All posts by mcgrebuild

Medicare Vision Benefits

Does Medicare Cover Vision Benefits?

 

If you’re a Medicare beneficiary looking for Medicare coverage of routine eye exams or glasses, don’t look to Original Medicare, Part A and Part B, for these benefits in most situations. Original Medicare doesn’t cover routine vision care.

Medicare Part A typically covers vision care only in circumstances where something happens to the eye(s) that requires inpatient hospitalization.

Medicare Part B covers part of the cost for one pair of glasses or one pair of contact lenses following cataract surgery where a new lens was implanted to replace your damaged lens. Other than that, Part B does offer some vision benefits, but it’s hardly comprehensive as far as vision care is covered. Some Medicare Advantage plans offer routine vision benefits.

The Medicare Part C program (Medicare Advantage) offers an alternative way of receiving your Original Medicare, Part A and Part B, benefits. Available from private insurance companies that contract with Medicare, Medicare Advantage plans include all Part A and Part B benefits except hospice care, which is still covered under Medicare Part A.

In some cases, Medicare might cover certain vision-related items or services if an illness or injury resulted in eye problems. If you’re in this category, contact your Medicare plan (if you’re enrolled in Medicare Part C) or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week; TTY users call 1-877-486-2048.

Medicare typically pays 80% of Medicare-approved amounts for vision-related items and services  covered by Medicare Part B such as those listed below, while  you pay 20%. For items such as glasses, contact lenses, artificial lenses, and artificial eyes, you must use a Medicare-approved supplier to get Medicare coverage.

Vision screening and risk factors

Although Original Medicare doesn’t cover routine vision care, Medicare Part B covers one preventive vision screening per year for those at high risk for glaucoma. According to the Centers for Medicare & Medicaid Services, African-Americans aged 50 and older, Hispanic Americans aged 65 and older, people with diabetes, and people with a family history of glaucoma are at high risk for the disease. An eye doctor who’s legally permitted by your state must perform the exam.

Eyeglasses, intraocular lenses and contact lenses

Certain Medicare Advantage plans cover eyeglasses, intraocular (artificial) lenses, and contact lenses, but Original Medicare generally doesn’t include these vision benefits, except when following cataract surgery. You must use a Medicare-approved supplier.

Cataract surgery

Medicare covers cataract surgery and related costs, including the procedure to restore your vision by replacing the damaged lens with an artificial one. Make sure you know if you’re an inpatient or outpatient because what you pay may be different. Medicare covers the cost for one pair of eyeglasses, contact lenses, or intraocular lenses that may be necessary to correct your vision following cataract surgery.

Eye prostheses (artificial eyes)

Medicare covers eye prostheses (artificial eyes) for beneficiaries without an eye or who have eye shrinkage because of birth defect, vision trauma, or surgery. You’re also covered for polishing and resurfacing of your artificial eye. Medicare will pay for a replacement once every five years.

If you are enrolled in Medicare Part B, you are covered. You’ll pay 20% of the Medicare-approved amount for the eye prostheses, and the Part B deductible applies. You must use a Medicare-approved supplier.

Routine eye refraction tests

This is simply a routine vision screening. Original Medicare doesn’t offer this vision benefit, although some Medicare Advantage plans may.

Macular degeneration diagnosis and treatment

According to the National Institutes of Health, this disabling vision disease is associated with aging. Often gradually, vision is reduced in the center of the visual field, making it difficult to identify faces even though your vision allows you to see around the edges. Medicare Part B (and, by extension, Medicare Advantage) vision benefits may cover the costs of diagnosis and treatment, including certain prescription drugs used to treat macular degeneration.

Finding Medicare coverage for routine vision services

Medicare Advantage plans may offer benefits such as routine vision coverage, but such additional benefits vary among plans, so you may want to research plans carefully. You might find a Medicare Advantage plan that covers prescription drugs, vision services, and other items and services that are important to you, at a cost you can easily afford. To find a plan in your area, just enter your zip code in the box on this page.

...
Continue Reading

Medicare Part D Plans

Medicare Part D: An Overview of Medicare Prescription Drug Coverage

 

If you’re already enrolled in Original Medicare or a Medicare Advantage plan, you may already be familiar with Medicare Part A (hospital coverage) and Part B (medical coverage). But you may still be wondering how prescription drug coverage works and how you can get help with the costs of your medications. The answer depends in part with how you’re currently getting your Part A and Part B benefits and whether you’re enrolled in Original Medicare or a Medicare Advantage plan.

Medicare Part D (prescription drug coverage)

Medicare Part D is the prescription drug coverage, available through Medicare-approved private insurance companies. You can either get this coverage through a stand-alone Medicare Prescription Drug Plan if you’re enrolled in Original Medicare or a Medicare Advantage plan that includes prescription drug benefits, also known as a Medicare Advantage Prescription Drug plan.

If you enroll in a Medicare Prescription Drug Plan that works alongside your Original Medicare coverage, keep in mind that this plan may come with its own separate costs, which may include a plan premium, deductible, copayments, and coinsurance. If you enroll in a Medicare Advantage plan that includes prescription drug coverage, the cost of your prescription benefits may be included in the plan’s premium cost, in addition to cost sharing expenses. For both Medicare Prescription Drug Plans and Medicare Advantage plans, you must continue to pay the Part B premium, in addition to any premium required by your Medicare plan.

One benefit of enrolling in a Medicare Advantage plan that includes prescription drug benefits is that you can get your Part A, Part B, and Part D coverage through a single plan. Keep in mind that if you have Medicare Part C and want prescription drug coverage, you should generally get it through a Medicare Advantage Prescription Drug plan. In some situations, you can enroll in a Medicare Prescription Drug Plan if you have a Medicare Advantage plan type that doesn’t include prescription benefits, such as a Medicare Savings Account (MSA) plan, but this is an exception.

Signing up for Medicare Part D coverage

You’re eligible for Medicare prescription drug coverage if:

  • You have Part A and/or Part B.
  • You live in the service area of a Medicare plan that covers prescription drugs.

Like other parts of Medicare, you can only enroll in Part D during certain periods. You’re first eligible for Medicare prescription drug coverage during your Initial Enrollment Period (IEP) for Part D, which is the seven-month period that usually coincides with your Initial Enrollment Period for Part B. This period starts three months before your 65th birthday, includes the month you turn 65, and ends three months later. If you qualify for Medicare because of disability, your IEP for Part D starts three months before your 25th month of disability benefits from Social Security or the Railroad Retirement Board and lasts seven months.

