Category Archives: Medicare Tips

How Medicare Covers Durable Medical Equipment

Crutch-Wheelchair-Disability

Does Medicare Cover Medical Equipment at Home?

Once you are covered by Medicare Part B (medical coverage), it’s important to understand all your options when it comes to medical supplies and equipment at home. Part B doesn’t cover common medical supplies such as like toilet seats, bandages and gauze, but it does cover other supplies defined as durable medical equipment, also known as DME.

What is considered DME?

It is defined as medical equipment prescribed by your doctor for use in the home that can withstand repeated use, is used for a medical reason, and has an expected lifetime of at least three years. DME can only be prescribed to you by your doctor, and—depending on the type of equipment—you may be required to either rent it or buy it through Medicare.

Some eligible items include:

  • Blood sugar monitors
  • Blood sugar (glucose) test strips
  • Canes
  • Commode chairs
  • CPM machine
  • Crutches
  • Hospital beds
  • Infusion pumps and supplies
  • Manual wheelchairs and power mobility devices
  • Nebulizers and nebulizer medications
  • Oxygen equipment and accessories
  • Patient lifts
  • Sleep apnea and CPAP devices and accessories
  • Suction pumps
  • Traction equipment
  • Walkers

Medicare will only cover your DME if your doctors are enrolled in Medicare. So your first step is to ask if they are enrolled. To be enrolled in Medicare, there are strict standards doctors must meet. If they are not enrolled in Medicare, your DME will not be covered. It’s also important to ask your DME suppliers if they participate in Medicare. For the lowest costs, you will want to choose suppliers that are participating. If they are participating, they will accept the Medicare-approved cost for the equipment (also known as assignment) and will not overcharge you. If suppliers don’t accept assignment, there’s no limit on the amount they can charge you. Be aware that some suppliers may be enrolled in Medicare but aren’t considered “participating.”

To find Medicare-participating suppliers in your area, visit the Medicare Supplier Directory.


How does my Medicare Supplement Plan work with this?

How Medicare covers the different pieces of DME varies depending on the piece of equipment. Your Medigap Plan will help to cover all if not part of the 20% of the Part B Medicare-approved costs. Knowing what “letter plan” you have along with calling your provider will help you determine if you have to pay and how much with each piece of DME.


What if I have a Medicare Advantage Plan?

Medicare Advantage plans (like HMOs or PPOs) must cover at least the same level of coverage as Original Medicare. But as with most Advantage Plan coverage, your doctor and DME supplier must be in-network to be covered. How your Advantage plan covers each piece of equipment will vary—primarily in whether they cover it as a purchase or a rental. If you need DME and are in a Medicare Advantage plan, your first step would be to contact your plan provider and find out your options. Ask specifically if the equipment you need is covered and how much it will cost you.

Need more guidance on this topic?

We are here to help navigate you through the Medicare maze, customizing a plan to your situation that will get you where you need to be today while preparing for tomorrow. Griffin Insurance Solutions is an independent agency that offers plans from 15 different insurers. We understand that each client is a unique individual, and we want to help you find the best plan and the right insurer. We ensure that your options remain flexible so you can use the providers and doctors of your choice. We’ll happily address your questions and concerns and help you find the best plan for you. Contact us today for in-person appointment by email or phone at 919-704-6147 or 800-774-1434.


Sources:
https://www.medicare.gov/Pubs/pdf/10110.pdf

Annual Wellness Visit


https://www.medicare.gov/coverage/preventive-visit-and-yearly-wellness-exams.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

Medicare-Approved Annual Visits

doctor-with-patient-exam

So what is a Medicare Approved Annual Visit?

Medicare Part B (Medical Insurance) offers many services, but will it cover an annual physical? The short answer is no. The long answer is that Medicare Part B doesn’t cover an annual physical, but it does cover other annual visits to evaluate your health and discuss any concerns.

So what does it cover?

During your first year of enrollment in Medicare Part B, you’re going to schedule a ‘Welcome to Medicare’ appointment with your doctor. It is a one-time appointment offered to all those enrolled in Part B during your first 12 months of enrollment. The visit will be free of charge (no deductible or copay) if:

  1. You are enrolled in original Medicare. (Prior to the appointment, confirm that your doctor accepts the Medicare-approved payment as full payment, or you will be stuck paying it out-of-pocket.)
  2. Or, you are enrolled in a Medicare Advantage plan. (Prior to the appointment, confirm that you have chosen a doctor in the plan’s provider network.)

