Category: Medicare

If you have limited income and resources, you may qualify for extra help in paying for prescription drugs. If you have a higher income, you may still qualify under certain circumstances, such as if you still work or have dependents living with you. Resources include money in a checking or savings account, stocks, and bonds. Resources do not include items like your car or your home or your life insurance policy. 

You can apply for extra help through your state Medicaid office or the Social Security Administration. If you believe you may qualify for extra help, contact Social Security for an application at 1 (800) 772-1213. You can also apply online at http://www.ssa.gov. After you apply, Social Security will review your application and notify you if you qualify for extra help.  

If you currently receive both Medicaid with prescription drug coverage and Medicare, Medicare and Supplemental Security Income, or if the State of West Virginia pays for your Medicare premiums, you will automatically receive the extra help. Medicare will send you a letter if you automatically qualify, and you will not need to apply. 

If you are not already in a Medicare drug plan, you must join one to get the extra help. Medicare might automatically enroll you if you do not do so yourself. The application for extra help is completely separate from enrollment in a prescription plan. If you qualify for extra help, you still need to enroll in a Medicare-approved prescription drug plan. 

For more information, see: Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2015), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015).

When you join a Medicare Prescription Plan, you pay a monthly premium. The average plan premium varies depending on the plan you choose. This premium will be in addition to any premiums you already pay for Medicare Part A and Part B coverage. There are minimum standards required by Medicare for all plans, but the plan providers have the flexibility to have different premiums, deductibles, and co-payments. Competitive providers may choose to offer better plans for consumers, but may not provide less than the standard. 

For the standard plan, the deductible is subject to change annually. After you pay the deductible, coverage is broken down into three additional levels. How you progress through these levels depends on the costs of your medications. 

For more information, see: Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2015), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015).

The Medicare prescription drug program, which is often referred to as Medicare Part D, began on January 1, 2006. The Part D program is different from Part A and Part B because Part D Medicare contracts with private companies to provide the drug coverage. There is no coverage available directly through Medicare itself. Part D covers both brand name and generic prescription drugs at participating pharmacies.  

The prescription drug program is similar to other types of insurance and is optional for Medicare beneficiaries. Though there are minimum standards required by Medicare, each plan has different premiums, deductibles, co-payments, and some plans do not cover certain medications. Because there are so many plans and so many variables to consider, the easiest way to compare plans is through Medicare’s Plan Finder Website at http://www.medicare.gov. You can access the site yourself, have someone access the site on your behalf, contact the SHIP counselor at your local senior center to assist you, or call our state Part D hotline at 1 (877) 987-4463 or Medicare at 1 (800) 633-4227. 

Important considerations for choosing a plan include whether the drugs you currently take are on the plan’s formulary, what the out-of-pocket costs are to you, whether your preferred pharmacy will accept the plan, and what the accessibility and quality of customer service is for the plan.  

You may be able to get extra help in paying your out-of-pocket costs for a plan if you are low-income and have limited assets. You can apply for this extra help by calling Social Security at 1 (800) 772-1213 or by visiting http://www.ssa.gov. (See also the question about Extra Help on page 41.) 

Any West Virginian with Medicare Part A and/or Part B may choose to join a Medicare prescription drug plan. Most people become eligible when they enroll in Medicare. The initial enrollment period lasts six months, and it begins three months before you get Medicare. There is also an open enrollment period every year from October 15 through December 7. If you were eligible when the program began your initial enrollment period was November 15, 2005 to May 15, 2006. If you missed your initial enrollment period, you may be subject to late enrollment penalties. The penalty amount changes every year, and you will have to pay it as long as you have Medicare prescription drug coverage. To calculate your penalty amount estimate, multiply 1% of the national base beneficiary premium ($33.13 × 1% = .33 in 2015) by the number of months you were eligible to join a medicare drug plan but didn’t. Then, round this number to the nearest ten cents. As mentioned previously, this amount is added to your Medicare drug plan’s premium each month for as long as you have the plan. 

If you already have prescription coverage, such as a plan from an employer or union, you can likely keep that coverage. A prescription plan that offers benefits that are the same as or better than a Medicare prescription plan is called a creditable coverage plan. If your employer or union plan is creditable coverage, you will not be penalized with a higher premium if you decide to join a Medicare plan later. You also may drop your employer or union coverage and enroll in a Medicare approved plan. However, it is important to note that once you drop employer or union coverage, you may be unable to get that coverage back. If your employer or union plan covers less than a Medicare prescription drug plan, you can keep your current drug plan and also join a Medicare prescription drug plan to obtain more complete coverage. Your current insurer can tell you if you have creditable coverage right now. SHIP counselors are available to assist with questions and problems related to Medicare Part D including enrollment, penalties, coverage, and more. 

