Interesting Hotline Cases

Prescription Drugs (Part D)
Private Health Plans
Coverage Issues
Low-Income Programs

Prescription Drugs (Part D)

True Out-of-Pocket (TrOOP) Costs and Changing Part D Plans

At the beginning of this year, Ms. N was getting her prescriptions covered through a stand-alone Part D plan that worked with her Original Medicare. Because she takes extremely expensive medications for rheumatoid arthritis and sleep apnea, by the end of January, Ms. N had spent enough out of pocket to reach her plan�s �catastrophic coverage� limit, which made her copays very low.

In February, Ms. N decided to move out of state to be closer to her family. She called 800-Medicare to ask whether her Part D plan would cover her after the move. The representative told her it would not. He then helped Ms. N choose a Part D plan in her new zip code that would cover all of her prescription drugs without restrictions. Ms. N asked the representative to enroll her in the plan effective March 1st.

In mid-March, after moving, Ms. N went to fill a prescription at a pharmacy in the new plan�s network. She was surprised when the pharmacist said that she needed to pay a very high amount. The pharmacist explained that this amount included both her deductible and a large copay. Ms. N paid, but was upset that her costs were so much higher than what she had last been paying under her old plan.

When she got home, Ms. N called the Medicare Rights Center and spoke with a hotline counselor about her high Part D costs. The hotline counselor told her that her new plan was charging too much. In all Part D plans, you reach catastrophic coverage when your out-of-pocket costs hit a certain amount, $4,350 in 2009. If you reach catastrophic coverage in one plan and then switch plans during the year, your balance is transferred and you should continue to pay catastrophic coverage copays until the end of the calendar year. You do not have to start paying your deductible and high copays again, but should continue to pay low copays.

The hotline counselor advised Ms. N to dispute the plan�s calculation of her TrOOP (�True Out of Pocket�) spending by filing a grievance. A grievance is a written complaint that you submit to your plan. The counselor advised Ms. N to explain in the grievance letter that she had already reached catastrophic coverage in her former plan, so she should also be in catastrophic coverage in the new plan. The counselor also encouraged Ms. N to gather her pharmacy receipts so she could request reimbursement for the amount she paid out of pocket. The plan is required to respond to the grievance within 30 days.

Enrolling in Medicare Part D Upon Loss of VA Benefits

Ms. K is 54 years old and has health and prescription drug coverage through the Veteran�s Administration (VA). As she is eligible for Medicare due to a disability, Ms. K also has Medicare Parts A and B. Usually, Ms. K goes to her local VA facility for health services and to fill prescriptions. But sometimes she uses doctors and hospitals outside the facility�for example, when she travels. For these visits, she uses her Original Medicare coverage because her VA benefits cover only her care at VA facilities. In January, Ms. K received a letter from the VA telling her that her VA benefits would end on February 1. While Ms. K would still have health coverage through Medicare Parts A and B, she would no longer have prescription drug coverage. Ms. K asked her pharmacist when she could enroll in the Medicare prescription drug benefit (Part D) and learned that she had just missed the period when people with Medicare can enroll in a Part D plan for the first time. The Annual Coordinated Election Period had ended on December 31st and would not be open again until November 15, 2009. Ms. K was concerned because she would not be able to pay out of pocket for her prescriptions for an entire year.

Ms. K called the Medicare Rights Center hotline for advice. The hotline counselor explained that even though Ms. K had missed the Annual Coordinated Election Period, she could still enroll in a Part D plan because of her circumstances with the VA. There are Special Enrollment Periods (SEP) that allow people in certain circumstances to enroll in or change their Part D plan outside of the standard enrollment periods. Ms. K would be entitled to one because she had VA prescription drug coverage, which is considered as good as or better than (�creditable�) Medicare�s prescription drug coverage. The counselor explained that Ms. K�s Special Enrollment Period began when she received notice that her creditable coverage was ending, and would last for either two months after she received the notice, or two months after her coverage ended�whichever date was later. In Ms. K�s situation, her SEP started in January, when she received the notice from the VA, and would end in April, two months after her creditable VA coverage ended.

Together, the Medicare Rights Center hotline counselor and Ms. K entered a list of Ms. K�s prescription drugs on the Prescription Drug Plan Finder, and they identified a plan that appeared to cover Ms. K�s prescriptions at the lowest cost and without restrictions. The hotline counselor instructed Ms. K to first call 800-MEDICARE and explain that she would be losing VA prescription drug coverage and would like to get Part D coverage as soon as possible using her Special Enrollment Period.

The hotline counselor then asked Ms. K about her income and resources, and found out that, while Ms. K was not eligible for Extra Help, a federal program that helps with the costs of Medicare Part D prescription drug coverage, she was eligible for her state�s State Pharmaceutical Assistance Program (SPAP). Many states have SPAPs, which can help with the cost of Medicare Part D coverage. The hotline counselor referred Ms. K to her local State Health Insurance Assistance Program (SHIP) to apply for her state�s SPAP after enrolling in the Part D plan.

