Thursday, March 31, 2011

Medicare Part D with TRICARE

Medicare Part D with TRICARE

Question: If you had TRICARE for Life would you even get a Part D plan of any kind?

Answer: Probably not. With TRICARE for Life your prescription coverage is considered creditable which means it is as good as or better than what you could get with a Medicare Part D plan. There is no reason to get other coverage unless you are unhappy with how TRICARE is covering your prescriptions (which I doubt you will be). In that case, you may enroll in a Part D plan without losing your TRICARE. Medicare Part D would pay first, TRICARE would pay second. I assume you are aware you need to enroll in Medicare Part B at or past age 65 once you are no longer active duty. For more specific questions about TRICARE prescription benefits call the TRICARE Pharmacy Program 1-877-363-1303.

Monday, March 28, 2011

Part D Excluded Medications

Part D and ED Medications
Question: I will be 65 in Oct. Are ED meds such as Viagra and testosterone injections covered by Medicare?

Answer: No. ED medications are not covered by Medicare unless they are prescribed for a medical condition other than sexual or erectile dysfunction. This is known as prescribing "off-label". Viagra is sometimes prescribed for treatment of pulmonary hypertension so if you are taking it for that and your doctor certifies nothing else will work for you then Medicare might cover it, but that’s a long shot because there are so many other drugs available. A few years back a glitch in the CMS system allowed ED drugs to be covered but that has been corrected.

For answers to your Medicare Questions or to request quotes on a Medicare Supplement or Part D Drug plan visit

Sunday, March 27, 2011

What is Medicare

Medicare with VA Benefits

Medicare with VA Benefits

Question: I am 61, on VA disability, and get free health care except dental. When I turn 65 and get Medicare, will I still be able to go to the VA for medical care?

Answer: Qualified veterans may have and use Medicare and VA benefits at the same time.

You're several years away from 65, so bear in mind this answer is for current guidelines and those could change by the time you reach 65.

In most cases you will have your VA benefits and Medicare once you reach age 65. With VA, there are several levels of eligibility so it is important to contact VA as the time nears to find out exactly what your coverage will be.

Typically, to automatically receive Medicare Part A you must have a minimum number of credits earned from employment or receive them under a spouse's coverage. You can find out how your disability effects this requirement by calling Social Security (1-800-772-1213). You likely will need to enroll in Medicare Part B. There is a premium for Part B. Your disability and financial circumstances will effect what you are required to pay. Also, there is a penalty for enrolling outside your initial enrollment period if you are not covered under a qualified plan. VA can advise you on how your VA coverage fits these guidelines.

Right now VA prescription coverage is considered "creditable coverage" to Medicare Part D -the drug plan for Medicare. This means you are not penalized for failing to enroll in a Medicare drug plan (Part D). You may have both Medicare Part D and VA but may only fill a prescription with one or the other, not both.

You don't say how long you have been on VA disability. I have talked to some disabled veterans who are under 65 and because they qualify for Social Security Disability they begin receiving Medicare benefits in their 25th month of disability. VA benefits, in general, and disability benefits even more so, are complicated so be sure to check with VA for specifics to your situation.

Saturday, March 26, 2011

Medicare Part D waiver

Requesting a Drug Waiver on a Medicare Part D Plan

Question: Why is it that insurance companies have the last say of all meds that we take even if the doctor’s order means that I cannot take a certain med because it causes real severe allergies that can make it more severe for my COPD? My doctor has made a great effort to help me and the insurance company won't listen. Is it because we are old and they don’t care of our quality of what little life we have left?

Answer: Insurance companies participating in Medicare Part D are required to cover drugs in all categories but not every drug available in a category. Generics are used where available. There is always an exception and there is a process for requesting an exception waiver. I have had several clients whose doctors have documented that my clients are unable to take a particular drug and must take a certain other drug, and of course the reason why. Their waiver has been granted. Perhaps your doctor is not providing the documentation required. Has your agent contacted the plan on your behalf? If your case is a documented need and not just a preference you should be able in most cases to get the drug your doctor is ordering. If you've tried all these things, you might want to consider switching plans when annual enrollment comes around (Oct 15-Dec 7, 2011). Some plans are more tightly managed and some are just easier to work with than others.

