Thursday, November 19, 2009

Does government law dictate your Medicare coverage? Yes

Unlike private health insurance, Medicare is a government owned and managed health insurance system. What that means is laws dictate what coverage a doctor or supplier is able to provide. This sounds onerous and sometimes it is. If healthcare professionals break the law the government can prosecute them. Some examples will demonstrate how laws impact your medicare coverage.

Suppose you need to be on an oxygen support system. Choose wisely because once you pick an equipment supplier you have to keep that same supplier for 5 years. That's because there is a law that was passed in 2006 to lower Medicare costs. It is structured to have Medicare provide the supplier with monthly payments for 3 years for the equipment. After 3 years the supplier is only paid for maintaining the equipment. At the end of 5 years you can get a new oxygen support system from a different supplier. If you want more modern equipment or to switch suppliers any time during the 5 years you have to pay for it totally out of pocket.

There are a myiad of rules and regulations. Doctors are not allowed to bill you for services over and above 5-15% (percentage depends on the state) of what Medicare says is the approved amount. If they do that is Medicare fraud. If you need to be in a skilled nursing facility to recouperate from an illness - you have to go to the facility from the hospital and need to have been in the hospital for at least 3 days. Otherwise Medicare will not cover it. It is the law. Nor will your IBM medical insurance cover it - because it will have been denied by Medicare. Just as with any law - ignorance of the law does not absolve you from suffering the consequences. These laws are constantly changing or being amended. Each time you face a given situation you have to do research to determine what rules currently apply.

How can you possibly know all the rules surrounding Medicare healthcare? You can't. Even healthcare professionals regularly give out wrong information. Unless you see it in writing don't believe it. Sadly, even the hotline 1-800-MEDICARE is not foolproof. The burden is on the patient and the family to do research for a given situation. It can take a great deal of time but the payback for knowing the rules can save you a great deal of money.

There are a number of agencies - both government and non-profit - that will help you find answers. Make sure the agency is legitimate as there are also a lot of scams around. What follows is a list of some resources:
  1. 1-800-Medicare and/or
    This is the official hotline and website for medicare. The hotline people are good - but overwhelmed (and with the boomers coming along will likely be more overwhelmed) so their answers are as brief as possible. The website is really excellent but complex. Take the time to learn the site.

  2. CMS centers for Medicare and Medicaid -
    This is the private agency that ADMINISTERS Medicare and Medicaid. Yep, it is a private agency that the government hires to do the paper work. You get your quarterly Medicare statements from CMS. There is a huge amount of information on the website. Many "white papers" detail specific situations such as "Who Pays First" which is about when Medicare is seconday insurance. They are available on the site.

  3. State Health Insurance Assistance Program -
    This is a national program to help seniors navigate the Medicare world. Some states have great agencies and others ... well ... This site will give you information about how to contact the agency within your state. For example, in New York the program is administered by the office of the aging (

  4. State Pharmaceutical Assistance Program -
    About 40 states have programs to help low income seniors cover their drug costs. You can find the program in your state by going to It is unlikely IBM retirees will meet the income eligibility requirements but there is some useful Medicare D information on the site.

  5. State health insurance information for consumers -
    Most states have complaint information about health insurance companies and particularly about HMOs. Before selecting a Medicare Advantage or medigap program look at how they rate on your state insurance website ( in NY it is

  6. Medicare Rights Center - and
    This is a non-profit organization that provides hotline support for Medicare questions, help finding Medicare D, medigap, medicare advantage plans and case advocates that will help navigate the appeals process if you feel you have been unjustly denied coverage. The hotline is staffed by volunteers so the answer quality ranges (Walter is great ... some others, well...). The fulltime staff reviews all the calls to try to remedy any bad answers. The regular staff also does the case work. The website (medicareinteractive) aggregates medicare information and links to other support sites. It is excellent.

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