Q: My doctor has started charging an additional fee on top of what she used to charge, and Medicare isn’t covering it. Why is this?
A: It’s likely your doctor has stopped participating with Medicare. So while she still accepts patients with Medicare, she no longer is accepting “assignment,” that is, the Medicare-approved amount.
As an example, let’s say the Medicare-approved amount for a check-up is $100, but the doctor does not accept assignment and charges an additional 15% (this percentage above the Medicare-approved amount is typically limited to a certain percentage.) So, the visit will cost $115. Medicare will pay their 80% (of the Medicare-approved amount), assuming the Part B deductible has already been met, so in this case, $80. The patient then pays the remaining $20 of the approved amount, but then also the $15 in “excess” charges, for a total of $35.
A Medicare Supplement, or Medigap plan might cover both the remaining 20% and the $15 in excess charges. However, several Medigap plans do not cover Medicare Part B excess charges. It is important, therefore, to not only verify with your physician(s) that they accept assignment, but also, if you have supplemental coverage, to understand what is covered by your plan.
Q. My friend says her Medicare plan gives her $180 every month to buy vitamins and food. We both have Medicare and Medicaid, but I have Medicare Parts A, B and D. How can I get what she has?
A. It sounds as though you have Original Medicare with Medicaid, and your friend has some form of a Medicare Advantage plan for dual eligible individuals. Being dual eligible means that you qualify for Medicaid due to having a lower income, and you are either disabled or over age 65 so you also qualify for Medicare.
Dual eligible individuals can access the benefits of Medicaid and Medicare in several ways. Some people have Original Medicare, Parts A and B, with a Part D drug plan, and Medicaid coverage for what Medicare does not cover. Other people might have a Medicare Advantage plan (sometimes referred to as Part C) which combines Parts A and B with a drug plan. Dual eligible individuals can also be enrolled in the MI Choice Waiver program, the Program of All-Inclusive Care for the Elderly (PACE,) or MI Health Link plans, all of which provide additional services such as care in the home, transportation, meals, and care management.
Some Medicare Advantage plans offer coverage for things Original Medicare doesn’t cover, like fitness programs, vision, hearing and dental services, transportation for doctor visits, and discounts or credits for over-the-counter (OTC) drugs and supplements. A Medicare Advantage Special Needs Plan offers benefits and services to people with specific diseases or health care needs, or those on limited incomes, such as dual eligible individuals. Also known as D-SNPs, these plans often offer the additional funds or OTC / healthy food credits.
It’s important to evaluate what you currently have against what is being offered. It might sound great to have $180 each month for OTC drugs and supplements and food costs, but are you giving up anything from your current coverage? For instance, if you have a paid in-home caregiver and transportation whenever it is needed does the new plan offer the same? Some D-SNPs have limited numbers of rides each year. Some do not offer in-home care providers and you would need to find a caregiver on your own. Some plans might require using certain medical providers and your current provider might not accept that new plan. Additionally, the extra funds or credits might not be provided or divided in a way that best meets your needs.
These are important cost / benefit considerations that should be made before changing to new coverage. Region IV Area Agency on Aging (RIVAAA) and the Michigan Medicare/Medicaid Assistance Program (MMAP) can help. Contact a certified MMAP Counselor: 1-800-803-7174; info@areaagencyonaging.org
Sara Duris is community information liaison of Region IV Area Agency on Aging in Southwest Michigan. Questions on age or independence services? Call the Info-Line for Aging & Disability at 800-654-2810 or visit areaagencyonaging.org.
The Generation’s Column appears each week in The Herald-Palladium.