Marci’s Medicare Answers
September 2010: Prostate cancer screenings… emergency ambulance calls… Hepatitis B shots… and more questions answered by a Medicare expert
Does Medicare cover screenings for prostate cancer?
Yes. Medicare covers one prostate screening per year (every 12 months) for men age 50 and older. Prostate cancer screenings can detect prostate cancer, which affects one in six men, in its early stages. The screening includes a Prostate-Specific Antigen (PSA) blood test and a digital rectal exam. Medicare will cover these services more than once per year if your doctor says you need them for diagnostic purposes. Medicare covers 80 percent of the cost of the digital rectal exam (after you pay your annual Part B deductible), and 100 percent of the cost of the PSA test (with no Part B deductible required). (If you are in a Medicare private health plan—HMO or PPO—you may have a copay for the PSA test or the digital rectal exam. Call your plan to find out what you will have to pay.)
If I have an emergency and call an ambulance, will Medicare pay for it?
Yes. Medicare will generally cover ambulance services in an emergency, as long as:
An ambulance is the only safe way to transport you (medically necessary); and
You are transported to and from certain locations.
An emergency is when your health is in serious danger and every second counts to prevent your health from getting worse. If the trip is scheduled as a way to transport you from one location to another when your health is not in immediate danger, it is not considered an emergency.
If it is not an emergency, Medicare coverage of ambulance services is very limited, but Medicare may cover nonemergency ambulance services in certain instances. For example, nonemergency services may be covered if you are confined to your bed or if you need vital medical services during your trip that are available only in an ambulance. Lack of access to alternative transportation alone will not justify Medicare coverage.
If covered, Medicare will pay for 80 percent of its approved amount for the ambulance service. You or your supplemental insurance policy will be responsible for the remaining 20 percent. All ambulance providers must accept Medicare assignment, meaning they must accept the Medicare-approved amount as payment in full.
Note: Medicare will never pay for ambulette services.
I’ve heard that some drug companies will offer their drugs at a discount for people with low incomes. Is that true?
Yes. Some drug companies offer free or low-cost drugs through programs called Patient Assistance Programs (PAPs). In most cases, your doctor must apply to the program for you. While many patient assistance programs do not allow you to apply if you are eligible for the Medicare drug benefit (Part D), some do.
Generally, PAPs require your doctor to be involved in the application process. You may be required to pay a copayment. If you have Part D, your PAP copayments will count toward meeting your Part D plan’s out-of-pocket limit ($4,550 in 2010), but you will need to submit your receipts to your plan, and any other required documentation in order for what you pay to count. What your PAP pays for your prescription drugs will not count toward the $4,550 in out-of-pocket costs that you must spend before catastrophic coverage begins and your drug costs go down significantly. To look up details about PAPs using an alphabetical list of drugs, go to www.medicare.gov/pap.
I’m planning to get a Hepatitis B shot. Will Medicare cover it?
Your Medicare health coverage (Part B) will cover vaccines to prevent Hepatitis B only if you are at medium to high risk for hepatitis B (you have kidney failure, hemophilia or travel to countries with high rates of the disease). In 2010, if you are at medium to high risk, Medicare will cover 80 percent of the cost of your hepatitis B vaccine after you pay your annual Part B deductible.
I just received a Medicare Summary Notice in the mail, and I’m not sure what it is. Is it a bill?
When Original Medicare processes a claim for health care services you received, the claim is detailed in a Medicare Summary Notice (MSN). The MSN is a summary of claims for health care services Medicare processed for you during the previous three months. The MSN is not a bill.
MSNs are mailed four times a year and contain information about submitted charges, the amount that Medicare paid, and the amount you are responsible for.
The most important fields on your MSN explain:
The total amount your doctor or other provider may bill you.
Non-covered charges, if any.
Try to save your MSNs for about seven years. You might need them in the future to prove that payment was made if a provider sends you a bill, or that services were received if you claimed a medical deduction on your taxes. If you have lost your MSN or you need a duplicate copy, call 800-MEDICARE. You will be redirected to the Medicare carrier who originally issued the MSN and can send you a copy.
If I have Medicare, am I allowed to enroll in Medicaid programs as well?
Yes. Medicaid programs can help pay for Medicare’s costs and for services that Medicare does not cover. If you are eligible for Medicare and have low income, you may qualify for help from certain Medicaid programs in your state. In general, your state will have more than one program that can help people who are eligible for Medicare. Whether you qualify for a Medicaid program will depend on:
• Your income (money you take in, for example, from Social Security payments or wages that you earn)
• Your assets (resources such as checking accounts, stocks and some property)
If you need long-term care, whether you meet your state’s “functional eligibility” or “level-of-care” criteria–standards for assessing your need for help with activities of daily living (for example, toileting, bathing, dressing) and your need for nursing care. Each state sets its own standards.
In general, people with Medicare who have low income may qualify for one of the following:
• Medicaid for people who are “over 65, blind or have a disability” and do NOT need long-term care
• Nursing Facility Medicaid
• Medicaid Waiver Programs for long-term care in your home or community
To find out what Medicaid programs exist in your state, contact your State Health Insurance Assistance Program (www.shiptalk.org) or local Medicaid office.
Marci’s Medicare Answers is a service of the Medicare Rights Center (http://www.medicarerights.org/), the nation’s largest independent source of information and assistance for people with Medicare. To speak with a counselor, call (800) 333-4114.