Navigating Medicare can be complex, and making mistakes can lead to financial repercussions or missed opportunities for coverage. Whether you’re new to Medicare or reviewing your options, understanding common pitfalls can help you make informed decisions. Here are some key mistakes to avoid:

1.Missing Initial Enrollment Period (IEP) – Your Initial Enrollment Period begins three months before your 65th birthday month, includes your birthday month, and extends three months after. Failing to enroll during this window could result in delayed coverage and potential late penalties for Part B (medical insurance) and Part D (prescription drug coverage).

Related: Curious About Medicare’s Annual Enrollment Period?

2.Not Understanding Coverage Gaps – Original Medicare (Parts A and B) doesn’t cover all healthcare costs. For comprehensive coverage, consider additional plans like Part C (Medicare Advantage) or Medigap (Medicare Supplement Insurance) plans. Without supplemental coverage, you may face significant out-of-pocket expenses.

>>Related Reading: The Pros and Cons of Medicare Supplement Insurance (Medigap)

3.Overlooking Part D (Prescription Drug Coverage) – Part D helps cover prescription drug costs. Not enrolling in a Part D plan when first eligible can lead to a penalty if you later need prescription coverage. Review plans annually during the Open Enrollment Period (October 15 to December 7) to ensure your medications are covered at the lowest cost.

4. Not Reviewing Medicare Advantage Plans Annually – Medicare Advantage plans can change their coverage, networks and costs each year. Failing to review your plan annually during the Open Enrollment Period could mean missing out on better coverage options or lower costs.

5.Assuming Medicare Covers Everything – Original Medicare covers many healthcare services, but not everything. For example, it doesn’t cover routine dental, vision, or hearing care. Understanding what’s covered and what isn’t can help you plan and budget for additional health expenses.

6.Choosing the Wrong Medigap Plan – Medigap plans help pay for costs that Original Medicare doesn’t cover, such as deductibles, copayments, and coinsurance. Each plan (labeled A through N) offers different coverage levels. Choosing the right plan depends on your healthcare needs and budget. Research and compare plans carefully.

7.Not Taking Advantage of Preventive Services – Medicare covers many preventive services at no cost to you, such as screenings for cancer, diabetes, and cardiovascular conditions. Regular screenings can catch health issues early when treatment is most effective.

>>Related Reading: Understanding Medicare’s Preventive Services: What’s Covered?

8.Assuming Spousal Coverage Automatically Transfers – If you’re covered under your spouse’s employer health insurance and they turn 65 or retire, you may need to enroll in Medicare separately. Understanding coordination of benefits and enrollment timing can prevent coverage gaps.

9.Ignoring State and Federal Assistance Programs – Various programs offer financial assistance for Medicare premiums, copayments, and other healthcare costs based on income levels. Check eligibility for programs like Medicaid, Medicare Savings Programs, or Extra Help to reduce healthcare expenses.

>>Related Reading: Medicare Savings Programs: Are You Eligible?

10.Not Asking Questions or Seeking Help – Medicare rules and options can be complex. Don’t hesitate to ask questions, either through Medicare itself or a trusted insurance agent specializing in Medicare plans. Understanding your coverage options ensures you receive the care you need without unexpected costs.

Navigating Medicare requires attention to detail and proactive decision-making. By avoiding these common mistakes and staying informed about your options, you can maximize your benefits and ensure comprehensive healthcare coverage throughout your retirement years.

Remember, we are here to help! Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

Understanding Medicare Savings Programs

Medicare Savings Programs are state-administered initiatives designed to help low-income Medicare beneficiaries afford their healthcare costs. These programs provide assistance with Medicare premiums, deductibles, coinsurance, and copayments, ensuring that eligible individuals have access to essential healthcare services without facing undue financial hardship.

Types of Medicare Savings Programs: There are several types of Medicare Savings Programs, each catering to different income levels and financial needs:

• Qualified Medicare Beneficiary (QMB) Program: The QMB program helps individuals with incomes slightly above the federal poverty level (FPL) by covering Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. Beneficiaries enrolled in QMB are not responsible for any Medicare cost-sharing expenses.
• Specified Low-Income Medicare Beneficiary (SLMB) Program: SLMB provides assistance to individuals with incomes slightly above the federal poverty level but below 120% of the FPL. This program covers Medicare Part B premiums only, helping beneficiaries afford their monthly insurance costs.
• Qualified Individual (QI) Program: QI is designed for individuals with incomes slightly above 120% of the federal poverty level but below 135% of the FPL. Like SLMB, QI covers Medicare Part B premiums, offering financial relief to eligible beneficiaries.
• Qualified Disabled and Working Individuals (QDWI) Program: QDWI assists disabled individuals under 65 who are working, have lost their premium-free Part A coverage due to returning to work, and meet income and resource requirements.

