Medicare basics

Glad to be living in Canada....I don't have to worry about whether I'm covered or not! All I have to worry about is how long will it take to see a specialist...if I were to need one.

Clemson Fan said:

Just a little side note on vision plans. Vision plans are only meant to help defray the cost for glasses or contacts and a yearly refraction. That's it! Anything medical with the eyes (cataracts, glaucoma, etc.) is covered under your primary Medicare or insurance plan and has almost nothing to do with any vision plan you may have.

As an ophthalmologist my billers have to answer questions about that every single day because the patient is responsible for a 20% co pay with stand alone Medicare or whatever co pay they may have with their private insurer. Many ask why we're not billing their vision plan and why we're billing their regular insurance or Medicare. We have to explain to them that I'm treating their cataracts or glaucoma or whatever which is considered medical and thus doesn't fall under the vision plan. In fact, cataract surgery and the costs surrounding that are typically the #1 Medicare budget expense each year.

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an ophthalmologist is a new neighbor. another neighbor claims he does 35 cataract surgeries a day. Is this possible?

I think 35/day is a stretch. On this site, cataract surgery can take between 10-45 minutes. If every single cataract is the 10 minute deal, it could happen, but not all cataracts are the same.

TS

the same neighbor just had back surgery, and she claims they removed two discs from her back. she isn't any shorter though.

I just received a big bill for three visits from January when i was on Medicare that Medicare refused, and which my statements ssid i was not responsible for. I did not carry these statements with me when i left for the summer, and I can no longer access Medicare on line because I went on the Medicare advantage plan in Feb. How can I get copies of all Eob's from Medicare,?
obviously the provider incorrectly billed, because all the other visits which were identical were covered, and i paid them my copay a long time ago (which they are not crediting me)

A couple questions:

(1) Were you on "basic" Medicare when you went to those visits? Scrolling back to the original post, Medicare has a $1216 copay for hospital (in-patient) visits, while Part-B (outpatient) is $147 + 20%. The original post is everything Medicare pays for. It is not the "official" EOB, but my information is straight from Medicare. Their EOB is the 150-ish page book everyone gets called "Medicare And You", but my first post is easier to understand (I hope)!
(2) Did you go to a facility that accepts Medicare? "Basic" Medicare will only pay for procedures that a Medicare doctor has prescribed at a facility that accepts Medicare.

My suggestion, if they bill you the full amount (not a 20% out-patient or $1216 in-patient), take the bills to your local Social Security office. They can either help you out, or point you in the right direction. Your MAPD is a different matter, anything after February 1st (but not before) is their responsibility.

TS

I was on basic medicare with cigna as secondary. I went to a facility that accepts medicare. i had lots of dr bills, my deductible was met, i went to therapy ten times, three visits were rejected, so cigna can't pay their part because they pay only what medicare doesn't pay. I did not go over my physical therapy limit. i asked physical therapy to resubmit claims with correct codes, they are obviously doing something wrong. they want me to pay the entire bill for these three visits, at their full rate, not the amount medicare would have paid, I was paying for two insurance plans at the time, i paid them my portion, and they want the rest.
I think if I go to social security, they will tell me i have to contact Medicare, it is not their business.

it is obviously human error, either on the billing from PT or from Medicare, but no one will take care of it.

rapmarks said:

an ophthalmologist is a new neighbor. another neighbor claims he does 35 cataract surgeries a day. Is this possible?

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Yes it's possible, but you need a lot of help! You need to run multiple OR rooms at the same time with multiple anesthesiologists and very capable staff that basically have the patient draped and all ready to go the second you enter the room. You can then just scrub and gown and immediately sit down, do the surgery and then the second you're finished you leave and go to the next OR room where the next patient is ready to go. The support staff will then undrape the patient and give them all their instructions, etc.

During my fellowship with my fellowship director and I (when I did my fellowship I was already a board certified and fully licensed ophthalmologist), we routinely did 15 cataracts and 5 cornea transplants in one day and would be done by 2 in the afternoon. He would basically start a case and I would finish it and he would move onto the next case.

In my private practice the most I've done is 15 in a day and that was just with one OR and one anesthesiologist. My typical day, though, is 10 cases because frankly I don't want to work that hard and at such a frenetic pace. I like to spend some time talking and interacting with my patients as well as taking a break for lunch, etc. I then typically finish up around 2pm which gives me time to do my dictations and then go and pick my son up from school at 3pm.

Ironwood said:

Glad to be living in Canada....I don't have to worry about whether I'm covered or not!

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yes, health care does seem less complicated and cheaper in Canada

I have regular Medicare and Cigna as Secondary. It works fine for me other than Cigna who puts off paying their share. I finally figured out that if I send Cigna a copy of a Statement from my Doctor; a copy of the Medicare EOB; and Cigna's most recent denial, they pay at once. Sounds like a lot of trouble but actually it isn't and other than annual deductibles I pay nothing.

George

I believe I straightened out my unpaid bills. Cigna told me they take up to 52 weeks to pay. they cannot pay if Medicare denies and says i am not liable. If Medicare says I am liable for the bill, then they will pay their portion as primary. only took two half days on phone to get straightened out.

FYI, the Annual Enrollment Period begins in exactly 21 days. I suggest contacting your agent the week of the 15th to see if any new plans will save money. If you want to do it on your own, you can go to medicare.gov to compare plans. Back when I worked for now-bankrupt PUP, I met people who had old plans that were more expensive. Remember, if you have not received notice that your plan is cancelled, you can keep it as long as possible.

