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    Medicare Basics Today: Your One-Stop Source
    Medicare Basics Today: Your One-Stop Source
    Medicare Basics Today: Your One-Stop Source
    Ebook192 pages2 hours

    Medicare Basics Today: Your One-Stop Source

    By Florence M. Gogel

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    About this ebook

    What do you do if you receive a bill for a Medicare wellness exam or are charged for preventative care that should have been fully covered?

    Your response to such unwelcome surprisesas well as the many steps you take along the waycan have significant implications for your wallet and health care options.

    In this simple, one-stop guide to Medicare, the author draws on her more than thirty years of experience helping patients with their insurance and benefits coverage to help you respond to these and other scenarios. Learn how to:

    navigate questions related to eligibility and enrollment;

    avoid mistakes that limit health care options;

    evaluate differences among supplemental Medicare plans; and

    take cost-effective steps to promote physical and mental well-being.

    Medical providers are in the business of treating your healthnot serving as your insurance benefits adviser. Take charge of your wallet, understand recent changes to Medicare, and expand your treatment options with the essential guidance in Medicare Basics Today.

    LanguageEnglish
    PublisherArchway Publishing
    Release dateJul 23, 2018
    ISBN9781480863545
    Medicare Basics Today: Your One-Stop Source
    Author

    Florence M. Gogel

    Florence M. Gogel has specialized in medical insurance and benefits coverage for more than thirty years. Her experience ranges from private medical practices to hospitals and urgent care facilities, and she serves hundreds of patients on a regular basis. A native Texan, she lives in Harker Heights, Texas, with her husband and children. Visit me at www.florencemgogel.com.

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      Book preview

      Medicare Basics Today - Florence M. Gogel

      Medicare

      Basics Today

      Your One-Stop Source

      FLORENCE M. GOGEL

      41584.png

      Copyright © 2018 Florence M. Gogel.

      All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.

      This book is a work of non-fiction. Unless otherwise noted, the author and the publisher make no explicit guarantees as to the accuracy of the information contained in this book and in some cases, names of people and places have been altered to protect their privacy.

      Archway Publishing

      1663 Liberty Drive

      Bloomington, IN 47403

      www.archwaypublishing.com

      1 (888) 242-5904

      Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

      Any people depicted in stock imagery provided by Getty Images are models, and such images are being used for illustrative purposes only.

      Certain stock imagery © Getty Images.

      ISBN: 978-1-4808-6355-2 (sc)

      ISBN: 978-1-4808-6354-5 (e)

      Library of Congress Control Number: 2018946806

      Archway Publishing rev. date: 7/18/2018

      Contents

      Introduction

      Chapter 1 What Is Medicare?

      Chapter 2 What’s New In 2018?

      Chapter 3 Eligibility And Enrollments

      The Initial Enrollment Period

      Lack Of Employment Quarters:

      General Enrollment Period:

      Special Enrollment Period (Sep):

      Delaying Enrollment In Medicare,

      If There Are Special Circumstances

      Retiree Plan:

      Disability:

      Chapter 4 Medicare Premiums And Cost

      Chapter 5 Medicare Savings Programs/State

      Assistance Programs

      Chapter 6 Medicare Part A And Coverage

      Mental Health:

      Skilled Nursing:

      Home Health Services:

      Hospice Care:

      Chapter 7 Medicare Part B And Coverage

      Clinical Research Studies:

      Ambulance Services:

      Durable Medical Equipment (Dme):

      Mental Health Services:

      Medicare Part B may help cover the

      following outpatient medications:

      Chapter 8 Preventive Services/ Laboratory

      Testing Coverage

      Medicare Screenings Offered:

      Laboratory Criteria And Restrictions:

      Chapter 9 Medicare Part C (Medicare

      Advantage Plan) And Coverage

      Medicare Advantage Plan Enrollment Period:

      Medicare Advantage Disenrollment Period:

      There Are Different Types Of Medicare Advantage Plans Available:

      Chapter 10 Medicare Part D And Coverage

      Medicare Part D Plan Enrollment Period:

      Medicare Advantage Disenrollment Period:

      The 2018 Medicare Part D Plan’s Coverage Is As Follows:

      Chapter 11 Medigap Plans And Insurance

      Supplements

      Medigap Plans:

      Medigap Coverage Outside The United States:

      Medigap Enrollment Period:

      Medicare Supplements/Secondary Retiree Plans:

      Chapter 12 Medicare And Travel Coverage

      INTRODUCTION

      Medicare can be a nerve-wracking experience when trying to determine the best process and coverage. I understand how frustrating this can be. I have over thirty years’ experience working in the medical profession and specializing in insurance benefits. I have assisted and currently assist my patients with the selection process of interpreting and understanding this complex medical benefit. I hope this book will make it easier for you to navigate through and understand this complex process. This book breaks down the Medicare system into a simpler format, to assist you in making the correct decisions, whether or not you are just about to become Medicare eligible or currently have Medicare. This book will provide you with the tools you need to understand your Medicare benefits. Knowledge is power, and having power over your decisions and choices can eliminate costly errors.

      Common Errors

      The following are the most common errors I see when working with my patients.

      Believing more insurance is better than less

      Example: A common misconception among patients is that having more insurance will cover everything and eliminate all out-of-pocket costs. Unfortunately, it’s not that simple.

      • Too much insurance can hinder your treatment and does not necessarily eliminate all out-of-pocket costs for some or all of your medical services.

