Life After 50 Expo

Dear Marci,

My doctor is recommending I get surgery. I do trust them but I want to get another opinion before agreeing to something so big. Will Medicare cover a second opinion, even if another doctor recommends the same thing?

-Rana (El Paso, TX)

Dear Rana,

For our other readers, a second opinion is when you ask a doctor other than your regular doctor for their view on symptoms, an injury, or an illness you are experiencing in order to better help you make an informed decision about treatment options. 

There are countless reasons why someone would want a second opinion, but here are just a few examples:

You have a rare condition with which another doctor may have more experience or training.
Your doctor recommends a treatment that is risky, invasive, involves surgery, or has lifelong consequences.
You want assurance that you’ve considered all treatment options.
You believe your diagnosis could be incorrect.
 
Original Medicare covers second opinions if a doctor recommends that you have surgery or a major diagnostic or therapeutic procedure.

Medicare will also cover a third opinion if the first and second opinions are different from each other.

The second and third opinions will be covered even if Medicare will not ultimately cover your procedure. Do note, however, that Medicare does not cover second and third opinions for excluded services, such as cosmetic surgery.
  
If you have a Medicare Advantage Plan, your plan may have different cost and coverage rules for second and third opinions. Contact your plan for more information about costs and restrictions.  

Some people may feel uncomfortable or nervous asking their doctor for a second opinion. Doctors are professionals and most will respect your want for a second opinion. Many consider it standard medical practice to get another opinion. In fact, your doctor may even be ready to give you referrals for a second opinion. Trust yourself and remember that you are your strongest advocate!

-Marci

Dear Marci,

I learned that Medicare may cover home health care for people who are homebound. How do I know if I am considered homebound?

-Alejandro (Madison, WI)

Dear Alejandro,

That’s a great question. As you said, Medicare covers home health care if you qualify. One of the requirements to qualify is that you be homebound. But what exactly does this mean?

Medicare considers you homebound if both of the following apply to you:

You need the help of another person or medical equipment to leave your home. For example, you need crutches, a walker, or a wheelchair to leave your home. Or, your doctor believes that your health or illness could get worse if you leave your home
And, it is difficult for you to leave your home and you typically cannot do so

Your doctor should decide if you are homebound based on their evaluation of your condition. If you qualify for Medicare’s home health benefit, your plan of care will also certify that you are homebound. After you start receiving home health care, your doctor is required to evaluate and recertify your plan of care every 60 days.

Even if you are homebound, you can still leave your home for medical treatment, religious services, or to attend a licensed or accredited adult day care center, without putting your homebound status at risk. Leaving home for short periods of time or for special non-medical events, such as a family reunion, funeral, or graduation, should also not affect your homebound status. You may also take occasional trips to the barber or beauty parlor.

I hope this helps as you and your doctor consider your needs for home health!

-Marci

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