Eligibility Criteria

Eligibility for Medicare Savings Programs is based on income and asset limits established by each state. While these criteria may vary slightly from state to state, individuals typically must have incomes below a certain threshold and limited resources to qualify for assistance. Additionally, eligibility for MSPs is separate from eligibility for other low-income assistance programs, such as Medicaid.

>>Related Reading: 10 Easy Ways to Make the Most of Your Medicare Coverage

How to Apply

To apply for Medicare Savings Programs, you can contact your state’s Medicaid office or local Social Security Administration office. The application process may require providing documentation of income, resources, and Medicare enrollment. Upon approval, beneficiaries will receive notification of their eligibility and any assistance they qualify for under the program. If you live in Tennessee, we can help guide you!

Medicare Savings Programs offer a vital safety net for low-income Medicare beneficiaries, providing much-needed financial assistance to help cover healthcare costs. By easing the burden of premiums, deductibles, and other out-of-pocket expenses, MSPs ensure that eligible individuals can access the care they need to stay healthy and maintain their well-being. If you or someone you know is struggling to afford Medicare costs, explore the options available through Medicare Savings Programs and take advantage of this valuable support system. Your health and financial security are worth it.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

Preventative Service Options

Medicare offers a comprehensive array of preventive services aimed at maintaining health, preventing illnesses, and detecting medical conditions early when they’re most treatable. These services are divided into different categories, including:

• Welcome to Medicare Visit: This initial preventive visit, available within the first 12 months of enrolling in Medicare Part B, includes a review of your medical and social history, vital measurements, and personalized health advice.
• Annual Wellness Visit: After the first year of Medicare Part B coverage, beneficiaries are eligible for an annual wellness visit. During this visit, your healthcare provider will develop or update a personalized prevention plan based on your current health and risk factors.
• Screening Services: Medicare covers a wide range of screening tests and services to detect various medical conditions early, such as cancer, cardiovascular disease, diabetes, and osteoporosis. These screenings may include mammograms, colonoscopies, bone density scans, and cardiovascular risk assessments.
• Vaccinations: Medicare covers several vaccines recommended by the Centers for Disease Control and Prevention (CDC) to prevent illnesses such as influenza (flu), pneumococcal disease, and hepatitis B. Beneficiaries should check with their healthcare provider to ensure they’re up to date on recommended vaccinations.
• Counseling Services: Medicare also covers counseling and education services to promote health and prevent disease. This may include counseling on topics such as smoking cessation, obesity, nutrition, and alcohol misuse.
• Advance Care Planning: Medicare covers advance care planning discussions between beneficiaries and their healthcare providers to help them make informed decisions about their future medical care preferences.

Learn What is Provided

It’s important for Medicare beneficiaries to understand that while many preventive services are covered at no cost, some services may require payment of deductibles, coinsurance, or copayments. Additionally, coverage may vary depending on factors such as the beneficiary’s age, risk factors, and whether the service is provided by a participating Medicare provider.

>>Related Reading: Physicals are NOT Covered with Medicare, but a Wellness Visit IS!

Schedule Regular Appointments

To take advantage of Medicare’s preventive services, beneficiaries should schedule regular appointments with their healthcare providers and discuss which screenings and preventive measures are recommended based on their age, gender, and medical history. Staying proactive about preventive care can help beneficiaries stay healthy, detect medical conditions early, and ultimately improve their quality of life.

Medicare’s preventive services play a crucial role in promoting the health and well-being of beneficiaries across the nation. By understanding what preventive services are covered and how to access them, Medicare beneficiaries can take proactive steps to protect their health and enjoy a better quality of life in their golden years. Stay informed, stay proactive, and prioritize your health with Medicare’s preventive services.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

The Rise of Telehealth in Medicare

Telehealth, encompassing services such as video consultations, remote monitoring, and electronic communication between patients and providers, has gained momentum within the Medicare program. Recognizing its potential to improve access to care and enhance patient outcomes, Medicare has expanded coverage for telehealth services over the years.