Ms. K immediately called 800-MEDICARE and successfully enrolled in the Part D plan. Her new coverage would begin on February 1, ensuring she would have no gap in coverage.


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Private Health Plans

Remeber to Switch Private Plans When You Move to a New Area

Mr. C, who lived in Queens, NY, was enrolled in a Medicare private health plan. When he moved to Newburgh, NY, in January 2009, Mr. C notified his private plan of the move and was given forms to fill out with his new address and contact information. After filling out the forms, Mr. C received a letter saying that he would be disenrolled from the plan within 30 days. Mr. C liked the coverage that he received from his private health plan and did not understand why he was being disenrolled from it, so he called the Medicare Rights Center�s national consumer hotline for help.

A counselor on the hotline explained to Mr. C that while some private plans offer regional or national coverage, most will cover you only within a specific geographic area (except in emergencies), for example, within a certain county or group of counties. Since Mr. C had moved out of his plan�s service area, his plan would no longer cover him.

The counselor advised Mr. C to join a new plan. The counselor explained that because Mr. C. had moved permanently and notified his plan of the move, he was entitled to a Special Enrollment Period (SEP), which would let him make changes to his health and drug coverage outside of standard enrollment periods. His SEP would last for two months, beginning with the month he provided notice of his move.

The counselor advised Mr. C that when considering a plan, he should make sure it not only works in his area, but that it also covers the drugs he takes and the local hospitals and doctors he prefers to use.

Luckily, the company that provided Mr. C�s Medicare private health plan with drug coverage in Queens offered a similar plan in Newburgh that covered the services he needed. Mr. C was able to use his SEP to enroll in the plan with coverage beginning the month after he submitted his completed application.

Getting Compatible Drug Coverage for Your Medicare Health Plan

When Ms. S became eligible for Medicare she enrolled in a Medicare HMO. HMOs are a type of Medicare private health plan (also called a �Medicare Advantage� plan) paid a set amount by Medicare to provide Medicare benefits. Through the HMO, Ms. S received Medicare health coverage, but she did not have Medicare prescription drug coverage (Part D).

The next year, Ms. S started to take a prescription regularly for arthritis. During the Annual Coordinated Election Period (from November 15 to December 31, when people with Medicare can add, switch or drop health or drug coverage), she spoke to an insurance agent about a stand-alone Medicare prescription drug plan (PDP), a private plan that only offers drug coverage. Ms. S figured that, since she already had health coverage, all she needed was her prescriptions covered and she would be set.

The insurance agent told Ms. S if she joined the PDP, she could keep her HMO. Her drug coverage would begin January 1. So, with the agent�s help, Ms. S enrolled in the stand-alone drug plan. However, when Ms. S went to her doctor in February and her doctor billed the HMO, Ms. S received a denial of coverage. She called the HMO and was told that she had been disenrolled from the plan.

Ms. S called the Medicare Rights Center hotline for help. She was told by a counselor that the insurance agent had given her incorrect information; if you are in an HMO you cannot also have a PDP. You must get your drug coverage as part of your HMO�s benefits package. The counselor further explained that the insurance agent was at fault for giving her incorrect information and should not have enrolled her in the stand-alone Part D plan. PDPs are generally only for people with Original Medicare (the traditional Medicare health plan that is run directly through the federal government). There are a few private health plans types that let you have a PDP but an HMO is not one of them. When you choose Part D coverage, you need to choose drug coverage that works with your Medicare health coverage. If she wanted to keep an HMO�which Ms. S said was her preference�she would have had to switch to a different one that offered both Medicare health and drug coverage.

The counselor went on to explain that because the insurance agent misled Ms. S, her enrollment in the PDP was fraudulent. Therefore, Ms. S had the right to ask Medicare for a Special Enrollment Period to change plans. She could retroactively disenroll from her PDP, and enroll in a Medicare HMO with drug coverage. She should be sure to choose one that has her preferred doctors and hospitals in its network. Her coverage would be retroactive to January 1. She would then need to have her doctor submit the bill for her February visit to the new plan to have it covered.

By retroactively enrolling in a Medicare private health plan that offers drug coverage, Ms. S would be covered for her health and prescription costs back to January. However, she would need to pay her new plan�s monthly premium for the two months of retroactive coverage. Because Ms. S did not enroll in Part D when she was first eligible and she did not have any other creditable prescription insurance, she will have to pay a monthly premium penalty for her drug coverage that is equal to an extra one percent of the national average Part D premium for every month that she did not enroll after she was first eligible.