Saturday, March 19, 2011

Part B Penalty

Medicare Part B Late Enrollment Penalty /Appealing the Penalty

Question:  When I turned 65 I did not sign up for Medicare. I was working and paid my own insurance...thought that was a patriotic thing to do....well, 7 yrs later, I signed up for Medicare and they penalized me to pay 70% higher for my SS check is about 600.00....can't stand this much more since I plan to live to at least 100.  Do you think I can get this penalty cancelled?

Answer: Bottom line, it never hurts to try.

Coverage in an Employer group health plan that has 20 or more employees and is primary to Medicare allows the covered person to postpone enrollment in Medicare Part B until the employment terminates or the health plan terminates. The person then has 8 months to enroll in Medicare Part B without a penalty. Employers of less than 20 people and individual health plans are generally secondary to Medicare. Coverage under these plans usually does not allow postponement of Part B enrollment without a penalty once you do enroll in Part B. In most cases it costs more to stay enrolled with small group or individual plans than it does to enroll in Medicare so people elect to go the Medicare route.

If you believe your situation fits the guidelines for postponing Medicare Part B enrollment, then you may appeal the decision on your Part B premium by contacting Social Security (1-800-772-1213).

I recommend you investigate an appeal. Good luck, it can be frustrating but persevere! Let me know how it turns out and if I can help you please contact me but I recommend you call (512.557.2269)as this could be more complicated than is suited for e-mail.

For answers to your Medicare Questions or to request quotes on a Medicare Supplement or Part D Drug plan visit

Monday, March 14, 2011

Medicare Beneficiary Advocates

Resolving Medicare Covered Services Complaints
Question:  Connie, my father's doctor prescribed oxygen late in the day Thursday. Home Health called Friday after 5 p.m. to say [the nurse] had worked late to coordinate with the contract provider of the oxygen. HOWEVER, they cannot bring the equipment until Monday, as the battery on the equipment would not last over the weekend and Medicare requires an overnight test to determine that he needs oxygen. It doesn't seem right that my father must wait 5 days (Th-Fri-Sat-Sun-Mon) before getting the oxygen needed. Where do we turn for an advocate?
Answer: You, informed and empowered, are your best advocate. If that fails to resolve an issue, there is The Medicare Ombudsman program through CMS (the Center for Medicare and Medicaid Services). They receive complaints and do take action. It isn’t necessarily punitive. They have a “reeducation” process when mistakes are made from lack of knowledge or understanding. Negligence and fraud are another matter and they do handle this also. There are also Ombudsmen affiliated with local/regional Area Agencies on Aging who advocate for Medicare beneficiaries. These area agencies focus primarily on Assisted Living and Nursing Home facilities. I’m pretty sure they also step in with Home Health complaints. If your dad is covered by an Advantage plan, you must contact the Advantage plan. They have full caseloads so try the informed and empowered route first!

So…How to be informed and empowered. The answers are out there, you just have to know where to look and I’m happy to point you in that direction. Here are 2 links so you understand Medicare’s process for providing Oxygen.

You’ll see there are criteria for justifying oxygen (or any other service). I’m guessing your doctor took care of documenting the criteria as being met.

Next, call Medicare 1-800-633-4227, explain what has happened. You’ll need your dad on the phone to give his permission for you to speak to them on his behalf. If Medicare feels the situation is not right, they will help initiate the complaint process. At this point you may want to request a different home health agency and/or different oxygen provider if you aren’t feeling confident in this one. It’s OK for you to do this.

It does not seem reasonable, based on the information you provided, for it to take 5 days. Your concern is justified.

Friday, March 11, 2011

Medicare Initial Enrollment

Medicare Initial Enrollment Time Periods

Question: I will be 65 on August 1st, six months from now. Can I sign up early for Medicare--so it will be effective on my birthday?
Answer: You may enroll in Medicare 3 months prior to your 65th Birthday. So, you can enroll in Medicare Part B in May. Because your birthday is 08/01, your effective date will be July 01 (that is only the case for people with birthdays on the 1st of the month) You may apply for a Medicare Supplement 6 months prior to your 65th birthday and up to 6 months after your 65th birthday. In your case the supplement would be effective July 01 also. You may apply for a Part D drug plan 3 months prior to your birthday and the effective date will be July 01.