Medicare Coverage for Telehealth Services

Medicare coverage for telehealth services has evolved, especially in response to the COVID-19 pandemic. Temporary waivers and regulatory changes have enabled Medicare beneficiaries to receive a broader range of telehealth services from various providers, including doctors, nurse practitioners, and mental health professionals. These services encompass primary care, specialty consultations, mental health counseling, and chronic disease management, among others.

>>Related: Medicare Changes in 2024: What Medicare Beneficiaries Need to Know

Benefits of Telehealth for Medicare Beneficiaries

Telehealth offers numerous benefits for Medicare beneficiaries, including:

• Enhanced Access: Telehealth eliminates geographic barriers, enabling beneficiaries to connect with healthcare providers from the comfort of their homes.
• Convenience: Virtual visits save time and effort associated with traveling to a healthcare facility, making it easier for older adults to access timely care.
• Continuity of Care: Telehealth facilitates regular check-ins and follow-up appointments, promoting continuity of care and proactive management of chronic conditions.
• Safety: Amidst public health concerns such as the COVID-19 pandemic, telehealth minimizes the risk of exposure to infectious diseases by reducing the need for in-person visits.

Challenges and Considerations

While telehealth offers significant advantages, certain challenges and considerations remain, including:

• Digital Divide: Some Medicare beneficiaries may lack access to the technology or internet connectivity required for telehealth visits, exacerbating disparities in healthcare access.
• Reimbursement and Regulation: Medicare reimbursement policies and regulatory frameworks for telehealth services continue to evolve, impacting provider participation and sustainability.
• Patient-Provider Relationships: Establishing and maintaining rapport through virtual interactions may pose challenges for some patients and providers, emphasizing the importance of effective communication and technology literacy.

Looking Ahead

As telehealth becomes increasingly integrated into the healthcare landscape, it is positioned to play a central role in Medicare’s efforts to improve access, quality, and efficiency of care delivery. Continued innovation, policy refinement, and investment in infrastructure are essential to maximize the potential of telehealth in meeting the evolving needs of Medicare beneficiaries.
Telehealth represents a promising avenue for transforming healthcare delivery for Medicare beneficiaries, offering greater convenience, accessibility, and quality of care. By embracing telehealth and leveraging its benefits, Medicare is paving the way for a more patient-centered and technologically advanced healthcare system.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!
*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

1. Get to Know Your Medicare ABCs
   Understanding the different parts of Medicare can feel like decoding a secret message, but fear not! Part A covers hospital stays, Part B covers medical services, Part C (Medicare Advantage) bundles Parts A and B, and Part D covers prescription drugs. Knowing these basics will help you navigate your coverage like a pro.
2. Enroll at the Right Time
   Enrolling in Medicare during your Initial Enrollment Period (IEP) is crucial to avoid late enrollment penalties. If you miss your IEP, you can enroll during the General Enrollment Period (GEP), but it’s best to get it done early to keep those penalties at bay.
3. Explore Extra Coverage Options
   Consider adding a Medicare Supplement (Medigap) plan or enrolling in a Medicare Advantage plan to beef up your coverage and minimize out-of-pocket costs. It’s like adding sprinkles to your ice cream – extra goodness all around!
4. Give Your Coverage a Check-Up
   Your healthcare needs change, so it’s essential to review your Medicare coverage annually during the Annual Enrollment Period (AEP). Make sure your plan still fits your needs and budget, and make changes if necessary.
5. Take Advantage of Preventive Services
   Did you know that Medicare covers a slew of preventive services? From screenings to vaccines to annual wellness visits, these services can help you stay healthy and catch any potential health issues early. It’s like a healthcare spring cleaning for your body!
6. Know Your Prescription Drug Coverage
   If you have Medicare Part D prescription drug coverage, stay on top of your plan’s formulary to ensure your medications are covered. Consider switching plans if your current one no longer fits the bill. Keep in mind if you change plans and do not have a prescription drug plan you could end up with a penalty unless your current prescription plan is considered creditable with Medicare.
7. Stick with In-Network Providers
   If you’re on a Medicare Advantage plan, sticking with in-network providers can help you maximize your coverage and keep costs down. It’s like shopping at your favorite store – you get the best deals when you stay loyal!
8. Embrace Telehealth
   Telehealth services are a convenient and cost-effective way to receive healthcare services. Give them a try when appropriate to save time and money – plus, you can stay in your PJs!
9. Don’t Take No for an Answer
   If Medicare denies coverage for a service or treatment, you have the right to appeal. Don’t be afraid to stand up for yourself and fight for the coverage you deserve.
10. Stay Informed and Stay Healthy
    Stay informed about changes to Medicare coverage and regulations. Follow reputable sources for Medicare news and updates to ensure you have the most up-to-date information. And most importantly, take care of yourself – because your health is the ultimate wealth!

