What You Need to Know About Opt-Out Providers

Recent changes in Medicare procedures for MSNs

SRSRA Advisory on Medicare Prescription Drug Plans

U. S. Government Medicare Web Site

How to File a Medicare Claim Yourself

View Medicare Summary Notices (MSNs) on the Internet

Carolina Center for Medical Excellence (Medicare Assistance)

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What You Need to Know About Opt-Out Providers

(This information first appeared in an article in the SRSRA Newsletter, May, 2005

You can’t be asked to sign a private contract in an emergency situation or when you need urgent care.

A vexing situation appears to be repeating itself with greater frequency for SRSRA retirees age 65 and over. Vital health care needs are not always available from Medicare Providers. This may occur in one of two situations. One, Medicare does NOT cover the medically necessary test or treatment. Two, best practice providers have chosen to “Opt-Out” of Medicare.

The first situation involving a Medicare non-covered item is not too problematic. Medicare requires the provider to inform you that Medicare probably will not pay and have you sign an Advanced Beneficiary Notice, ABN. Sometimes the Medicare non-covered item is still covered by the SRS Team Health coverage being administered by BCBS. Medicare may not cover an item at all, only at specified frequencies, or only when medically necessary. On occasion reports have been noted that ABNs are being used for medically unnecessary items that serve only to protect the provider from liability.

The second situation involving providers that have chosen to Opt-Out of Medicare is most problematic. Opt-Out providers can gouge out whatever the market will bear.

In this situation, as prescribed by US Code, Our Health Choice self-insured plan is still only the “secondary” insurance. As such, when the benefit coordination occurs the portion that Medicare (“primary”) would have paid (called the Medicare “limiting” amount) is first subtracted. This is sometimes referred to as the “carve-out”.

Recently a SRSRA member reported a case where the only successful health care option was from a provider that has chosen to Opt-Out of the Medicare system. Medicare refers to this as a “Private Contract”. See page 36 of Medicare & You 2008.

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Recent Changes in Medicare procedures for MSNs

A Medicare representative has stated that Medicare will now only send Medicare Summary Notices to participants on a quarterly schedule provided there were claims processed in the participant's account during that quarter. Previously Medicare had sent notices to participants about every 30 days when there had been activity in their account.

As a result of this change, participants may receive an Explanation Of Benefits from Blue Cross on a claim before receiving their quarterly Medicare Summary Notice. Retirees should carefully review their Medicare and Blue Cross statements until they become familiar with this change in the notification procedure.

As a result of these cost saving administrative changes, retirees may find it more difficult to track their medical expenses. If a retiree needs information about a medical claim they should not hesitate to contact Customer Service at Medicare.   The Medicare Helpline telephone number is 1‑800‑633‑4227

Please note that you can also view your MSNs online at the Medicare.gov link listed below on this page.

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MEDICARE PRESCRIPTION DRUG COVERAGE OPTION

     If you are over 65 and on Medicare, you certainly have been receiving solicitations to sign up for Medicare prescription drug coverage. The following information is taken directly from the August, 2005, SRSRA Newsletter, and describes our best advice on what to do about this new option.

"SRSRA recommends keeping your current WSRC/BSRI prescription drug coverage coverage. Do not elect the Medicare Prescription Drug Program."

"But before you act either way, please read further in this article."

"The SRSRA is monitoring developments related to the new Part D, Medicare Prescription Drug Coverage, option. We are recommending the nominal best choice when comparing the current Retiree WSRC/BSRI Health Choice Medical Plan to the new Medicare Part D Prescription Drug Coverage. The SRSRA thinks that it is very important to reach all retirees faced with this important choice, both SRSRA members and non-members alike. We encourage SRSRA members to become well informed about Medicare Part D as compared to the WSRC/BSRI Health Choice Medical Plan and to share that information with all retirees."

That assessment is still valid today (as of Aug. 2008).

Facts:

     • You decide if you want to join a Medicare prescription drug plan

     • Signup will be from November 15, 2005, through May 15, 2006.  A subsequent signup began in Nov. 2007.

     • Medicare will help pay for employer retiree drug coverage that meets Medicare's standards for their retirees with Medicare

     • Medicare will charge you a premium for Part D coverage if you elect Part D coverage

     • The Site BCBS prescription drug plan is better than any of the Medicare prescription drug plans for all but exceptional cases. The figure below shows the out-of-pocket cost for prescription drugs for three options:

(1) No insurance
(2) SRS-BCBS plan
(3) Medicare Part D coverage

The figure below clearly shows that the out-of-pocket cost for prescription drugs is lowest for the SRS-BCBS plan.

Choose to either:

     • keep your current drug plan. If you choose to join a Medicare prescription drug plan later (after May 15, 2006) your monthly Part D premium won’t be higher (no surcharge), or

     • drop your current drug plan and join a Medicare prescription drug plan, but you may not be able to get your WSRC/BSRI drug plan back.

     You may want to begin looking at your current retiree health insurance coverage and see what prescription drugs aren't covered or what part of the costs you pay yourself. Medicare is working with employers to help you keep your current drug coverage. At one time, Medicare had a handy downloadable chart (PDF) to record ongoing prescription medications that you currently use, and we had a link to it here. However, due to improvements in the Medicare site, that link was closed and we haven't been able to find that chart.

     Medicare will help pay for employer retiree drug coverage that meets Medicare's standards for their retirees who are on Medicare by giving the employer incentives to retain their program.

     In a recent meeting with WSRC Benefits personnel, your SRSRA Benefits Committee members learned that the Site plans to mail all retirees information they need concerning prescription drug benefits under the current WSRC/BSRI Health Benefit and how it may relate to the new Medicare Part D.

     Additionally, WSRC/BSRI has already sent you a notice stating that our Prescription Drug coverage under the WSRC Team Health Choice Plan already meets Medicare’s standards for retirees on Medicare.   YOU SHOULD KEEP THAT LETTER FOREVER!

      [IMPT. NOTE:You can download a copy of that vital letter here.]

[A more recent letter, dated November 1, 2009, can be obtained by clicking here.]



     On-line tools that you may want to use are at:

          Your Medicare Prescription Drug Coverage Options

          Prescription Drug Coverage Frequently Asked Questions

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