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By Terence G. Brady
Brady Chiropractic 

Are you covered by Medicare?

Dr Brady the 'Spine Guy'

 


If you are at least 65 or older you are eligible for Medicare. You can choose to take your Social Security at an earlier age, but Medicare cannot be taken earlier unless you are disabled in some way.

Medicare will cover 80% of their fee schedule covered charges. For example, if the doctor charges $100 for an exam or procedure, and the Medicare fee schedule is $50 then Medicare will only pay $40. The difference of $10 is your co-pay and will be charged to you. Each year your Medicare deductible must be met before Medicare will pay anything. In 2015 the deductible is $147. That is money out of your pocket. Medicare recipients also have a separate deductible for hospital stays, but we won’t get into that here. You can see here that if your medical or hospital bills go up into the thousands you could be liable for some pretty large co-pay amounts. Not a good thing.

Most people buy a supplemental or secondary coverage that covers the co-pay and sometimes the deductible as well. In most cases, supplemental coverage only pays the co-pay on procedures that Medicare covers. That means that if the doctor performs a procedure that is not covered you can be charged for that service. A true secondary coverage will very often cover those procedures that are not covered by Medicare. Secondary coverage is usually more expensive than supplemental. In all cases you as the patient you must be informed by the doctor’s office all procedures that are not covered by Medicare. You are also required to sign a form called “Advanced Beneficiary Notification” (ABN) at every visit.

So; if you have Medicare and a secondary/supplemental coverage, you’re out of pocket expenses could be zero.

Now let’s talk about the Senior Advantage type of coverage. Many insurance companies offer this type of coverage wherein you literally give up your straight Medicare coverage and are included into a group somewhat like an HMO. Some examples are Kaiser, Anthem, GemCare, Humana and quite a few others. If you go with one of these companies, you have to understand that the doctor can no longer bill Medicare. All billing has to go through the Senior Advantage carrier. In my practice I encounter a number of people that are unaware of this. They often think that Medicare is the “primary” carrier and should be billed first and that the senior advantage company is the “secondary/supplemental” carrier. The up side to a senior advantage plan is that they are usually less expensive to enroll and you have lower co-pays. The down side is that you may not be able to go to the doctor of your choice but will have to choose from that company’s panel.

All these questions need to be answered to your satisfaction before you sign up. If you buy into a particular plan you are basically stuck with it for a year. Open enrollment is only once per year.

My office tries hard to understand the ins and outs of your coverage, but sometimes we do need and appreciate help from our patients.

I am on the panel of many of the senior advantage plans and we accept many different insurance plans.

We also customize payment plans for those people who do not have insurance coverage.

Call (661) 823-8888 for an appointment. A consultation only is always complimentary.

 
 

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