Thursday, March 10, 2011

Medicare and Other Health Insurance

Medicare with Other Health Insurance

Question: Hi Connie, this is ALL NEW to me (Medicare Supplement/Advantage Plans) I know you sell insurance for a living, however it appears from your site that you do have an interest in the recipients (and THEIR best interests) - so - let me fire this at 'ya.

I am 67 years old now. I've been enrolled in PART A since 65 (however, never used it) Now that I'm being forced to retire (due to hearing loss) I will NOT have a GROUP health plan available to me after May 31. Medicare has told me that I may sign up for PART B after March 1 (but before May 1) in order to have coverage by June 1.

Since I am a Service Connected Veteran, I do have VA medical benefits available to me should the need arise, however would prefer to use an outside provider for health maintenance and less serious health matters (including medications) The Advantage Plans that I've looked into will provide this for my Medicare Premiums (NO EXTRA COST. )Bearing in mind that you are an insurance salesman; would this not be my best route?

Answer: Even though I AM a salesperson, I'm not going to try and sell you any particular thing! But I will try to help you answer your question.

There are several points you need to consider to make the best choice for YOU! They all revolve around cost and convenience.

The most convenient option is original Medicare (A&B) paired with a Supplement and Drug plan. You can go anywhere you want and with the exception of some copays for drugs, your medical treatment will be covered 100%. This option will run you about $250 /month (in Texas) in premiums, including your Part B premium (assuming you make less than $85,000 single/ $170,000 jointly)

The next level of convenience would be original Medicare (A&B) plus your VA benefits. In most cases VA only pays if you get services directly from them. How far away is the VA facility from you? Medicare A has a deductible of $1132 per hospitalization for 2011. Medicare B (outpatient) has a deductible of $162 for the calendar year 2011. After that, you pay 20% for outpatient services. If you use the VA you will have little if any out of pocket cost based on how you are entered in the system. VA will provide prescriptions by mail order with little or no copay. Should you use Medicare B for doctor visits you may go where you want (as long as they accept Medicare) and it will cost you around $20- $40 for a typical office visit after deductible. Your cost would be your Part B premium of $115.40/month for 2011 and whatever your arrangement with VA is. You would have the risk of the additional A & B costs I mentioned. (This is the option my dad uses)

The least convenient would be a Medicare Advantage plan. You assign your part A & B Medicare to the company you enroll with and you must go to their in-network providers to realize the benefits from the plan. You may not revert to your original Medicare if you are unhappy except at certain times of the year. If you are healthy and are just seeing the doctor a couple times a year for checkups, this can work very well. Of course you don't really have insurance for those situations. You have it for the emergencies and catastrophic events. Advantage plans make money by managing the care they allow members to have. They may be generous with the little expenses but when it gets to the big expenses, they are tightly managed. I haven't talked to anyone who has gone through a catastrophic event in an Advantage plan that was happy with the service provided by the plan. If you're aware of this and the cost outweighs the possible inconvenience, this could be the best option. You do have the risk of out of pocket expenses of up to $5000 in-network with most Advantage plans. If you go out of network your cost risk is unlimited. If an Advantage Plan is the route you choose, ask lots of questions about what is and is not covered as well as what out of pocket expense risk there is, before enrolling. Also check the provider list for providers in your area.

Some other points to consider

Getting VA to pay in an emergency situation outside VA facilities is difficult. This is also the case with an Advantage plan. With the Medicare/VA option you at least have the flexibility of being treated anywhere with your Medicare and Medicare paying a substantial portion of the cost. With the Advantage Plan option, if they don't pay, it's your bill.

You didn't mention if you qualify for any special assistance based on your income or the hearing loss. Have you checked in to that?

Enroll in Part B early rather than late! You will need to call Social Security ( 1-800-772-1213 ) to do that and often they can take care of enrollment over the phone. You may also get information about special help because of the disability or income level from them. The sooner the better!!

I hope this helps you answer your question. Please let me know if I may be of further assistance. I can help you with Supplements, Drug plans and Advantage plans so when you decide on the route you want to take I hope you will consult with me.

Medicare drug coverage

Medicare Drug Coverage

Question: Does Medicare cover the cost of Coumadin when it must be taken for the rest of one's life due to a mechanical heart valve?

