Dear Marci, I was just diagnosed with a terminal illness. My doctor and social worker have suggested that I speak with my family and consider beginning hospice care. How will Medicare cover hospice care if I choose it? – Manny (Bridgeport, CT) Dear Manny, 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 offers end-of-life palliative treatment, including support for your physical, emotional, and other needs. It is important to remember that the goal of hospice is to help you live comfortably, not to cure an illness. To elect hospice, you must:Be enrolled in Medicare Part AHave a hospice doctor certify that you have a terminal illness, meaning a life expectancy of six months or lessSign a statement electing to have Medicare pay for palliative care (pain management), rather than curative care (unless your hospice is participating in the Medicare Care Choices Model (MCCM) program through the Centers for Medicare and Medicaid Innovation (CMMI))The MCCM program lets hospice patients receive both palliative and curative care for their terminal condition.And, receive care from a Medicare-certified hospice agencyOnce you choose hospice, all of your hospice-related services are covered under Original Medicare, even if you are enrolled in a Medicare Advantage Plan. Your Medicare Advantage Plan will continue to pay for any care that is unrelated to your terminal condition. Hospice should also cover any prescription drugs you need for pain and symptom management related to your terminal condition. Your stand-alone Part D plan or Medicare Advantage drug coverage may cover medication that are unrelated to your terminal condition. The hospice benefit includes two 90-day hospice benefit periods, followed by an unlimited number of 60-day benefit periods, pending certification by a doctor. If you are interested in Medicare’s hospice benefit:Ask your doctor whether you meet the eligibility criteria for Medicare-covered hospice care.Ask your doctor to contact a Medicare-certified hospice on your behalf.Be persistent. There may be several Medicare-certified hospice agencies in your area. If the first one you contact is unable to help you, contact another.Once you have found a Medicare-certified hospice:The hospice medical director (and your doctor if you have one) will certify that you are eligible for hospice care. Afterwards, you must sign a statement electing hospice care and waiving curative treatments for your terminal illness.Your hospice team must consult with you (and your primary care provider, if you wish) to develop a plan of care. Your team may include a hospice doctor, a registered nurse, a social worker, and a counselor.-Marci

Dear Marci, I travel often, both within the U.S. and abroad. If I have a medical emergency when I’m traveling, will my care be covered by Medicare? -Myrna (Davenport, IA) Dear Myrna, Both Original Medicare and Medicare Advantage Plans cover emergency or urgently needed services that you receive anywhere in the United States or its territories. If you have a Medicare Advantage Plan, be aware that if you are receiving emergency or urgently needed services:Your plan cannot require you to see an in-network providerYou do not need a referralThere are limits on how much your plan can bill you if you receive emergency care while out of your plan’s networkYour plan must cover medically necessary follow-up care related to the medical emergency if delaying care would endanger your healthYou have the right to appeal if your plan does not cover your careIf your condition was not an emergency but appeared to be an emergency at the time, Original Medicare or Medicare Advantage must still cover your care. For example, let’s say you have chest pain that you think may be a heart attack. If you go to the emergency room and doctors discover that your pain is heartburn, your care should still be covered because the situation appeared to be an emergency. If your Medicare Advantage Plan denies coverage of an emergency or urgently needed service because you saw an out-of-network provider or failed to get a referral or prior authorization, you should appeal their denial. You should ask your doctor to provide medical documentation that the services you needed were emergency or urgently needed services. If you need assistance appealing the denial contact your State Health Insurance Assistance Program (SHIP). Medicare generally does not cover medical care that you receive while traveling outside the U.S. and its territories. However, Original Medicare and Medicare Advantage Plans must cover care you receive outside the U.S. in certain circumstances:Medicare will pay for emergency services in Canada if you are traveling a direct route, without unreasonable delay, between Alaska and another state, and the closest hospital that can treat you is in Canada.Medicare will pay for medical care you get on a cruise ship if you get the care while the ship is in U.S. territorial waters. This means that the ship is in a U.S. port or within six hours of arrival or departure from a U.S. port.In limited situations, Medicare may pay for non-emergency inpatient services in a foreign hospital (and any connected provider and ambulance costs). Your care is covered if the hospital is closer to your residence than the nearest available U.S. hospital. This may happen if, for example, you live near the border of Canada or Mexico.Some Medigap policies provide coverage for travel abroad. Medigap plans C through G, M, and N cover 80% of the cost of emergency care abroad. Check with your policy for specific coverage rules. Medicare Advantage Plans may also cover emergency care abroad. Contact your plan for more information about its costs and coverage rules. -Marci

