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What Is Assignment?

Assignment is an agreement between you, Medicare, and doctors, other health care providers, or suppliers. When you “assign” a claim to your doctor, Medicare will pay your doctor, provider, or supplier directly for the services you get.

If your doctor, provider, or supplier accepts assignment

Getting services and supplies from a doctor, provider, or supplier who accepts assignment can reduce your out-of-pocket costs.

Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. In some cases they must accept assignment, like when they have a participation agreement with Medicare and give you Medicare-covered services.

If a doctor, provider, or supplier accepts assignment, they agree to only charge you the Medicare deductible or coinsurance amount and will wait for Medicare to pay its share.

All doctors, providers, and suppliers that give you Medicare-covered services have to submit your claim to Medicare directly. They can’t charge you for submitting the claim.

If your doctor, provider, or supplier doesn’t accept assignment

They still must submit a claim to Medicare when they give you Medicare-covered services. If they don’t submit the claim for these services, you should contact the company that handles Medicare claims for your State to file a complaint. You can call 1-800-MEDICARE (1-800-663-4227) for their telephone number. TTY users should call 1-877-486-2048. In the meantime, you might have to pay the entire charge at the time of service, and then submit your claim to Medicare to get paid back.

They may charge you more than the Medicare-approved amount, but there is a limit called “the limiting charge.” They can only charge you 15% over the Medicare-approved amount (but may be lower in your state). The limiting charge applies only to certain services and doesn’t apply to some supplies and durable medical equipment.

How are Bills Paid in Original Medicare?

If you get a Medicare-covered service, like a lab test or doctor’s visit, you will get a Medicare Summary Notice (MSN) in the mail. The MSN shows all the services or supplies that were billed to Medicare during each 3-month period, what Medicare paid, and what you may owe the provider. The MSN isn’t a bill. When you get your MSN, you should do the following:

·         If you have other insurance, check to see if your other insurance covers anything that Medicare didn’t.

·         Keep your receipts and bills and compare them to your MSN to be sure you got all the services, supplies, or equipment listed.

·         If you pay a bill before you get your MSN, compare your MSN with the bill to make sure you paid the right amount for your services.

MSNs are mailed out every 3 months. If you are due a refund check from Medicare, the MSN will be mailed out as soon as the claim is processed. If you need to change your address on your MSN, call Social Security.  We have their contact information here, click here to go to the page.  

What if I have other health insurance?

Tell your doctor and hospital that you have other insurance so they will know how to handle your bills correctly. If you have Original Medicare and you have questions about how it works with your other insurance, or you need to update your other health insurance information, call the Coordination of Benefits Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782. 

What if I need a health care service or supply that Medicare doesn’t cover?

If you have Original Medicare and your health care supplier or provider thinks that Medicare probably (or certainly) won’t pay for certain services for you, the supplier or provider must tell you in writing. This is called an Advance Beneficiary Notice, or ABN, and it explains what items and services Medicare won’t pay for and why. You will be asked to choose an option on the ABN indicating whether you still want to get the service and to sign the ABN. If you choose to get the service listed on the ABN, you must agree to pay if Medicare doesn’t pay.

An ABN isn’t an official denial of coverage by Medicare. You can still ask your health care provider or supplier to submit the bill to Medicare. If payment is denied, you can file an appeal. If you aren’t sure if Medicare was billed for the services you got, call or write to the health care provider and ask for an itemized statement. This statement will list each Medicare item or service you got from your health care provider.  

What happens if Medicare doesn’t pay for a health care service or supply?

After you get a service or supply, your provider should bill Medicare. Later, Medicare will send you a Medicare Summary Notice (MSN) that describes the bills it got from your providers. The MSN will also tell you whether Medicare paid the bills. Read it carefully. If Medicare didn’t pay for a service or supply, and you think it should have, you have 120 days from the date you get the notice to file an appeal. The back of your MSN will have information on how to file an appeal.

If you are getting Medicare-covered services from a hospital (as an inpatient), skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your services are ending too soon, you may have the right to a “fast appeal.” This fast appeal is also called an “expedited determination.” An independent reviewer will decide if your services should continue. 

