Marci's Medicare Answers
October 2008

Dear Marci,
I went in for my annual mammogram last month, but my doctor wants me to come in for another one because he saw an abnormality. Do I have to pay out of pocket for the second mammogram?
--Sally

Dear Sally,
No. Your second mammogram is what is known as a diagnostic mammogram, and Medicare covers as many diagnostic mammograms as necessary. In addition to diagnostic mammograms, Medicare covers 80 percent of the cost of one screening mammogram (what you had last month) every 12 months for women who are 40 or older. Medicare will also pay for one baseline mammogram for women 35 to 39 years of age. Screening and baseline mammograms will be covered with no Part B deductible required.
--Marci

Dear Marci,
I have been homebound and receiving physical therapy at home for several months. I am now well enough to leave my house and get out and about on a regular basis. My doctor wants me to continue physical therapy at his office. Will Medicare pay?
--Arnold

Dear Arnold,
Yes, Medicare will pay as long as your doctor submits a new plan of treatment stating that you now need to get therapy at his office. In 2008, if you get therapy at a doctor’s office or at home, Medicare will cover up to $1,810 for physical and speech therapy combined, and another $1,810 for occupational therapy. Exceptions to the limits are allowed if more therapy is medically necessary. No matter where you receive your therapy, your doctor must periodically review your plan of treatment and state whether your needs have changed.
--Marci

Dear Marci,
My mother has cancer. We know that Medicare will not cover the costs of an aide to clean her house and cook her meals. But now that my mother is in declining health, and needs a nurse to visit her at home, will Medicare pay for that?
--Terry

Dear Terry,
If your mother qualifies for the home health benefit, Medicare will pay in full for skilled nursing, which includes services and care that can only be performed safely and effectively by a licensed nurse. Such services may include medication administration, tube feedings and regular observation and assessment of your mother’s condition.

Your mother qualifies for the home health benefit if (1) her doctor certifies that she is homebound (it takes considerable and taxing effort for her to leave home); and (2) she needs skilled physical, speech or occupational therapy services, or skilled nursing on an intermittent (less than seven days a week) or part-time (less than eight hours a day) basis. If she required only skilled nursing, she must either need it fewer than seven days a week (even as little as once every 60 to 90 days) or daily (seven days a week) for a short period of time (usually two to three weeks); and (3) her doctor certifies her need for home care; and (4) she receives her care from a Medicare-certified home health agency (HHA).

If your mother’s condition were to be diagnosed as terminal and she elected palliative care, Medicare would continue to cover skilled nursing for her as part of Medicare’s hospice benefit.
--Marci

Dear Marci,
I have had diabetes for many years and became eligible for Medicare in September. Does Medicare pay for my monitoring supplies?
--Ed

Dear Ed,
Yes, Medicare will cover certain diabetic supplies, such as glucose monitors and control solutions, lancets, and test strips. You can get these benefits even if you don’t use insulin. If you use an insulin pump, the insulin and the pump may be covered as durable medical equipment under Medicare Part B. Contact your Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for more information. To find the number of your local DME MAC, call 1-800-MEDICARE. If you inject your insulin with a needle (syringe), the Medicare drug benefit (Part D) covers the cost of insulin and the supplies necessary to inject the insulin, including syringes, needles, alcohol swabs and gauze. Medicare will pay 80 percent of the Medicare-approved amount of all covered diabetes supplies and services, after you have paid the yearly Part B deductible. (If you are in a Medicare private health plan-HMO or PPO-you may have a copay for these services. Call your plan to find out what you will have to pay.)
--Marci

Dear Marci,
I have had Pap smears every year, but last month when I went for my exam, I was told that Medicare won’t pay for my exam this year. Why might this be?
--Helen

Dear Helen,
Original Medicare covers 100 percent of the cost of one Pap smear every two years for all women with Medicare (if you are in a Medicare private health plan you may pay a copay). If you are in your second year with Original Medicare, and had a Pap smear last year, and you are generally healthy, you will not have another one covered until next year. However, if you are considered at high risk for cervical or vaginal cancer (e.g. have had a sexually transmitted disease or your mother was given the drug diethylstilbestrol (DES) during pregnancy), or are of child-bearing age and have had an abnormal Pap smear in the past 36 months, Medicare covers the cost of one Pap smear a year (every 12 months). Medicare will cover the full cost of your Pap lab test, 80 percent of the cost of the Pap test collection, a pelvic exam (used to help find fibroids or ovarian cancers) and a clinical breast exam. Medicare will cover all of these services with no Part B deductible required.
--Marci

Dear Marci,
I applied for Extra Help paying for Medicare drug coverage (Part D) and was denied. Is there anything I can do?
--Vincent

Dear Vincent,
If it is before you receive the final decision—you get a notice from the Social Security Administration (SSA) saying you may be denied because your application is incomplete—you can correct your application. If you received a “Notice of Denial” from SSA saying that you do not qualify for Extra Help, and if you disagree with that decision, you can appeal. It is best not to reapply for Extra Help and appeal instead, because if you win, your Extra Help will be effective from the first day of the month that you originally submitted your application. To appeal you should request a review of your case (a hearing) within 60 days of receiving SSA’s decision. If you do not want a hearing, you can just ask for a “case review,” where an SSA agent will review your application and any additional information you send in.
--Marci

Medicare Rights Center (www.medicarerights.org) is the nation’s largest independent source of information and assistance for people with Medicare. To speak with a counselor, call (800) 333-4114. For MRC’s free educational e-newsletter, simply e-mail dearmarci@medicarerights.org. To learn more about the services that Medicare will cover and how Medicare works with Medicaid, log on to Medicare Interactive Counselor at the Medicare Rights Center’s website at www.medicareinteractive.org.