Dear Marci,

I’m in the hospital after surgery and am getting ready to go home. I think it will be difficult to get around or leave my house for appointments and physical therapy, though. Will Medicare cover physical therapy in my home?

-Wallace (Buffalo, WY)

Dear Wallace,

Yes, Medicare covers home health care, if you qualify. Medicare can cover the following home health services:

Skilled nursing services, such as injections, tube feedings, catheter changes, observation and assessment of your condition, and wound care
Provided up to seven days per week for generally no more than eight hours per day and 28 hours per week.
Skilled therapy services, such as physical therapy, speech language pathology, and occupational therapy
Home health aide, who provides personal care services like bathing, toileting, and dressing
Note: Medicare pays in full for an aide if you require skilled care. Medicare will not pay for an aide if you only require personal care and do not need skilled care.
Medical social services, such as counseling or help finding resources in your community. Medical social services are ordered by your doctor to help with social and emotional concerns you have related to your illness.
Medical supplies, such as wound dressings and catheters
Durable medical equipment (DME), such as wheelchairs and walkers

There are certain requirements you must meet to be eligible for the home health benefit. For example, you must be considered homebound and have a plan of care approved by your doctor. It is also important to know that your home health care is covered by Medicare even if your condition is chronic or if you are not showing signs of improvement.

Speak with your doctor or hospital discharge planner to begin home health care. If you need home health care, it should be included as part of your hospital discharge plan. If you have Original Medicare, call 1-800-MEDICARE or visit www.medicare.gov/care-compare to find a list of Medicare-certified home health agencies (HHAs). If you have a Medicare Advantage Plan, you should contact the plan directly for a list of HHAs in your plan’s network.

-Marci

Dear Marci,

I didn’t enroll in Medicare when I turned 65, because I was still working and covered by my employer health insurance. Now I’m retiring at age 67 and have missed my Initial Enrollment Period. How do I enroll?

-Loretta (Tampa, FL)

Dear Loretta,

You can enroll in Medicare using a Special Enrollment Period (SEP). SEPs are periods of time outside normal enrollment periods where you can enroll in health insurance. They are typically triggered by specific circumstances.

There is an SEP that begins when you have coverage from current work (job-based insurance) and you are in your first month of eligibility for Part B. It ends eight months after you lose coverage from current employment because the employment or insurance ends. Using this Part B SEP also means you will not have to pay a Part B late enrollment penalty (LEP).

To use this Part B SEP, you must meet two criteria:

You must have insurance from current work (from your job, your spouse’s job, or sometimes a 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 either Medicare or insurance from current work. You are ineligible for the Part B SEP after going for more than eight months without Part B or job-based insurance.

In most cases, you should enroll in Medicare before losing job-based insurance to avoid gaps in coverage. Remember, even if you use the SEP to avoid a late enrollment penalty, you may still be responsible for any health care costs you incur in the months after losing job-based coverage before your Medicare coverage takes effect. For help timing your Medicare enrollment to ensure it starts immediately after you no longer have job-based insurance, reach out to your human resources department one to two months in advance.

If you are considering delaying Part B enrollment because you have job-based insurance, make sure to learn whether your coverage will be primary or secondary.

Note: Beginning in 2023, you may also qualify to use an SEP to enroll in Medicare if you meet certain requirements, such as if you mistakenly delayed Medicare enrollment based on employer misinformation.

Congratulations on your retirement!

-Marci

Dear Marci,

My dad is 67 and was released from prison at the beginning of February. He didn’t enroll in Medicare when he turned 65 while he was incarcerated, so now he is back home and without health insurance. How should he enroll in Medicare now? Will he owe a late enrollment penalty?

-Abigail (Fort Wayne, IN)

Dear Abigail,

It is usually best if someone enrolls in Medicare when they are first eligible. As you mentioned, many people who delay enrolling in Medicare must wait for the General Enrollment Period and then may owe a late enrollment penalty for life.