Protect Yourself and Medicare from Billing Fraud

Most doctors, pharmacists, plans, and other health care providers who work with Medicare are honest. Unfortunately, there may be some who are dishonest.

Medicare is working with other government agencies to protect you and the Medicare Program from such dishonesty. Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud takes a lot of money every year from the Medicare Program. You pay for it with higher premiums. A fraud scheme can be carried out by individuals, companies, or groups of individuals.

 The following are examples of possible Medicare fraud:

·         A health care provider bills Medicare for services you never got.

·         A supplier bills Medicare for equipment different than what they provided to you.

·         Someone uses another person’s Medicare card to get medical care, supplies, or equipment.

·         Someone bills Medicare for home medical equipment after it has been returned.

·         A company offers a Medicare drug plan that hasn’t been approved by Medicare.

·         A company uses false information to mislead you into joining a Medicare plan.

If you suspect billing fraud, here’s what you can do:

1. Contact your health care provider to be sure the bill is correct.

2. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

3. Call the Inspector General’s hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.   

Protect Yourself from Identity Theft

It’s also important to keep your personal information safe. You have control over when you provide and who you allow to have your personal information. 

Generally, no one should call you or come to your home uninvited selling Medicare-covered products. Don’t give your personal information to someone who does this. Only give personal information to doctors, other providers, and plans approved by Medicare, and to people in the community who work with Medicare, like your State Health Insurance Assistance Program (SHIP) or Social Security. Call 1-800-MEDICARE (1-800-633-4227) if you aren’t sure if a provider is approved by Medicare. TTY users should call 1-877-486-2048.

If you think someone is using your personal information, you can call any of these numbers:

·         1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

·         The Fraud Hotline of the HHS Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.

·         The Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338 to make a report. TTY users should call 1-866-653-4261. For more information about identity theft, visit www.consumer.gov/idtheft on the web 

The Senior Medicare Patrol Program Can Help You

The Senior Medicare Patrol (SMP) Program educates and empowers people with Medicare to take an active role in detecting and preventing health care fraud and abuse. There is a SMP Program in every state, the District of Columbia, Guam, U.S. Virgin Islands, and Puerto Rico. To find your state’s SMP Program, click here. 

When can I join a Medicare MSA Plan?

You can join a Medicare MSA Plan during the following times:  

--When you first become eligible for Medicare during the period that starts three months before the month you turn age 65 and ends three months after the month you turn age 65. If you have Medicare because you are disabled, you can join three months before and after your 25^th month of getting cash disability benefits.  

--The plan will tell you when your coverage will begin based on when during this period it received your request to enroll. 

--Between November 15 and December 31 of each year. Your enrollment will be effective on January 1 of the following year.

Note: There is a special enrollment period for people who join Medicare MSA Plans sponsored by an employer or union group. This special enrollment period may be used during the employer’s or union’s open enrollment period or at any other time that the employer or union allows enrollment. Your enrollment will be effective no earlier than the first day of the month following your request to enroll.  

How do I join a Medicare MSA Plan?

When and how can I leave a Medicare MSA Plan?

Enrollment is generally for a calendar year. You can choose to leave your current Medicare MSA Plan between November 15 and December 31 of every year. Your request to disenroll during this time will be effective on the following January 1st. However, in certain cases, such as if you enter a nursing home or move; you can leave your plan at other times. If you leave the plan before the end of the year, you may have to repay some of the money in your account. After you request to leave, your plan will let you know, in writing, the date your coverage ends. If you don’t get a letter, call the plan and ask for the date.   

If you want to leave your Medicare MSA Plan at the end of the year and return to Original Medicare, you need to contact your current plan, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.  