Appealing a SNF Termination of Care in a Medicare Private Health Plan

Mrs. B and her husband, Mr. B, are both enrolled in a Medicare private health plan. Last month, Mr. B had invasive surgery that made it very difficult for him to walk. He then entered a skilled nursing facility (SNF) for physical therapy to help him regain his strength. A few weeks later, Mr. B�s therapist told Mrs. B that because her husband�s progress had �plateaued� and he did not seem capable of full recovery, his health plan would probably not pay for his care for much longer. Mrs. B was concerned that Mr. B was not yet strong enough to leave the SNF, so she consulted with Mr. B�s doctor. The doctor said that she disagreed with the therapist and that the plan should still pay for the SNF care because Mr. B still needed skilled care from a physical therapist to keep his condition from deteriorating. Soon after, Mr. B received a notice from the SNF, called a Notice of Medicare Non-Coverage, which told him that his coverage would end in two days.

Mrs. B called the Medicare Rights Center right away and spoke with a hotline counselor. The counselor advised Mrs. B that Medicare does not require that full recovery be possible for SNF care to be covered. SNF care is considered �medically necessary,� and so can be covered if it is needed to maintain your condition or prevent it from getting worse. The counselor then explained that when a plan says it will no longer pay for SNF care, you still have the right to appeal. However, in order to meet the appeal�s strict deadlines, Mrs. B would have to get to work right away. The hotline counselor told her that on the Notice of Medicare Non-Coverage, there would be instructions explaining how to contact an organization called a QIO, or a Quality Improvement Organization, to start an appeal. Mrs. B found the QIO�s telephone number and the hotline counselor told her to call the QIO to say she wanted to start an appeal by noon on the day before Mr. B�s services were set to terminate.

The counselor explained to Mrs. B that after she called the QIO, it would contact the SNF to request documentation. The hotline counselor encouraged Mrs. B to ask her husband�s doctor for a letter explaining why ending Mr. B�s SNF care would be harmful to his health and why physical therapy was necessary for Mr. B to maintain his condition. Mrs. B was advised that it would also be helpful for her to submit that written statement to the QIO as well. The counselor informed Mrs. B that she had a right to see the information that the SNF submitted to the QIO if she asked for it.

The QIO would have to make its decision within 48 hours. If the QIO agreed with the therapist (that SNF care should no longer be covered for Mr. B), Mr. B might be able to continue to receive care, but he would have to pay for it himself. If the QIO agreed with Mr. and Mrs. B, Mr. B would have the right to continue to get covered SNF care.

Mrs. B called the QIO right away and began the appeal. She then called Mr. B�s doctor, who wrote a letter of support and sent it to the QIO. Two days later, the QIO informed Mrs. B that they had made a favorable decision. Mr. B would be able to continue to receive covered SNF care.

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Medicare Advantage is Not Supplemental Insurance

Mr. R turned 65 in April and signed up for Original Medicare and a stand-alone Medicare prescription drug plan (PDP). Mr. R goes to his doctor regularly, so his 20-percent coinsurances were starting to add up. He decided he wanted to purchase supplemental insurance to cover some of the out of pocket expenses of Original Medicare. He called an insurer to ask about Medicare supplemental insurance policies, commonly known as Medigap plans. An agent advised Mr. R that a Medicare Advantage plan would be a better option for him.

After he finished speaking with the agent, Mr. R did not quite understand what he would be getting with a Medicare Advantage plan. In June, he called the Medicare Rights Center for clarification. The counselor explained to Mr. R that while both types of policies are offered by private insurance companies, a Medicare Advantage plan is not a Medigap plan. Medigaps are supplemental to Original Medicare, helping to cover deductibles, coinsurances and some additional benefits. A Medicare Advantage plan, however, is a private health plan (like an HMO or PPO) that contracts with Medicare and delivers health insurance instead of Original Medicare.

Medigap plans allow you to keep the flexibility of Original Medicare while helping to pay for the out-of-pocket costs. Medicare Advantage plans provide all Part A and Part B services offered by Original Medicare, but they do so with different rules, costs and restrictions that can affect how and when you can get care. For example, Mr. R might be limited to only seeing certain doctors (in a �network�) in a Medicare Advantage plan. The counselor continued that while Mr. R would not have to pay a coinsurance (a percentage of cost) under a Medicare Advantage plan, he would still be responsible for copayments (set costs for services) and possibly deductibles. Furthermore, he could not purchase a Medigap plan to cover those out of pocket costs. Switching to a Medicare Advantage plan could also affect his ability to keep his stand-alone drug plan.

The counselor explained that each Medigap plan pays for a particular set of benefits. Plan A offers the fewest benefits and is usually the least expensive. Plans that offer more benefits, like Plan J, are generally more expensive. Mr. R could call his state Senior Health Insurance Program (SHIP) to get the latest rates and costs of Medigaps for his state. The counselor warned that Medigap plans can become costly as they cover more benefits.

The counselor stressed that Mr. R. should consider his options carefully. In most states people with Medicare only have the right to buy Medigap coverage at certain times. You generally have the most choices when you first qualify for Medicare. Beginning the month you are both 65 or older and enroll in Medicare Part B, in all states you have at least a six-month open enrollment period to join any Medigap plan. During this time, Medigap companies must sell you a plan at the �best available rate� regardless of your health status, and cannot deny you coverage. If you miss this time period, you may be limited in when you can buy a Medigap and what your choices will be. He also warned Mr. R. that people with Medicare can only make changes to their Medicare health benefits (switching between Original Medicare and a private health plan) at specific times of year.