After this period has passed, your next chance to sign up for or make changes to your Medicare prescription drug coverage is during the Annual Election Period, also known as the Fall Open Enrollment, which runs from October 15 to December 7 every year. During this period, you can:

  • Enroll in a Medicare Prescription Drug Plan
  • Enroll in a Medicare Advantage plan that includes or doesn’t include prescription drug coverage
  • Switch Medicare Prescription Drug Plans
  • Switch Medicare Advantage plans
  • Disenroll from your Medicare Prescription Drug Plan
  • Disenroll from your Medicare Advantage plan to return to Original Medicare

If you’re enrolled in a Medicare Advantage plan, you can change your mind and return to Original Medicare during the Medicare Advantage Disenrollment Period, which occurs from January 1 to February 14. If you disenroll from your Medicare Advantage plan, you’ll also have the opportunity to enroll in a stand-alone Medicare Prescription Drug Plan, whether or not your Medicare Advantage plan included prescription drug coverage. These are the only changes you can make during this period; you can’t use this period to switch Medicare Advantage plans or make other changes to your Medicare prescription drug coverage.

It’s important to enroll in Medicare Part D when you’re first eligible, especially if you don’t have other creditable prescription drug coverage (insurance that is as good as the Part D benefit). If you wait to sign up for Part D and go without creditable coverage for 63 consecutive days or more, you may have to pay a late-enrollment penalty if you decide to sign up for Part D later on. Please note that if you’re eligible for Extra Help (see below), you won’t have to pay a late-enrollment penalty, even if you didn’t get Part D when you were first eligible.

Medicare Part D costs

Medicare Part D costs vary, depending on the specific Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan you’re enrolled in, what medications you take, whether you take generic or brand-name drugs, and the cost tier that your prescription drugs fall under. Medicare plans that include prescription drug coverage place covered drugs into different “tiers,” with different copayment and coinsurance costs for the medications on each tier.

Some of your Part D costs may include a monthly premium, deductible, copayments, and/or coinsurance. Because each plan determines its own costs, it’s important to shop around and compare plan options to find the plan that covers your medications at the lowest cost sharing. See this article for more information on Medicare Part D costs and how Medicare plans cover prescription drugs.

Keep in mind that some beneficiaries may have to pay a higher premium for Medicare Part D if they make above a certain income. Also known as the Part D income-related monthly adjustment amount, or IRMAA, this extra cost gets added to your Part D premium if the income as reported on your tax return from two years ago falls above a certain threshold. This cost isn’t paid to your Medicare plan; instead, you’ll pay the Part D-IRMAA directly to Medicare. You’ll be contacted by the Social Security Administration if you need to pay this amount. Visit Medicare.gov for more information on how much you may have to pay for your Part D premium.

Some Medicare plans that cover prescription drugs have a coverage gap, or “donut hole.” A coverage gap is a temporary limit on what your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan will pay for your covered medications. Once you and your Medicare plan have spent a certain amount on covered prescription drugs (known as the initial coverage limit), you enter the coverage gap and pay a higher share of out-of-pocket costs for covered prescription drugs.  Government subsidies and manufacturer discounts are shrinking the costs you pay in the coverage gap every year until 2020, when the gap will finally be closed. You’re out of the coverage gap after your total costs for covered medications reach a certain amount; that’s when catastrophic coverage starts. This means that for the rest of the year, you will only have to pay a small copayment or coinsurance for covered medications the rest of the year.

For more information, including the specific costs you’ll pay each year while in the coverage gap, see this Medicare Part D coverage gap infographic for more detail. Please note that If you’re eligible for Extra Help (see below), you won’t enter the coverage gap.

Extra Help with Medicare prescription drug costs

If you have limited income and need help paying for Part D costs, you may qualify for additional help through the Extra Help (Low-Income Subsidy) program. This program helps with certain prescription drug costs, such as plan premiums, deductibles, copayments, and coinsurance. You must meet certain income and asset requirements to qualify, which may change from year to year. If you’re not sure if you qualify, contact your state’s Medicaid department or Social Security Administration to learn more on how to apply.

Do you have questions about how Medicare prescription drug coverage works? If you’d like help finding Medicare Prescription Drug Plans or Medicare Advantage plans that may cover your specific medications, feel free to contact eHealth today to speak with a licensed insurance agent. We can help you find plan options that fit your health and prescription drug needs.

...
Continue Reading

Medicare Advantage (Medicare Part C)

Medicare Advantage (Medicare Part C)

 

Medicare Part C, or Medicare Advantage, is a program that offers an alternative way to receive your Original Medicare benefits (Part A and Part B).

Medicare Advantage plans are available from private insurance companies that contract with Medicare. They’re required to cover everything that Original Medicare (Part A and Part B) does, except for hospice care, which Medicare Part A covers when you have a Medicare Advantage plan. Under the Medicare Part C program, you get your Original Medicare coverage through the Medicare Advantage plan instead of directly through Medicare.

If you sign up for Medicare Advantage, you aren’t leaving the federal Medicare program. You actually remain enrolled in Medicare Part A and Part B. Many Medicare Advantage plans include extra benefits as well, such as wellness programs or routine vision care. Most of them include prescription drug coverage.

In many cases, Medicare Advantage plans (such as Health Maintenance Organizations, or HMOs) include networks of clinics, doctors, and hospitals. If you belong to one of these plans, then you may need to seek treatment from providers within that network, or risk paying considerably more in out-of-pocket spending.

There are several Medicare Advantage plan options, although not every plan type may be available in your area. You may want to compare the available options, as each plan’s coverage details may differ. Consider all your current health-care needs before making a decision, such as whether you need prescription drug coverage. You may also wish to consult your doctor and other health-care providers to see what they recommend in terms of your coverage scope.

What Medicare Advantage plans are available?

Here are some brief descriptions of common types of Medicare Advantage plans. Each of these is available from private insurance companies that contract with Medicare. Availability and cost may vary by plan and service area.

Medicare Preferred Provider Organization (PPO)–A network of doctors, clinics, hospitals, and other health-care providers. With this type of plan, you don’t have to choose a primary care physician up front to coordinate your care. Instead, you can see any doctor or specialist who accepts Medicare assignment. If you go to providers outside your PPO network, your out-of-pocket costs may increase.

Medicare Health Maintenance Organization (HMO)–A type of plan in which you choose a primary care physician who will coordinate your care and refer you to any specialists you have to see. An HMO typically has a network of health-care professionals, and going outside of that network could require you to pay the full amount for any services.

Medicare Private Fee-for-Service (PFFS)–A type of Medicare Advantage plan in which the plan, not Medicare, sets payment terms. Some plans cover your visits to any doctor or specialist without worrying about network restrictions if the doctor or health-care provider accepts the plan’s terms, fees, and conditions. Other PFFS plans have provider networks.