 If you want to leave your current Medicare MSA Plan at the end of the year to join a new Medicare Advantage Plan at the beginning of the year, simply join the new plan. You don’t need to tell your old plan you are leaving or send them anything. You will be disenrolled automatically from your old plan when your new plan coverage begins. You should get a letter from your new plan telling you when your coverage starts. Joining a Medicare Prescription Drug Plan won’t automatically disenroll you from your Medicare MSA Plan.Note: If you choose a Medicare MSA Plan for the first time and then change your mind, you can cancel your enrollment by December 15 of the same year. Contact the plan by December 15 if you would like to cancel your enrollment.  

Can my Medicare MSA Plan cancel my enrollment?

Your plan must cancel your enrollment if one of the following events occur:

·         You get Medicaid

·         You enroll in a Federal Employee Health Benefits Program plan

·         You get health care benefits from the Department of Defense (TRICARE) or the Department of Veterans Affairs

·         You get benefits that cover all or part of the yearly MSA deductible permanently

·         You move outside of the service area of the plan, or are temporarily out of the service area for longer than six months

What happens to the money in my account if I leave the plan before the end of the year?

If you leave your Medicare MSA Plan before the end of the year, no more money will be added to your account. Part of the most recent yearly deposit (based on the number of months left in the current calendar year) will have to be refunded to Medicare.

Will my spouse be able to use money in the account if I die?

Any funds in your account that were deposited before the current calendar year are part of your estate. Part of the most recent deposit (based on the number of months left in the current calendar year) will have to be refunded to Medicare. 

What if my beneficiary isn’t my spouse?

If you name a beneficiary for your account who isn’t your spouse, the money in it after your death is counted toward that person’s gross income when he or she files that year’s income tax return. If your estate receives the money in your account, it’s counted as gross income on your final tax return.

Medicare Part A

Medicare Part A helps cover your inpatient care in hospitals (critical access hospitals and inpatient rehabilitation facilities), skilled nursing facilities after a hospital stay, and Religious Nonmedical Health Care Institutions. Part A also helps cover hospice services and home health care services. Medicare doesn’t cover custodial or long-term care. You must meet certain conditions to get these benefits.

Cost: Most people are automatically enrolled in Part A and don’t have to pay a monthly premium if they or a spouse paid Medicare taxes while they were working. If you (or your spouse) didn’t pay Medicare taxes while you worked and you are age 65 or older, you may still be able to apply for Part A, but you will have to pay a premium. You pay up to $423 each month in 2010 if you don’t get premium-free Part A. This amount changes each year.

Medicare Part B

Medicare Part B helps cover medically-necessary services like doctors’ services, outpatient care, and other medical services that Part A doesn’t cover. Part B is optional. Part B helps pay for covered medical services and items when they are medically necessary.  Cost: Most people will pay the standard monthly Part B premium of $96.40 or $110.50 for 2010, but some people will pay a higher premium based on their income. If you are single (file an individual tax return) and your yearly modified adjusted gross income is more than $82,000 or if you are married (file a joint tax return) and it is more than $164,000, your monthly Medicare Part B premium may be higher than the standard premium. These amounts change each year.

Also, in some cases, your monthly premium amount may be higher if you didn’t sign up for Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn’t sign up for it. You will have to pay this extra amount as long as you have Part B, except in special cases. You can find out if you have Part A and/or Part B by looking at your Medicare card. Your card may look slightly different than the card below. It’s still valid. Keep this card safe. You will use this card to get your Medicare-covered services in Original Medicare.

Medicare Part C

Part C: Medicare Advantage Plans (like HMOs and PPOs) are sometimes referred to as Medicare Part C. There are private health plans that Medicare approved of to offer health care to eligible people. When you join a Medicare Advantage Plan, you are still in Medicare.

Medicare Advantage Plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services. They generally offer extra benefits, and many include Part D drug coverage. These plans often have networks, which mean you may have to see the plan's doctors and go to certain hospitals to get care. Medicare Advantage Plans can save you money, since out-of-pocket costs in these plans are generally lower than with Medicare alone. However, your cost will vary by the services you use and the type of policy you purchase.

