Health Under Medicare

Mr. A, a 75-year-old man with Original Medicare coverage, has a history of depression and eating disorders. Two years ago, he started having suicidal thoughts and was refusing to eat. His wife helped him find a psychiatric hospital, where he received inpatient care for a total of 140 days—he first went for 90 days, was out of the hospital for six months, then returned for another 50 days. Mr. A was able to live safely at home for the next year while going to see a psychologist as an outpatient. Then, a few months ago, Mr. A’s wife passed away. He began having suicidal thoughts again and returned to the same psychiatric hospital for inpatient treatment. Mr. A was in the psychiatric hospital for about 50 days when the hospital’s billing department informed Mr. A’s daughter that Medicare would no longer pay for Mr. A’s hospital stay. Mr. A was not yet well enough to return home, but the hospital said Mr. A could stay in the hospital only if he agreed to pay the full cost of the rest of his stay.

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Medicare Set-aside ProposalSubject on Medicare due to mental disability - had a workers comp case settlement - for which a set aside for health care only was arranged.

• • All parties in a Workers’ Compensation (WC) case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving WC cases that include future medical expenses. The recommended method to protect Medicare’s interests is a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA), which allocates a portion of the WC settlement for future medical expenses. The amount of the set aside is determined on a case-by-case basis and should be reviewed by CMS, when appropriate. Once the CMS determined set aside amount is exhausted and accurately accounted for to CMS, Medicare will agree to pay primary for future Medicare covered expenses related to the WC injury.
• Medicare Set-aside Proposal

Mrs. L was enrolled in a Medicare private health plan, an HMO, with prescription drug coverage (Part D). Even with that coverage, she was having trouble paying for her medications because the copayments were very expensive. In January, she decided to enroll in a stand-alone prescription drug plan that offered lower copayments for her medications. Mrs. L assumed that she would be able to keep her health coverage through the Medicare private health plan, but would just get her prescription drug coverage through the stand-alone drug plan. But then she got a letter from the HMO stating that she had been disenrolled. Realizing that she must have made a mistake, Mrs. L called 800-MEDICARE to say that she wanted to re-enroll in the HMO. However, the Medicare representative told her she would have to wait until the next enrollment period—in November—to make another change and her new coverage would not start until January.

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Mrs. M is enrolled in a Medicare private health plan. A few months ago, she tripped and injured her ankle. Her doctor prescribed a special ankle brace to help her get around the house. When Mrs. M went to get the brace at the medical equipment supplier, she made sure that the supplier billed her Medicare private health plan. The next month, however, Mrs. M got a letter from her plan, stating that it would not pay for the ankle brace.Mrs. M called the Medicare Rights Center and asked a hotline counselor why the plan would not cover her brace. The counselor explained to Mrs. M that things like ankle braces are usually considered Durable Medical Equipment, or DME, and are covered under Medicare Part B when obtained from a supplier who is enrolled in Medicare. However, if you are in a Medicare private health plan, your plan may also require you to go to a DME supplier in the plan’s network, or get prior authorization to have your DME covered. Together, Mrs. M and the MRC counselor called her plan and found out that the plan requires members to use DME suppliers in the plan’s network. While the DME supplier Mrs. M used was enrolled in Medicare, it was not a part of the plan’s network.

The counselor explained that Mrs. M is responsible for the full cost of the brace and advised her to always remember to check with the plan to make sure that she chooses an in-network provider, whether it be for DME, home health or any type of service. Mrs. M decided to switch back to Original Medicare during the Annual Coordinated Election Period (November 15-December 31 each year), so that she could go to any Medicare-enrolled provider without having to worry about a plan’s network.

 CASE FLASH: PART D APPEALS

Ms. S was enrolled in Original Medicare Part A hospital insurance and Part B medical insurance. She also had Part D prescription coverage though a stand-alone drug plan. Ms. S went to the pharmacy and was charged the full cost for her medication instead of her prescription drug plan’s standard copayment. Since she needed the medication immediately, Ms. S paid the entire cost of the prescription at the pharmacy.

Ms. S later checked and made sure that the medication was on her prescription drug plan’s list of covered drugs formulary. She also called the plan to confirm that she was not in the “coverage gap” doughnut hole and should not have been charged the drug’s full cost.

Ms. S spoke to her pharmacist who found that the pharmacy and the drug plan had a miscommunication about Ms. S’s coverage. The pharmacist was able to fix the error so that in the future, Ms. S would only be charged the standard copayment for her medication. A few months passed, and Ms. S filed a claim for reimbursement with her prescription drug plan. She received a response from the plan that her request was denied because she had exceeded the plan’s 90-day limit to file for reimbursement.

Ms. S called the Medicare Rights Center and explained her problem to a counselor. The counselor explained that Medicare regulations do not allow the plan to place a 90-day time restriction on requests for reimbursement. The counselor advised Ms. S to appeal the plan’s denial right away. Ms. S requested a redetermination submitted an appeal from her prescription drug plan. The prescription drug plan ultimately accepted Ms. S’s appeal and reimbursed her.

CASE FLASH: THE IMPORTANCE OF KEEPING RECORDS

Before leaving on a two-month vacation in December, Ms. Y called her Medicare private health plan with drug coverage to pay her quarterly premium for November, December and January. As she had done before, she gave the plan her debit card information as payment. When Ms. Y returned from vacation in mid-February, she found a letter from her plan that had arrived in her absence saying that she would be disenrolled from the plan, effective at the beginning of February, due to lack of payment of her premium. Ms. Y checked her bank account and found that no money had been deducted to pay for the premiums as it should have been.

Ms. Y called her plan to explain the situation and again paid the quarterly premium that was never deducted from her account this time getting confirmation of the transaction. After many more conversations with customer service representatives at her plan, Ms. Y was reinstated into the health portion of her plan, but the plan would not re-enroll her into the drug coverage portion. The plan said that without proof that she had tried to pay her drug plan premiums before she left the country, it could not re-enroll her into the drug portion of the plan without Medicare’s express consent. Consequently, Ms. Y had no drug coverage and would have to wait until next January to get drug coverage again.

Ms. Y called Medicare to explain the situation and was told that someone would be working on her case, but after a month of not hearing anything back, she called her local State Health Insurance Assistance Program SHIP for help. A SHIP counselor was able to contact the Centers for Medicare & Medicaid Services, which administers the Medicare program, to get Ms. Y reinstated into her plan. Ms. Y once again had drug coverage and she learned to always keep a record of the time that she called Medicare or her health and drug plans, the person with whom she spoke and the action taken on the phone.

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