Medicare Special Needs Plans (SNPs)–Plans designed for people with certain chronic diseases or other special health needs. All of these plans must include prescription drug coverage.

Medicare Medical Savings Account (MSA)–Plans consisting of two parts:

  • A high-deductible plan where coverage doesn’t start until the annual deductible is met.
  • A savings account plan where Medicare deposits money to help you pay toward the high-deductible amount.

Do you need prescription drug coverage?

Not all Medicare Advantage plans include prescription medication coverage, but most do. When comparing plans, ask the plan (or review its description) to make sure it includes drug coverage if that coverage is important to you.

Who’s eligible to enroll in a Medicare Advantage plan?

To be eligible for Medicare Part C, you must already be enrolled in Original Medicare, Part A and Part B. You continue paying your Part B premium, along with any premium your Medicare Advantage plan may charge. You must live within the plan’s network, and in most cases you’re not eligible if you have end-stage renal disease (although there are exceptions, and some Special Needs Plans may accept you).

When can you enroll?

To enroll in a Medicare Advantage plan, you can take advantage of certain election and enrollment periods.

The Initial Coverage Election Period (ICEP) is when you’re first eligible for a Medicare Advantage plan.

When you become eligible for Medicare and you’re enrolled in Medicare Part A and Part B, you can enroll in a Medicare Advantage plan. In this case, your ICEP is the seven-month period that starts three months before the month where you turn 65, runs through your birth month, and continues for the three months after that. This is the same as your Medicare Initial Enrollment Period.

If you don’t sign up for Medicare Part B when you’re first eligible (for example, if you’re covered through an employer’s plan), your ICEP is the 3-month period before your Part B start date. For example, if you enrolled in Part B during the General Enrollment Period (January 1 to March 31), your Part B start date would be July 1, so your ICEP would be April 1 to June 30.

Your next chance to enroll in a Medicare Advantage plan is during the Annual Election Period (AEP), also called the Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage. It runs from October 15 to December 7 each year. You can add, change, or drop Medicare Advantage plans during the AEP, and your new coverage starts on January 1 of the following year.

If you have Original Medicare, you can also add a stand-alone Medicare Part D Prescription Drug Plan during the Annual Election Period. Alternatively, you can leave your Medicare Advantage plan, return to Original Medicare, and add a stand-alone Medicare Prescription Drug plan.

In some situations, you can enroll in a Medicare Advantage plan during a Special Election Period. Examples of these situations include (but are not limited to): moving to a new address, losing your current health coverage, qualifying for a different type of coverage, or experiencing changes in your current plan that affect your health benefits.

If you decide to drop your Medicare Advantage plan and return to Original Medicare, Part A and Part B, you can do so during the Medicare Advantage Disenrollment Period, from January 1 to February 14 each year. You can also add a stand-alone Medicare Part D prescription drug plan during this time.

How do you enroll?

Medicare Advantage isn’t as complicated as it sounds. Before you decide on the type of Medicare insurance plan that may work for you, we recommend that you understand the coverage and costs, such as premiums, coinsurance, copayments, and deductibles. This isn’t guesswork; don’t be afraid to ask questions. A licensed eHealth insurance agent can help you find the answers. For help finding a plan to suit you, feel free to contact eHealth using the information below.

...
Continue Reading

Medicare Part B

Medicare Part B

 

The Medicare program has several “parts,” and you may wish to understand them all when making your health-care coverage choices. Learning how Medicare works will help you choose the best plan for your needs. One part of the Medicare program is called Medicare Part B.

What is Part B?

Medicare Part A and Part B, together, are called Original Medicare. Through the Center for Medicare &Medicaid Services, the United States government set up Original Medicare to cover a wide range of medical expenses for individuals 65 and older and individuals with certain disabilities. Part A is hospital insurance.

Medicare Part B is medical insurance; coverage includes (but is not limited to):

  • Medically necessary doctor services
  • Screenings
  • Ambulance transportation
  • Outpatient hospital care, such as some physical or occupational therapy
  • Mental health services
  • Some home health care services
  • Durable medical equipment

What does it cover?

A range of preventive treatments, tests, services, and supplies are covered by Part B.

Medicare Part B covers the following:

Preventive and diagnostic services

  • Physical examinations, including a one-time ‘Welcome to Medicare’ preventive visit and annual ‘Wellness’ visits*
  • Tests, labs and screenings
  • Glaucoma screening once a year if you’re at high risk for glaucoma and the test is performed by an eye doctor who’s legally authorized to give this test in your state
  • Bone mass measurement, every two years (or as medically necessary), if you’re at risk for osteoporosis
  • Lab services such as blood tests or urinalysis
  • Colorectal cancer screenings to find any pre-cancerous growths and detect cancer early. If your doctor feels they’re necessary and you meet eligibility requirements, tests may include one or more of the following: annual fecal occult blood test, flexible sigmoidoscopy, colonoscopy screening, multi-target stool DNA test, and/or screening barium enema
  • Diabetic screenings, if you have risk factors, such as high blood pressure, dyslipidemia, obesity, or high blood sugar; you’re also covered if two or more of the following factors apply:
    • You’re 65 or older.
    • You’re overweight.
    • You have a family history of diabetes.
    • You have a medical history of gestational diabetes or have delivered a baby weighing more than nine pounds.
  • Diabetic supplies, such as monitors, test strips, lancet devices, and therapeutic shoes
  • Diabetic self-management training for beneficiaries at risk for complications
  • Cardiovascular screenings to help prevent heart attack or stroke. A screening consists of testing your triglyceride, lipid, and cholesterol levels every five years.

*Doctor services don’t include routine physical exams except the one-time “Welcome to Medicare” exam. You can get this free exam from a Medicare-assigned doctor during the first 12 months you’re enrolled in Part B. After you’ve had Part B for longer than a year, you’re covered for one annual “Wellness” visit every 12 months.

Doctor, hospital, and home health care

  • Home health services (usually short-term), including limited, reasonable, and medically necessary intermittent care and services such as skilled nursing care, physical or occupational therapy, home health aide services, speech language pathology, and medical social services
  • Certain durable medical equipment used at home, such as wheelchairs, hospital beds, walkers, and oxygen equipment
  • Certain medical supplies, such as (but not limited to) continuous positive airway pressure (CPAP) devices, oxygen, and oxygen equipment
  • Chiropractic services only if the purpose is to correct one or more of the bones that has moved out of place in your spine (subluxation); all other chiropractic services aren’t covered
  • Ambulance services, if it’s a medical emergency and any other form of transportation would endanger your health
  • Blood (pints) that you receive during an outpatient visit or another Part B-covered service
  • Clinical trials, if the trial meets eligibility criteria for Medicare coverage
  • Ambulatory surgery center fees for approved surgical services
  • Emergency room services for severe injuries and illnesses that quickly worsen (note: emergency care is only rarely covered outside of the United States)
  • One pair of eyeglasses and standard frames or one pair of contacts lenses after cataract surgery that inserts an intraocular lens

Preventive shots

  • Flu shots are covered one time per year during flu season.
  • Pneumococcal vaccines are covered for all beneficiaries with Part B.
  • Hepatitis B shots are covered if you’re at medium or high risk for the disease.