Dear Marci,

I do not have a car of my own, and I wanted to learn more about how Medicare covers medical transportation. When does Medicare cover transportation in an ambulance? Does it cover ambulette transportation?

-Paula (Fayetteville, AR)

Dear Paula,

Medicare Part B covers emergency ambulance services and, in limited cases, non-emergency ambulance services. Medicare considers an emergency to be any situation when your health is in serious danger and you cannot be transported safely by any other means. If your trip is scheduled when your health is not in immediate danger, it is not considered an emergency.

Part B covers emergency ambulance servicesif:

• An ambulance is medically necessary, meaning it is the only safe way to transport you
• The reason for your trip is to receive a Medicare-covered service or to return from receiving care
• You are transported to and from certain locations, following Medicare’s coverage guidelines
• And, the transportation supplier meets Medicare’s ambulance requirements

To be eligible for coverage of non-emergency ambulance services, you must:

• Be confined to your bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair)
• Or, need essential medical services during your trip that are only available in an ambulance, such as administration of medications or monitoring of vital functions

Original Medicare never covers the services of ambulettes, wheelchair vans, or litter-vans. These are wheelchair-accessible vans that provide non-emergency transportation. Medicare also does not cover ambulance transportation just because you lack access to alternative transportation. Medicare Advantage Plans must cover the same services as Original Medicare, and may offer some additional transportation services. Check with your plan to learn about its coverage of non-emergency ambulance transportation.

Note that if you are receiving skilled nursing facility (SNF) care under Part A, most ambulance transportation should be paid for by the SNF. The SNF should not bill Medicare for this service.

Under Original Medicare, Part B covers medically necessary emergency and non-emergency ambulance services at 80% of the Medicare-approved amount. In most cases, you pay a 20% coinsurance after you meet your Part B deductible ($185 in 2019). All ambulance companies that receive Medicare payments must be participating providers who accept assignment in all cases.

If you have a Medicare Advantage Plan, contact your plan to learn about the costs of ambulance transportation.

-Marci

Dear Marci,

My mother is 66 and has Original Medicare. She would like to purchase a Medigap policy. When can she do that?

-Gale (Tacoma, WA)

Dear Gale,

Medigaps are health insurance policies that offer standardized benefits to work with Original Medicare (not with Medicare Advantage). They are sold by private insurance companies. Medigaps pay for part or all of certain remaining costs after Original Medicare pays first.

If your mother wants to purchase a Medigap policy, she needs to find out the best time to buy one in her state. In most states, insurance companies must only sell someone a policy at certain times and if they meet certain requirements. If your mother misses her window of opportunity to buy a Medigap, her costs may go up, her options may be limited, or she may not be able to buy a Medigap at all.

Under federal law, your mother has the right to buy a Medigap policy if she:

• Is 65 or older and enrolled in Medicare
• And, she buys her policy during a protected enrollment period. The two kinds of federally protected enrollment periods are:
  • Open enrollment period: Under federal law, your mother has a six-month open enrollment period that begins the month she is 65 or older and enrolled in Medicare Part B.
  • Guaranteed issue right: Your mother has a guaranteed issue right within 63 days of when she loses or ends different kinds of health coverage.

At times when your mother has the guaranteed issue right to buy a Medigap policy, an insurance company cannot:

• Deny her Medigap coverage
• Or, charge her more for her a policy because of past or present health problems.