Plans options can include:

· Medicare Preferred Provider Organization (PPO) Plans

· Medicare Health Maintenance Organization (HMO)

· Medicare Private Fee-For-Service (PFFS)

· Medicare Special Needs Plans (SNP)

· Medicare Medical Savings Account (MSA) Plans

You can generally join if:

· You live in the service area of the plan you want to join.

· You have Medicare Part A and Part B coverage.

· You don't have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)   

Medicare Part D

Medicare offers prescription drug coverage (Part D) for everyone with Medicare. To get Medicare Part D drug coverage, you must join a Medicare drug plan. Medicare drug plans are run by insurance companies and other private companies approved by Medicare. Each plan can vary in cost and drugs covered. Even if you don’t take a lot of prescription drugs now, you should still consider joining a Medicare drug plan.

If you join a Medicare drug plan, you usually pay a separate monthly premium in addition to your Part B premium. There are two ways to get Medicare prescription drug coverage:

· Join a Medicare Prescription Drug Plan. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

· Join a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan that includes prescription drug coverage. You get all of your Medicare coverage (Part A and Part B) and prescription drugs (Part D) through these plans. These plans are sometimes called “MA-PDs.”

Even if you wait to sign up for Medicare drug coverage, you won’t have to pay a late-enrollment penalty if you have been covered under certain other types of prescription drug coverage, called “creditable prescription drug coverage.” You may not have to pay a late-enrollment penalty if you join later and you have creditable coverage through another source. This could include drug coverage from a former employer or union, TRICARE, the Department of Veterans Affairs, or certain Medigap policies. Your current prescription drug coverage is required to tell you each year whether the drug coverage you have is creditable. Keep this annual notice, as you may need it if you decide to enroll in a Medicare drug plan later.

Your Yearly Medicare Review

EACH YEAR, MEDICARE PLANS CAN CHANGE WHAT THEY COST AND COVER. Every fall, all people with Medicare should review their current health and prescription drug coverage. Shop and compare to find the best plan for you.

IS YOUR PLAN STILL A GOOD PLAN FOR YOU?

Medicare can show you plans in your area that may:

· Cost less

· Cover your drugs

· Let you go to the providers you want, like your doctor or pharmacy

You can also get:

· An estimate of your out-of-pocket costs

· Quality and customer service ratings from current plan members

REMEMBER, MEDICARE PLANS CAN CHANGE EACH YEAR    IMPORTANT MEDICARE DATES

October—Review and Compare

Review: Your plan may change. Review any notices from your plan about changes for next year.

Compare: In mid-October, use Medicare’s tools to find the best plan for you.

November 15—Enrollment Begins

Decide: November 15 is the first day you can change your Medicare coverage for next year. This is the one chance each year most people with Medicare have to make a change to their health and prescription drug plans. Enroll as soon as possible—the sooner the better—to avoid any issues at the pharmacy counter in January.

December 31—Enrollment Ends

In most cases, December 31 is the last day you can change your Medicare coverage for next year.

January 1—Coverage Begins

Your new coverage begins if you switched to a new plan. If you stay with the same plan, January 1 is the date that any changes  to coverage, benefits, or costs for the new year will begin.

Things to consider before choosing a Medicare MSA Plan:

·         Medicare pays your monthly MSA Plan premium, but you must still pay your Medicare Part B premium amount.

·         If you use all of the money in your account, you will have to pay out-of-pocket for all of your health care costs until you meet your deductible. You need to be aware of which expenses count towards the deductible (only Medicare-covered Part A and Part B services count).

·         Medicare MSA Plans must cover all Medicare Part A and Part B services once you meet your deductible.

·         Some plans may offer additional benefits for an extra cost.

·         You must generally stay with the plan for a full calendar year except in certain cases, like when you permanently move out of the plan’s service area.

·         You have flexibility in choosing your health care services and providers.

·         Some plans may help you get information on the cost and quality of providers in your area.

Things to ask when choosing a plan

·         How much will be deposited in my account each year?

·         What is the plan’s deductible?

·         How are services counted against the deductible? Is there a limit on the charges that will count toward the deductible?

·         What am I responsible for paying after I meet the plan’s deductible?

