Unlike private health insurance, Medicare is a government owned and managed health insurance system. Even when you used IBM group health plans IBM offerings for primary coverage (that is, original Medicare or Medicare Advantage plans) were still regulated by Medicare law. What that means is congress passes laws that dictate what coverage a doctor or supplier is able to provide. Medicare Advantage (aka private plans) are bound by that coverage law - they can only fiddle with who provides services or whether they think the medical procedure is necessary for your treatment. 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 myriad of rules and regulations regarding fees and billing. 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 for that service. If the provider tries to charge you more that is Medicare fraud. Medicare Advantage plans are also required to cap fee for services at the same rate as original Medicare - but are allowed to vary your copay so they can have higher copays for specialty services and lower copays for routine services.
Another important rule pertains to using a skilled nursing facility to recuperate from an illness. You MUST 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 private primary (e.g., Medicare Advantage) or secondary (e.g., medigap) 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 ask questions before you agree to anything - 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 government infromation hotline 1-800-MEDICARE is not foolproof - they give a lot of wrong answers. 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:
- 1-800-Medicare and/or http://www.medicare.gov/
This is the government 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. It is a 24 hour service (to cover Hawaii and Alaska) and the best time to call is late at night to get better service. The website is really excellent but complex. There are many reference documents on the site that are excellent but you have to search to find them. Take the time to learn the site.
- CMS centers for Medicare and Medicaid - http://www.cms.gov/
This is the government agency that ADMINISTERS Medicare and Medicaid. The actual services are provided by regional private agencies that the government hires to do the paper work. You get your quarterly Medicare medical statements from CMS. There is a huge amount of information on the website as well as data bases that detail Medicare coverage and fees. Many "white papers" detail specific situations such as "Who Pays First" which is about when Medicare is secondary insurance (e.g., if you work past 65 and have employer coverage). There is also something call "local coverage determinations" that details what procedures have been approved by regional administrators. That information is hugely helpful if you are appealing an insurance plan denial. But it is hard to navigate and typically you need experts to help you find the right information - such as the Medicare hotline agents.
- State Health Insurance Assistance Program - http://www.shiptalk.org/
This is a national program to help seniors navigate the Medicare world. It is a federal mandate that each state must have the agency and typically the states setup the agencies within the Department of Aging. This is an important resource because the rules about how Medicare medigap insurance is administered differs from state to state. There are also some special setups such as Medigap Select programs that states have setup. They will also know about state unique assistance programs, clinics and charities designed to help seniors. Generally the agencies are referred to as state SHIPs. However, states have a habit of giving agencies unique names - for example in Florida the agency is call "SHINE", in New York City it is called "HICAP". Some states have great agencies and others ... well ... they staff with mostly volunteers that are not well trained. If you are getting mediocre assistance press the agency to give you someone better to work with. They will do it if you make noise. The site above will provide the phone number of the agency in your state.
- State Pharmaceutical Assistance Program - part D insurance help
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 www.medicare.gov . It is unlikely IBM retirees will meet the income eligibility requirements but there is some useful Medicare D information on the site. You also should look into getting a prescription discount card in case your Rx is denied by your current insurance and you lose an appeal. Sometimes the state offers one. There is a non-profit that offers one at www.needymeds.org - you might also want to price your drugs using the prescription discount card versus your insurance as sometimes you'll get a better discount. The negative side of doing that is the cost of the drug will not be included in the "doughnut hole" computation. If you use a lot of drugs it is likely unwise to use a prescription drug discount card.
- State health insurance information for consumers -
Most states have complaint data 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 http://www.ins.state.ny.us/). There are also star ratings for Medicare Advantage plans in the Medicare publication "Medicare & You" that is specific to your state and you receive the boook every year.
- Medicare Rights Center 1-800-333-4114 http://www.medicarerights.org/ and http://www.medicareinteractive.org/
This is a national non-profit organization that provides advocacy and helpline support for Medicare questions, help finding part D plans, help understanding medigap and medicare advantage plans. The agency is not affiliated with the government but often testifies in congressional hearings as well as provides evidence of consequences of poorly structured laws. Occasionally case advocates will help clients navigate the appeals process if they feel you have been unjustly denied coverage. The helpline is mostly staffed by volunteers so the answer quality ranges however, the full time staff reviews all the call notes will call you back to try to remedy any bad answers. The regular staff does the case work and there are staff as well as volunteer lawyers that help. They will also help low income clients enroll in low income subsidy programs. The information search website (medicareinteractive.org) aggregates medicare information and provides links to other support sites. It is excellent