July's Medicare Column: Know Your Medicare Rights

Know Your Medicare Rights

 

By David Sayen

As a person with Medicare, you have certain rights and protections. And it’s worth knowing what they are.

You have rights whether you’re enrolled in Original Medicare – in which you can choose any doctor or hospital that accepts Medicare – or Medicare Advantage, in which you get care within a network of health care providers. Such networks are run by private companies approved by Medicare.

Your rights guarantee that you get the health services the law says you can get, protect you against unethical practices, and ensure the privacy of your personal and medical information. You have the right to be treated with dignity and respect at all times, and to be protected from discrimination.

You also have the right to get information in a way you understand from Medicare, your health care providers, and, under certain circumstances, Medicare contractors. This includes information about what Medicare covers, what it pays, how much you have to pay, and how to file a complaint or appeal. Moreover, you’re entitled to learn about your treatment choices in clear language that you can understand, and to participate in treatment decisions.

One very important right is to get emergency care when and where you need it -- anywhere in the United States.

If you have Medicare Advantage, your plan materials describe how to get emergency care. You don’t need permission from your primary-care doctor (the doctor you see first for health problems) before you get emergency care. If you’re admitted to the hospital, you, a family member, or your primary-care doctor should contact your plan as soon as possible. If you get emergency care, you’ll have to pay your regular share of the cost, or copayment. Then your plan will pay its share.

If your plan doesn’t pay its share, you have the right to appeal.

In fact, whenever a claim is filed for your care, you’ll get a notice from Medicare or your Medicare Advantage plan letting you know what will and won’t be covered. If you disagree with the decision, you have the right to appeal.

For more information on appeals, you can read our booklet “Medicare Appeals,” available at www.medicare.gov/Publications. Or call us, toll free, at 1-800-MEDICARE.

You can also file a complaint about services you got from a hospital or other provider. If you’re concerned about the quality of the care you’re getting, call the Quality Improvement Organization (QIO) in your state to file a complaint. A QIO is a group of doctors and other health care experts who check on and improve the care given to people with Medicare. You can get your QIO’s phone number atwww.medicare.gov/contacts or by calling 1-800-MEDICARE.

Many people with Original Medicare also enroll in Medicare prescription drug plans. Here, too, you have certain rights.

For example, if your pharmacist tells you that your drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you’re required to pay, you can request a coverage determination.

If the decision isn’t in your favor, you can appeal.

You can ask for an exception if you, your doctor, or your pharmacist believe you need a drug that isn’t on your drug plan’s list of covered medications, also known as a formulary.

 

You don’t need a lawyer to appeal in most cases, and filing an appeal is free. You won’t be penalized in any way for challenging a decision by Medicare or your health or drug plan. And many people who file appeals wind up with a favorable outcome.

This is a brief overview of your Medicare rights. For more details, read our booklet, “Medicare Rights and Protections,” at http://www.medicare.gov/Publications/Pubs/pdf/11534.pdf.

 

David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, and Nevada. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

June's Medicare column focuses on help for kidney disease

Medicare covers kidney disease

 

By David Sayen

 

A diagnosis of kidney failure could be a real shock. And it’s becoming more common as the number of Americans with diabetes and high blood pressure grows. But even with this serious diagnosis you can survive and move on. 

 

Medicare can help. The program helps pay for kidney dialysis as well as kidney transplants.

Chronic kidney disease is a serious health problem in the United States. In 2010, more than 20 million Americans aged 20 and older had this disease.

 

And in 2008, nearly 550,000 Americans were getting treated for end-stage renal disease, or ESRD, which is permanent kidney failure.

 

Most people have to be at least 65 years old to get Medicare. But people with ESRD can get Medicare at any age. Even children with ESRD can enroll in Medicare.

 

ESRD is treated by dialysis, a process which cleans your blood when your kidneys don’t work. It gets rid of harmful waste, extra salt, and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids.

 

Dialysis treatments help you feel better and live longer -- but they aren’t a cure for permanent kidney failure.

 

Medicare covers a number of things related to dialysis.

 

If you’re admitted to a hospital for special care, Medicare covers inpatient dialysis treatments under Part A, which is hospital insurance.

 

Medicare Part B covers outpatient dialysis treatments and doctors’ fees for outpatient care.