After learning about Medicare Advantage, Mr. R told the counselor that he was happy with Original Medicare and was not interested in switching. The counselor then advised him to shop around for the best Medigap rates and to be sure to do so during his Medigap open enrollment period.

Switching Prescription Coverage from a Medigap Plan to Part D

Mr. S has had Original Medicare Parts A and B since 2005. He has also had a Medicare supplemental plan with drug coverage, Medigap Plan H. Medigap Plan H (along with Plans I and J) with drug coverage has not been sold since January 1, 2006, when the Medicare drug benefit (Part D) began. However, people like Mr. S, who bought one of these Medigap plans with prescription drug coverage before that time, can keep the Medigap�s drug coverage.

In the past year, Mr. S�s overall health has declined. As a result, his prescription drug costs have gone up, but Mr. S�s Medigap plan only pays up to a certain amount each year for his drugs, leaving him paying a high price out-of-pocket for the medications he needs. Mr. S began looking for other options to get more comprehensive coverage for his prescription needs. He decided that he would prefer to enroll in a Medicare Part D plan for his prescription drug coverage.

In August Mr. S called the Medicare Rights Center for help choosing a Medicare Part D plan. The Medicare Rights Center hotline counselor told Mr. S that he would have to wait until the Annual Coordinated Election Period (ACEP) to switch plans; the ACEP runs from November 15th to December 31st. For people who sign up for a Part D plan during the ACEP, Part D coverage becomes effective on January 1st.

The hotline counselor went on to warn Mr. S that he would likely have to pay a Part D premium penalty when he enrolled in a drug plan because Medigap Plan H drug coverage is not considered �creditable coverage��coverage that is as good as or better than the Medicare drug benefit. In most cases, people with Medicare who do not enroll in Part D when they are first eligible and do not have creditable coverage have to pay a premium penalty for enrolling late. People who qualify for Extra Help�a federal program that helps pay for Part D costs�can avoid this penalty regardless of when they enroll. Since Mr. S had income too high to qualify for Extra Help, he would have to pay a premium penalty in addition to his monthly premium for as long as he remained enrolled in Medicare Part D. Since Mr. S could have enrolled in a Medicare drug plan in the spring of 2006 when the first Part D enrollment period ended, he would have to pay a premium penalty that would be calculated based on the number of months that he delayed enrollment in Part D.

Mr. S decided that even with the premium penalty, it would be a better idea for him to choose a prescription drug plan that provided him better coverage than to stick with his Medigap plan with prescription drug coverage. The longer Mr. S waited to enroll in Part D, the greater his premium penalty would be. Together, Mr. S and the hotline counselor used the Prescription Drug Plan Finder on and searched for different Part D plans that covered Mr. S�s medications without restrictions at the lowest cost.

The hotline counselor also mentioned that Mr. S has the option of enrolling in a Medicare private health plan with prescription drug coverage, but Mr. S told the hotline counselor that he wanted to stay in Original Medicare because he would be able to continue to see the same doctors. If Mr. S wanted to keep the health benefits of his Medigap Plan H, Mr. S could enroll in a Part D plan and then call his Medigap plan to request that they drop him from the prescription drug component of the plan and adjust his monthly Medigap premium so that he is no longer paying a prescription drug premium to his Medigap plan.


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Coverage Issues

If Medically Necessary, Some Vaccinations Are Covered by Part B

Mr. G stepped on a nail and his foot became infected. He went to his Medicare private health plan�s urgent care center, and his doctor recommended that he have a tetanus vaccination. Shortly after he was discharged from the urgent care facility, he received a bill from the doctor for about $40. Mr. G recently received his Explanation of Medicare Benefits notice, and confirmed that his plan had denied the vaccination.

Mr. G called the Medicare Rights Center for further assistance. He did not think he should be responsible for the cost of the tetanus shot. The counselor agreed with Mr. G. Medicare Part B covers a limited number of preventive vaccines (e.g. flu) and certain vaccines if they are related to treatment of an injury or exposure to a disease or condition. For example, if you are bitten by a dog, Medicare will cover your rabies shots. Since Mr. G had been injured by the nail, the tetanus shot should be covered. Medicare private plans are required to cover all Part A and B benefits, although they can impose different costs and rules to obtain coverage.

The counselor told Mr. G that he has the right to appeal his private health plan�s decision. The counselor noted that the appeals process has several stages and a few deadlines that he must meet. He has 60 days from when he received his Explanation of Medicare Benefits notice to appeal to the plan (i.e. request a reconsideration). In most cases, you will need to send a letter to the plan explaining why you needed the service. The counselor also recommended that Mr. G try to include a supporting statement from the doctor who treated him explaining why the care was medically necessary.