For more information, see: Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2015), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015).

Yes, you will be responsible for the bill unless a Medicare Peer Review Organization (PRO), an Administrative Law Judge (ALJ), or a U.S. District Judge finds that Medicare should continue to cover your hospital expenses. You must receive written notice that Medicare will no longer cover your hospital stay. If you receive such a notice, first look and see whether the notice is from the hospital or the Medicare PRO. The PRO makes the decision for Medicare whether the care you are receiving is necessary and reasonable. PROs are run by physicians and are not connected to the hospital in which you are staying. 

If the hospital decides that you no longer qualify for Medicare coverage, it must give you three days of advanced notice to leave the hospital before the coverage stops. This is the first notice you would receive. 

The hospital must notify the PRO. The PRO will then check with your treating physician and decide whether your Medicare coverage should continue. Even if your physician feels you should stay, the PRO can disagree. If the PRO decides that your coverage should end, then the PRO must tell you the day after it is notified by the hospital that your coverage will stop. This is the second notice you would receive. 

You can ask the PRO for a reconsideration of its decision. You should request the reconsideration in writing. You can send this letter to the PRO or the Social Security Administration. However, you may request an expedited reconsideration; this request you must make directly of the PRO. You can call the PRO, but sending a written request is best. The request must be made within three days of the notice of termination of your coverage. If you choose to make a normal request for reconsideration instead of an expedited request, you must file within 60 days after receipt of the initial notice. The PRO then must reconsider either type of request within three days. 

If you receive another unfavorable decision by the PRO, you can file an appeal with an ALJ and then you can go to the Medicare Appeals Council. There is no money requirement for the Appeals Council but you must file with in 60 days of the ALJ decision. After this, you may also then file with a U.S. District Judge. To appeal to an ALJ, the amount you owe must be at least $150. To appeal to the District Judge, the amount you owe must be at least $1,460. 

It is important for you to decide whether or not you are going to stay in the hospital and fight the decision, or make arrangements to leave. If you stay in the hospital and then lose all your appeals, you will have to pay for the non-covered time you stayed in the hospital. Of course, if you win, Medicare will cover the entire stay. If your physician agrees that you are well enough to leave the hospital, your chances at appeal are not very good. If your physician thinks you should stay, then you have a difficult decision to make: whether to stay in the hospital to receive the care that your doctor thinks you need and possibly incur large medical bills, or whether to leave the hospital and try to get treatment with your doctor in another setting. (See also the question Bills Beyond Medicare Limits, p. 34.)  

For more information, see: 42 U.S.C. §§ 1320c-3, 1395f(a)(2), 1395y(a)(1), 1395q(d) (2015); 42 C.F.R. §§ 412.42(c)(3), 476.70, 476.78(b)(3)-(4), 476.85, 476.90, 476.94, 478.16, 478.18, 478.20, 478.32, 478.40, 478.46 (2015); Joan M. Krauskopf et al., Elderlaw: Advocacy for the Aging §§ 10.101-.106 (2nd ed. 1993).

Probably. Medicare pays only a portion of a doctor’s bill that is covered. You are responsible for paying the rest. This is called a co-payment. If you do not pay your co-payment, you are indebted to the doctor just as you would be to any other creditor. However, there are limitations on the total that a doctor may charge you. 

Doctors who treat Medicare recipients fall into two categories: participating and non-participating. Participating doctors enter into an agreement with Centers for Medicare and Medicaid Services (CMS) to follow guidelines set by Medicare. Many times a participating doctor will charge directly to Medicare and you never receive the bill. The Medicare guidelines do not allow a participating doctor to charge the patient more than the Medicare-approved charge, although you may still have to pay your co-payment amount. 

A non-participating doctor, on the other hand, is not subject to the same rules. However, Congress placed a cap on how much these doctors can charge. The cap is called a limiting charge (LC). Non-participating doctors can only charge 15% over the Medicare-approved amount for their services. If they charge more, they may be subject to sanctions by CMS. 

