USA: Answers About Medicare: Part 3
By THE NEW YORK TIMES
Courtesy of the Medicare Rights Center
Joe Baker, president of the Medicare Rights Center, is taking reader questions on Medicare.“Ask an Expert” is a recurring feature on Bucks where you have the opportunity to question big-brained individuals about a particular area of personal finance or consumer affairs.
Our focus now turns to Medicare, the government health insurance program that covers Americans 65 and older. Many consumers are wondering how changes to the program in the new health care law will affect them. In recent months, our colleagues at the Prescriptions blog have answered reader questions including how the new health care law will affect Medicare prescription and generic drug coverage, whether Medicare will cover adult children, teenage children and spouses and how the program will be cut, among other subjects.
At the same time, many Americans turning 65 — or older Americans thinking about changing their coverage — are trying to figure out how to sort through a wide array of confusing materials to make sure they make the right decision. We decided to devote some time here at Bucks to reader questions about Medicare, in general, and we’ve asked Joe Baker, president of the Medicare Rights Center, to take your questions about Medicare.
Before becoming president of the Medicare Rights Center, a nonprofit organization that helps Medicare recipients understand their rights and benefits, Mr. Baker served as New York State deputy secretary for health and human services and directed the Health Care Bureau in the state attorney general’s office. He was also the executive vice president of the Medicare Rights Center from 1994 to 2001. Before that, he was associate director of legal services for Gay Men’s Health Crisis. He is a graduate of the University of Virginia School of Law.
He answered his first round and second round of questions earlier this month and the third installment can be found below. If you have a question, please submit it in the comment section of our original post.
Q.Why doesn’t Medicare have to follow the Mental Health Parity Act, which mandates that insurance plans cover both physical and mental ailments equally, including maximum limits on hospital stays? mileena, California
A.Medicare will cover office- and clinic-based therapy as well as services you receive in an outpatient hospital program, as long as your provider is one of the following:
• a general practitioner
• a nurse practitioner
• a physicians’ assistant
• a psychiatrist
• a clinical psychologist
• a clinical social worker
• a clinical nurse specialist
Medicare will help pay for the services of non-medical doctors (like psychologists and clinical social workers) only if the providers are Medicare-certified and take assignment, meaning that they accept Medicare’s approved amount as payment in full.
For your initial visit to a mental health professional to determine your diagnosis, and for brief appointments to manage your medications, Medicare pays 80 percent of its approved amount. For other appointments after your initial visit, Medicare pays 55 percent of its approved amount. You or your supplemental insurer are responsible for the remainder of the bill (20 percent or 45 percent coinsurance, respectively).
These are among the mental health services Medicare covers:
• Individual and group therapy.
• Family counseling to help with your treatment.
• Tests to make sure you are getting the right care.
• Activity therapies, like art, dance or music therapy.
• Occupational therapy.
• Training and education (like training on how to inject a needed medication or education about your condition).
• Substance abuse treatment.
• Laboratory tests.
• Prescription drugs that you cannot administer yourself, like injections that a doctor must give you.
You are correct that the Mental Health Parity and Addiction Equity Act of 2008 prohibits insurers from charging more for mental services than other services, but the law applies only to employment-based insurance plans. Thus, Medicare is not affected. But under the Medicare Improvement for Patients and Providers Act of 2008, Medicare coinsurance for mental health services will be gradually reduced over the next five years. This year and next year, consumers will pay 45 percent for most mental health services, in 2012, they will pay 40 percent, in 2013 they will pay 35 percent and by 2014, consumers will pay 20 percent — just as they do for most other services.
The Medicare improvement law will not change how Medicare covers inpatient mental health services. If you receive care in a psychiatric hospital, Medicare helps pay for up to 190 days of inpatient care in your lifetime. After you have reached that limit, Medicare may help pay for mental health care at a general hospital. Your out-of-pocket costs are the same in a psychiatric hospital as they are in any hospital. In February, Senators John Kerry and Olympia Snowe introduced the Medicare Mental Health Inpatient Equity Act, which would eliminate the 190-day limit on inpatient psychiatric hospital stays and cover inpatient psychiatric hospital stays much as it does all other hospital stays under Medicare. Congress has yet to take action on this legislation.
Q.I plan to move to the U.K. at least by the time I retire. Will I be covered by Medicare there? More generally, does Medicare cover emergencies when traveling abroad? Vickness, Los Angeles
A.If you are eligible and enroll in Medicare, it will only cover you while you are in the United States.
If you have Original Medicare, you can travel anywhere in the United States and its territories (this includes all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa and the Northern Mariana Islands) and get the medical care you need from almost any doctor or hospital. Medicare does not cover medical care you get outside the country. If you will be traveling to a foreign country and want insurance, we suggest you talk to your travel agent about special travel insurance.
The only exceptions in which Medicare may cover medical care you get outside of the United States are these:
• Medicare will pay for emergency services in Canada if you are traveling a direct route between Alaska and another state.
