Mrs. Turner is comparing her employer’s retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her?
Original Medicare covers ambulance services.
Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern?
Medigap plans help beneficiaries cover Original Medicare benefits, but they coordinate with Original Medicare coverage.
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him?
Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare.
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs?
Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
What impact, if any, have recent regulatory changes had upon Medigap plans?
The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020.
Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?
Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs.
Mrs. Geisler’s neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can’t remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her?
Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed.
Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him?
Medicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered.
Mr. Alonso receives some help paying for his two generic prescription drugs from his employer’s retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him?
He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare’s coverage of care in a skilled nursing facility?
Medicare will cover Mrs. Shield’s skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days.
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?
Medicare will cover, at its allowable amount, as many stays as are needed throughout Mr. Rainey’s life, as long as no single stay exceeds 190 days.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her?
Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance?
She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?
Medicare does not cover massage therapy, or, in general, glasses or dentures.
Mr. Diaz continued working with his company and was insured under his employer’s group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him?
Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s plan.