Additional services covered include, but are not limited to:

  • Diagnostic hearing and balance exams (routine hearing exams or tests to get fitted for hearing aids aren’t covered)
  • Mammograms
  • Dialysis
  • Pap tests, pelvic exams, and clinical breast exams to screen for breast cancer
  • Outpatient mental health care services (for example, depression screenings)
  • Medical nutrition therapy
  • Hospital services that you get as an outpatient
  • Occupational therapy
  • Outpatient surgery service and supplies
  • Limited prescription drugs you get in an outpatient setting (for example, chemotherapy drugs)
  • Nurse practitioner services
  • Physical therapy
  • Prosthetic devices
  • Transplant services

Part B premiums

You’ll typically pay a premium for Medicare Part B unless you qualify for financial assistance. Because of this, you have the option of turning it down, although you might pay a late-enrollment penalty if you decide to enroll in Medicare Part B later on. This monthly Part B premium amount may vary from year to year. Remember, you must have both Part A and Part B if you decide to enroll in a Medicare Advantage plan.

You can also check to see if you’re qualified to receive help from your state to help you pay for premiums or deductibles. Otherwise, the premium is usually deducted from a Social Security, Railroad Retirement, or Civil Service Retirement check. You can also choose to pay the Part B premium quarterly, through the electronic payment option, or through Medicare Easy Pay.

Overall, Part B provides many outpatient medical services to help minimize your health-care coverage worries. Still, it doesn’t cover everything; for example, routine dental care isn’t covered if you’re enrolled in Original Medicare, but some Medicare Advantage plans may offer this coverage. Whatever health-care coverage you choose, make sure you have a clear understanding of coverage options and costs.

Need help figuring out Medicare plan options that may work for your situation? Feel free to contact eHealth to speak with a licensed insurance agent and get assistance with your questions.

...
Continue Reading

Medicare Part A

Medicare Part A

 

Understanding the basics of Medicare and how it works will help lay the foundation you need to make decisions about your Medicare coverage choices. This article explains Medicare Part A (hospital insurance).

Medicare Part A is part of Original Medicare (along with Part B), the government-sponsored health insurance program for those who qualify by age, disability, or certain health conditions. Medicare is generally available to United States citizens and permanent legal residents of at least five years in a row, who are at least 65 years old or receive disability benefits. Most of those who qualify for Medicare are automatically enrolled in the program. For more information about eligibility, see Medicare Eligibility.

Most people do not have to pay a premium for Medicare Part A. If you or your spouse worked at least 10 years (40 quarters) and paid Medicare taxes while working, you’ll get premium-free Part A. If you don’t qualify for premium-free Medicare Part A, you’ll typically pay a monthly premium.

What is Medicare Part A?

Medicare Part A is hospital insurance provided by Medicare through the Centers for Medicare & Medicaid Services. Part A coverage includes (but may not be limited to) inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals. Part A does not include long-term or custodial care. If you meet specific requirements, then you may also be eligible for hospice or limited home health care.

If you’re enrolled in Original Medicare, doctors and suppliers are required by law to file Medicare claims for covered services and supplies you get. In most cases, you don’t need to file Medicare Part A claims as a beneficiary.

What does Medicare Part A Cover?

Medicare Part A is mainly hospital insurance. For coverage of doctor visits and medical services and supplies, see Medicare Part B.

Part A helps cover the services listed below when medically necessary and delivered by a Medicare-assigned health-care provider in a Medicare-approved facility. For more cost information, read about Medicare costs.

Blood transfusions

In most cases, the hospital gets blood from a blood bank at no charge, so if you receive blood as part of your inpatient stay you won’t have to pay for it or replace it. If the facility has to buy blood for you, usually you need to pay for the first three units you get in a calendar year or have it donated. Medicare Part A covers the cost of blood beyond the first three units you receive during a covered stay in a hospital, critical access hospital, or a skilled nursing facility.

Hospital stays

Medicare Part A generally covers hospital stays, including a semi-private room, meals, general nursing, and certain hospital services and supplies. Part A may cover inpatient care in:

  • Critical access hospitals
  • Inpatient rehabilitation facilities
  • Acute care hospitals
  • Qualifying clinical research studies
  • Long-term care hospitals
  • Psychiatric hospitals (up to a 190-day lifetime maximum)

Medicare Part A covers this care if all of the following are true:

  • A doctor orders medically necessary inpatient care of at least two nights (counted as midnights).
  • The facility accepts Medicare and admits you as an inpatient.
  • You require care that can only be given in a hospital.
  • The hospital’s Utilization Review Committee approves your stay.

Nursing home or skilled nursing facility

Medicare Part A covers limited care in a skilled nursing facility (SNF) if your situation meets a number of criteria:

  • You’ve had a “qualifying inpatient hospital stay” of at least three days (72 hours). The time begins the first midnight after admission and does not include any hours on the discharge date.
  • The SNF is Medicare-certified.
  • Your doctor has determined you need skilled nursing care every day. This care must come from (or be directly supervised by) skilled nursing or therapy staff.
  • You haven’t used all the days in your benefit period. (According to Medicare, this period begins the day you’re admitted to an SNF or a hospital as an inpatient, and ends when you haven’t had inpatient care or skilled nursing care for 60 consecutive days.)
  • You require skilled nursing services either for a hospital-related medical condition, or a health condition that started when you were getting SNF care for a hospital-related medical condition.

Nursing home or skilled nursing facility stays must be related to your diagnosis during a hospital stay. For instance, suppose your hospital stay was for a stroke and your doctor determined that a nursing home or skilled nursing facility was medically necessary for your recovery. In that case, Medicare may cover a nursing home or skilled nursing facility stay for rehabilitation. A nursing home or skilled nursing facility stay includes a semi-private room, meals, and rehabilitative and skilled nursing services and care.

The coverage is limited to a maximum of 100 days in a benefit period. The first 20 days are paid in full, and the remaining 80 days will require a copayment. Medicare Part A will not cover long-term care, non-skilled, daily living, or custodial activities.

Swing beds

Certain hospitals and critical access hospitals have agreements with the Department of Health & Human Services that lets the hospital “swing” its beds into (and out of) SNF care as needed. The same cost-sharing and coverage rules apply as if these services were delivered in an SNF.