• Medicare will pay for medical care you get on a cruise ship if the ship is registered to the United States; the doctor is registered with the Coast Guard; and you get the care while the ship is in American territorial waters. This means the ship is in a port in the United States or within six hours of arrival at or departure from an American port.
• Medicare may pay for nonemergency in-patient services in a foreign hospital (and related physician and ambulance costs), if it is closer to your residence than the nearest American hospital that is available and equipped to treat your medical condition. This may happen if, for example, you live near the border of Mexico or Canada.
Some supplemental insurance, like Medigap plans, covers 80 percent of the cost of emergency care abroad during the first two months of a trip with a $250 deductible and up to $50,000 in a lifetime. We have created a chart that summarizes which plans offer this coverage.
Q.I have received Social Security Disability Insurance since its inception, as a result of multiple birth defects causing me to not be able to remain employed. I turn 65 in less than two years. What, if any, changes will occur in my benefits at that time? Charles, Colorado Springs, CO
A.Comment No. 22 to the original post is indeed correct. What the person is calling “enhanced benefits” are improvements to the Medicare program that are a result of health reform, and will be available to everyone with Medicare.
Q.My wife and I are brand new to Medicare. Due to the impossibility of understanding all of the options, we turned to a friend in finance for help. He ran our drugs and suggested a plan D that seems to be just fine. He also recommended a plan F Supplemental plan that stood out from other plan F’s. Now, I have someone telling me that I should have gone with a specific plan C (Advantage plan), instead of the plan F, since the Supplemental plan C would cost me nothing.
I am very skeptical of the plan C for the following reasons:
1) I can’t figure out how a free plan can provide the same coverage and have no or a smaller deductible. (if it sounds too good to be true, it probably is)
2) I had heard that the Advantage plans (like C) were going to be dropped and our financial adviser agreed. The Advantage plan C person says that if it does go away, I will have saved a significant sum of money (true if all else is equal) in the meantime and the politics will probably insure that it doesn’t happen any time soon.
3) Reading in some of the literature, it seems that if you go with an Advantage plan and don’t like it, you may not be able to switch back to the Supplemental plan.
4) There seems to be more provider resistance to Advantage plans than for Supplemental plans.
5) The specific Advantage plan C requires adherence to a provider network. The Supplemental plan F does not.
6) After a phone call to Medicare, I came away with the following advice: “If you go to an Advantage plan you lose your red, white, and blue Medicare card — you don’t want to do that — and the Advantage plans have lots of problems.”
Am I doing the right thing by sticking with the Supplemental plan F as opposed to switching to the Advantage plan C? If everything else was equal, the Advantage C plan would save us $180/month plus about $300/year in deductibles.
gdehuff, Columbus, MS
A.The question here is not so much about choosing between two plans, but a larger one that involves deciding how one wants to receive Medicare benefits. And cost is just one of the factors that determine whether the choice you make is the “best” one for you. It is important to understand your Medicare coverage choices and to choose your coverage carefully. How you choose to get your benefits can affect the quality of your care and the extent of your coverage. Let’s first review the options.
Original Medicare or a Medicare Private Health Plan
Medicare has different parts that cover inpatient services (Part A), outpatient services (Part B) and prescription drugs at the pharmacy (Part D).
When you become eligible for Medicare, you will have Original Medicare, the traditional fee-for service program offered directly through the federal government, unless you make another choice for how to get your benefits. In Original Medicare, you are covered for care at almost any doctor or hospital in the country.
People can also choose to get their Medicare benefits through a Medicare private health plan, like an H.M.O. or P.P.O. These plans, which are also called “Medicare Advantage” plans or Part C of Medicare, must offer at least the same benefits as Original Medicare, but can have different rules, costs and coverage restrictions. They can also offer extra benefits, like dental and vision care and gym memberships. You are generally only covered for the care you get from doctors, hospitals and other health care providers that are in the Medicare Advantage plan’s “network,” except in emergencies. If you travel frequently, or spend part of the year in a different area of the country, this may not be the best option for you. And keep in mind that doctors are allowed to leave a plan’s network at any time.
Everyone who has Medicare receives a red, white and blue Original Medicare card. If you have Original Medicare, you will show this card when you get services. If you choose to get your health benefits through a Medicare private health plan, you will still get an Original Medicare card but you will show your private plan card when you get services. No matter how you get your Medicare health benefits, keep the Original Medicare card as proof of your Medicare eligibility.
Now, to address your question about how Medicare Advantage plans can offer the same coverage while charging no or a smaller deductible. The government pays a subsidy to the private insurance companies to provide Medicare benefits to enrollees. The independent Medicare Payment Advisory Commission estimated in 2009 that Medicare Advantage plans were paid, on average, 14 percent more than it cost Medicare to serve the same people and in 2010, plans are paid, on average, 9 percent more. It is these subsidies that allow Medicare private health plans to offer lower premiums and extra benefits.
