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2017-09-07

Countdown to Oct 15th Medicare’s annual enrollment, get prepared

Contributed

Toni:
I am turning 65 this November and currently am enrolled in a high deductible individual health insurance plan. My biggest medical expenses are shots that I receive from 2 doctors.
One is a shot of Lucentis for macular degeneration and it costs over $2,000 per shot. It does not take me too many months or treatments to make the $4,000 deductible.
The other is for allergy shots taken 3 times a week from my allergist that are not too expensive.
My concern is what or how does Medicare Part B pay for these 2 medical procedures? Look forward to your answer, Shannon from Cypress area.

Great question, Shannon:
Most Americans do not realize what is covered under Medicare Part B, which is the medical insurance part of Medicare.
In the Medicare and You handbook, it discusses “What does Part B cover?” It states that Part B “helps to cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment and other medical services.
Many preventative services and other medical services covered under Part B are discussed in the Medicare and You handbook.
Shannon, you mentioned that you have a concern about whether the expensive macular degeneration shot for your eye and the allergy testing and shots can be covered under Medicare Part B. If these procedures are medically necessary, then Medicare will pay for those procedures.
“Medically necessary” as defined by Medicare means “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
Under “Doctor and other health care provider services,” the handbook states that “Medicare covers medically necessary doctor services (including outpatient services and some doctor services you get when you’re a hospital inpatient) and covered preventative services. Medicare covers other health care providers like physician assistants, nurse practitioners, social workers, physical therapists and psychologists.
The 2017 Part B medical/doctor deductible is $183 with Medicare paying 80 percent of the Medicare approved amount and you (the Medicare beneficiary) paying 20 percent of the Medicare approved amount.
To help pay for the 20 percent out of pocket after the $183 deductible, many enrolled in Medicare chose a Medicare Supplement to help defray the Medicare Parts A and B deductibles and out of pocket charges. With a Medicare Supplement, Sharon, you will have low or no out of pocket for Medicare medically necessary approved amounts depending on which Medicare Supplement plan you are enrolled.
Discuss your macular degeneration eye procedure with your doctor’s office manager because you may not need to order the prescription from a pharmacy preventing using your Medicare Part D prescription drug plan and possibly going into the Donut Hole.
The Medicare handbook states that “if you’re in a Medicare Advantage Plan (like a HMO or PPO) or have other insurance, your costs may be different. Contact your plan or benefits administrator to find out the costs.”
Visit Tonisays.com for a list of Medicare workshops this fall.
Toni King, author of the Medicare Survival Guide®, which is a simple guide that puts Medicare in “people” terms, is on sale at www.tonisays.com. Email questions to info@tonisays.com or call the Toni Says® Medicare team at 1/844-250-TONI (8664).