 

Part B also pays for self-dialysis training, which includes instruction for you and the person helping you with your home dialysis treatments.

 

And Part B covers home dialysis equipment and supplies – like the machine and water treatment system – as well as most drugs for home dialysis.

 

How much would you have to pay for dialysis in a Medicare-certified facility? If you have Original Medicare, you’d pay 20% of the Medicare-approved amount for all covered services.

 

Medicare pays the other 80%.

 

Dialysis and kidney transplants are paid through Original Medicare.

 

In most cases, you can’t join a Medicare Advantage plan if you have end-stage renal disease.

 

Keep in mind that dialysis can be done in your own home or in a Medicare-certified facility.

 

Ask your kidney doctor what facility he or she works with. Or you can look for a facility on Medicare’s “Dialysis Facility Compare” website.

 

It’s located at www.medicare.gov/dialysis.

 

The website has important information such as addresses and phone numbers, how far certain facilities are from you, and what kind of dialysis services the facilities offer.

 

You also can compare facilities by certain quality-of-care information.

 

If you don’t have a computer, you can call us, toll-free, at 1-800-MEDICARE (1-800-633-4227).

 

Medicare Part A also helps pay for hospital inpatient services if you need a kidney transplant.

 

Medicare will help cover the costs of finding the proper kidney for your transplant, and the full cost of care for your kidney donor.

 

For more details on transplants, please consult our pamphlet, “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services” (CMS Product No. 10128).

 

It’s available online or by calling 1-800-MEDICARE.

 

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

May Medicare Column by David Sayen

Medicare and Mental Health

 

By David Sayen

 

Mental health problems like depression and anxiety can affect anyone’s life at any age. If you think you have a mental health condition, Medicare may be able to help.

 

The symptoms of mental health issues include feelings of sadness, emptiness, or hopelessness; a lack of energy; and difficulty concentrating or sleeping. You might find yourself losing interest in activities you used to enjoy, or even having thoughts of ending your life.

 

If you have any of these symptoms, talk to your doctor or other health care provider.

 

Medicare’s coverage of mental health includes outpatient and inpatient treatment, as well as prescription drugs.

 

If you get your Medicare benefits through a Medicare Advantage health plan, check your plan’s membership materials. Or call the plan for details about your Medicare-covered mental health benefits.

 

If you have Original Medicare, Part A covers inpatient care and Part B covers outpatient care. Part D covers medications you may need.

 

Part A helps pay for mental health services given in a hospital that require you to be admitted as an inpatient. These services can be provided in a general hospital or in a psychiatric hospital that cares exclusively for people with mental health conditions.

 

How much do you pay? Medicare measures your use of hospital services in benefit periods. A benefit period begins the day you go into a hospital and ends after you’ve had no hospital care for 60 days in a row. If you go into a hospital again after 60 days, a new benefit period begins, and you must pay a new inpatient hospital deductible.

 

There’s no limit to the number of benefit periods you can have when you get mental health care in a general hospital. You can also have multiple benefit periods when you get care in a psychiatric hospital, but a lifetime limit of 190 days applies to inpatient psychiatric care.

 

For each benefit period, you pay a $1,156 deductible (in 2012) and no coinsurance for days 1–60. For days 61–90 of each benefit period, your cost would be $289 per day.

 

Medicare Part B helps cover services by doctors and other providers if you’re admitted as a hospital inpatient. You pay 20% of the Medicare-approved amount for these services while you’re an inpatient.

 

Part B also helps pay for outpatient visits to psychiatrists or other doctors; clinical psychologists, social workers, and nurse specialists; and other professionals. (Make sure your provider accepts Medicare payment before you schedule an appointment.)

 

Outpatient services are covered by Part B as well. These include psychiatric evaluation; medication management; individual and group psychotherapy with doctors or certain other licensed professionals; and family counseling if the main purpose is to help with your treatment.

 

For outpatient care, you’ll have to pay the Part B deductible, which is $140 this year. After that, how much you pay depends on whether the purpose of your visit is to diagnose your condition or to get treatment.

 

When you visit a doctor or other professional diagnostician, you pay 20% of the Medicare-approved amount.

 

For outpatient treatment such as psychotherapy, you pay 40% of the Medicare-approved amount in 2012.

