Navigating The Mysteries of Medicare

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It mystifying, tedious, and no one really wants to talk about it. If you’re struggling to navigate the complex paperwork involved with the Medicare program, you’re definitely not alone. One in five Medicare beneficiaries describes Medicare as confusing, according to the United Healthcare Medicare Made Clear Index.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. There are numerous aspects to the program and steps that must be taken to avoid penalties or gaps in care. Every year the complexity of Medicare is highlighted when seniors choose their Medicare plans for the following year.

Often adult children are left with learning the ins and outs of Medicare on their parent’s behalf or spouses are left with a ton of paperwork and difficult decisions. When your loved one is having a hard time managing finances and the mailbox is a steady stream of medical bills or notices from Medicare, the task can be overwhelming. You find yourself scouring Medicare summary of benefits notices for unexpected charges and acting as an advocate for your parent or spouse. There are many factors to consider when choosing the Medicare plan that’s right for you, your spouse, or parent. If your parents take expensive medications make sure the plan continues to cover their drugs in the new plan year. Get a list of your parents’ or spouses’ medications, and go to the tool to estimate the out-of-pocket costs for their medications under each plan available in their area. This is especially important for cancer patients who take more expensive drugs.

Two recent trends among Part D and Medicare Advantage plans are to shift drugs to more-expensive pricing tiers and make patients jump through hoops before certain medications will be covered—for example, by requiring step therapy which means they must try cheaper drugs first or preauthorization that requires their doctor to prove their need for that particular drug. Many plans are switching from fixed co-payments to coinsurance, which is based on a percentage of the drug’s cost. If a parent takes expensive cancer-treatment drugs, for example, the out-ofpocket costs could rise exponentially.

If your parents have a Medicare Advantage plan, make sure their key doctors, like their primary-care doctor (PCP) and their oncologist, for instance, will be in the plan’s network the following year. Don’t assume that doctors remain in the plan from year to year. Ask the plan about specific providers, and look carefully at the Annual Notice of Change, which Part D and Medicare Advantage plans are required to send in September. The notice alerts participants to plan changes for the next year.

Also, see how a Medicare Advantage plan handles coverage for out-of-network providers. Some plans charge a higher co-payment if you go out of network, but others make you pay the entire cost yourself. Especially for cancer patients who are looking for special treatments, having the flexibility to go out of network can be important to finding the right treatment or simply extending quality of life. They might only get out-of-network coverage if they can prove that it’s an emergency or that no doctor in the network can provide that type of treatment.


1. ORGANIZE THE PAPERWORK Keep track of key documents will help you determine what your parents owe and don’t owe. It can make a huge difference if you need to appeal a charge. If you’re helping with your parents’ finances, gather all the paperwork your parents bring home from doctors’ visits and that arrives in the mail. Set aside a place for healthcare-related statements. Organize all of the statements by the date of service before paying any bills. When matching bills to the summary notice you receive, look for unexpected charges. Organizing the paperwork by date makes it easy to see if there was double billing or inaccurate coding.

2. ASK QUESTIONS UPFRONT Doctors must give patients a notice (called an “advance beneficiary notice of noncoverage”) with traditional Medicare if they believe a procedure won’t be covered. These notices are not an official denial, but they give patients a heads-up that a claim will probably be denied. Patients are asked to sign the notice before care is provided. You and your parents need to be on the lookout for these notices and ask questions before signing. The patient can still choose to have the service submitted to Medicare anyway, preserving the right to appeal if they sign the notice. However, it’s much easier to work with your doctor to fix coding issues and answer questions than to go through a formal appeals process.

3. WHERE TO FIND HELP Organizations like the local Area Agency on Aging or representatives at non-profit organizations like The Jewish Home can arrange long-term care and often help navigate insurance or provide referrals to resources within the community that you might not know about. “The health care system is constantly evolving. It’s important to understand your health care choices and to be your own advocate in the ever-changing health care system,” Brittany Elko from the Jewish Home says. Todd Kelleher at the Jewish Home happily assists seniors, spouses, and adult children in navigating the healthcare continuum. You can contact Todd at 570-344-6177 ext. 1151 or email him at questions about healthcare, short-term rehab- and long-term care

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