This ‘Welcome to Medicare’ visit is strictly to identify your current health status and establish a baseline to create a personalized health plan of action moving forward. You will need to provide your doctor with your medical records (including immunizations), your family health history, and a list of all current medications—over the counter and prescriptions.

During this visit, your doctor will:

  • Assess your vitals
  • Discuss your family medical history
  • Perform a simple vision test
  • Discuss relevant and serious health concerns
  • Possibly suggest future test and screening appointments to be scheduled

Although it seems very similar to a physical, it lacks the preventative services and tests that physicals include. This visit is strictly to document a snapshot of your current health for comparison with future visits and to potentially catch serious health concerns early. To understand exactly what is included in this visit, click here.

What about my yearly exam?

Although the ‘Welcome to Medicare’ appointment is a basic discussion and look into your health, you can have access to annual wellness visits in the years following. To be qualified for these yearly wellness visits, you must remain enrolled in Medicare Part B for more than 12 months. These annual visits serve as checkpoints to evaluate your health plan, discuss any concerns, and to confirm any changes in your plan. You doctor helps coordinate a schedule for appropriate preventative services and creates a list of risk factors and treatment options. To understand all preventative services offered by Medicare, refer to Your Guide to Medicare’s Preventive Services. It will break down each service by what’s covered, how often, and who is covered.

Some highlights from the guide linked above include full coverage for the following tests:

  • Lipid blood panel to check cholesterol every five years
  • Colorectal cancer screenings every 12 to 120 months (depending on the test)
  • Mammogram screenings once a year

If you need more frequent testing than outlined above, you could be charged the Part B deductible, copays, excess charges, and coinsurance. This is where Medigap comes into play. Medigap may cover all or part of these costs, including many deductibles and copays. To learn more about your options, click here.

Your takeaways?

Medicare will not provide you with an annual physical, but through Medicare Part B you can schedule your one time ‘Welcome to Medicare’ appointment and future annual wellness visits (after your first year of enrollment). Through these appointments, you and your doctor will discuss and create a personalized health plan based on your health and wellness needs and situation.

Need more guidance on this topic? We help hundreds of seniors every year navigate through the Medicare maze. With options from 15 different insurers, we can customize the right plan for your health and finances and help you today while preparing for tomorrow. We understand that each client is a unique individual, and we want to help you find the best plan and the right insurer. We ensure that your options remain flexible so you can use the providers and doctors of your choice. We’ll happily address your questions and concerns and help you find the best plan for you. Contact us today for in-person appointment by email or phone at 919-704-6147 or 800-774-1434.


Sources:
https://www.medicare.gov/Pubs/pdf/10110.pdf

Annual Wellness Visit


https://www.medicare.gov/coverage/preventive-visit-and-yearly-wellness-exams.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

How Medicare fits in if you’re still working

new vs old medicara cards 2018

Turning 65 and still working? What that means for your Medicare coverage.

Remember when 65 meant retirement? Well, the big birthday is here and you are still employed. But what does that mean for your healthcare coverage and Medicare?

Before we get into next steps, let’s review two important points:

  1.     If you have already filed for Social Security, you will be automatically enrolled in Medicare A and B when you turn 65. If you are covered by an employer plan (you or your spouse), you can potentially opt out of Part B coverage.
  2.     For almost everyone else, working or not, your Initial Enrollment Period (IEP) begins three months before you turn 65 and ends three months after you turn 65. Medicare will not notify you about this IEP so be proactive in reviewing your options. You may assume that your work plan will exempt you, but Medicare has several regulations and deadlines that affect that decision.

When you turn 65, you need to understand what your current plan covers and how it compares to Medicare’s coverage.

  • 1. Contact your benefits administrator or plan provider about your current insurance coverage. Acquire your coverage documentation, and ask questions that will allow you to directly compare your coverage with Medicare options, such as:

-How much does my current plan cost every month?

-How will my plan be affected if I enroll in Medicare?

-What have past employees in my position generally done?

  • 2. Familiarize yourself with what Medicare (Parts A, B, C, and D) covers and the costs associated with each (this page can help with that).
  • Third, if you’re married, note how the plans differ with spousal coverage. Understand that switching to Medicare could impact your spouse’s coverage.

 

So, what about the Parts of Medicare?