After he submits the request and supporting statement, he should wait 60 days for a response from the plan. If Mr. G is denied again or if the plan does not respond within 60 days, it will be forwarded to the next level of appeal�the Independent Review Entity (IRE), which is an independent group of doctors and other professionals that contracts with Medicare to ensure that you receive quality care. There are several other levels of appeal, but since the cost for the service in dispute is under $120, the IRE would be the final level for Mr. G.

Mr. G decided he would appeal, and the counselor sent him several documents and written information to help him through the appeals process.

Medicare Will Not Cover Durable Medical Equipment in a SNF When It Is Not Covering the Stay

Mrs. G, who has Original Medicare, was in the hospital for a broken leg and then went to stay in a skilled nursing facility (SNF) for rehabilitation. A SNF is a Medicare-certified facility that provides skilled care at a less intensive level than would be provided in a hospital. A SNF can be a nursing home, or part of one, but it is generally not a retirement home, rehabilitation center or assisted living facility. Because Mrs. G required skilled nursing care�rehabilitative therapy�Medicare paid for her stay. A need for skilled nursing care is required for Medicare to cover a SNF stay. During her stay, she required a wheelchair, which was also covered by the SNF benefit.

After a few weeks, Mrs. G�s SNF terminated her therapy because her doctor believed she no longer needed daily skilled care. Because Mrs. G did not feel quite ready to return home, her family decided to pay out-of-pocket to continue her SNF care. The SNF agreed to let Mrs. G stay. However, Mrs. G now needed a walker, and they told her that she would have to pay for it out-of-pocket. Mrs. G wondered why Medicare would not cover her walker when it had covered her wheelchair. She called the Medicare Rights Center national hotline to ask why this should be.

A hotline counselor explained to Mrs. G that when Medicare was covering her SNF stay, her wheelchair was covered under the SNF benefit. A wheelchair is considered by Medicare to be �durable medical equipment� (DME). Such equipment is covered under the SNF benefit. Now that she no longer qualified for SNF coverage, the only way to get Medicare to cover a new piece of DME (in this case a walker) would be under Medicare�s �durable medical equipment� (DME) benefit. Unfortunately for Mrs. G, Medicare pays for equipment under the DME benefit only when its main purpose is for use inside of your home. The problem was that Medicare did not consider the SNF facility to be Mrs. G�s home.

Under the DME benefit, Medicare will consider only certain locations �home.� These include your own house or apartment, a relative�s home, a home for the aged or some other type of institution that does not provide skilled nursing care. Even though Mrs. G was sleeping and eating at the SNF, Medicare would not consider it her home because her primary purpose in being there�and the primary purpose of the facility�was for medical care.

Mrs. G would need to pay for her walker out-of-pocket until she moved out of the SNF and in with her family in a house that Medicare would consider her home. She could prepare for her move home by finding a supplier that takes Medicare through which she could get a walker that Medicare would cover. She could use Medicare�s durable medical equipment supplier finder ( to compare prices among suppliers in her area, and choose a supplier who accepts Medicare.

Medicare Does Not Cover Claims for Doctors Who Have Opted Out of Medicare

Mrs. Z has Original Medicare, the traditional Medicare health plan that is run directly through the federal government�not a private plan like an HMO or PPO�and can see any doctor in the country who accepts Medicare, without referral. Her doctor, whom she had been seeing regularly for years, told her recently that he had decided to �opt out� of Medicare, meaning that he would no longer participate in the Medicare program at all. Mrs. Z�s doctor said that, going forward, Mrs. Z would need to pay for her care upfront. He told Mrs. Z, however, that he would still submit claims to Medicare on her behalf, so that she could be reimbursed for the cost of her care.

Mrs. Z paid her doctor $1,500 at her appointment and her doctor submitted the claim to Medicare so Mrs. Z could get reimbursed. However, a few weeks later Mrs. Z received a Medicare Summary Notice (MSN)�the summary of claims for health care services Medicare processed during the previous three months�that said the claim had been denied. The MSN included a message that said her doctor would be paid nothing by Medicare, and also that Mrs. Z should not have been charged anything for the services because the doctor had opted out of Medicare. Mrs. Z did not understand this confusing message and needed reimbursement, so she called the Medicare Rights Center�s hotline for help.

The counselor explained that doctors who have opted out of Medicare do not receive payments from Medicare at all and cannot submit claims to Medicare. They are required to have Medicare patients sign a form that says they understand Medicare will not pay and they must pay for services themselves. However, if a doctor who has opted out fails to have the patient sign such a form, Medicare will pay. Because Mrs. Z�s doctor did not have her sign this written contract, Mrs. Z could not know that she was responsible for the full cost of care. Mrs. Z�s doctor should not have billed her for the services.

The counselor told Mrs. Z that she could ask for a redetermination of Medicare�s decision to deny payment for the services, based on her doctor�s failure to have her sign a written contract and for not following Medicare�s opt-out requirements. Medicare would then ask Mrs. Z�s doctor for proof that a contract had been signed. When the doctor fails to produce the contract, Medicare should reimburse Mrs. Z directly for the services. Medicare will reimburse Mrs. Z up to 15 percent above Medicare�s payment amount for the service she received, minus the amount of any deductibles and coinsurance due.