Home health services

Eligible home health services may include limited part-time care with services like intermittent skilled nursing care, physical or continued occupational therapy, home health aide service, speech-language pathology, and more. It may also include certain medically necessary in-home medical equipment (wheelchairs, hospital beds, walkers, oxygen), and other medical supplies.

Hospice care

Hospice care is for the terminally ill who are expected to have six months or less to live. Coverage includes pain-relief and symptom-control prescription drugs, medical and support services, grief counseling, and other services. Care is provided by a Medicare-approved hospice provider who will visit you at your home. Medicare also provides additional care for a hospice patient so that the usual caregiver can take a time of rest. Medicare may not cover all services that are provided to patients who receive hospice assistance.

Whatever health care insurance coverage you choose, make sure you have a clear understanding of all the options, coverage and premiums. Don’t be afraid to ask questions and seek a Medicare representative that can help you to fully understand and tell you what you will need to do to sign up.

...
Continue Reading

Medicare and Nursing Home Care

Medicare and Nursing Home Care

 

Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period when the stay is medically necessary and follows a qualifying three-day inpatient hospital stay. Keep in mind that this is different from nursing home care that is considered custodial care, where a person is assisted with daily tasks such as dressing and bathing. Custodial care, or personal care, is not covered by Medicare if it’s the only type of care you need. Most nursing homes provide this type of care, also known as long-term care, and you’ll have to pay the full cost for this type of care.

What services does Medicare cover in a skilled nursing facility?

Medicare Part A covers these services while you’re in a skilled nursing facility:

  • A semi-private room
  • Meals
  • Skilled nursing care
  • Physical therapy, occupational therapy, and speech-language pathology (covered if medically necessary to meet your health goals)
  • Medical social services
  • Medications, medical supplies, and equipment used in the skilled nursing facility
  • Ambulance (if other transportation could endanger your health) to the nearest supplier of needed services not available at the skilled nursing home
  • Dietary counseling

Non-essential services from nursing homes are not covered.

Your benefit period begins the day you start using your skilled nursing facility benefits under Medicare Part A. You can get up to 100 days of skilled nursing facility care in one benefit period.  If you use up these benefits or if you stop getting skilled nursing facility care for more than 30 days, your benefit period must end and you must have another three-day qualifying hospital stay to get coverage to get another 100 days of skilled nursing facility coverage.

Your benefit period can also end once 60 consecutive days have passed since you were in a hospital or skilled nursing facility, or you haven’t received skilled nursing care in the facility for 60 consecutive days. If you leave the skilled nursing facility but get re-admitted within 30 days, you may not need another qualifying three-day inpatient stay.

What are the requirements for Medicare to cover skilled nursing care?

Skilled nursing facility care is covered under Medicare Part A (hospital insurance) when the following conditions are met:

  • You must have Medicare Part A.
  • You must have days left in your skilled nursing facility benefit for the benefit period (Medicare Part A includes 100 days of this benefits).
  • Medicare beneficiaries must first be an inpatient in a hospital for three consecutive days before entering the skilled nursing home. The qualifying inpatient hospital stay begins the first day you’re admitted to the hospital but does not include the day of discharge. Keep in mind any time you spend in the hospital under observation services (even if you stay overnight) doesn’t count towards your three-day qualifying inpatient stay; you must be formally admitted to the hospital as an inpatient. If you’re beginning a new Medicare benefit period of 100 days of skilled nursing facility coverage, then you must repeat the three-day qualifying hospital stay to meet the requirements for Medicare Part A skilled nursing home benefit.
  • A doctor must determine that the skilled services are medically necessary, needed on a daily basis, and cannot be provided outside a skilled nursing facility. The skilled care that the nursing home provides and that you needs must have been part of the treatment during the qualifying three-day hospital stay or it must be to treat a condition that developed while you were being treated in the hospital or skilled nursing facility
  • The skilled nursing services of the nursing home must be considered reasonable and necessary by Medicare.
  • The skilled nursing facility must be Medicare-certified for Medicare to cover the services.

Getting more coverage for nursing-home care

Other Medicare coverage options could potentially increase your coverage when it comes to nursing homes.

  • Medicare Supplement insurance: Some Medigap plans will help pay for Medicare coinsurance associated with care in a skilled nursing facility.
  • Medicare Advantage (Medicare Part C) plans: Medicare Advantage plans are offered through Medicare-contracted private insurance companies. These plans must offer at least the same amount of coverage as Original Medicare, Part A and Part B, but some can offer additional benefits beyond that coverage. Medicare Advantage plans could cover nursing homes, and some may only cover them when the nursing homes have a contract with the Medicare Advantage plan. Since benefits vary by plan, be sure to contact the specific Medicare Advantage plan you’re interested in for more information.

Nursing homes and Medicare Part D

Medicare Part D is prescription drug coverage. If you live in a nursing home or other type of long-term care facility, long-term care pharmacies contract with Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans to cover your prescription medications. As mentioned above, Medicare Part A covers prescription drugs you need during a short-term stay in a skilled nursing facility; these tend to be the type of medications that need to be administered by a registered nurse or doctor, such as intravenous drugs.

Medicare beneficiaries who move into or move out of a nursing home or other institution can change Medicare drug plans at that time. You can change Medicare drug plans at any time while you’re living in the institution. You’ll have an ongoing Special Election Period that you can use to enroll in or disenroll from a Medicare Prescription Drug Plan or Medicare Advantage plan (in applicable states and subject to state-specific eligibility rules); if you’re already enrolled in a Medicare plan, you can use this Special Election Period to switch plans as well. This period does not end until two months after the month you move out of the institution. You don’t need to wait until the next Annual Election Period to make changes to your coverage.

Visit Medicare.gov’s Nursing Home Compare tool to learn more about Medicare coverage of nursing homes. Do you have questions about Medicare plan options that may fit your health needs? Feel free to give us a call at the phone number on this page to speak with a licensed insurance agent.

...
Continue Reading

What to Do if You’re on Medicare and Need a Hearing Aid

What to Do If You’re on Medicare and Need a Hearing Aid

 

Original Medicare, Part A and Part B, doesn’t cover routine hearing exams, hearing aids, or exams to get fitted for hearing aids. However, Medicare Part B may cover a diagnostic hearing test to determine hearing loss and decide if you need further treatment. In this case, you would pay 20% of the Medicare-approved amount (subject to the Medicare Part B deductible). If you get this exam in a hospital setting, you may have to pay a hospital copayment.

While Original Medicare doesn’t cover hearing aids or exams, some Medicare Advantage plans, available through the Medicare Part C program, do. Medicare Advantage plans are offered by private insurance companies that are approved by Medicare and may cover benefits that go beyond Original Medicare, such as hearing services and hearing aids.

