Medicare For Dummies. Barry Patricia

and the medical director of a hospice program must certify that you probably have less than six months to live.

      ❯❯ You must enroll in a hospice program that Medicare has approved.

      ❯❯ You must have Medicare Part A hospital insurance.

      If you qualify, Medicare pays in full – 100 percent – for a wide range of services, including

      ❯❯ Medical and nursing care, plus round-the-clock on-call support

      ❯❯ Medical equipment and supplies

      ❯❯ Homemaker and home health care services

      ❯❯ Physical therapy

      ❯❯ Social worker services and dietary counseling

      ❯❯ Support for your caregiver

      ❯❯ Grief and loss counseling for you and your family

      Your share of the cost is limited to a maximum of $5 per prescription for drugs used to control the symptoms and pain of your terminal illness; and 5 percent of the cost of respite care if you’re taken into a nursing home to give your caregiver a break. However, if you have Medigap supplemental insurance, both these costs are fully covered, as Chapter 4 explains. (Costs related to any medical conditions other than your terminal illness are covered by Medicare Part B or Part D in the usual way.)

      

You’re free to stop hospice care any time you want to – and also to resume it again if that’s your wish. Coverage continues for as long as your doctor and a hospice doctor continue to certify that you’re terminally ill, even if you live longer than six months. If your health improves and the doctors decide you no longer need hospice care, the benefit ends – though you still have the right to appeal. If your health deteriorates again, the benefit can resume.

      

For more details, see the official publication “Medicare Hospice Benefits” at www.medicare.gov/Pubs/pdf/02154.pdf.

       Pregnancy and childbirth

      Medicare does indeed cover pregnancy and childbirth. Are you astonished? That’s probably because you see Medicare as a program only for people way past childbearing age. But of course Medicare is also for much younger people who qualify through disability, and some of them become pregnant.

      The relevant regulation in the Medicare Benefit Policy Manual explains the scope of coverage: “Skilled medical management is appropriate throughout the events of pregnancy, beginning with the diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.” Medicare also helps cover the cost of treatment for miscarriages, and for abortions in circumstances where pregnancy is the result of incest or rape or would threaten your life if you went to term. It doesn’t cover elective abortion if you choose to terminate your pregnancy.

      To receive hospital services, you need Part A hospital insurance. For doctors’ services and outpatient procedures (such as lab tests), you need Part B coverage. If you’re enrolled in Medicaid because your income is low, that program may pay some or all of your out-of-pocket Medicare costs, depending on your state’s eligibility rules. Medicaid may also pay for your infant’s medical care. But after the birth, Medicare doesn’t cover services for your baby at all.

       Medical supplies and equipment

      What if you need a wheelchair, an artificial limb, an oxygen tank, or other items that help you function but really qualify as things rather than services or treatments? Medicare has a suitably bureaucratic name for these things – durable medical equipment – and its meaning is precise. Durable means long-lasting, and Medicare covers only items that will stick around a while. With only a few exceptions, it doesn’t cover disposable items that you use once or twice and then throw away.

      To get Medicare coverage for durable medical equipment, it must be

      ❯❯ Medically necessary for you, not just convenient

      ❯❯ Prescribed by a doctor or another primary care professional

      ❯❯ Not easily used by anyone who isn’t ill or injured

      ❯❯ Reusable and likely to last for three years or more

      ❯❯ Appropriate for use within the home

      ❯❯ Provided by suppliers that Medicare has approved

      Durable equipment that Medicare covers includes walkers and crutches; scooters and manual and powered wheelchairs; commode chairs; hospital beds; respiratory assistance devices; pacemakers; artificial limbs and eyes (prosthetics); limb, neck, and back braces (orthotics); and many other items. Medicare also covers some supplies, such as diabetic test strips and lancets, but not disposable items, such as catheters and diapers.

      

For some items – such as oxygen equipment or seat lifts that help incapacitated people get into or out of a chair – Medicare requires a doctor to fill out and sign a Certificate of Medical Necessity; without it, Medicare will deny coverage. In fact, to combat fraud and manage resources, Medicare is very picky about the evidence it requires for coverage – but your doctor and the supplier (not you) are responsible for providing this proof.

      Medical equipment is most often rented, but some items may be purchased. In either case, Medicare Part B pays 80 percent, and you pay the remaining 20 percent (unless you have Medigap insurance that covers your share). That’s the breakdown in traditional Medicare if you use a supplier that accepts the Medicare-approved amount as full payment. Otherwise, you pay whatever the supplier asks. If you’re in a Medicare Advantage plan, coverage is the same, but you may have different co-pays; check with your plan for details.

      

For more information, and to find out how to select an approved supplier, see the official publication “Medicare Coverage of Durable Medical Equipment and Other Devices” at www.medicare.gov/Pubs/pdf/11045.pdf.

Knowing What Part D Covers

      Part D, Medicare’s program for covering prescription drugs, is a complicated benefit that resembles no other type of drug coverage ever devised. That’s why understanding how it works before plunging in is really important. This section focuses on the peculiarities of Part D coverage – how it can fluctuate during the year, how different plans have their own lists of drugs they cover, and which drugs are excluded from Part D and which must be covered.

       Making sense of drug coverage that can vary throughout the year

      

It sounds crazy, but you may find yourself paying different amounts for the same medicines at different times of the year. That’s because Part D drug coverage is generally divided into four phases over the course of a calendar year. Whether you encounter only one phase or two, three, or all four depends mainly on the cost of the prescription drugs you take during the year – unless you qualify for Extra Help (see Chapter 4). Here’s the breakdown:

      ❯❯ Phase 1, the annual deductible: If your Part D drug plan has a deductible, you must pay full price for your drugs until the cost reaches a limit set by law ($320 in 2015; $360 in 2016) and drug coverage actually begins. Many plans don’t charge deductibles or charge less than the limit. But if your plan has a deductible, this period begins on January 1 or whenever you start using your Medicare drug coverage.

      ❯❯ Phase 2, the initial coverage period: This stage begins when you’ve met any plan deductible. Otherwise, it begins on January 1 or whenever you start using Medicare drug coverage. You then pay the co-payments required by your plan for each prescription, and the plan pays the rest. This period ends when