The counselor advised that, in the future, to avoid having to pay in full for doctor�s services, Mrs. Z should always see a doctor who accepts Medicare, preferably one who accepts Medicare�s assignment. When you see a doctor who takes assignment, you are responsible only for the Medicare coinsurance amount�the amount you must pay for services covered by Medicare. Not all doctors who accept Medicare also accept Medicare�s assignment, so you should ask. If they do not accept assignment, you can be charged up to 15 percent more than Medicare�s approved payment for the service in addition to your Medicare coinsurance. All doctors who have not opted out of Medicare, regardless of whether they accept assignment or not, must submit claims to Medicare. Doctors who have properly opted out of Medicare may not submit claims to Medicare.


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Low-Income Programs

QMB Coordination with a Medicare Private Health Plan

Mrs. L has a Medicare private health plan, an HMO. Because she has very low income, she also has Medicaid and a Qualified Medicare Beneficiary (QMB) Medicare Savings Program, both of which help pay for the out-of-pocket costs of Medicare. Mrs. L thought she understood that if she went to a provider in her HMO�s network she should not be charged a copayment for any covered services she receives. However, Mrs. L recently ran into trouble when she went to a podiatrist�s office. The podiatrist was an in-network provider in her private health plan. However, his office had a difficult time billing the state Medicaid Department for her copayment of $25.00 and so billed Mrs. L for it instead. Mrs. L had been counting on QMB to pick up her copayment. She must visit the podiatrist weekly as the visits are crucial to her staying mobile, but she cannot afford the $25.00.

Mrs. L called the Medicare Rights Center for help. Mrs. L was worried that QMB was simply not working with her health plan and asked if she should consider switching plans. The counselor told Mrs. L that QMB�s coordination with her plan should not be a problem; QMB is supposed to work with any Medicare Advantage plan as well as it does with Original Medicare. With Medicaid, QMB and her current private health plan, Mrs. L should be able to go to any doctor in her health plan�s network without having to pay the Medicare copayments or deductibles. Essentially, Mrs. L should not be responsible for the $25.00 copayment and her doctor should not bill her for it. The counselor advised Mrs. L to let her doctor know that she is a QMB recipient and that, therefore, he cannot bill her.

Mrs. L explained this to her doctor and learned that he was simply not billing the services correctly. The office�s staff corrected the problem, and Mrs. L can now continue going to her weekly podiatry appointments without charge.

Continuing Extra Help Eligibility from One Year to the Next

Mr. L has Original Medicare Parts A and B and a stand-alone Part D prescription drug plan. In November of last year, he applied for Extra Help, the federal program that helps with most of the costs of Medicare Part D coverage. Mr. L qualified for partial Extra Help, which reduced his Part D premium, deductible and copayments for all of 2020. However, Mr. L recently received a letter in the mail letting him know that his Extra Help would end on December 31st.

Mr. L called the Medicare Rights Center hotline and spoke with a counselor about his Extra Help status. The counselor asked Mr. L whether his income or assets had changed in the past year. Mr. L said his income had not changed significantly. The counselor assessed that Mr. L should still be eligible for Extra Help in 2009. The hotline counselor then asked Mr. L whether he had received a form from Social Security called �Review of Your Eligibility for Extra Help.� The counselor explained that when you apply for Extra Help, Social Security will sometimes send out a form in August or September to assess whether you continue to qualify for Extra Help. Not everyone gets the form, but those who do receive it must fill it out. If you receive the form and do not return it, your Extra Help will not be recertified, and your assistance will stop at the end of the year.

Mr. L looked through his old mail and found that he had received a recertification letter, but, since his income and assets had not changed, he had not realized that he was supposed to return the enclosed form to Social Security. The counselor told Mr. L that even though his Extra Help was set to end, he could reapply for assistance for the following year by going in person to his local Social Security office, or by applying online at The counselor advised Mr. L to reapply as soon as possible to ensure that his Extra Help coverage continuesin January 2009. Mr. L took the counselor�s advice and went to his local Social Security office that day to reapply for Extra Help for the following year. Four weeks later, he was notified that he would again have partial Extra Help coverage for the year in 2009.

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Part B Immunosuppressants Available to Kidney Transplant Recipients

Mrs. H enrolled in Medicare Part A (inpatient/hospital insurance) in July 2000 and is enrolled in a Medicare private health plan. In March 2003, Mrs. H had a kidney transplant in a Medicare-certified facility to treat her End-Stage Renal Disease (ESRD) and had to start taking a self-administered immunosuppressive drug, CellCept, so that her body would not reject her new kidney. Mrs. H paid $50 for each fill of her prescription until November of 2020, when the pharmacy suddenly charged her $500. Not understanding why she suddenly had to pay so much money, Mrs. H called the Medicare Rights Center national hotline for help.