·         Is other insurance offered to work with my plan, like dental, vision, or long-term care?

·         Is there any coverage of preventive services before meeting the deductible?

Things to ask when considering an alternative bank or financial institution

·         Are there any custodial fees? If so, how much are they and how are they collected?

·         Is there a minimum amount that I have to keep in my account?

·         How do I withdraw money from my account?

·         Will my account earn interest and, if so, how much?

What is a Medicare PPO Plan?

A Medicare PPO Plan is a Medicare Advantage Plan offered by a private insurance company. Medicare pays a set amount of money every month to the private insurance company to provide health care to people with Medicare. A Medicare PPO Plan has a list (called a “network”) of primary care doctors, specialists, and hospitals that you may go to. You can go to any doctor, specialist, or hospital not on the plan’s list, but it will usually cost more.

Some Medicare PPO Plans offer prescription drug coverage. Some plans also offer additional benefits, such as vision and hearing screenings, disease management, and other services not covered under the Original Medicare Plan. Monthly premiums and how much you pay for services vary depending on the plan.

There are two types of Medicare PPO Plans:

· Regional Preferred Provider Organizations Plans—these plans serve one of 26 regions decided by Medicare (these may be a single state or multi-state area)

· Local Preferred Provider Organizations Plans—these plans serve the counties the PPO Plan chooses to include in its service area

Regional PPO Plans have an added protection for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) benefits. There is an annual limit on your out-of-pocket costs. This limit varies depending on the plan.

Note: You can get your Medicare prescription drug coverage from your Medicare PPO Plan if your plan offers prescription drug coverage. Insurance companies offering a Medicare PPO Plan are required to offer a plan that includes Medicare prescription drug coverage. If you join a Medicare PPO Plan that doesn’t include such coverage, you can’t join a Medicare Prescription Drug Plan.

How do Medicare Preferred Provider Organization (PPO) Plans work?

· Each plan has a list (called a “network”) of doctors, hospitals, and other providers that you may go to.

· Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.

· You may get care from specialists without a referral or prior authorization from another doctor. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

· Each plan may choose to offer a discount to members if they voluntarily use preauthorization or if they pre-notify the plan when getting out-of-network services.

· You get all services covered under Medicare Part A and Part B, although the amount you pay for these services might not be the same as under the Original Medicare Plan.

· Each plan can charge you a monthly premium amount above and beyond the Medicare Part B premium.

· Each plan can charge deductible and coinsurance amounts that are different than those under the Original Medicare Plan.

· In a Regional PPO Plan, you have an added protection for Medicare Part A and Part B benefits. There is an annual limit on your out-of-pocket costs. This limit varies depending on the plan.

· Medicare PPO Plans operate like Health Maintenance Organizations (HMOs) except in HMOs you can only go to doctors, hospitals, and specialists that are part of the plan’s network, and often HMOs require referrals and pre-authorizations.

How are Medicare Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), and the Original Medicare Plan different?

Click here to download an Excel file that will give you the essential differences between HMO's, PPO's and Original Medicare.

What are the costs of being in a Medicare PPO Plan?

In a Medicare PPO Plan, you pay the following:

· The monthly Medicare Part B premium ($96.40 or $110.50 in 2010)

· A monthly premium that includes coverage for Part A and Part B benefits, prescription drug coverage (if offered), and extra benefits (if offered) above the Medicare Part B premium

· Any plan deductible, coinsurance, or copayment amounts that the plan charges. For example, the plan may charge a set amount (copayment) of $10 or $20 every time you see a doctor.

· A maximum amount (cap) you have to pay for out-of-pocket costs for both in- and out-of-network care in a Regional PPO. In a local PPO, the PPO Plan may or may not choose to have a cap.