Pros:

1. Coverage of Medicare Gaps: One of the biggest advantages of Medigap plans is that they help cover the “gaps” in Original Medicare, such as deductibles, copayments, and coinsurance. This can provide you with greater financial predictability and protection against high out-of-pocket costs.
2. Freedom to Choose Providers: With Medigap plans, you can typically see any healthcare provider who accepts Medicare. This can be advantageous if you want to continue seeing a specific doctor or specialist without worrying about network restrictions.
3. No Referrals Needed: Unlike some Medicare Advantage plans, Medigap policies do not require referrals to see specialists. You have the freedom to visit any specialist without needing approval from a primary care physician.
4. Coverage While Traveling: Many Medigap plans offer coverage for emergency medical care when you’re traveling outside the United States. This can provide peace of mind for seniors who enjoy traveling or spending time abroad.
5. Guaranteed Renewable: As long as you pay your premiums on time, your Medigap policy is guaranteed renewable. This means the insurance company cannot cancel your coverage as long as you continue to pay your premiums.

Cons:

1. Higher Premiums: Medigap plans typically have higher monthly premiums compared to Medicare Advantage plans. However, this trade-off can be worthwhile for those who want more comprehensive coverage and predictable out-of-pocket costs.
2. Requires Original Medicare: To enroll in a Medigap plan, you must already be enrolled in both Medicare Part A and Part B. This means you’ll need to pay the premiums for Part B in addition to your Medigap premiums.
3. No Prescription Drug Coverage: Medigap plans do not cover prescription drugs. If you want this coverage, you’ll need to enroll in a separate Medicare Part D plan.
4. Limited Enrollment Period: The best time to enroll in a Medigap plan is during your six-month Medigap Open Enrollment Period, which starts the month you’re 65 and enrolled in Medicare Part B. Outside of this period, you may be subject to medical underwriting, which could result in higher premiums or denial of coverage.
5. Plan Standardization: Medigap plans are standardized in most states, meaning the coverage for each plan type is the same regardless of the insurance company. While this simplifies comparison shopping, it also means you may not find as much variation in coverage options.

Medigap plans offer valuable benefits for Medicare beneficiaries who want greater financial protection and flexibility in their healthcare choices. However, it’s important to weigh the pros and cons carefully and consider your individual healthcare needs and budget before making a decision.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

First, What Does an IPPE Visit Include?

When you first enroll in Medicare, they allow you an IPPE that is covered one time, within the first 12 months of receiving Medicare Part B coverage. This initial physical exam will cover the following items to assess your overall health:

• Record and evaluate your medical and family history, current health conditions and prescriptions.
• Check your blood pressure, vision, weight, and height to get a baseline for your care.
• Make sure you are up to date with preventive screenings and services, such as cancer screenings and shots.
• Order further tests, depending on your general health and medical history.
• You do not pay a copayment for your “Welcome to Medicare” visit. The Part B deductible does not apply to the cost of the visit either.

When the exam is complete, your provider will give you a prevention plan, or list, of screenings and preventive services that are recommended for you. *These services are not part of the “Welcome to Medicare” visit and may require you to pay a copayment when you get them. Your Part B deductible may also apply. *

>>New to Medicare? Make sure you sign up for your Medicare.gov account!

Physical Exams vs. Wellness Visit

What’s Included in a Physical Exam?

An annual physical exam is an assessment of your body’s overall health. The primary purpose is to look for health issues. The list below shows some of the things your doctor may do during a physical exam (This is not a comprehensive list).

• Visually check your body overall for signs of existing health issues
• Look into your eyes, ears, nose and throat for potential problems.
• Listen to your heart and lungs to detect irregular sounds.
• Check your body for abnormalities.
• Test your motor function and reflexes.
• Perform pelvic and rectal exams.
• Measure your weight, height and blood pressure.