If Medicare does not cover the charges, and the charges are not beyond the LC, you are responsible for them. If you don’t pay, the doctor can report you to a collection agency, or even sue. If you cannot afford the co-payment, you should inform the doctor of your financial situation and make whatever payments you can. If the amount you owe is small, the doctor may not spend time or money attempting to collect. However, you cannot rely on this. You legally owe the doctor regardless of how small or large the bill may be. If the doctor does attempt to collect, neither the doctor nor a collection agency may engage in harassing conduct to collect the balance due. 

Patients should read their medical bills carefully. If a service has been provided to you that was not covered by Medicare, the doctor might have asked you to sign a waiver of liability, or Advance Beneficiary Notice (ABN), before you received the service. An ABN is a written notice that tells the patient why Medicare probably (or certainly) will not pay for a service. If you still want to get the service, you will be asked to sign an agreement that you will pay for the service yourself if Medicare does not pay for it. ABNs are used in the Original Medicare Plan, but not in Medicare managed care plans. 

For more information, see: 42 U.S.C. §§ 1395w-4, 1395w-4(g) (2015); W. Va. Code §§ 46A-2-124 to -129a (2015); 42 C.F.R. §§ 424.50, 424.53, 424.56 (2015); Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2015), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015).

Medicare and Medicaid are the two government-sponsored health care programs. Medicare is generally available to most citizens who are disabled or at least 65 years old. There are three main types of Medicare: hospital insurance (Part A), medical insurance (Part B) and prescription drug coverage (Part D). Medicaid is a need-based program that is available to those who, regardless of age, meet certain financial requirements. 

Medicare 

You are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment, are at least 65 years of age, and you are a citizen or permanent resident of the United States. You can also qualify if you are a younger person with a disability, or you suffer from an end stage renal disease. Medicare is divided into several programs: Part A, Part B, Medicare Advantage, and Medicare Part D. 

PART A: Part A is hospital insurance which helps pay for care in hospitals, skilled nursing facilities, hospice, and some home health care. Anyone who is at least 65 years old and receives Social Security or Railroad Retirement Benefits is eligible for Medicare Part A coverage. This includes a retired worker or a survivor or dependent of a retired worker who receives benefits. 

Those receiving disability benefits from Social Security are also eligible for Medicare Part A. A person under 65 who has been receiving disability benefits for more than two years is eligible for Medicare Part A. The months you are disabled do not have to be consecutive. If you have End-Stage Renal (kidney) Disease you are also eligible for Medicare Part A. If you need dialysis, you must first serve a waiting period before you are eligible for benefits. 

If you are in any of the above groups, you can get Medicare Part A coverage without paying any monthly premiums. If you are at least 65 years old and you do not fall into one of the categories above, you can pay for Medicare Part A coverage. If you participate in this voluntary pay system, you have to pay a monthly premium. Those paying for Medicare Part A are required to purchase Part B coverage as well. The monthly price for this coverage is set each year by law. Additionally, those paying for Medicare Part A are required to purchase Part B coverage as well.  

Finally, the state must buy Medicare Part A and Part B coverage for some Medicaid recipients. This coverage is extended to Medicaid recipients that meet certain income requirements. You may qualify for a Medicare assistance program as a Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiary (SLIMB), or Qualifying Individual (QI-1). The state pays the QMB’s Medicare premiums, deductibles, and coinsurance. The state pays the SLIMB’s Medicare Part B premium. The state pays a QI-1’s monthly Part B premium. 

PART B: Medicare Part B is called supplemental medical insurance. Medicare Part B covers physician services, outpatient services, home health care, and some laboratory and diagnostic services. Part B Medicare coverage is voluntary, and you must pay a monthly premium to receive coverage. 

Those who receive Medicare Part A are eligible for Part B. Also, anyone who is a U.S. resident and is at least 65 years old can participate. Additionally, those who have been legal aliens for more than 5 years can apply. The monthly premium is set by law, and it increases when your income is above a certain level. Social Security will notify you by mail if your premium will increase because of your income.  

Medicare will pay benefits to an insurance provider rather than straight to you. The providers are private insurance companies. Medicare will only pay for services under Part A and B that are reasonable and necessary. If you have questions about your eligibility or premium for Medicare Part A or Part B, or if you want to apply for Medicare, call the Social Security Administration at 1 (800) 772-1213. 