Example: Mrs. Smith is thinking about joining a Medicare PPO Plan. The PPO Plan has a $75 monthly premium, but covers additional benefits the Original Medicare Plan doesn’t cover. To be in the plan, Mrs. Smith would have to pay the monthly Medicare Part B premium ($96.40 or $110.50 in 2009) and the additional monthly premium ($75) the plan charges. This plan also charges $10 for every doctor visit. If Mrs. Smith goes to her in-network doctor three times in one month, she would have to pay $96.40 (or $110.50) to Medicare, $75 to her PPO Plan, and $30 ($10 per visit) to her doctor for that month. Her total costs for that month would be $201.40 ($96.40 + $75 + $30). 

How do out-of-pocket costs vary?

Medicare PPO Plans differ in the amount they charge for premiums, deductibles, and services. The PPO Plan (rather than Medicare) decides how much you pay for the covered services you get. Contact the plan before you get services to find out how much you will have to pay and if the service you want is covered.

Generally, you will get more benefits for lower costs than the Original Medicare Plan. However, you may be able to get extra benefits for an additional premium. Every Medicare PPO Plan must pay for all medically-necessary covered services, but every plan is different in what you must pay. Contact the Medicare PPO Plan you are interested in to find out more.

Your costs depend on the following:

· Which Medicare PPO Plan you choose

· Whether the plan charges an additional monthly premium

· Whether the doctors, hospitals, and other providers you go to are part of or outside of your plan’s network

· How much the plan charges per visit

· How often and the type of health care you get

· Which extra benefits are covered by the plan

Who can join a Medicare PPO Plan?

You can generally join if you meet these conditions: 

· You have Part A and Part B.

· You live in the service area of the plan.

· You don’t have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Note: In most cases, you can join a Medicare PPO Plan only at certain times. 

When can I join, switch, or drop a Medicare PPO Plan?

You can join, switch, or drop a Medicare PPO Plan at the following times:

1. When you first become eligible for Medicare (3 months before you turn age 65 to 3 months after the month you turn age 65)

2. If you get Medicare due to a disability, you can join during the3 months before to 3 months after your 25th month of disability benefits.

3. From November 15–December 31 each year. Your coverage will begin on January 1 of the following year.

4. From January 1–March 1 of each year. However, you can’t add or change to a plan with prescription drug coverage during this time unless you already have Medicare prescription drug coverage.

Note: In certain situations, you may be able to join, switch, or drop Medicare Advantage Plan sat other times (like if you move out of the service area, have both Medicare and Medicaid, or live in an institution). 

How do I join a Medicare PPO Plan?

Once you choose a Medicare PPO Plan, you may be able to join by completing a paper application, calling the plan, or enrolling online. Talk with the plan to find out how you can join. When you join a Medicare PPO Plan, you will have to provide your Medicare number from your Medicare card and the date your Medicare Part A and/or Part B coverage started. 

How do I switch Medicare PPO Plans?

If you are already in a Medicare Advantage Plan and want to switch during the times listed earlier, this is what you need to do: 

· To switch to the Original Medicare Plan, contact your current plan or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

· To switch to a new Medicare Advantage Plan, simply join the plan you choose during one of the periods listed previously. You will be disenrolled automatically from your old plan when your new plan’s coverage begins.

Remember, no one should call you or come to your home uninvited to sell Medicare-covered products.

What if I move out of the plan’s service area?

If you permanently move out of the plan’s service area, you may have to switch to another plan. However, you can call your current plan to see if you can stay with them even though you have moved. If you must switch to another plan, you can choose to join another Medicare Advantage Plan or another Medicare Health Plan if one is available in your new area, or you can also return to the Original Medicare Plan. If you move out of the plan’s service area and don’t join a new plan, you will automatically return to the Original Medicare Plan. 

What happens if my Medicare PPO Plan leaves the Medicare Program?

If your Medicare PPO Plan leaves the Medicare Program, the plan will send you a letter about your options. Generally, you will be automatically returned to the Original Medicare Plan if you don’t choose to join another Medicare Advantage Plan. You will also have the right to buy a Medigap Policy.

What services must a Medicare PPO Plan cover?

A Medicare PPO Plan must cover all benefits covered by Medicare Part A and Part B. A PPO Plan must also cover all medically-necessary benefits such as emergency services. They may also cover extra benefits, such as extra days in the hospital—but you may have to pay more for these extra benefits. 