Medicare Part A: You have the option to enroll or delay enrollment in Part A, or “Hospital Insurance.” If you are thinking of enrolling, know that it is free for most people and it can pick up many services not covered by your current plan. By enrolling during your IEP, you could eliminate issues with future coverage. If you want to delay Part A coverage, you don’t need to do anything when you turn 65.

Regarding enrollment in Part A: If you have a Health Savings Account (HSA), your employer will likely stop contributing to the HSA plan once you are enrolled in Medicare. Be sure to be proactive and have the conversation with your benefits administrator or plan provider before you turn 65 so you do not run into any unnecessary complications.

Medicare Part B: The size of your employer will determine if you should consider enrolling in Part B, or “Medical Insurance.”

If your employer has 20 or more employees, your employer coverage will remain your primary insurer and you can delay Part B enrollment without penalty or gaps in coverage. If delaying enrollment, you don’t need to do anything when you turn 65. You have 8 months after leaving your employer to enroll in Part B through a Special Enrollment Period (SEP).

If your employer has fewer than 20 employees (19 or less), you should sign up for Part A and Part B when you’re first eligible because Medicare will be your primary insurer, no matter what. This means your employer coverage will become secondary, only picking up what Medicare cannot cover. If you do not enroll in Part B right when you’re eligible during your IEP, there will be a penalty and potential gap in coverage.

Regarding enrollment in Part B: There is a premium associated with enrollment whether it’s during your IEP or delayed enrollment. Your income will determine your premium and is outlined in this link: Part B Enrollment Premiums

 

What about Medicare Part C and D?

Medicare Part C (Medicare Advantage) – Part C, or Medicare Advantage, is an umbrella plan that includes all the services of Part A, B, and often prescription drugs. Key considerations to know with Medicare Part C if you’re still working include:

  • You might be better staying with your employer’s coverage to maintain the same physicians. With this plan, you will be required to choose care providers within restricted networks.
  • Medicare Advantage could cause you to automatically forfeit your employer’s plan. Due to this automatic forfeit, you’ll need to meet with your benefits administrator or plan provider prior to making any decisions.

Medicare Part D—Your employer may offer prescription drug coverage, but it must be deemed ‘creditable’ by Medicare. Creditable coverage can be defined as “as good as or better than the coverage provided by Medicare’s prescription drug benefit.” If this does not describe your coverage or your employer does not offer a plan, you will want to enroll as soon as you’re eligible. If you do not, there will be a late fee for enrollment. Note, you cannot buy both a Part C and Part D, however most Part C’s include Part D.

So what does all of this mean?

Overall, your current coverage, employer size, and Medicare premiums will help you choose the right plans. There are a lot of decisions to make when you turn 65 so if there’s anything you take away from this article, just know:

  • First, you need to contact your benefits administrator or plan provider and get educated on your current coverage. Understand how it will be affected by enrolling in the different parts of Medicare
  • To avoid penalties and coverage gaps, you’ll want to enroll in Medicare during your IEP. even while remaining on your employer’s plan. Medicare may not be your primary coverage, depending on the size of your employer and there are standard fees for Part B.
  • Lastly, don’t be afraid to ask questions. There are a lot of moving parts but asking questions and being knowledgeable about your choices ahead of time will help you find a plan that best fits your needs.

 

Need help navigating this process or customizing a plan? Griffin Insurance Solutions is an independent agency that offers plans from 15 different insurers. We understand that each client is a unique individual, and we want to help you find the best plan and the right insurer. We ensure that your options remain flexible so you can use the providers and doctors of your choice. We’ll happily address your questions and concerns and help you find the best plan for you. Contact us today for in-person appointment by email or phone at 919-704-6147 or 800-774-1434.

 

7 Services you didn’t know Medicare covered

 

7 Services you didn’t know Medicare covered

We all are familiar with Medicare as covering hospital and medical bills, but it covers a variety of Medicare services and tests that are less widely known.

 

 

1. Sleep studies
Do you think you’re suffering from sleep apnea or at least would like to be tested? Medicare actually covers the four categories of sleep tests and devices. As long as you get tested in a sleep lab facility and your doctor orders the test, Part B will cover the standard 80% (with your Medigap Plan covering the rest). It will even cover a 3-month trial of CPAP therapy.

