Following up on our blog from a few weeks ago — having “double the benefits” with two working spouses and two health plans — we’re adding Medicare to the mix.
Sample Scenario —
Husband: takes retirement, is 65 or older (and/or is disabled), and has Medicare as his primary health insurance coverage.
Wife: continues working, has employer based health care benefits for her and her husband.
He goes to the doctor and assumes Medicare will cover the visit and any treatments or tests. But it ain’t necessarily so! And that’s why he MUST let his health-care providers know about his wife’s employer-based plan.
In a nutshell . . .
As a non-active employee (an individual who is retired, on COBRA or Long Term Disability), the husband would typically be covered by Medicare as his primary insurance. However, as a dependent on his wife’s insurance, the size of her employer’s group will determine primacy: if there are fewer than 20 employees, Medicare pays first; more than 20, her health insurance pays first and Medicare pays second.
The rules for coordination can be complex. Keep your health plan administrators informed of changes or other coverage. Make sure your doctors know about the dual coverage and present both cards at the time of your visit.
Questions? That’s our specialty — finding answers, determining solutions. So, call if you need us. You can also contact the Medicare Coordination of Benefits Contractor at 1-800-999-1118.
Meanwhile, just remember, the answer to Who’s on First? can be a tricky one!
Quick Test:
- Are you — or someone you’re caring for — on Medicare and suffering from a variety of chronic health conditions?
- Do you worry about taking all those meds: are they more than you need; are they even necessary?
- Are you concerned about side effects or drug interactions?
If you’ve answered “yes” to any of the above questions, it’s time for answers. And you won’t have to search high and low to find them. Help is available through a federal program called Medical Therapy Management (MTM), offered by your Medicare Part D or Advantage prescription plan.
With MTM, a clinical pharmacist will:
- evaluate your conditions and medications to ensure safe, appropriate, and cost-effective use.
- contact your doctor(s) about any problems and work to help resolve them.
- meet with you several times a year to help you keep track of all of your medicines and conditions and monitor your progress.
- be available for questions and problems as they arise.
The best part? If you qualify, this service is free!
Why is this important?
The more medicines you take, the greater the risk for dangerous interactions, adverse side effects and mismanagement (not taking them as directed), leading to serious consequences. In fact, this is a growing public problem across the United States. Experts estimate that 1.5 million preventable adverse events occur each year, resulting in $177 billion in injury and death.
Find out if you qualify.
Contact your Medicare Part D prescription plan or your Medicare Advantage Plan; ask about their MTM services and how to qualify. Also ask for the names of clinical pharmacists in your area. It’s that simple.
Do this for yourself. Be Informed. And stay healthy!
We were sorry to hear the news about Billy Joel and Christine Brinkley’s daughter, Alexa Ray, who apparently attempted suicide. We’re deeply saddened for her and her family and wish them healing and support.
Among other things, this tragic incident once again calls attention to the disparity between the “haves and have-nots” when it comes to getting good mental health treatment. Depression and other psychiatric problems cross all age and economic boundaries. But access to appropriate care does not.
No offense to Alexa, but we bet she won’t have any problem getting the help she needs. It’s not so easy for the rest of us. Especially those on Medicare.
Private health plans are required to demonstrate credible provider networks across all medical specialties. They also have to show they have contracts in place and that appointments are available.
Medicare (original), on the other hand, is not held to similar standards. In addition, docs are leaving Medicare due to low reimbursement. The result? Inadequate networks of providers across specialties and across the country. If Medicare was a private health plan, this situation would be blatantly unacceptable.
If you’re on Medicare and having trouble finding a qualified mental health professional, here are some tips. And, if you’re uncomfortable advocating for yourself, enlist the help of someone you trust.
Explain you’re paying out-of-pocket to a provider who doesn’t take Medicare; ask for a block of sessions at a discounted price.
- Contact Medicare for a list of participating mental health providers. Call 1-800 Medicare. Verify current participation.
- Use these national resources:
National Institute of Mental Health Information Line:
Provides information and literature on mental illness by disorder for professionals and the general public. Call: 1-800-647-2642
- National Mental Health Association:
Provides information on specific disorders, referral directory to mental health providers, national directory of local mental health associations, and a Stigma Watch. Call: 1-800-969-NMHA (800-969-6642)
- Share your story. Giving voice to the problem is essential for positive change.