How do I know if a service I need is medically necessary?

A Medicare PPO Plan must use Medicare’s coverage rules to decide what services are medically necessary. This means that if a service is medically necessary under the Original Medicare Plan, then the PPO Plan also must cover the service. 

Can I get care when I travel or am away from the plan’s service area?

You can get care anywhere in the United States. Remember, if you get care for a non-plan provider, your costs will generally be higher. However, you won’t have to pay more if you are getting care for a medical emergency.

Medigap (Medicare Supplement Insurance) 

Original Medicare pays for many health care services and supplies, but there are many costs it doesn’t cover. To help cover health care costs, you might want to buy a Medigap (Medicare Supplement Insurance) policy. Medicare doesn’t pay any of the costs for a Medigap policy. 

A Medigap policy is health insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage. Medigap policies help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services, and some policies cover certain costs not covered by Original Medicare.

Help from Your State

States have programs for people with limited income and resources that pay Medicare Part A and/or Part B premiums, and in some cases, may also pay Medicare deductibles and coinsurance.

 How do I qualify for these programs?

·         You must have Medicare Part A. (If you are paying a premium for Medicare Part A, these programs may pay the Medicare Part A premium for you.)

·         You must be an individual with resources of $4,000* or less, or a married couple with resources of $6,000* or less. Resources include things like money in a checking or savings account, stocks, and bonds, but doesn’t include things like your home or car.

·         You must be an individual with a monthly income of less than $1,190*, or a married couple with a monthly income of less than $1,595*.

Many states figure your income and resources differently, so you may be eligible in your state even if your income is higher.

*These amounts may change each year. If you live in Alaska or Hawaii, income limits are slightly higher. Individual states may have higher income and/or resource limits. 

Medicaid

If your income and resources are limited, you may qualify for full coverage under Medicaid. Most of your health care costs are covered if you have both Medicare and full coverage from Medicaid. Medicaid is a joint Federal and state program that helps pay medical costs for some people with limited income and resources.

Medicaid programs vary from state to state. People with Medicaid may get coverage for services like nursing home care and home health care that aren’t fully covered by Medicare. For more information about Medicaid, call your State Medical Assistance (Medicaid) office. To get the telephone number, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.  

Extra Help Paying for Medicare Prescription Drug Coverage

If you have limited income and resources, you may qualify for extra help paying your prescription drug costs. If you qualify, you will get help paying for your drug plan’s monthly premium, yearly deductible, and prescription copayments. 

The amount of extra help you get will be based on your income and resources (including your savings and stocks, but not counting your home or car). In 2009, you may qualify if your monthly income is less than $1,300 ($1,750 for a married couple living together), and your resources are less than $11,990 ($23,970 for a married couple living together). 

Social Security sends people with certain incomes an application for this extra help. If you get this application, fill it out and send it back to Social Security as soon as possible. If you don’t get an application, but think you may qualify, call 1-800-772-1213, visit www.socialsecurity.gov on the web, or apply at your State Medical Assistance (Medicaid) office. TTY users should call 1-800-325-0778. After you apply, you will get a letter in the mail letting you know if you qualify, how much extra help you will get, and what you need to do next.

You automatically qualify for extra help and don’t need to apply if you meet any of the following conditions:

·         You have Medicare and full Medicaid coverage.

·         You get Supplemental Security Income (SSI) benefits.

·         You get help from your state Medicaid program paying your Medicare Part B premiums (belong to a Medicare Savings Program).

What are Programs of All-inclusive Care for the Elderly (PACE)? 

PACE is a Medicare program for older adults and people over age 55 living with disabilities. This program provides community-based care and services to people who otherwise need nursing home level of care. PACE was created as a way to provide you, your family, caregivers, and professional health care providers’ flexibility to meet your health care needs and to help you continue living in the community.

An interdisciplinary team of professionals will give you the coordinated care you need. These professionals are also experts in working with older people. They will work together with you and your family (if appropriate) to develop your most effective plan of care. 