 

 

 

 

2. Mammograms

In 2016, a study presented at the Radiological Society of North America concluded that cancer frequency did not decrease among women older than 74, and there was not a recommended age cutoff for when women should stop annual mammograms. For those with Part B, Medicare covers one yearly preventive mammogram test for all women over 40. It also covers additional diagnostic mammograms when your doctor has deemed it  medically necessary. So neither age nor cost should prevent you from these valuable screenings.

 

 

 

 

3. Over the border care

As a guiding rule, Medicare doesn’t cover health care (see page 57 of Medicare and You 2018 Handbook) when you’re outside the U.S., but there are a few exceptions for those who live near the borders of the US. When a foreign hospital is closer to you than the U.S. hospital, Medicare will cover your care for both standard visits and emergencies. There is also an exception for those U.S. citizens directly en route to Alaska through Canada; if there is an emergency in that situation, Medicare will cover your care in Canada.

 

 

 

 

4. Depression Screenings

older-man-with-depression-black-and-whiteDepression can often accompany other health problems. But it should not be considered part of the aging process: it’s a treatable medical condition, and Medicare will cover your care if you decide to seek diagnosis and treatment. As long as your appointment takes place in a primary care doctor’s office that can provide both follow-up treatment and referrals, Medicare will completely cover one depression screening. If you are diagnosed,  Medicare will cover your therapy with your doctor’s referral to a psychiatrist or counselor for treatment. Your prescriptions, of course, will either be covered by your Prescription Drug Plan or your Medicare Advantage plan.

 

 

 

 

5. Physical Therapy

In 2018, Congress lifted the calendar year limit caps on what Medicare will pay for occupational, physical, and speech pathology therapy. Stipulations? As usual, this service coverage hinges on your therapists confirmation that these services are medically necessary and reasonable. Once you reach $2,010, Medicare asks your therapist to confirm and explain the need for therapy to continue. Once you have that confirmation, you can continue your therapy fully covered. To read about the additional financial benchmarks that Medicare examines, click here.

 

 

 

 

6. Obesity Screenings

overweight-waistline-measurementMany seniors who find activity more difficult as they age may start gaining weight and leave the doctor’s office with instructions to start taking action. But losing weight becomes more of a challenge as you get older and heavier, and Medicare offers help for those who have a diagnosed BMI of over 30 (30< is considered obese). Services also include behavioral counseling sessions and therapy. Like many items on this list, in order for Medicare to cover it, your primary care doctor must refer you for them.

 

 

 

 

7. Foot Care

Now, Medicare won’t cover your next pedicure, but if you are having a foot ailment that can be medically identified and treated, Medicare will cover it. Common treatable ailments include bunions, hammer toes (also called a rotated toe: when there is abnormal bend in the middle joint), deformities, and heel spurs. Many seniors don’t seek treatment because many of these issues seem “minor,” but if they are causing you pain and discomfort (and they don’t fall under routine care, like callus removal), we encourage our clients to seek treatment because it’s covered.

 

Medicare covers many of these medical services with Part B, so since that is only 80%, your Medigap plan will cover the 20% left of the costs. Unhappy with your Medigap Plan coverage?

Griffin Insurance Solutions is an independent agency that offers plans from 15 different insurers. We understand that each client is a unique individual, and we want to help you find the best plan and the right insurer. We ensure that your options remain flexible so you can use the providers and doctors of your choice. We’ll happily address your questions and concerns and help you find the best plan for you. Contact us today for in-person appointment by email or phone at 919-704-6147 or 800-774-1434.

 

Top Five Questions have about Skilled Nursing Facility Care (and how Medicare bills you!)

doctor and nurse visiting senior woman at hospital

Top five questions seniors have about Skilled Nursing Facility (SNF) care (like how Medicare bills you!)

You’ve heard about the term SNF, and maybe you thought nursing home, but there’s a lot more to it.

1. What defines SNF?

An easy way to think of SNF is as a specialized type of care that only skilled RNs or therapists can provide to treat, manage, observe, and evaluate a high level of medical care. Most commonly, SNF patients are recovering from an illness, injury, or surgery. Facilities must meet certain requirements to be certified as an SNF, and sometimes hospitals are also SNF facilities.

Most people do not receive SNF care for very long, with an average stay of 28 days. SNF care is only designed to treat a health concern for as long as it requires daily care. For example, if you broke your leg, you would go to an SNF after being released from the hospital. The initial care you receive would be considered SNF because it requires staff members specializing in surgery recovery. After you no longer need specialized follow-up care, you would then receive custodial (everyday) care, if you still needed assistance.

