Medicare For Dummies. Patricia Barry

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СКАЧАТЬ if they’ve reached a point of illness where they’re unable to say what they want. Discussing with a doctor how to make those plans is known as end-of-life counseling, or advance care planning.

      The counseling session may include information on making an advance care directive — a legal document in which you specify whether or not you want to continue treatment or be revived if close to death — and on giving someone (a family member, friend, or legal advisor) legal power of attorney to make medical decisions for you if you are incapacitated. It may also provide information about hospice and palliative care (which I cover earlier in this chapter).

Medicare has provided coverage for such discussions since the beginning of 2016 as a benefit you can choose to receive. As it’s voluntary, nobody can require you to take it, and if you are offered it but don’t want it, you’re free to decline, without forfeiting the right to take part sometime in the future. You can decide if and when the time is right to receive counseling: while you’re still well, with no health issues; when you become ill; or while you’re receiving hospice or palliative care.

      Under this benefit, Medicare pays your doctor (or another authorized medical professional, such as a nurse practitioner) for a first counseling session of up to 30 minutes, and for further 30-minute sessions if you need them. There is no limit on the number of sessions, and they can take place in a variety of settings — doctors’ offices, hospitals, and nursing facilities, for example. If the counseling takes place during an annual wellness visit (which I describe in the earlier section on preventive care), the counseling is free, provided that the doctor accepts assignment. If you schedule a separate session outside the wellness visit, you pay the usual Part B co-pay and the Part B deductible is applied, unless you have supplemental insurance that covers these expenses.

      Pregnancy and childbirth

      Medicare does indeed cover pregnancy and childbirth. Are you astonished? That’s probably because you see Medicare as a program only for people way past childbearing age. But of course Medicare is also for much younger people who qualify through disability, and some of them become pregnant.

      The relevant regulation in the Medicare Benefit Policy Manual explains the scope of coverage: “Skilled medical management is appropriate throughout the events of pregnancy, beginning with the diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.” Medicare also helps cover the cost of treatment for miscarriages and for abortions in circumstances where pregnancy is the result of incest or rape or would threaten your life if you went to term. It doesn’t cover elective abortion if you choose to terminate your pregnancy.

      To receive hospital services, you need Part A hospital insurance. For doctors’ services and outpatient procedures (such as lab tests), you need Part B coverage. If you’re enrolled in Medicaid because your income is low, that program may pay some or all of your out-of-pocket Medicare costs, depending on your state’s eligibility rules. Medicaid may also pay for your infant’s medical care. But after the birth, Medicare doesn’t cover services for your baby at all.

      Medical supplies and equipment

What if you need a wheelchair, an artificial limb, an oxygen tank, or other items that help you function but really qualify as things rather than services or treatments? Medicare has a suitably bureaucratic name for these things — durable medical equipment — and its meaning is precise. Durable means long-lasting, and Medicare covers only items that will stick around awhile. With only a few exceptions, it doesn’t cover disposable items that you use once or twice and then throw away.

      To get Medicare coverage for durable medical equipment, it must be

       Medically necessary for you, not just convenient

       Prescribed by a doctor or another primary-care professional

       Not easily used by anyone who isn’t ill or injured

       Reusable and likely to last for three years or more

       Appropriate for use within the home

       Provided by suppliers that Medicare has approved

      Durable equipment is covered under Medicare Part B and includes walkers and crutches; scooters and manual and powered wheelchairs; commode chairs; hospital beds; respiratory assistance devices; pacemakers; artificial limbs and eyes (prosthetics); limb, neck, and back braces (orthotics); and many other items. Medicare also covers some supplies, such as diabetic test strips and lancets, but otherwise does not generally cover disposable items, such as catheters and diapers.

      

For some items — such as oxygen equipment or seat lifts that help incapacitated people get into or out of a chair — Medicare requires a doctor to fill out and sign a Certificate of Medical Necessity; without it, Medicare will deny coverage. In fact, to combat fraud and manage resources, Medicare is very picky about the evidence it requires for coverage — but your doctor and the supplier (not you) are responsible for providing this proof.

      Medical equipment is most often rented, but some items may be purchased. In either case, Medicare Part B pays 80 percent, and you pay the remaining 20 percent (unless you have Medigap insurance that covers your share). That’s the breakdown in traditional Medicare if you use a supplier that accepts the Medicare-approved amount as full payment. Otherwise, you pay whatever the supplier asks. If you’re in a Medicare Advantage plan, coverage is the same, but you may have different co-pays; check with your plan for details.

      

For more information, and to find out how to select an approved supplier, see the official publication “Medicare Coverage of Durable Medical Equipment and Other Devices” at www.medicare.gov/Pubs/pdf/11045-Medicare-Coverage-of-DME.pdf.

Knowing What Part D Covers

      Part D, Medicare’s program for covering prescription drugs, is a complicated benefit that resembles no other type of drug coverage ever devised. That’s why understanding how it works before plunging in is really important. This section focuses on the peculiarities of Part D coverage — how it can fluctuate during the year, how different plans have their own lists of drugs they cover, and which drugs are excluded from Part D and which must be covered.

      Making sense of drug coverage that can vary throughout the year

      

It sounds crazy, but you may find yourself paying different amounts for the same medicines at different times of the year. That’s because Part D drug coverage is generally divided into four phases over the course of a calendar year. Whether you encounter only one phase or two, three, or all four depends mainly on the cost of the prescription drugs you take during the year — unless you qualify for Extra Help (see Chapter 4). Here’s the breakdown:

       Phase 1, the annual deductible: If your Part D drug plan has a deductible, you must pay full price for your drugs until the cost reaches a limit set by law ($435 in 2020) and drug coverage actually begins. Many plans don’t charge deductibles or charge less than the limit. But if your plan СКАЧАТЬ