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Marci’s Medicare Answers

June 2014

 

Dear Marci,

I have Original Medicare. Do I need to get a referral from my primary care doctor to see a specialist?

—Jericho 

Dear Jericho,

If you have Original Medicare, the traditional Medicare program administered directly through the federal government, you do not have to get a referral from your primary care doctor in order to see a specialist (e.g., a dermatologist). Medicare should cover the care you receive from a specialist as long as the care you get is covered by Medicare and you get the care from a specialist who accepts Medicare.

If you have Original Medicare, you can go to any doctor in the U.S., as long as the doctor accepts Medicare. In order to get care at the lowest cost, you should get care from a doctor who accepts Medicare and takes assignment. Doctors who accept Medicare and take assignment accept the Medicare-approved amount for covered health care services as full payment.

Be aware that Medicare generally does not pay for care you receive from opt-out doctors, or doctors who do not accept Medicare and have formally opted out of the Medicare program. Opt-out doctors do not submit medical claims to Medicare and are not subject to the Medicare law that limits the amount they may charge patients with Medicare. If you have Original Medicare and you see an opt-out doctor, the opt-out doctor must provide you with a contract informing you of their opt-out status and letting you know that you would be responsible for the cost of the care you receive. If the opt-out doctor does not give you this contract before providing you with care, you are not responsible for paying for that care.

Also, keep in mind that psychiatrists have been more likely to opt out of Medicare in recent years, compared to other doctors. Be sure to ask your doctor if he/she accepts Medicare, before you begin to receive health care services.

Keep in mind that some Medicare Advantage plans, also known as a Medicare private health plans, may require you to get a referral from your primary care doctor before seeing a specialist. In addition, plans will most likely pay for care you receive from in-network doctors, as opposed to out-of-network doctors. If you have a Medicare Advantage plan, you should check with your plan directly to learn more about plan rules, benefits and costs.

—Marci

 

Dear Marci,

Does Medicare cover the shingles vaccine?

—Andrea

Dear Andrea,

Yes, Medicare Part D plans, also known as Medicare prescription drug plans, should cover commercially available vaccines, such as the shingles vaccine. Your Part D plan should pay for the vaccination itself and should also pay your doctor or other health care provider to administer the vaccine.

Keep in mind, however, that the amount you pay for the vaccine may vary depending on your Part D plan’s costs and rules. You should check with your Part D plan directly to see where you can get vaccinated at the lowest cost.

Remember, you can get Medicare Part D through one of two ways. Specifically, you get Part D through a stand-alone Part D plan that works with Original Medicare, the traditional Medicare program administered directly through the federal government. Alternatively, you can get Part D through a Medicare Advantage Prescription Drug Plan, also known as a Medicare private health plan that offers prescription drug coverage.

If you have Extra Help, the federal assistance program that helps individuals with limited finances pay for their Medicare prescription drug costs, you should not pay more than the Extra Help copayment or copay for your vaccination. For more information on Extra Help, you can go online and visit http://www.socialsecurity.gov/prescriptionhelp. You can also contact the Social Security Administration at 800-772-1213 or visit your local Social Security office to learn more about Extra Help.

—Marci

 

Dear Marci,

I receive $1,200 each month from my Social Security retirement benefits. I don’t have any other source of income and I have about $4,000 worth of assets. Do I qualify for Extra Help?

—Gabby

Dear Gabby,

Yes, based on your income and assets you will most likely qualify for Extra Help, the federal assistance program that helps individuals with limited finances pay for their Medicare prescription drug costs.

In 2014, individuals who receive $1,459 or less each month and have $13,440 or less in assets should qualify for Extra Help. In 2014, couples who receives $1,966 or less each month and have $26,860 or less in assets should qualify for Extra Help.

If you have Medicaid, a Medicare Savings Program or you receive Supplemental Security Income (SSI), you should get Extra Help automatically. If you do not get Extra Help automatically, you can apply for Extra Help online by visiting https://secure.ssa.gov/i1020/start. You can also apply for Extra Help by calling the Social Security Administration at 800-772-1213 or by going in-person to your local Social Security office.

—Marci

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Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. To subscribe to “Dear Marci,” MRC’s free educational e-newsletter, click here.

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Last Modified: 09/19/2013 14:08:42
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