As another option, many states offer hearing benefits, including hearing aids, through Medicaid or other programs for qualified residents. The Hearing Loss Association of America, at www.hearingloss.org, includes a state-by-state list of such programs and phone numbers to call to find out if you’re eligible.

If you’re a veteran and your hearing loss is connected to your military service, veterans’ benefits may cover the cost of your hearing aid.

Scheduling your hearing exam

Under Part B, you can expect to pay 100% of the cost for exams to get fitted for hearing aids and hearing aids. If you have the financial resources and are willing to pay for it, call your doctor or hearing loss specialist to schedule a hearing exam.

If you have a Medicare Advantage plan and hearing services are covered, then follow your health plan’s rules for scheduling hearing appointments. For example, don’t call a hearing specialist directly if your Medicare Advantage plan requires you to go through a primary care doctor first for a referral. You might want to contact your Medicare Advantage or other health plan to see if it offers hearing exams and hearing aid discounts through a specific program.

If you belong to Medicaid, or any other program that may help cover hearing costs, then follow the program’s instructions for accessing your hearing benefits or buying a hearing aid.

Shopping for hearing aids

If your doctor confirms that you need hearing aids, he or she may recommend a specific device, possibly through a specific vendor. The amount you pay depends on what type of insurance you have.

You may want to do a thorough search for available options if you’re paying out of pocket for the hearing aids. You can search online for “hearing aids” to find a wealth of products from many hearing-aid companies. Check around for a hearing-aid style that best fits your needs, and compare prices and reviews to ensure that you find a product that will serve you well.

If you have a Medicare Advantage plan or Medicaid program that covers all or part of the cost for a pair of hearing aids, you may be restricted to buy them through approved companies. Check with your health plan and follow their instructions, or you may not be covered for the cost of the hearing aids.

This article is for informational purposes only. It should never be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

...
Continue Reading

Preventing Medicare Fraud

Preventing Medicare Fraud

 

Every year, money is taken from the Medicare program through deceptive practices, according to the Centers for Medicare & Medicaid Services (CMS). Medicare fraud is not only a waste of taxpayer dollars, but it hurts the program as a whole, including everyone who receives Medicare benefits. This quick guide reveals how Medicare fraud takes place, why it affects you as a beneficiary, and what you can do to help prevent it.

Defining Medicare fraud and abuse

Simply put, Medicare fraud is when false claims are knowingly made for services or procedures that were never received.

There are many types of Medicare fraud. For instance, it’s fraud when a provider bills Medicare for a medical appointment that didn’t occur. Another example of Medicare fraud is a supplier who charges Medicare for durable medical equipment that’s never been furnished to a beneficiary.

Medicare fraud is different from abuse. According to CMS, Medicare abuse occurs when doctors and health providers give medically unnecessary services or supplies, such as ordering a lab test that isn’t needed or billing Medicare for home health services when the patient isn’t homebound. This can also result in unnecessary costs to the Medicare program, but in a different way.

Why Medicare fraud matters

You may ask, “Why should I care if someone else commits Medicare fraud?” There are at least two main reasons you may want to join the battle against Medicare fraud. One is that Medicare fraud results in higher health-care costs for everyone, both beneficiaries and people without Medicare. Just as a retail store might increase prices to cover the losses of theft, Medicare costs will increase for everyone when fraud occurs.

Secondly, you or your loved one could be the next victim. Anytime you visit the emergency room, pharmacy, or doctor’s office, there’s a risk of Medicare fraud occurring. Someone may steal your Medicare card, or you might encounter a dishonest person working at a doctor’s office or pharmacy. Either way, the burden of proof might fall upon you because the Medicare card and billing information will be in your name.

Looking out for Medicare fraud

Uncovering Medicare fraud is easy if you keep an eye out for suspicious activities. Some red flags to watch out for include providers that:

  • Offer services “for free” in exchange for your Medicare card number or offer “free” consultations for Medicare patients
  • Pressure you into buying higher-priced services
  • Charge Medicare for services or equipment you have not received or aren’t entitled to
  • Charge you for copayments on services that are supposed to be covered 100% by Medicare
  • Use marketing tactics like telemarketing or door-to-door sales
  • Tell you they represent the government or use scare tactics

One way to detect and prevent Medicare fraud is to keep a record whenever you visit a doctor or health provider, including the date you received the service, the provider name, the service or equipment received, and the amount charged. Save all the statements your doctor sends and compare them against your Medicare statements. If you have Original Medicare, you can find your Medicare statements by logging into MyMedicare.gov or checking your Medicare Summary Notice, which is a notice Medicare mails out every three months.

Keep an eye out for discrepancies between your records and your Medicare statements, such as items you never received or if you don’t recognize the provider on a claim.

If you suspect that a provider has committed Medicare fraud, remember the adage “trust, but verify.” You should start by double-checking with the provider to be sure it is not a simple mistake first. Sometimes human and computer errors do occur unintentionally.

However, if so-called “errors” seem to be happening often, then it may be time to investigate further. You wouldn’t want to wrongly accuse your health-care provider, so be sure to approach suspected Medicare fraud with caution.

Reporting Medicare fraud

If you’ve done your due diligence and still believe your provider may have committed Medicare fraud, you should report the incident to Medicare.

Before contacting Medicare, you’ll need to gather all the facts about the incident so you can clearly present your case. Make sure to have the following information on hand:

  • The provider’s information, including name, phone number, address, and type of practice
  • The specific item(s) or service(s) that were billed incorrectly
  • The date that the service or equipment was supposedly given or delivered
  • The amount that was charged and approved by Medicare
  • The date on your Medicare Summary Notice
  • Why you think Medicare was falsely billed

To report Medicare fraud, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you’re a TTY user, call 1-877-486-2048.

Preventing Medicare fraud

Don’t let yourself be a victim of Medicare fraud. The following tips may prevent this from happening to you:

  • Never give anyone your Medicare card number who is not your caregiver or physician.
  • Beware of those who wish to review your medical records when they are not providing medical services to you.
  • Beware of “free” consultations and Medicare services being offered by a clinic or physician.
  • Never allow your provider to request medical services that you do not actually need.
  • Beware of providers that offer to get Medicare to pay for services or items that aren’t covered by Medicare or that you aren’t eligible for.

Most importantly, follow your instincts. If a situation doesn’t seem right, investigate to find the answers. Keep in mind that Medicare fraud may be committed by a person who doesn’t fit your idea of a “criminal”; it can happen with a doctor you think you know and trust.

With this knowledge, you can help fight against Medicare fraud and prevent waste in the Medicare program.

