New Medicare beneficiaries want to know: Does Medicare cover a physical? No, Medicare does not cover physical examinations. Medicare does offer a “Welcome to Medicare Preventive Visit,” sometimes referred to as the “Initial Preventive Physical Examination.” However, do not mistake this for a physical. It is a free visit that focuses on prevention. Here are the various components.
- A review the beneficiary’s medical and social history, including past medical and surgical history
- Family history and events that can increase the beneficiary’s risk
- Status of preventive screenings and services, including immunizations
- Current medications and supplements
- A review ofthe beneficiary’s functional ability, including hearing, activities of daily living, risk for falls, and level of safety
- An examination of height, weight, body mass index (BMI), blood pressure, and visual acuity
- History of alcohol, tobacco, and illicit drug use
- Physical activities
- Potential risk factors for depression and other mood disorders
- End-of-life planning (advance directives) with beneficiary’s agreement
- Education, counseling, and referral based on the visit findings
- Discussion about Medicare’s preventive services
- Brief education, counseling, and referral to address any pertinent health issues
The visit may also include performance and interpretation of an electrocardiogram (EKG or ECG). Medicare considers this the “once in a lifetime” screening EKG. If done, Part B deductible and coinsurance can apply.)
This visit is not a head-to-toe examination. The “examination” part is very focused, looking only at a few components. If the visit goes beyond these components or the physician orders any additional services or tests, Medicare Part B deductible and coinsurance can apply.
Those with Original Medicare must see providers who accept assignment in order for visit to be free. Medicare Advantage plan members should consult a plan representative. They will likely have to see in-network providers. But know, Advantage plans are not allowed to charge for any preventive services that Original Medicare covers for free.
For more on Medicare's wellness visit, click on this link —http://www.medicare.gov/people-like-me/new-to-medicare/welcome-to-medicare-visit.html.
I have power of attorney for my husband’s financial and health decisions. However, when I try to talk with Medicare or Social Security about him, I get nowhere. Because of his medical issues, I need to be able to communicate on his behalf.
Establishing powers of attorney must be done while a person is of sound mind and able to make financial and medical decisions. Then, a power of attorney document allows an appointed person to make financial, legal, and property decisions on an individual’s behalf.
Joe had a stroke and his wife, Janet, has power of attorney. When selling a car titled in Joe’s name, she provided a copy of this document.
A durable power of attorney for healthcare allows an agent to make important and necessary healthcare decisions.
Janet gave the long-term care facility a copy of Joe’s durable power of attorney for healthcare. She could then make decisions about his care plan.
Unfortunately, neither of these documents will work when it comes to Medicare or Social Security. Even more important, each program requires its own documentation.
By law, Medicare requires a beneficiary’s written permission to use or provide personal medical information for any purpose not defined the privacy notice contained in the “Medicare & You” handbook. If the person is no longer able to give consent, his or her personal representative can complete an “Authorization to Disclose Personal Health Information.
A power of attorney form does not give the legal authority to negotiate and manage a beneficiary’s Social Security payments. In order to do this, a person must apply for and be appointed as a “representative payee.” This individual manages benefits for someone who cannot handle money or finances. Social Security will ask the representative payee to document how the benefits were used.
The process of becoming a representative payee is more involved. The individual must apply in person at a Social Security office and submit a letter from the beneficiary’s physician documenting the need for a representative payer.
Check these links for important information:
Medicare authorization— www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10106.pdf.
Representative payee — www.ssa.gov/pubs/EN-05-10076.pdf.
Medicare Part B confuses some Medicare beneficiaries. They think it's a supplement and, if they have it, they don’t need any other coverage or, because it’s a supplement, they can skip it.
The founders of Medicare deserve some credit for this confusion. The first two parts of Medicare were Part A, hospital insurance (HI), and Part B, supplementary medical insurance (SMI). Part B provided benefits, such as doctors’ visits, that supplemented hospital insurance. Over time, the SMI label has faded, especially since the introduction of Medicare supplement insurance in 1980. More commonly known as Medigap, Medicare supplement insurance help pay the costs that Part A and Part B (now known as medical insurance) don’t cover.
It’s important to realize that Part B is core component of Medicare, not a supplement. Without Part B, there would be no coverage for outpatient services, those that are necessary to diagnose and treat a medical condition. These include doctors’ visits, diagnostic tests, equipment, and outpatient surgery surgery, therapy and other care. Part B also covers many preventive services, often with little or no copayment.
The question then becomes: If you’re enrolled in Part A and Part B, do you need any other coverage? If you want to stay away from debt collectors, the answer is a definite "Yes." This additional coverage would either be a Medigap policy and Part D drug plan or a Medicare Advantage plan with prescription drug coverage.