Again, as a rule, Medicare does not cover annual exams. This and any recommended testing or screenings are separate services, so there may be additional costs related to each depending on your Medicare plan.

What’s included in a Medicare Wellness Visit?

A Medicare Wellness Visit (wellness exam) is a review of your overall health and well-being by combining information from your visit with your medical records to assess your risk for common preventable health issues such as heart disease, type 2 diabetes and cancer. The purpose of a wellness visit is to develop a baseline for current well-being and prevent future issues. Medicare covers a wellness visit on time every 12 months (11 full months must have passed since your last visit), once you have had Medicare Part B for 12 months, you are eligible for it. Based on what’s learned, your provider will create a prevention plan including screenings you should have.

Some of the things your provider may do during a wellness exam (this is not a comprehensive list).

• A health risk assessment (questions you answer about your health)
• A review of your medical and family history
• A review of your current prescriptions and providers
• Measure and document your height, weight, and blood pressure
• Look for signs of memory loss, dementia or frailty
• Assess your health risk factors and treatment options
• Provide specific health advice
• Develop a screening schedule for the preventive services recommended for you

Although Medicare Part B covers your annual wellness exam and many preventive screenings with no copay or deductible, if your provider performs additional services and tests during your appointment that aren’t covered, you will be responsible for these costs. Be sure to state clearly to your provider and their office that this is a Medicare Wellness visit and NOT an annual physical to avoid unexpected bills. 

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

The Information You Can Access

When you access the Medicare.gov website, there is a lot of information for Medicare beneficiaries, along with information for those beginning their Medicare journey. 

Without an account, you can use the Medicare.gov website to:

• Learn basic information about Medicare
• Learn how health plans and drug coverage work
• Learn what Medicare covers
• Find health and drug plans in your area
• Compare health and drug plans
• Find care providers
• Compare hospitals, nursing homes, and other providers near you
• Learn how to sign up for coverage
• Locate forms, publications, and information about things Medicare mails you
• File claims, complaints, and appeals
• Use Medicare’s live chat feature (available 24/7 except some holidays)
• If you’re not ready to create an account yet, you can sign up for news and updates at the bottom of the Medicare.gov website’s homepage. They will email you things like reminders about open enrollment and ways to save costs.

Additional benefits to creating your own account:

• View your Medicare Summary Notice within 24 hours of your visit
• Manage details and claims
• Add your prescriptions to help you better compare health and drug plans in your area.
• View your Original Medicare claims as soon as they’re processed.
• Print a copy of your official Medicare card.
• Review a list of preventive services you’re eligible to get in Original Medicare.
• Learn about your Medicare premiums, and pay them online if you get a bill from Medicare.
• Receive letters
• Retain a record of your drugs, pharmacy preferences, and see information about your current coverage. This information is especially useful when comparing alternative coverage plans.
• Add your prescriptions to help you better compare health and drug plans in your area.
• Review a list of preventive services you’re eligible to get in Original Medicare.
• Learn about your Medicare premiums, and pay them online if you get a bill from Medicare.

Related: How an Explanation of Benefits HELP You

Signing Up for Your Medicare.gov Account

REMEMBER: The government uses .gov web addresses, make sure that the site you are applying on is the official Medicare.gov website. 

You will need your Medicare number to create your account, along with your Part A or Part B start date, both of which can be found on your Medicare card. If you don’t have your Medicare card yet, you can log into your secure Social Security account to get your Medicare Number, or call 1-800-MEDICARE (1-800-633-4227) for help. TTY users can call 1-877-486-2048.

Things to note:

• If you join a Medicare health or drug plan, your plan may offer an online account to track your claims.
• Give Medicare permission to talk to someone you trust such as a spouse, family member or care giver. Medicare cannot share any information about your Medicare account, like claims or billing, unless you give them written permission first. Fill out and mail an authorization form or log into your Medicare account to permit them.

It is not a requirement to create a Medicare.gov account to use Medicare services, but it definitely has its advantages. We encourage you to take a moment and review your options and what you may get out of it. If you have additional questions, we are always happy to help!

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations which offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

An EOB is NOT a Bill

Let’s go ahead and clear this one up. An EOB is not a bill! An EOB is there specifically to help you understand the charges for any visits or prescription claims. 

If It’s NOT a Bill, Why Do You Want It?

