Medical Insurance Assistance Blog

Starting in 2011, if you have original Medicare you wil have NO coinsurance (20%) or deductible for certain preventive care services recommended by the US Preventive Services Task Force, as long as you see a doctor that accepts assignment.  NOTE:  These rules do NOT apply to Medicare Advantage Plans!!!

Services covered at 100% by Original Medicare are:

Diabetes Screening  —-  Medical Nutritional Therapy —- Blood Tests for Heart Disease —- Bone Mass Measurement —- Screening Mammograms —- Pap Smears, Pelvic Exams and Clinical Breast Exams —- Colon Cancer Screening —- Prostate Cancer Screening —- Flu Shot —- Pneumonia Vaccine —- Hepatitis B Vaccine —- Annual Wellness Visit —- A Welcome to Medicare Physical Exam

Medicare does NOT cover Shingles Vaccinations.  However; your Part D Drug Plan should cover the cost of the vaccination.  Any commercially available vaccine that is not covered by Part B should be covered by your Medicare prescription drug plan.

Before you get a vaccination, you should check with your Plan for coverage rules and see where you should get your shot so that it will be coverd for you at the lowest cost.

Be sure when you schedule your office visit with your doctor you tell them this is for your “Medicare Annual Wellness Visit”.  It must be filed this way in order to have it coveredat 100% by Medicare.

During the Annual Wellness Visit, you and your doctor will create and update a preventive care plan.  You doctor will also update your medical history, make a list of your current doctors and medications to take with you for you visit; create a 5 to 10 year screening schedule; identify health risk factors and discuss ways to possibly avoid them; check your height, weight, blood pressure and body mass index; and screen for cognitive issues.  In addition to what is covered at no cost to consumers during the annual wellness visit, other preventive services will also be free of charge under Medicare, including mammograms, colonoscopies and diabetic screenings.

Medicare will only cover the annual wellness visit  at 100 percent if you visit a doctor that accepts assignment of Medicare.  That means they accept Medicare rates as payment in full.  Doctors that do not accept assignment of Medicare can charge you 15% of the approved Medicare amount. 

NOTE:  The “annual wellness visit” is covered ONLY by ORIGINAL Medicare and the private Medicare health plans (Medicare Advantage) are NOT required to cover these charges.  However; CMS is considering requiring Medicare Advantage Plans to provide the same coverage for these services beginning in 2012.  The final rule has not yet been released.

If you have questions, call me 800-504-9501 or email. 

TAKE CARE!!   PAT

I can understand you having difficulty getting in and out of the shower and the need for the grab bars for safety reasons.  However; Medicare does NOT consider them to be “Durable” medical equipment.

In order for Medicare to over durable medical equipment (DME) it must meet these four criteria:

1)  It can withstand repeated use

2) It’s used for medical purposes

3) It’s usually not useful to a person who doesn’t have an illness or injury

4) You can use it in your home

Examples of DME is:  Wheelchairs, hospital beds, diabetic shoes, walkers and canes.

Medicare usually doesn’t cover supplies that you throw away after you use them.  Medicare also doesn’t cover items that anyone who doesn’t  have an illness could use in their home.  Home modification such as grab bars, ramps and door widening also aren’t covered by Medicare.

Part B of Medicare covers DME.  Medicare pays 80% of the cost of the DME.  If you live in North Carolina, South Carolina, Ohio, Kentucky, Indiana, Texas, Missouri, Kansas, Florida, Pennsylvania or California, you may need to get your DME from a specific provider for Medicare to cover it. 

Call Medicare 800-633-4227 for information about how Medicare covers DME in your state.

As with any insurance your have the right to appeal their decision.  You have legal rights to get the care you are entitled to regardless of which type of Medicare you choose.

It is not difficult to exercise your rights to an appeal.  If you have questions please call Medicare at 800-633-4227 or 800-Medicare.  They can tell you what you need to do.  The information and address for your appeal is also on the back of  your Medicare Summary Notice.

Or we can appeal for you…  Just give us a call at 800-504-9501 or email us.

If you have ORIGINAL Medicare you can travel anywhere in the United States and its territories and get the health care you need from any doctor or hospital that is accepts Medicare.  This includes all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa and the Northern Mariana Islands.

ORIGINAL Medicare does not usually cover care outside of the country.  An example of an exception to this would be if you are in the US and need EMERGENCY care and the closest hospital that can treat you is in Mexico or Canada.

NOTE:  If the doctor has opted out of Medicare completly, you must pay the FULL cost for the services.

For questions, please call 800-504-9501 or email me.  Take Care!! PAT PANE

With the Medicare Advantage Plans you must be very careful.  Some plans are not good outside of the county that you live in.   The best thing to do is to call you insurance carrier and ask them.  Tell them where you are planning to travel and if your insurance is good in those states/cities.   Every Medicare Advantage plan has different rules!!!   You should also ask if you were traveling outside of the US if your plan will cover you.  All plans must cover your care if you need EMERGENCY care.  Your charges for emergency room services must be NO more tha $50.00 or whatever you would have paid had you received the services in network.

If you have any questions, please call me at 800-504-9501