Common Concerns

 

 

 

 

Medicare

 

 

MEDICARE, WHAT IS IT?

 

Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, including those who have disabilities and those who have permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig’s disease). The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.

Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.

The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program.  However you apply for Medicare from Social Security.  They can give you general information about the Medicare program.

There are several web sites that are very informative and deal with your health care benefits under Medicare.  They include excellent links with information used in this introduction to Medicare

http://www.medicare.gov

http://www.cms.hhs.gov/home/medicare.asp

http://www.medicarerights.org/maincontentwhatismedicare.html

http://www.kff.org/medicare  

 

Overview:

 

Medicare has four parts

 

  • Hospital insurance (Part A) that helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.

  • Medical insurance (Part B) that helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.

  • Medicare Advantage (Part C) formerly known as Medicare + Choice plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.

  • Prescription drug coverage (Part D) that helps pay for medications doctors prescribe for treatment.

 

Beneficiary Cost Sharing and Out of Pocket Spending:

 

Medicare has relatively high cost-sharing requirements and covers less than half (45%) of beneficiaries’ total costs. Medicare premiums and cost-sharing requirements are indexed to rise annually; the monthly Part B premium has nearly doubled between 2000 and 2006.

In 2006, the Parts A, B, and D (standard) deductibles are $952, $124, and $250, respectively.

 

Unlike most employer-sponsored plans, Medicare has no cap on out-of-pocket spending.

 

The Role of Private Plans in Medicare:

 

Private plans are playing a larger role in Medicare through a revitalization of the Medicare managed care program, now known as Medicare Advantage, as well as through the new Part D drug benefit.

 

Medicare Advantage. Medicare HMOs have been an option under Medicare since the 1970s, although the majority of beneficiaries have remained in the traditional fee-for-service program.. In 2006, virtually all beneficiaries have a choice of one or more Medicare Advantage plans, with enrollment now at 16% of the total Medicare population.

 

Medicare pays HMOs and other plans to provide all Medicare-covered benefits).

 

Medicare Prescription Drug Plans. Beneficiaries can obtain the new Medicare drug benefit through private stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs). Medicare pays plans to provide the standard drug benefit, or one that is actuarially equivalent.

 

Additional Sources of Coverage:

 

In addition to Medicare, most beneficiaries have some form of supplemental coverage.

 

Employer-sponsored plans:

Employers are a key source of supplemental coverage, assisting about 11 million retirees on Medicare. However, retiree health benefits are on the decline; only 33% of large firms offered retiree benefits in 2005, down from 66% in 1988). An additional 2.6 million Medicare beneficiaries are active workers (or spouses) for whom employer plans are the primary source of coverage.

 

Medicaid:

More than 7 million low-income beneficiaries are dually eligible for Medicare and Medicaid. Most qualify for full Medicaid benefits, including long-term care and dental, and get help with Medicare’s premiums and cost-sharing requirements. Some do not qualify for full Medicaid benefits, but get help with Medicare premiums and some cost-sharing requirements under the Medicare Savings Programs, administered under Medicaid.

 

Medigap and other coverage:

Many beneficiaries purchase private supplemental policies, known as Medigap. 3 million beneficiaries receive supplemental assistance through the Veterans Administration or some other government program, according to HHS.

Advice from our Members

 

June 2011

This person, who asked for her Mom, is dealing with MediCare (HMO)with Secure Horizons as a primary. But She also has MediCal (Medicaid) as a second/backup (whatever that means). She is getting ready to have chemo and the drug is only 80% covered by Secure Horizons (MediCare).

The chemo provider should be told of her MediCal coverage on the
initial visit and should bill them as secondary after the HMO claim is
processed.

Secure Horizons Medicare Advantage health insurance plans are sold by
United Healthcare Insurance company . They offer, among other plans,
a Medicare advantage HMO. Medicare Advantage plans are private health
insurance plans that replace original Medicare for patients who choose
these plans. Mom has to be sure she follows the HMO rules on
referrals and stays in the HMO network of providers to get the most
benefit from her plan. She should have a benefit booklet which
explains all of this and a primary care doctor to oversee her care.
Secure Horizons offers more than one HMO plan so you need to
understand which one she is in . See her booklet and this website
www.securehorizons.com/options/medicareadvantage.html

Her Secure Horizons insurance is her primary insurance. The primary
insurance will pay first and the rules of the primary insurance have
to be followed to get them to pay and usually to get any coverage from
the secondary insurance.
Secondary insurance pays after the primary and may pick up any
balances or cost shares remaining. It is important that each medical
provider ( doctor, hospital, clinic, etc) know that she has a
secondary and bills to the secondary after the primary has paid. You
want to avoid having to bill the secondary yourself as the
documentation needed can be difficult to manage. Secondary private
insurance would process a received medical claim to determine what
they would have paid had their insurance been primary, compare that
amount to the balance remaining on the provider’s bill and pay the
lesser of the two amounts . Medi-Cal should work much the same way.

MEDI-Cal is California’s Medicaid program and will function as her
secondary insurance. As a publicly funded program, the claim
processing rules may be a little different so you need to check with
them to understand the specifics. It is likely that the chemo billers
are very familiar with all of this. See for information on MEDI-Cal.


www.dhcs.ca.gov/services/medi-cal/Pages/MediCalBenFAQs.aspx#med

Make sure that each medical office that she deals with understands
her insurance and has current copies of her insurance cards. Many
issues can be avoided if the medical bills are submitted correctly the
first time.

Nick Fuhs
Class of 94
Former health insurance analyst

 

From the Kaiser Family Foundation, February 2007

Information specific to Coverage of Supplies:

There have been many questions about Medicare coverage of Durable Medical Equipment (DME).  It is important to understand that our coverage and co-pays are affected by the provider we deal with.  Understanding this will help us understand the differences in coverage.  It is not that Medicare is different from state to state, the status of our provider with Medicare is what may be different.   Reimbursement from Medicare is standard based on the following criteria: 

Please pay particular attention to the following if you are covered by Medicare. 

 

What is the difference between "participating" and "non-participating" suppliers of durable medical equipment (DME)?

 

There are three types of Durable Medical Equipment (DME) suppliers. The one you choose affects how much your costs will be.

 

  • Suppliers who are enrolled and "participating" in Medicare must bill Medicare and accept assignment (the Medicare-approved amount) as payment in full. You can only be billed 20 percent of that amount (plus any unmet portion of your Part B deductible).
  • Suppliers who are enrolled but "not participating" in Medicare are not required to accept assignment. They are allowed to charge you their standard rate and can ask for payment up front. Medicare will then reimburse you for 80 percent of its approved amount, and you pay the balance.
  • Suppliers who are not enrolled in Medicare are not required to bill Medicare. You may have to submit the claim to Medicare yourself. These suppliers are allowed to charge you their standard rate and can ask for payment up front. Medicare may then reimburse you for 80 percent of its approved amount, and you pay the balance.

 

Note: You must go to an enrolled supplier to get coverage for medications, diabetes supplies and capped rental items.

 

Why is it better to find a durable medical equipment supplier who takes Medicare assignment?

 

Unlike doctors, if a DME supplier accepts Medicare but does not take Medicare’s assignment, it can charge you any amount over Medicare’s allowed amount. That means you will be responsible for the 20 percent coinsurance plus whatever else the supplier wants to charge.

 

Visit www.medicare.gov or call 1-800-MEDICARE for a list of DME suppliers who accept assignment.

 

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