(Recent legislation reduced these co-insurance amounts to keep them in line with other types of medical services; mental health co-insurance will drop to 35% next year and 20% in 2014.)

 

Part B also covers “partial hospitalization” in some cases. This is outpatient psychiatric treatment that’s more intense than the care you get in a doctor’s or therapist’s office. It’s provided during the day, usually through hospital outpatient departments and community mental health centers.

 

Many Medicare Advantage plans cover prescription drugs. If you have Original Medicare, you can join a Part D drug plan.

 

Medicare drug plans aren’t required to cover all drugs. However, they must cover all or almost all anti-depressant, anticonvulsant, and antipsychotic medications.

 

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

How Medicare covers hospice care

Monthly Medicare Column

By David Sayen

 

Coping with terminal illness can be very difficult, both for the patient and his or her loved ones.

 

That’s why I wanted to tell you about Medicare’s coverage for hospice care and how it works.

 

Hospice is a program of care and support for people who are terminally ill. The focus is on comfort, not on curing an illness.

Hospice is intended to help people who are terminally ill live comfortably.

 

If you qualify for Medicare’s hospice benefit, you’ll have a specially trained team and support staff available to help you and your family deal with your illness.

 

You and your family members are the most important part of the team. Your team may also include doctors, nurses, counselors, social workers, physical and occupational therapists, speech-language pathologists, hospice aides, and homemakers.

 

The hospice team provides care for the whole person. That includes his or her physical, emotional, and social needs. Hospice services are generally provided in the home and may include physical care, counseling, drugs, and medical equipment and supplies for the terminal illness, plus any related conditions.

 

Your regular doctor or a nurse practitioner can also be part of your team, to supervise your care.

 

Who’s eligible for Medicare-covered hospice services? You have to meet several conditions.

 

For one, you must be eligible for Medicare Part A, which is hospital insurance. Also, your doctor and the hospice medical director must certify that you’re terminally ill and have six months or less to live, if your illness runs its normal course.

 

You have to sign a statement choosing hospice care instead of other Medicare-covered benefits to treat your terminal illness. (Medicare will still pay for covered benefits for any health problems that aren’t related to your terminal illness.) And you must get care from a Medicare-approved hospice program.

 

If you qualify, your doctor and the hospice team will work with you and your family to set up a plan of care that meets your needs. A hospice doctor and nurse will be on call 24 hours a day, seven days a week to give you and your family support and care when you need it.

 

Medicare’s hospice benefit allows you and your family to stay together in the comfort of your home unless you need care in an inpatient facility.

 

Keep in mind that you have the right to stop hospice care at any time.

 

Medicare will pay for a one-time-only consultation with a hospice medical director or hospice doctor to discuss your care options and how to manage your pain and symptoms.

 

After that, Medicare covers doctor and nurse services; equipment such as wheelchairs or walkers; supplies such as bandages and catheters; drugs to control pain or other symptoms; hospice aide and homemaker services; physical and occupational therapy; and social worker services.

 

Medicare also covers dietary counseling; grief and loss counseling for you and your family; short-term inpatient care for pain and symptom management; and short-term respite care.

 

Respite care is designed to help the caregiver for a terminally person. Often a spouse or other family member becomes the caregiver, and at some point they may need a rest.

 

You can get inpatient respite care in a Medicare-approved facility (such as a hospice inpatient facility, hospital, or nursing home) if your caregiver needs a rest. You can stay up to five days each time. You can get respite care more than once, but it can only be provided on an occasional basis.

 

How much do you pay for hospice under Medicare?

 

There’s no deductible. You’ll pay no more than $5 for each prescription drug and similar products for pain relief and symptom control.

 

If you get inpatient respite care, you pay five percent of the Medicare-approved amount. For example, if Medicare pays $100 per day for inpatient respite care, you’ll pay $5 per day.

 

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

How the Health Reform Law improves Medicare

By David Sayen

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

 

We hear a lot of back and forth these days about the Affordable Care Act – aka the federal health reform law – but not much about how it affects people with Medicare.

 

When you sort through all the rhetoric, one thing is clear: the 2-year-old reform law contains some real benefits for those who get their coverage through Medicare.

 

Take the so-called “donut hole” in the Medicare prescription drug program, Part D.