While an EOB is not a bill, It is an important document from your insurance provider that explains how your insurance processed the claim for the services you received. It also details how much your health plan covers on these services and what you should owe when you get a bill from your provider. Anyone enrolled in Medicare Advantage and Medicare Prescription Drug Plan (Part D) will receive an EOB the month after a claim. 

What Information Your EOB will Include

Your EOB will include information about several things:

• You as a patient
• Your health plan
• Who your provider was 
• Date care was provided
• Description of service provided
• A claim number (could be called a reference number)
• Cost of care (provider charges)
• Amount provider will be paid (allowed charges)
• How much your health plan will pay your provider
• What you owe after the insurer has paid 
• May show some (not all) of your copayment or coinsurance payments you have made
• The person who will get reimbursed if there are overpayments

Related>> The Truth About Hospital Stays and Medicare Coverage

How to Use This Information

This detailed EOB can assist in helping you determine if the bills from your provider are correct. 

One example may be the ambulance service. Often they do not obtain your insurance information. This could result in an expensive bill to you directly that could be paid, or partially paid, by your insurance. Seeing that your ambulance bill is NOT on your EOB is a red flag that you will need to contact them and give them your insurance information. 

Other issues could include billing from diagnostics, hospital care, dental, and vision with the advantage plans. You always should be looking at your EOBs to verify that these bills are accurate and have gone through your insurance. 

A Few More Things

If you have not received an EOB or have misplaced it, you should contact your insurance company as soon as possible. A representative will verify your mailing address or confirm if you have a paperless option chosen. If you have a paperless option, you may be able to view your EOB at any time.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations which offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

Admission to the Hospital and Prescriptions

Medicare Part B does not pay for prescription medications when you are put under observation (considered outpatient) in the ER. However, your prescriptions ARE covered if you are admitted into the hospital directly. If you are under observation, Part B will not cover any prescriptions used during the overnight stay. What this means is that if you are in the ER and they want to keep you overnight for observation you must ask that you are admitted.

Skilled Nursing Care and Hospitalization

Patients who need skilled nursing care after being hospitalized for a health issue could see an additional bill if they are classified as “outpatient” when they are admitted into the hospital. This care is covered by Medicare, but only if the patient has been formally admitted as an inpatient for at least three days. Any time prior to being listed as an inpatient will NOT count towards the 3-day requirement.

Additional notes:

• If you refuse your daily skilled care or therapy, you could lose your Medicare skilled nursing facility coverage.
• If your break in skilled care lasts more than 30 days, you will have to start over with your 3-day hospital stay to qualify again.

>>Related Reading: Medicare Changes 2024 – What Medicare Beneficiaries Need To Know

Inpatient vs. Outpatient – Other Scenarios

There are other key points to note where you may incur costs when you are not admitted into the hospital and remain an outpatient. Examples include:

• You have outpatient surgery, but the provider decides to keep you overnight due to a concern. Medicare Part A pays nothing in this example, while Medicare Part B covers provider services and hospital outpatient services such as lab tests or IV medicine – you will be responsible for a copayment for all outpatient services.
• You are admitted as an inpatient, but your provider determines the status should change to outpatient. Medicare Part A pays nothing in this example, while Medicare Part B covers provider services and hospital outpatient services – you will be responsible for a copayment for all outpatient services.

The best thing to do if you are at the hospital is to just ask what your status is. The hospital will provide you a Medicare Outpatient Observation Notice (MOON). You must get this notice if you are under outpatient observation services for more than 24 hours.

Observation Care

As mentioned above, if you have been under observation for 24 hours, the hospital must give you a Medicare Outpatient Observation Notice (MOON). The hospital is required to provide notice to you with an explanation of your status as an outpatient and the financial implications of that status with regard to Medicare cost sharing and coverage.

Unlike other Medicare notices, patients do not have appeal rights with a MOON. However, there are a few steps you can take to protect yourself:

• Have a conversation with your doctor. Ask that you be admitted as an inpatient.
• If your request to be admitted as an inpatient is denied, request a written notice as to why they require you to remain in observation status.
• Inform the hospital that you want documentation from your doctor explaining why admission is not medically necessary.

Although appealing a MOON is not something you can do, once you are discharged you may be able to appeal the hospital care. You will want to speak with your doctor as soon as you receive the MOON to get support for your appeal and in that discussion make sure that your doctor is aware that there may be a potential issue with hospital observation and Medicare.

Need help looking at your options? Give Karen or Matt a call at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations which offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.