For more information, see:

...
Continue Reading

Medicare Eligibility: How to Qualify for Medicare Benefits

Medicare Eligibility: How to Qualify for Medicare Benefits

 

There are different ways to qualify for Original Medicare, Part A and Part B. Most people become eligible for Medicare by aging into the system when they turn 65. However, you can also qualify for Medicare before 65 if you have certain disabilities.

When it comes to other parts of Medicare, such as Medicare Part C (Medicare Advantage plans), Medicare Part D (prescription drug coverage), and Medicare Supplement insurance (Medigap), there’s another set of eligibility requirements.

Here are some situations where you may be eligible for Medicare Part A and Part B, Medicare Advantage plans, Medicare prescription drug coverage, and Medigap.

You’re 65 and a United States citizen

Typically, you’re eligible for Medicare if you’re 65 or older and either a United States citizen or a legal permanent resident of at least five continuous years. For purposes of Medicare, the U.S. includes the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

If you’ve worked at least 10 years (40 quarters) and paid Medicare taxes, you’ll usually get Medicare Part A for free. You may also get Medicare Part A without a premium if your spouse has worked long enough in Medicare-covered employment. If you haven’t worked long enough to get premium-free Medicare Part A, you’re still eligible for Part A, but you may have to pay a monthly premium. You’ll also typically pay a premium for Medicare Part B.

If you’re already receiving your retirement benefits from Social Security or the Railroad Retirement Board, you’ll be automatically enrolled in Medicare Part A and Part B on the first day of the month you turn age 65. This applies to Medicare-eligible beneficiaries living in the United States, District of Columbia, U.S. Virgin Islands, Guam, Northern Mariana Islands, and the American Samoa.

Please note: If you live in Puerto Rico and are receiving retirement benefits when you turn 65, you’ll be automatically enrolled in Part A but will need to manually sign up for Part B. If you qualify for automatic enrollment, you should receive your Medicare card in the mail showing your Medicare eligibility and coverage about three months before your 65th birthday.

If you aren’t yet receiving retirement benefits when you turn 65, you’ll need to manually enroll in Medicare. You can sign up for Medicare during your Initial Enrollment Period, the seven-month period that starts three months before you turn 65, includes the month you turn 65, and ends three months later.

If you miss your Initial Enrollment Period, your next chance to enroll in Medicare is the General Enrollment Period, which runs from January 1 to March 31 of every year. However, if you didn’t sign up for Part A and Part B when you were first eligible, you may owe a late-enrollment penalty.

You are allowed to delay your enrollment in Medicare Part B when you’re first eligible if you or your spouse is still working and have health insurance through a current employer or union (retiree coverage and COBRA don’t count as insurance based on current employment). In this situation, you may qualify for a Special Enrollment Period to enroll in Part B when that employment or health coverage ends. However, if you delay enrollment in Part B and you don’t qualify for a Special Enrollment Period, you may have to pay a penalty for late enrollment.

You receive disability benefits

You’re eligible for Medicare if you’re not 65 yet but have been receiving disability benefits from Social Security or the Railroad Retirement Board for at least two years. You’re automatically enrolled in Medicare Part A and Part B on the first day of the 25th month of disability benefits.

You have Lou Gehrig’s disease

If you have amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease), you’ll be eligible for Medicare and automatically enrolled in Medicare Part A and Part B on the first day of the month that you start receiving disability benefits. Unlike other disabilities, you don’t have to wait 24 months to be eligible for Medicare benefits.

You have end-stage renal disease

For people with end-stage renal disease (ESRD), you’re eligible for Medicare if your condition requires a kidney transplant or regular dialysis treatment. In order to qualify for Medicare, you also need to be eligible for or already receiving Social Security or Railroad Retirement Board benefits, or you need to have worked long enough under Social Security, the Railroad Retirement Board, or as a government worker. You can also qualify for Medicare if you’re the spouse or dependent of someone who is eligible for Social Security or Railroad Retirement benefits.

If you meet eligibility requirements for end-stage renal disease, your Medicare coverage begins after three months of kidney dialysis (on the first day of the fourth month of dialysis). For example, if you began treatment in September, you wouldn’t be eligible for Medicare until December.

If your condition requires a kidney transplant, Medicare coverage can start the month that a Medicare-approved hospital admits you for a kidney transplant as long as the transplant happens that same month or within the next two months.

If you’re admitted to the hospital for the transplant or other medical services, but your transplant is delayed for more than two months, your Medicare coverage could start two months before your transplant. For example, if you’re admitted into the hospital in January for pre-transplant medical services, but your transplant is delayed until May, your Medicare coverage would begin in March (two months prior to the transplant).

Please note that if you’re eligible for Medicare solely based on end-stage renal disease, your Medicare benefits will end at either of these times:

  • 12 months after you discontinue dialysis treatment
  • 36 months after you have had a kidney transplant and no longer need dialysis

For more information about qualifying for Medicare when you have ESRD, you can do any of the following:

  • See the Medicare publication “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services.”
  • Go to the Social Security Administration (SSA) website.
  • Call the SSA at 1-800-772-1213 (TTY users call 1-800-325-0778) Monday through Friday, from 7AM to 7PM.
  • Go to your local Social Security office; office hours may vary by location, so contact your nearest office directly.
  • If you worked for the Railroad Retirement Board, you can visit the website or call 1-877-772-5772 (TTY users: 1-312-751-4701). Railroad Retirement Board representatives are available Monday through Friday, from 9AM to 3:30PM.

You’re enrolled in Original Medicare and are looking for additional coverage

If you’re enrolled in Original Medicare, Part A and Part B, and you’re interested in other types of Medicare coverage, your eligibility will depend on the “part” of Medicare.

Medicare Advantage (Medicare Part C) plans are another way to receive your Medicare benefits, delivered through Medicare-contracted private insurance companies. These plans offer, at minimum, the same benefits as Original Medicare, but may include additional coverage, such as routine vision and dental, prescription drug benefits, or wellness programs. You must continue paying your Part B premium, in addition to any premium the Medicare Advantage plan charges. To be eligible to enroll in a Medicare Advantage plan, you must:

  • Have Medicare Part A and Part B.
  • Not have end-stage renal disease (with some exceptions).
  • Live in the service area of the Medicare Advantage plan you’re considering.

Medicare Part D is prescription drug coverage. This is optional coverage that doesn’t come with Original Medicare and must be obtained through a Medicare-approved private insurance company. You can get this coverage through a stand-alone Medicare Prescription Drug Plan (if you have Original Medicare) or a Medicare Advantage plan that comes with prescription drug benefits (also known as a Medicare Advantage Prescription Drug plan). To be eligible for Medicare Part D, you must:

  • Have Medicare Part A and/or Part B.
  • Live in the service area of the plan you’re considering.
  • Not have end-stage renal disease, with some exceptions (if the plan is a Medicare Advantage Prescription Drug plan).