Here’s why. You could live your entire life with just Part A and Part B but, if you become ill or are injured, the out-of-pocket costs associated with Parts A and B could force bankruptcy. For instance, the hospitalization deductible in 2022 is $1,556 per-benefit period. (Read more at www.65incorporated.com/topics/original-medicare/what-should-i-know-about-benefit-periods-original-medicare.) That means you could be on the hook for that deductible one, two, or more times in a calendar year. Every time you see a physician, have an x-ray, or use an outpatient service, you face a 20% coinsurance (after meeting the $233 Part B deductible).
Consider the example of LeRoy. At age 65, he enrolled in Part A and Part B only. He couldn’t see spending additional hard-earned cash on a supplement. At the age of 75, he injured his leg and then developed a bone infection that led to an amputation. He spent 30 days in a skilled nursing facility, getting IV antibiotics four times a day. Along with the hospitalization deductible and Part B charges for doctors, he had to pay a $194.50 a day copayment for the last 10 days of the SNF stay and a 20% coinsurance on the antibiotic therapy. Besides that, his choice of facilities was extremely limited because he had no insurance to cover the out-of-pocket costs. His wife finally found one that would accept her credit card.
When getting ready to travel the Medicare road, start with the core components, Part A and Part B. Then, study the paths and pick the option that will work best for you.
Learn about Part B at www.medicare.gov/what-medicare-covers/what-part-b-covers.
A drug tier is a way for insurance companies to group and price medications. Every prescription drug plan, including Medicare Part D, uses tiers in its formulary. Whereas most commercial drug insurance plans have two or three tiers, just about all stand-alone Part D drug plans have five tiers.
Here are the five tiers.
- Tier 1, preferred generics: These are commonly prescribed, low-cost medications.
- Tier 2, non-preferred generics: These generic medications will cost more than Tier 1 drugs.
- Tier 3, preferred brands: These are brand-name medications that do not have a generic alternative available.
- Tier 4, non-preferred drugs: These brand-name drugs cost more than those in Tier 3, usually because there is a generic alternative available. Most drug plans use a coinsurance (percentage of the cost) for these drugs.
- Tier 5, specialty drugs: These drugs treat complex conditions, like cancer, diabetes, and multiple sclerosis. These are the most expensive medications in a formulary, and can be either generic or brand name.
- Tier 6, select care drugs: Not every drug plan has this tier, which is limited to select generic medications to treat blood pressure, cholesterol, and diabetes.
There are requirements for tier structure.
- Tier 1 should have the lowest cost sharing and cost will go up with the tier. A quick check of plans in one zip code shows that the member’s cost for Tier 1 drugs can range from zero to $15 and, for Tier 2, from $7 to $47.
- Medicare limits the coinsurance for Tier 5 specialty drugs to 25% for plans that have a standard deductible ($505 in 2023). The coinsurance can be up to 33% for plans that have a deductible of less than $505.
- When a plan changes the tier of a medication during a calendar year, it is considered a formulary change, subject to approval.
Two tips to take home:
- Pay attention to the tiers and the associated charges. The same drug can be a Tier 1 in one plan and Tier 3 in another plan. For instance, a medication to treat Type 2 diabetes can be a Tier 1, 2, 3 or 4 depending on the plan, with out-of-pocket costs ranging from $5 to $115.
- Check changes to your drug plan every October during Open Enrollment. It can save you money. Example: Dave takes a Tier 2 medication that cost $15 this year. He discovers that his plan will change the medication to Tier 3, with a cost of $50. Checking other plans, Dave found this medication as a Tier 1 with no copayment for the mail-order service. That's the plan he will switch to during Open Enrollment.
Some companies selling Part D prescription drug plans also offer Medicare supplement plans, commonly known as Medigap policies. Many starting out on with Medicare think they have to get both plans from the same company. If it turns out one insurance company can offer the best deal, go for it. However, there is no mandate that both plans have to be sponsored by the same company. And, in most cases, that won’t be the best option.
Here are two examples.
- Working with an agent, Jean was going to enroll in one company’s supplement and drug plans. However, she found out that the drug plan did not cover one her medications. Choosing a different company’s Part D plan would ensure coverage of all her medications.
- Sam got both plans from the same company. It was just less hassle, he said. The drug plan cost $49 a month and he takes only one generic medication. He could have saved over $30 a month by getting a different company’s drug plan.
Remember three points.
- If you opt for Original Medicare, shop around for your best cost and coverage options. It’s okay to use two insurance companies.
- If you elected Medicare Advantage, one plan will provide your medical and prescription drug coverage.
- Check out changes in cost and coverage every year during the Fall Open Enrollment Period. (Read more at open enrollment.)