Dear Marci,

I recently enrolled in Medicare and learned that Medicare does not cover dental care. Why is this? And how should I receive dental care then?

-Brody (Dallas, TX)

Dear Brody,
Yes, dental care is excluded from Medicare coverage.* Medicare is health insurance that exists because of federal laws that were passed to create it. Initially, as created in 1965, Medicare consisted of Part A and Part B and reflected the restrictions and limitations of most health insurance at that time. (Some additions have been made over time, including prescription drug coverage through Part D.) The federal law that created Medicare benefits has specific provisions that exclude coverage for certain things, like dental care and routine vision services.

Just because something is not covered by Medicare, though, does not mean that it is not needed. You may be able to get assistance through the programs listed below:

· Medicare Advantage Plans: Some Medicare Advantage Plans offer routine dental coverage. Contact your plan to learn about services it may cover, any rules or restrictions, and costs. If you are considering joining Medicare Advantage, make sure the plan suits your other care needs.

· Medicaid: In some states, Medicaid covers some dental services. You may qualify for Medicaid if you have a low income and minimal assets. Contact your local Medicaid office for more information.

· Private stand-alone dental plans: You can purchase a separate dental plan from a private company.

· Reduced-cost or free dental clinics: These clinics are available in many states. Use resources available at NeedyMeds, healthcare.gov, freeclinics.com, and hhs.gov for more information.

· Local hospitals: Call the hospitals in your area to ask if they offer dental clinics, how you can become a patient there, which services they offer and at what cost, and if payment plans are available.

· Federally Qualified Health Centers (FQHCs): FQHCs are health care facilities located in medically underserved areas. People with Medicare are eligible to receive services from an FQHC. Some FQHCs may offer dental care.

· Community Health Centers (CHCs): CHCs provide free or reduced-cost health services, including dental care. CHCs are funded by the Health Resources & Services Administration (HRSA).

· Dental schools: Some dental schools provide low-cost dental care. Dental students work with patients under the supervision of experienced, licensed dentists.

To learn about local resources, you should either contact your State Health Insurance Assistance Program or use the government’s Eldercare Locator tool.

*Note: While Medicare does not cover dental services that you need primarily for the health of your teeth, it does offer very limited coverage for dental care needed to protect your general health. Read more here.

I hope this helps!

-Marci

Dear Marci,

My father began hospice care a few weeks ago. It seems that staff from the hospice agency have been coming to his home less and less, though… Is this hospice fraud?

-Viraj (Boston, MA)

Dear Viraj,
As we discussed in our last newsletter, hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. Medicare’s hospice benefit is primarily home-based and covers end-of-life palliative treatment, including support for one’s physical, emotional, and other needs. It is important to remember that the goal of hospice is to help an individual be as comfortable as possible, not to cure an illness.

Hospice fraud occurs when Medicare is falsely billed for any level of hospice care or service. As the family member of a Medicare beneficiary, you should look out for suspicious behavior from health care providers that might indicate Medicare fraud or abuse.

Report potential hospice fraud, errors, or abuse if you or a loved one are:

Being abused or neglected by a hospice worker

Receiving inadequate or incomplete services

Not receiving the services and care outlined in your doctor’s plan of care

Falsely certified as being terminally ill in order to qualify for the hospice benefit

Enrolled in hospice without your or your family’s permission

Offered gifts or incentives to receive hospice services or to refer others for hospice services

Have your medication stolen by a hospice worker

Billed for a higher level of care than was needed or provided, or for services not received (you can find this information on your Medicare Summary Notice or Explanation of Benefits)

Experiencing high-pressure and unsolicited marketing tactics of hospice services

Kept on hospice care for long periods of time without medical justification

To report potential hospice care fraud, errors, or abuse, you should contact your local Senior Medicare Patrol (SMP). Your SMP can also help you identify possible concerns. Find your local SMP by visiting www.smpresource.org or calling 877-808-2468.

-Marci

Dear Marci,

My mother-in-law has a terminal condition and is nearing the end of her life. I’m helping her figure out the logistics of hospice care but do not know how her Medicare will cover it. How does Medicare cover hospice?

-Dottie (St. Johns, MI)

Dear Dottie,
I’m so sorry to hear about your mother-in-law’s health. I hope the following information with be helpful to you and your family during what I imagine is a very challenging time.

Hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. Medicare’s hospice benefit is primarily home-based and covers end-of-life palliative treatment, including support for one’s physical, emotional, and other needs. It is important to remember that the goal of hospice is to help an individual be as comfortable as possible, not to cure an illness.

To elect hospice, someone must:

Be enrolled in Medicare Part A

Have a hospice doctor certify that they have a terminal illness, meaning a life expectancy of six months or less if the illness takes its normal course

Sign a statement electing to have Medicare pay for palliative care (pain management), rather than curative care

And, receive care from a Medicare-certified hospice agency

Once an individual chooses hospice, all of their hospice-related services are covered under Original Medicare, even if they are enrolled in a Medicare Advantage Plan, unless their Medicare Advantage plan is part of a specific demonstration program, in which case the plan will pay for hospice care. Their Medicare Advantage Plan will continue to pay for any care that is unrelated to their terminal condition. Original Medicare payments to the hospice provider also cover any prescription drugs needed for pain and symptom management related to the terminal condition. The individual’s stand-alone Part D plan or Medicare Advantage drug coverage may cover medications that are unrelated to their terminal condition.

The hospice benefit includes two 90-day hospice benefit periods followed by an unlimited number of 60-day benefit periods The doctor must recertify the person’s terminal illness before each benefit period.