Before your mother buys a Medigap, check to see if her state offers additional protections. Some states have expanded Medigap enrollment rights. Residents of New York and Connecticut, for instance, can buy a policy at the best available rate throughout the year, and Medigap insurers cannot deny coverage. If someone in a state without these additional protections wants to purchase a Medigap outside of a protected period, a Medigap insurer can refuse to sell them a policy. Depending on your mother’s age or health conditions, she may have trouble purchasing a Medigap policy outside of a protected period. You or she should call her State Health Insurance Assistance Program (SHIP) or Department of Insurance to learn more about her right to purchase a Medigap policy in her state. If you don’t know how to contact her SHIP, call 877-839-2675 or visit www.shiptacenter.org.

Even if your mother is not in a protected period to purchase a Medigap in her state, she may still be able to buy a policy if a company agrees to sell her one. However, know that companies can charge her a higher price because of her health status or other reasons.

-Marci

Dear Marci, I am 67 years old, and I have been enrolled in Medicare Part A since I turned 65. I did not enroll in Medicare Part B then, though, because I have been covered by insurance through my wife’s employer. My wife will retire this year and we will lose her insurance coverage. How can I enroll in Medicare Part B, and what other steps should I take? -Alex (Wilmington, NC) Dear Alex, Based on what you’ve said, you are likely eligible for the Part B Special Enrollment Period (SEP) to enroll in Medicare Part B without having to wait for the General Enrollment Period and without a late enrollment penalty. In order to use the Part B SEP, you must meet two criteria:You must have insurance from current work (from your job or your spouse’s job, or, in some cases, certain family member’s job) or have had such insurance within the past eight months.And, you must have been continuously covered by job-based insurance or Medicare Part B since becoming eligible for Medicare, including the first month you became eligible for Medicare.Note: You can have no more than eight consecutive months without coverage from wither Medicare or insurance from current work. You are ineligible for the Part B SEP after going for more than eight month without Part B or job-based insurance.In most cases, you should enroll in Medicare immediately after losing job-based insurance to avoid gaps in coverage. You can contact Social Security for more information on using the SEP, by calling 1-800-772-1213 or visiting your local Social Security office. If you use the Part B SEP, the effective date of your coverage depends on when you use the SEP:If you are still covered by insurance through current employment, or if it is the first full month after that coverage ends, you can choose whether Medicare Part B will become effective either:The month you enroll, orAny of the three months after the month you enrollIf you use the Part B SEP in the second month, or later, after your coverage ends, Medicare Part B will become effective the month after the month when you enroll.Once you have enrolled in Part B, you should take steps to ensure that you have creditable drug coverage, and should consider the options of enrolling in a Medicare Advantage Plan or purchasing a Medigap policy.If you have creditable drug coverage(coverage that is as good as or better than the Medicare prescription drug benefit) through your current insurance coverage, you will have a special enrollment period to choose a Part D plan for 63 days after you lose that coverage. You can also enroll in a drug plan or make changes to your drug coverage every year during Fall Open Enrollment, and there are several Special Enrollment Periods (SEPs) you could be eligible for to make changes to your coverage.Remember that if are without Part D or creditable drug coverage for more than 63 days while eligible for Medicare, you may face a Part D late enrollment penalty (LEP).You can enroll in a Medicare Advantage Plan after you have enrolled in Part B and before your Part B coverage is effective. You will also have opportunities to join a Medicare Advantage Plan or change your coverage during Fall Open Enrollment every year. In some circumstances, you could be eligible for an SEP to change coverage.When you enroll in Part B, you’ll enter your Medigap Open Enrollment Period, one of your protected times to buy a Medigap supplemental policy. This takes place the first six months that you are 65 or older and enrolled in Medicare Part B. During the Medigap open enrollment period, Medigap companies must sell you a policy at the best available rate regardless of your health status, and they cannot deny you coverage.For help evaluating your options, you can contact your State Health Insurance Assistance Program (SHIP), by calling 877-839-2675 or visiting www.shiptacenter.org. -Marci