I am licensed only in Florida, so i can't give you any MAPD/MedSupp information in your area. If you are a resident (receive mail/Social Security in) Florida, I can assist.

TS

And the deluge of mail has begun. Part D with my present provider is going from $17/mo and no dedectible to $30.70 and $320 dedeuctible. I will have my broker shop around for a better plan. My problem is that I take a brand name prescription with no generic equivalent and most plans don't cover it.

From now until December 7 is OPEN ENROLLMENT! The Annual Enrollment Period has begun. I suggest taking to an agent, figuring out if another plan may be cheaper in 2015.

TS
Medicare agent in Florida since 2012.

This is my Craigslist ad for those that live in Florida, and the pinpoint is close to where I live.

TS

Ironwood said:

Glad to be living in Canada....I don't have to worry about whether I'm covered or not! All I have to worry about is how long will it take to see a specialist...if I were to need one.

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I am always curious to how Canadians feel about their health plan since we are constantly hearing in the US how it is bad because of long wait times for surgery or seeing a specialist as you mentioned. If you are healthy, I guess you might think it is great since you don;t need to use it, but if you have a chronic condition and need a lot of ongoing care- how would you say it works? I am always looking for the truth in these things...

I got notification from my Medicare supplement carrier that my plan would not continue to be available next year. So last night, I went to www.medicare.gov entered my zip code, input my meds & pharmacy, answered just a couple of health questions (do you have end stage renal disease, are you in a care center?). It returned a very usable side-by-side comparison of plans, with expenses laid out for the year. I selected one, filled out the application, and was all set for next year. Saved about $20 a month.

The whole thing took under an hour. Piece of cake.

Jim

For those who are internet savvy, http://www.medicare.gov is a great way to get set up on a new Medicare Advantage Prescription Drug plan. Since Medicare is paying the insurer (so you don't have to), there's no cost difference between doing it online or having an agent do it.

On mpumilia's question about Canadian health care, I can relate a story. I have a friend in the Toronto area. Last year, she got sick, and the doctor (no wait to see her doc) said she had malignant cancer. She was in the hospital for a few months, and is now living at a nursing home, as more and more of her body falls to cancer - she is in her 40s by the way. She never had a wait to see her doctor, she nor her family paid one cent to the doctors/specialists/hospital/nursing home, and she is getting the best care possible. It is all politics in talking about the differences between Canadian and United States medical care.

TS

Q on Part D coverage.

My DH just turned 70 and is researching going off my employer coverage and going onto Medicare part B and D.

He is use to ordering his drugs mail order using a 90 day prescription. He can reorder about a month ahead so as to make sure he is never in a panic. Most of the drug plans seem to have a 30 day limit and use local pharmacy. Once you join is there any mail order pharmacies that can be used or plans that allow 90 day scrips?

He has one tier 3 brand name drug plus some lower price generics. I am thinking that if he picks a plan with a deductible and/or copay that he would be better off just buying the generics outside the plan and not claiming to insurance.

Any insight on how these Plans would change how is does things? FYI he is interested in the least restrictive plan. He will be paying the IRMAA so I am not sure any of the plans lower his cost overall. He would be doing this to protect himself in case he needed to add some new high price drug.

Short

It would be incredibly hard- and lucky- to get an accurate answer or suggestion for your DH. We don't know where you are and supplemental plans are keyed in to your location.

I'd suggest you get with an independent insurance agent and compare plans. Or. You CAN do it at www.medicare.gov That's what I did and it isn't difficult. Just have your (his) prescription formulary handy to type in. Getting 3 months' supply of 'scrips is allowed- even encouraged through my supplement carrier, so I suspect you (he) can find a plan that probably even has his regular mail-order pharmacy as an approved supplier.

Jim

To answer the question, most Part-D plans have a 90-day mail-order. I know for a fact that United HealthCare's Medicare Advantage and Part-D plans have a mail-order program (Optum). Being that I am a health insurance agent (licensed in Florida), I know the value in having an agent who will look for the best plans for you.

TS

Simpson,

I have been following this thread as DH will be retiring next year and moving to Medicare. He's on Part A now, but other coverage is through his employer.

You mention getting a good agent. What type of agent should we look for? Any independent insurance agent or is this a specialty? We do a lot of international travel, so this coverage is a must. Also, I am not eligible for Medicare and will hook back into my former employer's retiree group coverage paying full costs. I'll also be looking into Obamacare plans as my former employer's coverage is pricey.

Thank you.

Ingrid

I would definitely suggest an independent agent, because they would compare the best plan for your DH. Since you said you're looking at an "ObamaCare" plan, an agent would help.

Here's what I can do. Send me a message privately (e-mail or private message), and I will get you in touch with an agent in your area who can take care of both of you.

TS

Two important Medicare dates are coming up!

December 7 = deadline to change your plans for 2015.

Jan 1 - Feb 14 = Medicare Advantage Disenrollment Period, where you can drop your MAPD and get basic Medicare + Medicare Supplement. Just like you can not change your MAPD after December 7, you can not re-enroll in an MAPD until October 15, except for special enrollment periods.

TS

For those in Florida and are in the coverage area, "CarePlus" became the ***ONLY*** Medicare Advantage plan in the state to be ranked 5 stars by Medicare! What that means is, you can switch from ANY MAPD to CarePlus by December 31. It is another of Medicare's Special Enrollment Periods, and an agent can assist you in figuring out which ones you qualify for.

Currently, I am not appointed with CarePlus, but I can refer you to an agent here in Florida who can get you set up.

TS