If someone you care for is interested in Medicare’s hospice benefit:

Ask their doctor whether they meet the eligibility criteria for Medicare-covered hospice care.

Ask their doctor to contact a Medicare-certified hospice on their behalf.

Be persistent. There may be several Medicare-certified hospice agencies in your area. If the first one you or the doctor contact is unable to help, contact another.

Once you have found a Medicare-certified hospice:

The hospice medical director (and the individual’s regular doctor if they have one) will certify that they are eligible for hospice care. Afterwards, the individual must sign a statement electing hospice care and waiving curative treatments for their terminal illness.

Their hospice team must consult with the individual (and their primary care provider, if they wish) to develop a plan of care. Their team may include a hospice doctor, a registered nurse, a social worker, and a counselor.

I hope this helps you and your mother-in-law know where to start with getting Medicare-covered hospice care.

-Marci

Dear Marci,

I recently applied to the Medicare Savings Program and was enrolled in the QMB program. Can you explain improper billing and how it will affect me now?

-Henrik (Billings, MT)



Dear Henrik,

Congratulations on successfully enrolling in the QMB program. I am so glad you applied and will receive help paying your Medicare costs.

In Medicare, the term improper billing refers to a provider inappropriately billing a beneficiary for Medicare cost-sharing. Cost-sharing can include deductibles, coinsurance, and copayments. Federal law prohibits Medicare providers from billing people enrolled in the Qualified Medicare Beneficiary (QMB) program for any Medicare cost-sharing. This means that if you have QMB, Medicare providers should not bill you for Medicare copays or deductibles for any Medicare-covered services. *

If you have QMB and are enrolled in Original Medicare, you should not be billed for Medicare cost-sharing when receiving a Medicare-covered service from either:

A participating provider (one who takes assignment)
A non-participating provider If you have QMB and are enrolled in a Medicare Advantage Plan, you should not be billed for Medicare cost-sharing when receiving a plan-covered service from in-network providers, as long as you meet your plan’s coverage rules, such as getting prior authorization to see certain specialists.
To protect yourself from improper billing, be aware that:

Original Medicare and Medicare Advantage providers who do not accept Medicaid must still comply with improper billing protections and cannot bill you for Medicare cost-sharing.

You keep your improper billing protections even when receiving care from Medicare providers in other states (Note: You can be billed if you are enrolled in a Medicare Advantage Plan and see an out-of-network provider, or if you have Original Medicare and see an opt-out provider).

You cannot choose to waive these protections and pay Medicare-cost sharing, and a provider cannot ask you to do this.



Remember that if you have QMB, the Medicare providers you see must accept Medicare payment and any QMB payment as the full payment for any Medicare-covered services you received. Providers who violate improper billing protections may be subject to penalties. If you are having issues with a provider who continually attempts to bill you, or if you have unpaid cost-sharing bills that have been sent to collection agencies, call 1-800-MEDICARE or contact your Medicare Advantage Plan.

*Note: Some states may impose Medicaid copays for certain Medicare-covered services. Medicare and Medicaid should pay the majority of the cost, leaving you a smaller copay. Contact your local Medicaid office to learn more about Medicaid copays in your state.

-Marci

Dear Marci,

It has been challenging to live on a fixed income recently. A friend told me she has the Medicare Savings Program and that it really helps her financially. What should I know about this program?

-Sabrina (Randleman, SC)



Dear Sabrina,

Medicare Savings Programs help pay your Medicare costs if you have limited income and savings. Medicare Savings Programs are also called MSPs, Medicare Buy-In programs, or Medicare Premium Payment Programs. There are three main programs, with different benefits and eligibility requirements. *

Qualifying Individual (QI) Program: Pays for Medicare Part B premium. Also reimburses for premiums paid up to three months before your MSP effective date, and within the same year of that effective date.

Specified Low-income Medicare Beneficiary (SLMB): Pays for Medicare Part B premium. Also reimburses for premiums paid up to three months before your MSP effective day, but unlike QI, you may be reimbursed for premiums from the previous calendar year.

Qualified Medicare Beneficiary (QMB): Pays for Medicare Parts A and B premiums. If you have QMB, typically you should not be billed for Medicare-covered services when seeing Medicare providers or providers in your Medicare Advantage Plan’s network. This means you should not owe Medicare deductibles, copayments, and coinsurances, as long as you see the right providers.

*There is a fourth MSP called the Qualified Disabled Working Individual (QDWI), which pays for the Medicare Part A premium for certain people who are eligible for Medicare due to disability. Contact your local Medicaid office to learn more.

There are even more benefits to enrolling in an MSP. MSP enrollment:

Allows you to enroll in Part B outside of the regular enrollment periods

Eliminates your Part B late enrollment penalty if you have one

Automatically enrolls you in Extra Help, the federal program that helps pay your Medicare prescription drug (Part D) plan costs

To qualify for an MSP, you must have Medicare Part A and meet income and asset guidelines.

If you do not have Part A but meet QMB eligibility guidelines, your state may have a process to allow you to enroll in Part A and QMB outside of the General Enrollment Period.

It also may be helpful to note that income and asset guidelines vary by state. Certain income and assets may not count and some states do not count assets at all when assessing MSP eligibility. You can contact your State Health Insurance Assistance Program (SHIP) to learn more about MSPs in your state and to receive assistance with the application process.

This really is a great program that helps so many beneficiaries with their Medicare costs! Again, contact your local SHIP to see if you’re eligible for an MSP in your state. Best of luck!

-Marci