Medicare Supplement (Medigap) plans are also sold through private insurance companies. These plans pay for certain out-of-pocket expenses in Original Medicare and may offer some additional benefits, like emergency foreign travel coverage. To be eligible for Medigap, you must:

  • Have Medicare Part A and Part B.
  • Be enrolled in Original Medicare (Medigap doesn’t work with Medicare Advantage plans).
  • Live in the service area of the Medigap plan you’re considering.

Most states require you to be at least 65 to be eligible for Medigap, but there are some exceptions. To find out what the eligibility rules are in your state, contact your State Health Insurance Assistance Program (SHIP).

If you’re interested in comparing Medicare Part D, Medicare Advantage, or Medigap plan options in your area, eHealth’s plan comparison tool makes it easy to do so; just enter your zip code into the plan finder tool on this page to view plan options in your area. Prefer to speak with a live person? Just pick up the phone to get personalized assistance with an eHealth licensed insurance agent.

...
Continue Reading

Medicare Coverage for Diabetes Services and Supplies

Medicare Coverage for Diabetes Services and Supplies

 

Diabetes is a condition where your body lacks the ability to use blood glucose (blood sugar) for energy, according to the Centers for Disease Control (CDC). As a result, diabetics may have high blood glucose levels. In diabetics, the pancreas typically doesn’t make or use the insulin hormone efficiently. Your body uses insulin to turn sugar (glucose) into energy. Unused sugar can build up in your blood and cause both short-term and long-term problems. Diabetes can be diagnosed with a simple blood test.

Many older Americans have type 2 diabetes, where your body doesn’t produce enough insulin or develops resistance to it, according to the CDC. However, even adults can get type 1 diabetes, which used to be called juvenile diabetes. Medicare covers certain medical services and supplies for individuals who have diabetes or at risk for this condition.

Medicare coverage for diabetes screenings

If you have Medicare and your doctor considers you at risk for diabetes, you may be eligible for up to two blood sugar screenings per year under Medicare Part B ; you don’t pay anything for the screening itself if you use a Medicare-assigned provider at a Medicare-approved facility. However, you may have to pay 20% of the Medicare-approved amount for the visit to the doctor’s office.

Risk factors that may qualify you for a Medicare-covered diabetes screening include:

  • High blood pressure
  • History of abnormal cholesterol and triglyceride levels
  • Obesity
  • History of high blood sugar
  • Family history of diabetes
  • Older age (risk for type 2 diabetes increases with age)
  • Reduced blood sugar tolerance
  • High blood sugar levels when fasting

Medicare coverage for diabetes patients

If you’re diagnosed with diabetes, Medicare may cover services and supplies you will need to treat and control diabetes, such as those listed below.

Please note:

  • You might have to use certain Medicare-approved suppliers to get Medicare coverage; see the Medicare.gov supplier directory.
  • Original Medicare (Part A and Part B) include only limited prescription drug coverage. You can get this coverage through the Medicare Part D program, either through a stand-alone Medicare Prescription Drug Plan (alongside your Original Medicare coverage) or through a Medicare Advantage Prescription Drug plan.

Insulin and anti-diabetic drugs: Medicare Part D Prescription Drug Plans or Medicare Advantage Prescription Drug plans may cover insulin and prescription drugs to control your diabetes. To be covered under Part D, the insulin must be injectable, not administered through an insulin pump or infusion (however, Medicare Part B may cover insulin pumps; see below). You’d pay the Medicare plan’s copayment or coinsurance, and a deductible may also apply.

Diabetes supplies for insulin: Medicare Part D may cover diabetes supplies needed to inject insulin, including syringes, needles, alcohol swabs, gauze and inhaled insulin devices. You pay the Medicare plan’s coinsurance or copayment. These diabetes supplies may be subject to a deductible under your Medicare plan. Please note that your out-of-pocket costs may differ from one Medicare Prescription Drug Plan to the next.

Diabetes supplies for blood sugar monitoring: Medicare Part B covers certain supplies for testing your blood sugar, such as blood sugar test strips, lancets, and blood sugar monitors. Medicare may limit the amount and frequency of your diabetes supply purchases, depending on whether you take insulin. You pay 20% of the amount approved by Medicare for these diabetes supplies, subject to the Part B deductible.

Insulin pumps: Medicare Part B covers external insulin pumps when medically necessary and prescribed by your doctor for in-home use. Insulin pumps are considered durable medical equipment. In this case, Medicare Part B covers insulin administered through a pump. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Foot exams, treatment, and therapeutic shoes or inserts: Nerve damage, circulation problems, and severe foot disease are common in some diabetes patients. For people with diabetes with certain foot conditions, Medicare Part B may cover foot exams, treatment, and therapeutic shoes or inserts. You pay 20% of the Medicare-approved amount for these services and supplies, subject to the Part B deductible.

Diabetes self-management training: Medicare Part B covers educational programs to teach patients with diabetes how to manage their condition with a written order from your doctor or other health care provider to a certified diabetes self-management education program. You’d pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Glaucoma tests: Medicare Part B covers a glaucoma (a type of eye disease) screening once every 12 months if you have diabetes. You’d pay 20% of the Medicare-approved amount, after the Medicare Part B deductible.

Other preventive screenings and services: If you have diabetes, you may be at risk for other health issues. Medicare Part B covers medical nutritional therapy, flu shots, and pneumococcal shots for diabetes patients. Because these are considered preventive services for people with diabetes, you pay nothing if your provider accepts Medicare assignment.

How private Medicare-approved insurance companies cover diabetes

Many people with diabetes require insulin or prescription drugs to control their condition. Original Medicare doesn’t include comprehensive prescription drug benefits, and the out-of-pocket costs for medications can get very expensive. However, you can get prescription drug coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage Prescription Drug plan.

A Medicare Advantage plan is a different way to get your Medicare Part A and Part B health coverage through private, Medicare-approved insurance companies, and may include other benefits on top of what Original Medicare covers. Under Medicare Advantage plans, hospice care is covered under Medicare Part A instead of through the Medicare Advantage plan. Check with the individual plan to see if it includes additional benefits for people with diabetes. Be aware that when you’re enrolled in a Medicare Advantage plan, you still need to keep paying your monthly Medicare Part B premium. You can find and compare Medicare plans right away; just enter your zip code in the box on this page to get started.

For more information, see: The Centers for Medicare and Medicaid Services, “Medicare’s Coverage of Diabetic Supplies and Services.”

 

...
Continue Reading