 

The donut hole is a gap where you don’t have coverage even though you’re still paying premiums. After you’ve paid a certain amount out of pocket, your coverage resumes. Congress intended the hole to hold down costs in the drug program, the biggest expansion of Medicare benefits in many years.

 

Under the Affordable Care Act (ACA), the hole is being gradually closed until it completely disappears in 2020. This year, the law gives people with Medicare a 50-percent discount on covered brand-name drugs in the donut hole, and a 14-percent discount on covered generics.

 

In 2011, more than 65,000 Medicare beneficiaries in Arizona saved a total of $37 million in the donut hole. That’s an average savings of $563 per person.

 

The ACA also helps people with Medicare by eliminating coinsurance and deductibles on vital preventive health services. Such services can help keep people healthy and detect disease in its earliest, most treatable stages.

 

As a result, Medicare now offers a long list of preventive health services with no out-of-pocket costs, including screenings for cancer, diabetes, cardiovascular disease, osteoporosis, and shots for flu and pneumonia.

 

The health reform law also adds new preventive screenings and counseling for obesity, alcohol abuse, and depression.

 

More than 421,000 Arizonans with Medicare received at least one Medicare-covered preventive health benefit in 2011.

 

The health reform law also creates another important benefit for people with Medicare: annual wellness visits.

 

If you’ve had Medicare Part B for longer than 12 months, you can get a yearly wellness visit with your doctor to develop or update a personalized plan to prevent illness based on your current health and risk factors.

 

(The annual wellness visit is in addition to the one-time “Welcome to Medicare” preventive visit when you first enroll in Medicare.)

 

More than 57,000 Arizonans with Medicare took advantage of a wellness visit last year.

 

Because of financial incentives in the ACA, seniors also can expect to see better quality in their Medicare Advantage health plans. Such plans are operated by private insurers and generally require you to stay within a network of physicians and other providers or face higher out-of-pocket expenses.

 

Medicare Advantage plans that receive quality ratings of three stars or more under our Five-Star Rating System will get bonus payments. We believe the bonuses will motivate other plans to improve their quality as well.

 

Medicare Advantage plans that receive five stars – the highest rating – will be able to market to and enroll seniors year-round, not just during the open enrollment period in the fall. That means seniors can switch to the best plans at any time. (To check your plan’s rating, go to www.Medicare.gov.)

 

Lastly, the ACA provides a variety of new tools to crack down on Medicare fraud.

 

The law not only toughens federal sentencing guidelines for fraud (meaning crooks will spend more time in prison), it also allows us to suspend payments to providers suspected of trying to rip off Medicare.

 

In addition, we’re now using sophisticated predictive analytics software to identify patterns of fraud and target crooks. This is the same type of software credit card companies use to stop fraud.

Medicare is helping lead the Million Hearts campaign to prevent heart attacks and strokes

Reducing Your Risk of Heart Disease and Stroke

By David Sayen

Heart disease and stroke have reached epidemic levels in our country. Heart disease is the leading killer of Americans; stroke is the fourth leading killer. One of every three deaths in this county is caused by cardiovascular disease.

That’s why Medicare is helping to lead the Million Hearts campaign, a national initiative that aims to prevent 1 million heart attacks and strokes over the next five years. Because February is also American Heart Month, I wanted to tell you what Medicare is doing to help fight this serious public health problem. And what you can do to fight it, too.

Heart disease refers to several types of heart conditions. The most common one in the United States is coronary artery disease, which can trigger heart attack, severe chest pain, heart failure, and irregular heartbeat. Genetics, high blood pressure, high cholesterol, and lifestyle factors such as smoking, unhealthy diet, and lack of exercise can contribute to heart disease.

Stroke is a brain attack that occurs when blood flow to the brain becomes blocked. This can be caused either by a blood clot or by a burst blood vessel in or around the brain. Lack of blood flow during stroke can cause portions of the brain to become damaged, often beyond repair.

Thanks to the Affordable Care Act, Medicare recently began covering new preventive health services to help people with Medicare reduce their risk of heart disease and stroke.

Starting this year, Medicare will pay for one face-to-face visit each year so that Medicare beneficiaries can discuss with their care providers the best ways to help prevent cardiovascular disease.

The visit must be with your primary care provider, such as your family practice doctor, internal medicine doctor, or a nurse practitioner. And it has to take place in settings such as your primary care provider’s office.