A hotline counselor helped Mrs. H call her Medicare private health plan to see why there was such a drastic change in her copayment. A representative of the plan, which also provides Mrs. H�s Medicare prescription drug coverage (Part D), told Mrs. H that she had entered the �doughnut hole� at the beginning of the month. In most Part D plans, once your total drug costs (both what you pay and what the plan pays for your drugs) reach a certain amount, you must pay the full cost for your prescriptions instead of a copayment. The representative said that was why she was suddenly paying so much more for her drug.

However, the Medicare Rights Center counselor told the representative that anti-rejection drugs that are self-administered after a Medicare-covered kidney transplant should be covered by Part B, not Part D. Because Part B has no �doughnut hole,� Mrs. H should still be paying $50 for her prescription, the private plan�s Part B copayment for that drug.

Mrs. H�s plan recognized that they had made a mistake and told Mrs. H that she could get reimbursed for the extra money that she paid for her prescription as long as she could submit her receipt to the plan, and that going forward she would pay only her Part B copayment.

Coordination of Employer Insurance and Medicare

Ms. P is 70 years old and employed full time as a teacher. She has health and prescription drug coverage through her employer. Her employer coverage is primary (because she is over 65 and her employer has 20 or more employees). Her Medicare is secondary; she has Parts A and B.

Ms. P uses a wheelchair, and as a result, Ms. P has developed carpal tunnel syndrome. This year, Ms. P�s doctor determined that it would be necessary for Ms. P to have surgery for her carpal tunnel syndrome. Her doctor referred Ms. P to a surgeon and sent in a request to her employer plan for prior authorization for the surgery. Ms. P soon received notice from her employer plan that it would not cover the surgery for her.

Ms. P called the Medicare Rights Center and asked a hotline counselor whether Medicare could pay as her primary insurer for the carpal tunnel surgery that her employer plan would not authorize. The hotline counselor explained that whether Medicare would pay would depend on why her employer insurance would not pay. If your employer plan is primary and denies coverage of a particular service in your case only (it may cover the service in other cases), then Medicare will not pay for the service. However, if your employer plan never covers a particular service, then Medicare may pay as primary as long as the service is covered by Medicare.

The hotline counselor suggested that Ms. P read the letter from her employer plan to find out why the surgery was denied. Ms. P found in the letter that the plan actually noted that the service was not covered because all of the necessary information was not submitted in the prior authorization request. The hotline counselor explained to Ms. P that this could mean that her doctor simply needs to resubmit the prior authorization request, and include both a letter explaining why the surgery is medically necessary and all relevant medical records.

Ms. P promptly called her doctor and asked him to resubmit the request for prior authorization with all pertinent materials. Soon, Ms. P and her doctor received notice from the plan that because the materials they submitted showed the medical necessity of the surgery, the employer plan would cover it. Ms. P was able to get the carpal tunnel surgery, with her employer plan paying primary and Medicare paying second to cover the remaining costs.

Returning to Work--Coordination of Medicare and Employer Insurance

Mr. L is 68 years old and has Original Medicare Parts A and B. He retired two years ago, and since then has also had retiree insurance from his former employer�a large technology consulting company. Then, over the summer, Mr. L decided that he wanted to go back to work, and started working full-time again at his former employer.

In September, Mr. L went to a doctor�s appointment. When Mr. L got his Medicare Summary Notice (MSN) in the mail, he saw that Medicare had denied payment for the appointment.

Mr. L called the Medicare Rights Center and asked a counselor if she knew why the claim was denied. The counselor suspected that the change in Mr. L�s employment status might have something to do with it. When Mr. L was retired, Medicare was primary and his retiree insurance was secondary. Now that Mr. L had started working again, and because the company he works for has more than 20 employees, his employer insurance is again primary, and Medicare is secondary.

As the conversation continued, the hotline counselor found out that Mr. L had given the receptionist at the doctor�s office the card he used when he was retired. Because he was working again at the same company where he worked before retiring, he had not realized that he needed to give the doctor�s office the new insurance card from his employer. The counselor explained to Mr. L that the doctor�s office had likely billed Medicare as primary and the old retiree plan as secondary, when it should have billed the employer plan first. The hotline counselor advised Mr. L to take his new card to his doctor�s office and request that they resubmit the claim to the employer plan and then to Medicare. Mr. L promptly went to his doctor�s office, and they were able to successfully resubmit the claim. His employer insurance paid first, and Medicare paid second by covering the remaining coinsurance.

Retroactive Disenrollment Due to Misleading Marketing Information

Last year, Mr. H had Original Medicare to cover his health care costs and a stand-alone Part D plan that covered his prescriptions. At the end of last year, he received notice from the Part D plan explaining that the monthly premium would increase for the next year. In November, Mr. H spoke with an insurance agent about ways to lower his Part D costs. The agent told Mr. H that he could sign up for a plan that would lower his Part D coverage costs and still allow him to keep Original Medicare. Mr. H decided to enroll.

