Adirondack Health Institute News

Six Important Reminders About Medicare

From the Medicare Rights Center – Getting Medicare right

1.  Choose Wisely – Choose wisely when you decide what kind of Medicare coverage you want. There are two ways to get Medicare health benefits: through Original Medicare or Medicare Advantage.

Original Medicare – This is health insurance from the government. It’s what most people choose. Its lets you go to almost any doctor or hospital. Many people chose to buy supplemental insurance (Medigap plans) to help cover coinsurance and deductible costs.

Medicare Advantage - Private insurance companies sell Medicare Advantage plans. They’re often HMOs or PPOs. They cover Medicare benefits, but each plan has its own rules and costs. These rules may restrict which providers you can see and require you to get permission before you can receive certain services.

Most people must stay with their choice for the calendar year. Make sure it meets your needs and works with your other drug and health insurance.

2.  “B” Careful

Part B is the part of Medicare that covers outpatient services and doctor’s visits.

Generally, you should sign up for Part B when you first become eligible for Medicare. If you are working, check with the Social Security Administration to find out if your current employer insurance is primary to Medicare. If it is, you may consider delaying enrollment into Part B, but you must sign up as soon as you stop working.

If you don’t sign up for Part B when you should, you may have gaps in your coverage. You may also have to pay a penalty.

3.   Prescription for Health

You may want to sign up for a Part D drug plan to get coverage for prescription drugs. If  you have Medicare Advantage, drug coverage is usually included in your health plan. If you have Original Medicare, you must chooose a separate drug plan from a private insurance company. Important reminders:

When choosing a drug plan, make sure it covers the drugs you take.

Find out if the plan has any restrictions on the drugs you take — such as quantity limits, prior approval, or a requirement that you try other drugs first.

Learn how much the monthly premium is, and check how much the deductible and copays are before you sign  up for a plan.

4.   Don’t Take No for an Answer

Whether you are in Original Medicare, a Medicare Advantage plan, or a drug plan, you can appeal if any of them denies coverage.

An appeal is a formal request asking a plan to change its decision and provide you with coverage.

Many people win their appeals.  If you don’t win at first, you can continue to appeal to the next level.

There are a number of reasons you may appeal a drug plan’s decision. You can appeal if the plan is restricting the quantity of the drug you can get, making you get prior approval, having  you try other drugs first, or if your drug is not on its list of covered drugs (formulary).

5.    Save Money Now

Apply for programs that can help you pay your Medicare costs. If you are eligible, these programs can help pay your premiums, copays and deductibles for both health and drug coverage.

Apply even if your income and assets seem to be above the limits; some income and assets may not count towards the limit.

Programs include:  Extra Help, Medicare Savings Programs (MSPs), State Pharmaceutical Assistance Programs (SPAPs) and Medicaid.

Contact your local SHIP (State Health Insurance Assistance Program) to find out which programs are available in your state, if you are eligible, and how to apply.

6.   What’s Not Covered

Medicare does not cover all health care services and products.

Those that are not covered include:

Most dental care

Alternative medicine

Most personal or custodial care at home or in a nursing home

Hearing aids

Most cosmetic surgery

Most vision care

Most care received outside of U.S.

Most nonemergency transportation

Medicare Advantage plans may cover some of the above services.

For more information, visit

Medicare Interactive is an online resource that provides answers to all your Medicare questions.

Medicare Preventive Services

Under the Affordable Care Act, if you have Original Medicare, you may qualify for a yearly wellness visit and many preventive services for free.

Medicare provides preventive benefits to keep you healthy including a yearly wellness visit, tobacco use cessation counseling, and a range of no-cost screenings for cancer, diabetes, and other chronic diseases.

What This Means for You:  As of January 1, 2011, many preventive services are covered under Medicare if you get them from a doctor or other health care provider who accepts assignments.

Annual Wellness Visits:  If you are new to Medicare, your “Welcome to Medicare” preventive visit is now covered without cost sharing during your first 12 months of Part B coverage.  This exam is a one-time review of your health as well as education and counseling about preventive services and other care. If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors.

Several preventive services that qualify are listed below:

Tobacco Use Cessation Counseling:  This benefit is now considered a covered preventive service, whether or not you have been diagnosed with an illness caused or complicated by tobacco use. While the counseling is a covered service, the co-insurance and deductible will apply if you have already been diagnosed with a tobacco related illness.

Screenings:  No more Medicare Part B deductible or co-payment for these screenings if certain coverage criteria apply:

  • Bone mass measurement
  • Cervical cancer screening, including Pap smear tests and pelvic exams
  • Cholesterol and other cardiovascular screenings
  • Colorectal cancer screening (except for barium enemas)
  • Diabetes screening
  • Flu shot, pneumonia shot, and the hepatitis B shot
  • HIV screening for people at increased risk or who ask for the test
  • Mammograms
  • Medical nutrition therapy to help people manage diabetes or kidney disease
  • Prostate cancer screening (except digital rectal examinations)

See the full list of preventive services at

Some Important Details

  • For some preventive services, you will pay nothing. You may have to pay co-insurance (a part of the cost) for the office visit when you get these services.
  • Your first yearly wellness visit can’t take place within 12 months of your “Welcome to Medicare” preventive visit.
  • If you’re in a Medicare Advantage Plan, check your plan to see if these benefits will also be free for you.

Affordable Care Act Fact of the Day – Prescription Drug Discounts

Effective January 1, 2011, seniors who reach the coverage gap will receive a 50% discount when buying Medicare part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020.