PACE provides all the care and services covered by Medicare and Medicaid, as authorized by the interdisciplinary team, as well as additional medically-necessary care and services not covered by Medicare and Medicaid. PACE provides coverage for prescription drugs, doctor care, transportation, home care, checkups, hospital visits, and even nursing home stays whenever necessary. With PACE, your ability to pay will never keep you from getting the care you need 

Who can join a PACE Plan?

You can join PACE if you meet the following conditions:

·         You are 55 years old or older.

·         You live in the service area of a PACE organization.

·         You are certified by the state in which you live as meeting the need for the nursing home level of care.

You are able to live safely in the community when you join with the help of PACE services.  Note: You can leave a PACE program at any time 

PACE services include but aren’t limited to the following: 

·         Primary Care (including doctor and nursing services)

·         Hospital Care

·         Medical Specialty Services

·         Prescription Drugs

·         Nursing Home Care

·         Emergency Services

·         Home Care

·         Physical therapy

·         Occupational therapy

·         Adult Day Care

·         Recreational therapy

·         Meals

·         Dentistry

·         Nutritional Counseling

·         Social Services

·         Laboratory / X-ray Services

·         Social Work Counseling

·         Transportation

PACE also includes all other services determined necessary by your team of healthcare professionals to improve and maintain your overall health. 

The Focus is on You

You have a team of health care professionals to help you make health care decisions. Your team is experienced in caring for people like you. They usually care for a small number of people. That way, they get to know you, what kind of living situation you are in, and what your preferences are. You and your family participate as the team develops and updates your plan of care and your goals in the program. 

PACE Covers Prescription Drugs  

PACE organizations offer Medicare Part D prescription drug coverage. If you join a PACE program, you’ll get your Part D-covered drugs and all other necessary medication from the PACE program.

Note: If you are in a PACE program, you don’t need to join a separate Medicare drug plan. If you do, you will lose your PACE health and prescription drug benefits. 

PACE Supports Family Caregivers

PACE organizations support your family members and other caregivers with care giving training, support groups, and respite care to help families keep their loved ones in the community. 

PACE Provides Services in the Community

PACE organizations provide care and services in the home, the community, and the PACE center. They have contracts with many specialists and other providers in the community to make sure that you get the care you need. Many PACE participants get most of their care from staff employed by the PACE organization in the PACE center. PACE centers meet state and Federal safety requirements and include adult day programs, medical clinics, activities, and occupational and physical therapy facilities.

PACE is Sponsored by the Health Care Professionals Who Treat You

PACE programs are provider sponsored health plans. This means your PACE doctor and other care providers are also the people who work with you to make decisions about your care. No higher authorities will overrule what you, your doctor, and other care providers agree is best for you. If you disagree with the interdisciplinary team about your care plan, you have the right to file an appeal. 

Preventive Care is Covered and Encouraged

The focus of every PACE organization is to help you live in the community for as long as possible. To meet this goal, PACE organizations focus on preventive care. Although all people enrolled in PACE are eligible for nursing home care, only 7% live in nursing homes. 

PACE Provides Medical Transportation

PACE organizations provide all medically-necessary transportation to the PACE center for activities or medical appointments. You can also get transportation to appointments in the community. 

What You Pay for PACE Depends on Your Financial Situation  

If you qualify for Medicare, all Medicare-covered services are paid for by Medicare. If you also qualify for your State’s Medicaid program, you will either have a small monthly payment or pay nothing for the long-term care portion of the PACE benefit. If you don’t qualify for Medicaid you will be charged a monthly premium to cover the long-term care portion the PACE benefit and a premium for Medicare Part D drugs. However, in PACE there is never a deductible or copayment for any drug, service, or care approved by the PACE team.

Abdominal Aortic Aneurysm Screening

Medicare Part B covers a one-time screening ultrasound for people at risk. Medicare only covers this screening if you get a referral for it as a result of your “Welcome to Medicare” physical exam.

In 2010 YOU pay 20% of the Medicare-approved amount. The Part B deductible doesn’t apply.