also have rights to obtain Medigap coverage when your current health coverage changes, such as when you lose or drop the other health care coverage.  If you are uncertain whether Medigap coverage is right for you, in some cases you have the right to try a Medicare Advantage Plan and still buy a Medigap policy if you change your mind.

if your health coverage ended, either lost or dropped, or you joined a Medicare Advantage Plan, make sure you keep a copy of any written documentation as proof of coverage, all correspondence addressed to you specifically, and the postmarked envelope these papers come in as proof of when it was mailed.  This type of documentation may be required with your Medigap application as proof of your right, and qualification, to obtain the coverage.

It is better to apply for a Medigap policy before your current health coverage ends. This will ensure there is no gap between one policy ending and the date of initiation for Medigap coverage.  Aside from these Medigap coverage rights under federal law, your state may offer additional rights.  Check with your State Insurance Department.

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