Question: A Medicare Patient Received Treatment That Isn't Covered By Medicare

When a Medicare patient receives treatment that isn't covered by Medicare, it can lead to unexpected medical bills and financial stress. Understanding why this occurs, what steps you can take to address it, and how to prevent similar situations in the future is crucial. This comprehensive guide will help clarify these aspects, along with offering actionable solutions and external resources for further assistance.

Understanding Medicare Coverage Gaps

1. Basic Structure of Medicare: Medicare, a federal health insurance program primarily for individuals aged 65 and over, consists of several parts:

• Part A covers hospital inpatient stays, care in a skilled nursing facility, and some home health care.
• Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
• Part C (Medicare Advantage Plans) encompasses Parts A and B and sometimes Part D, offered by approved private companies.
• Part D is for prescription drug coverage.

2. Common Coverage Exclusions: Despite its extensive coverage, Medicare does have gaps. Common exclusions include:

• Long-term care (custodial care)
• Most dental care
• Eye exams related to prescribing glasses
• Dentures
• Cosmetic surgery
• Acupuncture
• Hearing aids and exams for fitting them

Understanding what Medicare does not cover helps prevent surprises when receiving treatments or services. Always verify if a proposed treatment is covered by consulting the Medicare handbook, the online Medicare plan finder, or your healthcare provider.

Steps to Take If A Treatment Isn't Covered

1. Review Your Medicare Summary Notice (MSN):

• The MSN is a notice you receive every three months if you received services or supplies. It shows the services billed to Medicare and what Medicare paid.
• It helps verify what specific treatments were denied coverage.

2. Check for Errors:

• There may be billing errors or coding issues. Contact the billing office of your healthcare provider for explanation and possible correction.

3. Appeal the Decision:

• Understand the Reason for Denial:
  • It can be due to a clerical error, the service being incorrectly deemed unnecessary, or it being explicitly not covered.
• Initiate the Appeal:
  • Use the instructions on your MSN. You generally have 120 days to file an appeal from when you receive the notice.
• Level of Appeals:
  • Redetermination by the company handled by Medicare
  • Reconsideration by a Qualified Independent Contractor
  • Third-level appeal with an Administrative Law Judge
  • Fourth-level appeal with the Medicare Appeals Council
  • A final step is a judicial review by a federal district court.

4. Seek Financial Assistance:

• Extra Help Program: For those with limited income, it helps with Medicare prescription drug plan costs.
• Medicare Savings Programs: Assist with other costs like premiums, deductibles, and coinsurance.
• Local Programs: State Health Insurance Assistance Programs (SHIPs) offer counseling and guidance on Medicare.

Long-Term Solutions and Preventive Measures

1. Consider a Medicare Supplement Insurance (Medigap) Policy:

• Medigap can help cover services that Original Medicare doesn't, like coinsurance, copayments, and deductibles.

2. Research and Choose a Suitable Medicare Advantage Plan:

• These plans often offer additional coverage, including vision, hearing, dental, and wellness programs.

3. Regularly Update Your Health Insurance Knowledge:

• Stay informed about changes in Medicare policies by attending local seminars, subscribing to Medicare newsletters, or consulting SHIP.

4. Proactive Communication with Healthcare Providers:

• Discuss all upcoming treatments with your healthcare provider and confirm Medicare coverage before proceeding. Request written confirmations if necessary.

Frequently Asked Questions

1. Can I change my Medicare plan if it doesn’t cover the treatments I need? Yes, you can change plans during the Medicare Open Enrollment period each year from October 15 to December 7. During this time, you can switch from Original Medicare to a Medicare Advantage Plan, or vice versa, depending on your needs.

2. How do Medicare Advantage Plans differ regarding coverage? Medicare Advantage Plans may offer extra benefits than Original Medicare. Always review what each plan covers, including any restrictions or network limitations, to ensure it meets your healthcare needs.

3. What if my income is too high for Medicaid or Extra Help, yet I still can't afford my treatment? Speak with your doctor or healthcare office about setting up a payment plan. Also, check local charities or foundations that might offer financial aid for medical treatments not covered by insurance.

Resources for Further Assistance

• Medicare's Official Website: Comprehensive source for Medicare policies, forms, and applications.
• National Council on Aging: Provides resources and support for Medicare-related issues, including financial aid.
• State Health Insurance Assistance Programs (SHIP): Contact them for localized advice and help with your Medicare plan.

Understanding your Medicare coverage and proactive planning can prevent and address issues when treatments fall outside the covered services. While unexpected medical bills can be stressful, utilizing available resources and pathways can effectively manage and resolve these situations, ensuring you maintain continued access to the necessary healthcare services.