Answer: Coumadin and its generic Warfarin Sodium are covered drugs under a Medicare Part D prescription plan. You would either enroll separately in a Medicare Part D plan or in some situations prescriptions are included in Medicare Advantage plans. You will pay a copay for the Coumadin in most cases. Original Medicare (Part A & Part B) does not cover drugs except in certain limited situations. Based on the information you provided, your situation does not meet the criteria. You may go to , download Medicare and You 2011 booklet and on page 40 it gives details about situations where Medicare Part B covers drugs.

Medicare and Medicaid

Medicare with QMB and MQMB
Question: I am a retiree living on $800.00 a month from Social Security. I qualify for QMB which is the same as the "extra help" program. I have Medicare and Medicaid. I need glasses, hearing aids and dentures. The lady at the hearing aid store said I didn’t qualify with them because there is not an "M" in front of my "QMB", in others words, it’s gotta be "MQMB" for me to get any help. My glasses need to be replaced. I can barely hear and the one hearing aid I have came from a friend of mine whose mother died. My mouth is sinking in from no dentures.
Can you please give me some kind of information on how I can get these things I need? 
Answer: You would need to contact your local Medicaid office to get information specific to you. Just in general, the extra help offered to Medicare beneficiaries is based on their income and assets and where that puts you in the level of assistance available. You may call 211 and you will be connected to a Medicaid representative. If you have trouble connecting through 211, you may call 1-877-541-7905. You may also go online to to search for the phone number to your local Medicaid office using your home zip code. Request Medicaid review your qualifications for extra help.

Wednesday, March 9, 2011

Medicare and Social Security Disability

Medicare and Social Security Disability: When Does Medicare Start?
Question: When on Social Security Disability, does Medicare start automatically?

Answer: Medicare Parts A & B automatically start on the 25th month of your disability. If you have ALS they begin right away. There are some options available in Texas for people under 65 without health insurance who are uninsurable given their disability.

Medicare and Durable Medical Equipment Coverage

Medicare and Durable Medical Equipment Coverage
Question: My friend just got an RX for a walker (Rolator). When I took her to the medical supply store, she was told that Medicare does not cover the nice rolator with the seat now. They only cover the silver metal type one. Is this true?

Answer: Medicare has no such policy about the type of walker they cover. Your friend's prescription determines what Medicare will pay for (& I called Medicare just to make sure nothing has changed!) If she needs one with the seat because she can only walk short distances, they cover that, but her doctor has to write the RX specifically. Not sure why you were told that. I’ve heard all sorts of explanations that aren’t based on fact given to my clients. Be sure you are using an approved supplier. Texas is participating in a "competitive bidding" program Medicare has and you are required to use specific suppliers. You can go to and look for a supplier in your area. Confirm they are participating in the program before you buy as things can change!

Medicare and Glucose Testing Supplies

Medicare and Glucose Testing Supplies

Question: How will Medicare pay for my glucose testing supplies?

Answer: Medicare Part B covers test monitors, test strips, lancet devices and lancets. Some blood sugar control solutions and therapeutic shoes, in some cases, are also covered. With original Medicare alone, you pay the deductible then coinsurance of 20% of the cost. Medicare Supplements or an Advantage plan will pay part or all of the deductible and coinsurance.

Medicare Coverage for Dental and Vision Care

Medicare Coverage for Dental and Vision Care

Question: Is there any way Medicare pays for dental work or eye exams?

Answer: Original Medicare does not cover routine dental or vision care. Some Medicare Advantage plans offer some coverage for vision and dental but make sure you know what is and IS NOT covered before enrolling. Read the fine print! Some Advantage plans only cover vision and dental as covered by original Medicare.

Medicare Part A will pay for certain dental services that you get when you are in the hospital. Medicare Part A can pay for hospital stays if you need to have emergency or complicated dental procedures, even when the dental care itself is not covered.

Medicare provides limited vision coverage in some cases such as after cataract surgery or for some cases of macular degeneration. If you are in a high risk category for glaucoma, Medicare will cover screenings every 12 months. It is a good idea to check with Medicare or your Advantage plan rather than assume a procedure is covered. For more information on Medicare coverage go to .