Here’s another example of SNF care: You’re hospitalized for a stroke, after which you receive occupational therapy at an SNF in order to relearn impacted basic daily tasks (eating, writing, etc.). If your doctor decides that the occupational therapy treatment isn’t working and that you instead need assistance with basic daily tasks, you are switched to custodial care, which is not covered by Medicare. Depending on the decision you and your doctor make together, you may next receive custodial care in the same facility, be sent home, or be transferred to a facility specializing in daily custodial care. This is because SNF facilities are not meant for maintenance of a health issue but rather for improvement.

2. Is SNF care the same thing as an assisted living?

No. The important difference between a skilled nursing facility and, say, an assisted living facility, is that you receive specialized services at an SNF. These terms are often interchanged mistakenly, so it is important to check your sources when gathering information. Remember Medicare rarely covers custodial care, which can be thought of as help with basic personal tasks. These other non-SNF facilities offer mostly custodial care. Custodial care facilities may have some medical equipment on the premises and may even have some medically trained staff, but the purpose of the facility is different. If your care is defined more by assistance than treatment, then, by most counts, it won’t count as SNF care. Custodial care may sometimes appear medical but is not considered specialized; custodial care can range from assistance with meals to using eye droppers or help bathing. Medicare doesn’t cover custodial care and thus does not cover assisted living facilities.

3. How do you get SNF care covered by Medicare?

Medicare has a number of requirements for your stay at an SNF to be covered, which are all outlined on medicare.gov. The most important one for seniors is the requirement of a qualifying inpatient hospital stay. This means an inpatient hospital stay of three consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital (see our previous blog post to learn about inpatient status). The second most important point is that you must enter the SNF within 30 days of leaving the hospital. Click here to read the full list of requirements.

4. How does a benefit period play in?

As Medicare.gov puts it, a benefit period is “the way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services.” A benefit period refers to the length of time that Medicare covers your care. As an SNF patient, your benefit period lasts 100 days, which means that on day 101, you will pay out of pocket for your SNF care.

You are also allowed up to 30 days after you leave SNF care to re-enter an SNF if needed, without needing a new qualifying inpatient hospital stay. But if it’s been more than 30 days since you had SNF care, Medicare does have some particular requirements:

  • Longer than 30, but less than 60: Your current benefit period continues, but you are required to have another three-day qualifying hospital stay.
  • Longer than 60: It’s like starting over. You’ll need a new 3-day hospital stay, and you’re eligible for a new 100-day benefit period.

There’s no limit to the number of benefit periods you can use. As long as 60 days have passed, you’re starting fresh. And with every new benefit period, there’s a new deductible.

It is important to note that breaks in SNF care can happen even without moving facilities. If at any time your care transitions from specialized to custodial, that is technically a break in SNF care, in which case the countdown to 30 days begins. We recommend that if you are expecting to need SNF care and you have days left on your benefit period, try to re-enter within 30 days so you can avoid the expense and hassle of another inpatient hospital stay.

5. What will I pay?

If you have a Medicare Supplement, or Medigap Plan, in most cases, you shouldn’t have to pay anything out-of-pocket. Medicare covers your qualifying hospital stay except for the deductible—which your Medigap covers—and 100% of your SNF care for the first 20 days.

Starting on day 21, SNF care Medicare requires a daily copay, currently $167.50. Medigap plans C, D, F, F-high deductible, G, M, and N all cover 100% of the copay until day 100, when your benefit period ends.

Your 100th day in an SNF is the last day of your benefit period, and thus your Medicare coverage. On day 101, you start paying full cost out-of-pocket.

Conclusions?

With SNF care, the high costs can add up quickly without meeting Medicare’s hospital and benefit period requirements, so it’s important to stay informed. When you are discharged from the hospital after your qualifying stay into SNF care, a hospital liaison should coach you through your financial transition with Medicare. If you are in the process of being discharged and you haven’t received that help, you can and should ask for it. If you can, ask a loved one to be with you and ask questions and to help you keep track of your days for both your inpatient hospital and SNF stays.

If you have questions about your coverage or your Medigap plan, we can help provide guidance. Our clients trust us and refer us because of availability and willingness to give help and advice throughout the year, not just when it’s time to renew. Please call us at 800-774-1434 or email with any questions you have while navigating this complex process. Call an agent to help shop around for a Medigap Plan to help cover this cost.