In January, Mr. H was having stomach problems and went to see his doctor. It turned out to be nothing serious, but the next month, Mr. H started receiving bills from the new plan, stating that he was responsible for the cost of the doctor�s visit because he had used an �out-of-network� provider. Mr. H was confused as to why the plan helping with his drug costs would be billing him for health care costs at all.

Mr. H called the Medicare Rights Center hotline and explained the situation. The hotline counselor asked whether there was a chance Mr. H might have mistakenly signed up for a private health plan with prescription drug coverage. Mr. H admitted he was not sure. Together, Mr. H and the hotline counselor looked at the plan�s information. They found that Mr. H�s plan was in fact a Medicare private health plan with prescription drug coverage and that Mr. H�s doctor was not part of the network. Mr. H no longer had Original Medicare.

Mr. H explained to the counselor that the insurance agent had given him the impression that he was signing up for a plan that would lower his Part D costs and let him keep his Original Medicare coverage. Fortunately, the counselor explained, Medicare has protections to help you get out of a plan if you decide to join based on misleading information from a plan representative. Based on these protections, Mr. H would be entitled to an �exceptional circumstances� Special Enrollment Period (SEP) to disenroll from the plan and go back to Original Medicare and the stand-alone Part D plan. Additionally, Mr. H could request �retroactive disenrollment� from the health plan, which would disenroll him back to January 1, and restore his Original Medicare coverage and previous stand-alone Part D plan coverage to that date.

Mr. H would need to call 800-Medicare and explain that he had been given misinformation from an insurance agent. He would need to explicitly state that he was requesting retroactive disenrollment using the �exceptional circumstances special enrollment period,� and that he wanted to go back to Original Medicare and his previous Part D plan. The counselor encouraged Mr. H to note the time and date of his call to 800-Medicare, the name of the representative with whom he spoke, and the enrollment confirmation number. The counselor advised Mr. H that once he was retroactively disenrolled from the plan, he would need to have the doctor�s office resubmit the claim to Original Medicare.

The hotline counselor then informed Mr. H that his monthly income and assets would qualify him for Extra Help, the federal program that helps pay for most of the costs of Part D coverage. With Extra Help, Mr. H�s monthly Part D premium and copayments would be much lower. The hotline counselor assisted Mr. H in completing an online application for Extra Help. Mr. H followed the counselor�s advice and first called 800-Medicare. He spoke with a representative who helped him retroactively disenroll from the Medicare private health plan, go back to Original Medicare and the old stand-alone Part D plan. He called the doctor�s office and asked them to resubmit the bill to Original Medicare. Soon after, Mr. H received his Medicare Summary Notice for the doctor�s visit. Original Medicare covered the visit, and Mr. H was responsible only for the Original Medicare deductible and coinsurance.

Options for Care after Exhausting a SNF Benefit Period

Mrs. D is enrolled in Original Medicare. Three months ago, she needed cardiac surgery and was admitted to the hospital as an inpatient for the operation. When Mrs. D was discharged, she was transferred to a Medicare-certified skilled nursing facility (SNF) to receive skilled nursing and skilled occupational therapy services. Mrs. D was about to reach the 100-day limit of Medicare�s SNF benefit period. Her daughter, Laura, recently spoke to Mrs. D�s doctor, who said while Mrs. D could benefit from further physical and occupational therapy in the SNF, it was safe for her to return home and receive therapy there. If she wanted to stay in the SNF, Mrs. D would need to pay for her care herself.

Laura called the Medicare Rights Center and relayed the situation to a hotline counselor. She explained that neither she nor Mrs. D could afford to pay for the entire cost for the SNF. She asked whether they could appeal for more Medicare SNF coverage. The hotline counselor explained that ordinarily, a termination notice and the right to a fast appeal are required when a SNF believes that Medicare will not pay for coverage. However, when you exhaust the Medicare benefit period, you do not have these same notice and appeals rights. As an alternative, he suggested that Mrs. D might be able to get help from Medicaid, the state-run program for people with low incomes. However, Laura explained that her mother had already been screened for Medicaid and did not meet financial income guidelines for the program.

The counselor then asked Laura whether she had considered the possibility of her mother getting care at home. Laura said she thought Medicare did not pay for home health services. The counselor explained that Medicare may pay for a home health aide under Medicare�s home health care benefit if you need skilled care (such as skilled nursing or skilled therapy services). Medicare would also pay for some personal care in this situation.

To qualify for Medicare coverage of home health care, Mrs. D�s doctor would first need to certify that she was homebound (meaning that it would take considerable and taxing effort for her to leave home) and needed skilled care. Mrs. D�s SNF could then refer her to a Medicare-certified home health agency (HHA). Depending on the amount of care the HHA determines Mrs. D will need, Medicare would pay for up to 35 hours a week of care at home (although usually much less). The next day, Laura talked with her mother�s doctor and the social worker at the SNF. Together, they arranged for Mrs. D to stay in the SNF until the end of her Medicare benefit period and then return home, where she would receive her care from a Medicare-certified HHA.

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