Beginning this year, though, if someone misses a first-time enrollment period, there are certain situations when they might qualify for an exceptional circumstances Special Enrollment Period (SEP). One of these new SEPs is for people who were are released from the custody of a penal authority, including a prison, after January 1, 2023.

To be eligible for this SEP, your father would have to:

Be eligible for Medicare
Have failed to enroll in Medicare while he was incarcerated
Be released on or after January 1, 2023

Note that Medicare defines “incarcerated” as individuals who are in the custody of certain authorities, including people under arrest, imprisoned, residing in halfway houses, living under home detention, or confined completely or partially in any way under a penal statue or rule.

If he is eligible, the SEP lasts for twelve months.
The SEP starts the day he was released.
The SEP ends the last day of the twelfth month after his release.

He can choose to have his coverage begin on the first of the month after he signs up, or to have it begin up to six months retroactively (but not before January 1, 2023, or before his release ). If he uses this SEP to enroll in Medicare, he will not owe a late enrollment penalty. To use this SEP, your father should contact SSA.

If your father then wants to enroll in a Medicare Advantage Plan or stand-alone Part D prescription drug plan, he should contact 1-800-MEDICARE (1-800-633-4227) to learn more about his enrollment period options. He may qualify for a Medicare Advantage or Part D SEP or have other enrollment periods available, depending on when he enrolls in Part B.

Best of luck to him as he enrolls in Medicare!

-Marci

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Dear Marci,

My mother is having a kidney transplant soon, and I am helping with the logistics of her recovery. I believe Medicare should cover the immunosuppressant drugs she will need after, but the details are confusing. How will her immunosuppressants get covered?

-Pauline (Austin, TX)

Dear Pauline,

As you likely know, after getting a kidney transplant, a kidney recipient will need to take immunosuppressant drugs for the rest of their life to prevent their body from rejecting the donor organ. Medicare covers these drugs differently depending on the circumstances:

Time-limited Part B coverage
If someone receives a kidney transplant in a Medicare-approved facility, Medicare Part B will cover their immunosuppressant drugs for 36 months after their hospital departure if:

They had Part A at the time of the transplant
They have Part B when getting their prescription filled
And, they are only eligible for ESRD Medicare
If the kidney transplant was successful, Medicare coverage will end 36 months after the month of the transplant

Note: If someone did not have Medicare at the time of their transplant, they can enroll retroactively in Part A within a year of their transplant.

Part B coverage for the rest of one’s life
If someone receives a kidney transplant in a Medicare-approved facility, Part B will cover their immunosuppressants for the rest of their life if:
They had Part A at the time of the transplant
They had Part B when getting their prescription filled
And, they qualify for Medicare based on age or disability

Part B-ID coverage
If someone’s ESRD Medicare benefits end 36 months after their transplant, they may qualify for Medicare’s new Part B-ID coverage of immunosuppressants if they:
Qualify for Part B coverage of immunosuppressants prior to losing ESRD Medicare
Do not have Medicaid or other public or private health insurance that covers immunosuppressants

Part B-ID coverage may not be the best choice if any other insurance is available. Part B-ID only covers immunosuppressant drugs and does not include coverage for any other Part B benefits or services. It also does not allow someone access to Part A.

Part D coverage
If someone does not have Part A when they receive a transplant, their immunosuppressants will be covered by Part D when they are enrolled in Medicare. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to specific in-network pharmacies for drugs, as compared to coverage under Part B.

All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once someone is stabilized on their immunosuppressant drug. However, prior authorization can apply. This might mean a Part D plan will verify that, for example, Part B will not cover the drugs before providing coverage. It’s good to look for plans that have the fewest coverage restrictions and where one’s pharmacy is in-network and has preferred cost-sharing available to minimize costs and disruptions.

I hope this helps. I’m wishing your mom a successful transplant and speedy recovery!

-Marci