      • Here is an example of the number-one common mistake I encounter on a regular basis, involving patients who have the Original Medicare with a retiree plan. The patient changes his or her Original Medicare to a Medicare Advantage Plan and retains the retiree plan as secondary insurance.

      o A patient has Original Medicare and Tricare for Life. Both plans do not require a prior authorization. Tricare for Life covers both Medicare’s deductible and coinsurance on covered services. There is no cost to you, as long as the services are covered by Medicare. Tricare for Life offers prescription plans.

      o The patient switches Original Medicare to a Medicare Advantage plan. As a result, some tests, expensive injections, and infusions may require a prior authorization through the Medicare Advantage Plan. This causes a delay in treatment while waiting for the decision of the Medicare Advantage plan to approve the request.

      o The Medicare Advantage plan may deny the request, resulting in denial of treatment or test.

      o If the patient had stayed with Original Medicare and Tricare for Life, the covered service by Medicare and Tricare For Life would have been performed, and the patient would not have a delay.

      Conclusion: Signing up with too many plans can hinder your treatment. Always make sure the insurance plan you select provides you with sufficient coverage for both your medical and prescription health-care needs. If your existing insurance covers what you need, you do not need to add additional insurance.

      Bundling symptoms with your yearly Medicare wellness appointment

      Example: A common mistake made by Medicare patients is that during their yearly Medicare wellness exam, they also have their doctor treat them for symptoms of a current illness or chronic condition.

      • Be Advised! The yearly Medicare Wellness exam can only be 100 percent covered by Medicare Part B if the wellness visit is for prevention and screening exams for disease, Not for any treatment of an illness! During the Medicare Wellness exam, you cannot be symptomatic, i.e. (experiencing any signs or symptoms of an illness) and request treatment for an unstable chronic condition during the Medicare Wellness exam. Your doctor may need to charge an additional code in addition to your Medicare wellness visit. To be clear, you may be charged for any medical service or treatment that is not part of the Medicare Wellness exam!

      o The Wellness Exam will be 100 percent covered, but the physician can charge an additional code for the evaluation and management of the illness or the chronic condition if it requires testing, evaluation and medication management. Your doctor will code this charge with a modifier advising the insurance company that you were treated for something in addition to your wellness visit. The diagnosis code associated with this additional code will define which condition was treated. The second charge will go towards your Medicare Part B deductible of $183 and/or your 20 percent coinsurance. You may see two charges on your explanation of benefits (EOB) that you receive from Medicare after they process the claim.

      o To recap: The very act of the patient requesting an examination and treatment for any illness or an unstable chronic condition during a wellness visit, can add an additional charge which will result in a balance to be paid by the patient if he or she does not have a secondary insurance to cover that balance.

      Conclusion: The medical providers are in the business of treating your health and not to serve as your insurance benefits advisor! You need to know for yourself and understand how your insurance benefits works. Knowing in advance what is covered and what is not will help you avoid unnecessary charges. Please refer to Chapter 8 for more information and specific details.

      Enrolling in a Medicare Advantage Plan (Part C) when your particular health care situation requires high-end treatment for your medical conditions

      Example: Some of my patients have switched from original Medicare to a Medicare Advantage plan without researching how their high-end treatments are covered. A common example I encountered while working in the rheumatology clinic in Killeen was the following scenario.

      - A patient was diagnosed with osteoarthritis of the knee. The patient was given Visco supplementation knee injections. Visco supplementation injections is a procedure whereby a lubricating fluid is injected into the joint in the knee.

      - Medicare Part B covers this Visco supplementation injection without a prior authorization under the current benefits of a deductible and coinsurance. There is, however, a frequency restriction that requires this injection to be done every six months. If you have a secondary insurance, then depending on the benefits provided by the secondary insurance, it would probably cover a portion of the cost or the balance secondary to Medicare.

      - Medicare Advantage’s plan most likely will require a prior authorization for this type of injection and medication. This plan may have a preferred method for the treatment of the diagnosis of osteoarthritis of the knee.

      o The plan may have a preferred medication that they require the patient to use, and that might not be the same one you have been receiving.

      o The plan may have a different coverage and cost for the medication, as well as the administrative procedure. The procedure, however, may not be covered under the office-visit benefit. Sometimes an office visit has a copayment, but this procedure may fall under a deductible and/or a coinsurance.

      o The plan may not cover the medication under the Part B benefit on this plan but instead on the Part D prescription services. If so, you need to find out if you have to purchase the medication through the pharmacy and pay upfront and have it mailed to your medical provider to administer to you.

      o The plan may deny the prior authorization and the treatment and require you to try other treatment options first.

      Conclusion: Remember—before enrolling in any plans, find out what your coverage is for expensive treatments and how it will affect your treatment plan. If your plan requires a different option for your treatment than what you were receiving, check first with your medical provider to see if that option is sufficient for your medical treatment.

      Common Medical Terminology You Need to Know:

      Original Medicare—The traditional Medicare insurance offered by the government. It pays for services directly to your medical providers, facilities, or suppliers.

      Deductible—The amount of money your insurance requires you to pay up front for your medical services, prescriptions, and/or supplies before your insurance plan starts paying on your behalf.

      Coinsurance—A percentage of the cost that your insurance requires you to pay for your medical services, prescriptions, and/or supplies.

      Copay—A fixed amount that your insurance plan assigns to specific covered services that you are required to pay for those specific medical services, prescriptions, and/or supplies.

      Out of Pocket—The amount you will have to pay for covered medical

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