Patricia Barry - Medicare For Dummies

Under this benefit, Medicare pays your doctor (or another authorized medical professional, such as a nurse practitioner) for a first counseling session of up to 30 minutes, and for further 30-minute sessions if you need them. There is no limit on the number of sessions, and they can take place in a variety of settings — doctors’ offices, hospitals, and nursing facilities, for example. If the counseling takes place during an annual wellness visit (which I describe in the earlier section on preventive care), the counseling is free, provided that the doctor accepts assignment. If you schedule a separate session outside the wellness visit, you pay the usual Part B co-pay and the Part B deductible is applied, unless you have supplemental insurance that covers these expenses.

Medicare does indeed cover pregnancy and childbirth. Are you astonished? That’s probably because you see Medicare as a program only for people way past childbearing age. But of course Medicare is also for much younger people who qualify through disability, and some of them become pregnant.

The relevant regulation in the Medicare Benefit Policy Manual explains the scope of coverage: “Skilled medical management is appropriate throughout the events of pregnancy, beginning with the diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.” Medicare also helps cover the cost of treatment for miscarriages and for abortions in circumstances where pregnancy is the result of incest or rape or would threaten your life if you went to term. It doesn’t cover elective abortion if you choose to terminate your pregnancy.

To receive hospital services, you need Part A hospital insurance. For doctors’ services and outpatient procedures (such as lab tests), you need Part B coverage. If you’re enrolled in Medicaid because your income is low, that program may pay some or all of your out-of-pocket Medicare costs, depending on your state’s eligibility rules. Medicaid may also pay for your infant’s medical care. But after the birth, Medicare doesn’t cover services for your baby at all.

What if you need a wheelchair, an artificial limb, an oxygen tank, or other items that help you function but really qualify as things rather than services or treatments? Medicare has a suitably bureaucratic name for these things — durable medical equipment — and its meaning is precise. Durable means long-lasting, and Medicare covers only items that will stick around awhile. With only a few exceptions, it doesn’t cover disposable items that you use once or twice and then throw away.

To get Medicare coverage for durable medical equipment, it must be

Medically necessary for you, not just convenient

Prescribed by a doctor or another primary-care professional

Not easily used by anyone who isn’t ill or injured

Reusable and likely to last for three years or more

Appropriate for use within the home

Provided by suppliers that Medicare has approved

Durable equipment is covered under Medicare Part B and includes walkers and crutches; scooters and manual and powered wheelchairs; commode chairs; hospital beds; respiratory assistance devices; pacemakers; artificial limbs and eyes (prosthetics); limb, neck, and back braces (orthotics); and many other items. Medicare also covers some supplies, such as diabetic test strips and lancets, but otherwise does not generally cover disposable items, such as catheters and diapers.

For some items — such as oxygen equipment or seat lifts that help incapacitated people get into or out of a chair — Medicare requires a doctor to fill out and sign a Certificate of Medical Necessity; without it, Medicare will deny coverage. In fact, to combat fraud and manage resources, Medicare is very picky about the evidence it requires for coverage — but your doctor and the supplier (not you) are responsible for providing this proof.

Medical equipment is most often rented, but some items may be purchased. In either case, Medicare Part B pays 80 percent, and you pay the remaining 20 percent (unless you have Medigap insurance that covers your share). That’s the breakdown in traditional Medicare if you use a supplier that accepts the Medicare-approved amount as full payment. Otherwise, you pay whatever the supplier asks. If you’re in a Medicare Advantage plan, coverage is the same, but you may have different co-pays; check with your plan for details.

For more information, and to find out how to select an approved supplier, see the official publication “Medicare Coverage of Durable Medical Equipment and Other Devices” at www.medicare.gov/Pubs/pdf/11045-Medicare-Coverage-of-DME.pdf .

Part D, Medicare’s program for covering prescription drugs, is a complicated benefit that resembles no other type of drug coverage ever devised. That’s why understanding how it works before plunging in is really important. This section focuses on the peculiarities of Part D coverage — how it can fluctuate during the year, how different plans have their own lists of drugs they cover, and which drugs are excluded from Part D and which must be covered.

It sounds crazy, but you may find yourself paying different amounts for the same medicines at different times of the year. That’s because Part D drug coverage is generally divided into four phases over the course of a calendar year. Whether you encounter only one phase or two, three, or all four depends mainly on the cost of the prescription drugs you take during the year — unless you qualify for Extra Help (see Chapter 4). Here’s the breakdown:

Phase 1, the annual deductible: If your Part D drug plan has a deductible, you must pay full price for your drugs until the cost reaches a limit set by law ($435 in 2020) and drug coverage actually begins. Many plans don’t charge deductibles or charge less than the limit. But if your plan has a deductible, this period begins on January 1 or whenever you start using your Medicare drug coverage.

Phase 2, the initial coverage period: This stage begins when you’ve met any plan deductible. Otherwise, it begins on January 1 or whenever you start using Medicare drug coverage. You then pay the co-payments required by your plan for each prescription, and the plan pays the rest. This period ends when the total cost of your drugs — what you’ve paid plus what your plan has paid — reaches a certain dollar limit set in law ($4,020 in 2020).

Phase 3, the coverage gap: This gap — often called the doughnut hole — begins when you hit the limit of initial coverage and ends if and when the amount you’ve spent out-of-pocket on drugs from the beginning of the year hits another dollar limit set in law ($6,350 in 2020).Until 2011, you would’ve had to pay 100 percent of the cost of your drugs in the gap. Now you pay a lot less because under the Affordable Care Act, the gap is gradually shrinking. In 2020, your plan will cover at least 5 percent of the cost of covered brand-name drugs, plus you’ll get a discount of 70 percent on brand-name drugs from the manufacturer, so the amount you will pay is 25 percent of the cost. Also, as of 2020, Medicare will cover 75 percent of the price for generic drugs for those in the coverage gap, so in 2020, you will pay only 25 percent for both generic and brand-name drugs. These discounts come partly from the drug manufacturers and partly from the government.What’s more, the 50 percent that the drug manufacturers contribute to the discounts on brand-name drugs counts toward the dollar out-of-pocket limit that gets you out of the gap; that is, you get credit for having paid full price even though you’re receiving the discount. But for any discounts funded by the government, such as those for all generic drugs and anything above 50 percent for brands, only what you pay counts toward getting out of the gap. (I explain the gap in more detail in Chapter 14.)