Medicare Advantage: If you have both Parts A and B, and you do not have End-Stage Renal Disease, you may be able to participate in a Medicare Advantage Plan, formerly known as Medicare + Choice. Medicare 

Advantage Plans will give beneficiaries an expanded set of options and include Medicare managed care plans (like HMOs) and Medicare Private Fee-for-Service plans. With the Medicare Advantage Plan, you may be able to get extra benefits, like prescription drugs, dentures or denture care, eyeglasses, hearing aids, long-term nursing care, custodial care, or additional days in the hospital. However, you may have to pay more money for a Medicare Advantage Plan, and you may only be able to go to certain doctors or hospitals that agree to treat plan members. For more information, call The Centers for Medicare and Medicaid Services at 1 (800) 633-4227.  

PART D: Medicare Part D is optional prescription drug coverage. Anyone who has Medicare A or B coverage is eligible to enroll in a Medicare Part D plan. Unlike other parts of Medicare, coverage is not available directly from Medicare. If you wish to enroll in prescription drug coverage, you must choose a Part D plan from a private insurance company. There are numerous different plans available to West Virginia residents, each with different premiums, deductibles, and co-payments. There are 3 tiers of “extra help” available to cover these costs if you have limited income and assets. To get extra help, you must apply through the Social Security administration. Qualified individuals who are dually-eligible (meaning they also receive Medicaid) are automatically enrolled in the tier of extra help that gives the individual the lowest co-insurance costs. 

Medicaid 

Medicaid is a need-based program. As a result, you must meet income and asset requirements to qualify for Medicaid coverage. Once you meet these requirements, Medicaid will pay your medical expenses. 

Medicaid is administered by the West Virginia Department of Health and Human Resources (DHHR). Even though the program is funded mostly by the federal government, DHHR is responsible for running the program in this state. Although Medicaid is not limited to the elderly and disabled, for our purposes, we will only consider Medicaid eligibility for the elderly. 

If you receive SSI, you are presumed to meet the eligibility requirements for Medicaid in West Virginia. If you do not receive SSI, you can still receive Medicaid assistance, but it may be very difficult. You must meet certain income and asset requirements. Medicaid coverage for nursing home care is slightly different. In that situation, you are allowed a higher income. You are also allowed to keep more assets if you have a spouse who lives at home. 

For more information, see: 42 U.S.C. §§ 1395c, 1395y(a)(1)(A)-(N), 1396a(a)(10)(E), 1396d(p) (2015); 42 C.F.R. §§ 400.200, 406.5(a), 406.10, 406.12, 406.13, 406.32, 407.40 (2015); Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2011), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015); West Virginia Department of Health and Human Resources, Income Maintenance Manual, §§ 10.2, 10.22, 11.2-.4, http://www.wvdhhr.org/bcf/family_assistance/policy.asp (last visited May 28, 2015); Joan M. Krauskopf et al., Elderlaw: Advocacy for the Aging §§ 10.1, 10.12, 10.14, 10.17, 10.18, 10.19, 10.20 (2nd ed. 1993); Centers for Medicare and Medicaid Services, Get Help With Your Medicare Costs, http://www.medicare.gov/Publications/Pubs/pdf/10126.pdf (last visited May 28, 2015).

Medicare is federal healthcare insurance for the elderly. It is broken into two parts: Part A and Part B. Part A Medicare is hospital insurance. Part B covers other forms of health care. Additionally, seniors may qualify for prescription drug coverage under Medicare Part D. Anyone who is at least 65 years old and receives any of the Social Security benefits listed above is eligible for Medicare Part A coverage. 

You must apply to receive any of the benefits listed above. Sometimes people are unaware that they are eligible for benefits, and they never even apply. If you wish to apply for any of these benefits, you should contact your local Social Security Administration. You can find the number under United States Government in the Blue Pages of your phone book. If you believe you were wrongfully denied benefits, contact an attorney. 

For more information, see: 20 C.F.R. §§ 404.1-.349, 404.390-.480, 404.1501-.1603 (2015); 42 C.F.R. §§ 400.200, 406.5, 406.10, 406.12, 406.13, 406.32, 407.40 (2015); Joan M. Krauskopf et al., Elderlaw: Advocacy for the Aging §§ 10.1, 10.12, 10.14, 10.17, 10.18 (2nd ed. 1993); Social Security Online, Electronic Booklet: Medicare, http://www.ssa.gov/pubs/10043.html (last visited May 27, 2015); Social Security Online, Social Security: What Every Woman Should Know (2010), http://www.socialsecurity.gov/pubs/EN-05-10127.pdf (last visited May 27, 2015).