During the visit, your doctor can screen you for high blood pressure and give you advice on how to eat a healthy diet. The idea is to empower people with Medicare to make heart-healthy lifestyle changes.

Medicare also now covers counseling to help people with Medicare lose weight if they’re obese. An estimated 30 percent of the men and women with Medicare are obese.

If you’re obese based on your body mass index, you’re eligible for face-to-face counseling sessions with your primary-care provider for up to a year.

In addition to the above services, Medicare pays for counseling to help people with Medicare stop smoking and to manage diabetes, which is a significant risk factor for cardiovascular disease.

The good news is that most major risk factors for heart disease and stroke are preventable and controllable. These factors include inactivity, obesity, high blood pressure, cigarette smoking, and high cholesterol.

What can you do to reduce your risk? A good first step is talking to your doctor about your heart health and getting your blood pressure and cholesterol checked. Many other lifestyle choices—including eating healthy, exercising regularly, and following your doctor's instructions about your medications—can help protect your heart and brain health.

Ask your doctor, too, if taking an aspirin each day is right for you.

For more information about the Million Hearts campaign, and about Medicare’s healthy-heart and other preventive health benefits, go to www.Medicare.gov.

If you’d like to check your 10-year risk of heart attack or dying from coronary heart disease -- and what you can do about it – go to the American Heart Association’s website, at www.heart.org. In the search box, type “heart attack risk calculator.”

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

Getting Medicare-covered health services at home

January Medicare Column by David Sayen

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories

 

 

Medicare covers a variety of heath care services that you can receive in the comfort and privacy of your home. These include intermittent skilled nursing care, physical therapy, speech-language pathology services, and occupational therapy.

 

Such services used to be available only at a hospital or doctor’s office. But they’re just as effective, more convenient, and usually less expensive when you get them in your home.

 

If you get your Medicare benefits through a Medicare Advantage health plan (instead of Original Medicare), check with the plan for details about how it provides your Medicare-covered home health benefits.  

 

To be eligible for home health services, you must be under a doctor’s care and receive your services under a plan of care established and reviewed regularly by a physician. He or she also needs to certify that you need one or more home health services.

 

In addition, you must be homebound and have a doctor’s certification to that effect. (Being homebound means leaving your home isn’t recommended because of your condition, or your condition keeps you from leaving without using a wheelchair or walker, or getting help from another person.) Also, you must get your services from a home health agency that is Medicare-approved.

 

If you meet the criteria, Medicare pays for covered home health services for as long as you’re eligible and your doctor certifies that you need them.

 

Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for Medicare to cover such care, it must be necessary and ordered by your doctor for your specific condition. You must not need full-time nursing care.

 

Skilled nursing services are given by either a registered nurse or a licensed practical nurse under an RN’s supervision. Nurses provide direct care and teach you and your caregivers about your care. Examples of skilled nursing care include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care. Any service that could be done safely by a non-medical person (or by yourself) without the supervision of a nurse, isn’t skilled nursing care.

 

Physical therapy, occupational therapy, and speech-language pathology services have to be specific, safe, and effective treatments for your condition.

 

Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you’ll have to pay for them. This should be explained by both talking with you and in writing. The agency should give you a notice called the Home Health Advance Beneficiary Notice (HHABN) before giving you services and supplies that Medicare doesn’t cover.

 

What isn’t covered? Some examples:

 

·       24-hour-a-day care at home;

·       Meals delivered to your home;

·       Homemaker services like shopping, cleaning, and laundry (when this is the only care you need, and when these services aren’t related to your plan of care);

·       Personal care given by home health aides like bathing, dressing, and using the bathroom (when this is the only care you need).

If your doctor decides you need home health care, you can choose from among the Medicare-certified agencies in your area. (However, Medicare Advantage plans may require that you get home health services only from agencies they contract with.)

 

One good way to look for a home health agency is by using Medicare’s “Home Health Compare” web tool, at www.medicare.gov/HHCompare. This tool lets you compare home health agencies by the types of services they offer and the quality of care they provide.

 

For more details on Medicare’s home health benefit, please read our booklet, “Medicare and Home Health Care.” It’s online at http://www.medicare.gov/publications/pubs/pdf/10969.pdf.

You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).