As a result of the health reform law that passed in March, payments to the private plans will gradually be reduced so that they are in line with the costs per person in Original Medicare. At the same time, Medicare Advantage plans that are proven to offer high-quality care will receive bonus payments. Whether an insurance company drops a Medicare Advantage plan remains to be seen. But insurance companies have dropped plans and added new ones to the Medicare Advantage marketplace every year, well before health reform became law.
Supplemental Plans for Original Medicare
Medicare supplemental insurance plans, also known as “Medigap” plans, are intended to fill gaps in Original Medicare. Neither Original Medicare nor Medigaps limit you to seeing doctors and hospitals in a network. Medigaps do not work with Medicare Advantage plans.
Medigaps can help cover Original Medicare deductibles, coinsurance and some additional benefits. If you do not have other supplemental coverage, like a retiree plan, you may want to consider purchasing a Medigap policy.
Medigap plans have standardized benefit packages, and the plans are labeled by letters — Plan A, Plan B, etc. Each Medigap plan pays for a particular set of benefits. The Plan F that you chose is one of the most popular type of Medigap plans. All Medigap plans must cover the following benefits:
• Hospital coinsurance coverage.
• 365 additional days of full hospital coverage.
• Full or partial coverage for the 20 percent coinsurance for doctor charges and other Part B services.
• Full or partial coverage for the first three pints of blood you need each year.
All plans that are sold after June 1 of this year must offer these basic benefits and also pay all or part of the hospice coinsurance for drugs and respite care. (People who bought Medigap plans before June 1 can keep them and their benefits will not change.) We have prepared charts that summarize the benefits covered in each type of Medigap plan: one for a summary of benefits for plans sold after June 1 and another for plans that were sold before June 1.
Not all plans are available in all areas of the country, and consumer protections and the rules governing the sale of Medigaps differ from state to state. Knowing when you have the right to buy a Medigap policy in your state is important, because there may be consequences if you miss this window of opportunity. If you do miss it, you may have limited choices of Medigaps, may only be able to enroll in a Medigap plan that costs more, or insurers may refuse to sell you a Medigap at all.
People who are buying Medigaps for the first time or who are considering switching Medigaps are advised to first call their State Health Insurance Assistance Program or Department of Insurance to (1) confirm that plans are required to sell them a new Medigap policy at that time; (2) get a current list of plans available in their area; (3) get information about the plans’ premiums; and (4) know the rules and protections in their state.
Under national law, you only have the right to buy a Medigap policy at certain times. All states must give people with Medicare, at minimum, the purchase protections offered under federal law. In all states, insurers must sell you a Medigap plan during the six months beginning the month you are both 65 or older and enroll in Part B, and also when you are within 63 days of losing or ending certain kinds of health coverage. A few states, like New York and Connecticut, give you much broader protections. Your rights are different depending on whether you are at least 65 years old or under 65. Again, it is important to know when you have the right to buy a Medigap policy to avoid potential complications.
Prescription Drug Coverage
Medicare’s drug benefit, also called Part D, is outpatient prescription drug coverage for anyone with Medicare. It is available only through private companies.
If you want Part D, you have to choose and enroll in a private prescription drug plan. If you have Original Medicare, you can choose a “stand-alone” prescription drug plan. If you want to receive your Medicare benefits through a Medicare Advantage plan and also want Part D, you should enroll in a Medicare Advantage plan that includes drug coverage.
Enrollment in Part D is optional and only allowed during approved enrollment periods. Keep in mind, however, that if you choose not to enroll in the Medicare drug benefit when you first become eligible and decide to enroll at a later date, you may have to pay a premium penalty.
Some people who are already enrolled in certain low-income assistance programs may be automatically enrolled in a Medicare drug plan and get financial assistance.
Questions to Ask When Considering Your Options
Choosing how you want to receive your Medicare benefits is a big decision, and you should ask questions to make sure you’re choosing an option that best suits your needs. Remember that an option that works well for a friend or even your spouse may not be the best one for you.
Here are some questions to ask if you are considering a Medicare Advantage plan:
• Will I be able to use my doctors?
• Are they in the plan’s network and are they taking new patients who have this plan?
• Do I need a referral from my primary care doctor to see a specialist?
• Are there higher co-payments for certain types of care, like hospital stays or cancer treatment?
• What service area does the plan cover?
If you are interested in enrolling in a Part D plan, use the Medicare Drug Plan Finder tool at www.medicare.gov or call 1-800-MEDICARE to review your options and get details. You should ask these questions as you compare plans:
• Does the plan cover all the medications I am taking?
• Does the plan require that I get special permission before it will cover the medication I need (like prior authorization or step therapy)?
• How much will I pay at the pharmacy (co-payments or coinsurance) for each drug I need? (Certain drugs may have high coinsurance.)
• Can I fill my prescriptions at the pharmacies I use regularly