Medicare Corner

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Filing an appeal with Medicare

Did you know that you can file an appeal if you disagree with a coverage or payment decision made by Medicare? If you decide to file an appeal, you should ask your doctor or other health care provider for any information that may help your case.

Steps to Filing Your Appeal:

Get the Medicare Summary Notice that shows the item or service you’re appealing (This is the notice you get in the mail every three months or it can be retrieved through MyMedicare.gov).
Circle the item you disagree with on the notice.
Write an explanation on the notice of why you disagree.
Sign the document and include your phone number and Medicare number.
Keep a copy for your records.
Send it to the Medicare contractor’s address listed on the notice along with any supporting documentation such as your provider’s information mentioned above.

Appeals must be filed within 120 days of the date you receive the notice. For additional details on filing an appeal, please visit medicare.gov or contact Alaska’s Medicare Information Office.

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Understanding Medicare and the AlaskaCare Retiree Plan at age 65

The first thing you should note is AlaskaCare Retiree Health Plan benefits become supplemental to Medicare once you reach age 65. This often comes as a surprise to retirees, even though it is printed in the Retiree Health Plan. This provision originates in Alaska Statutes and has been in the plan since 1975, when the health plan was initiated.

The effect of AlaskaCare becoming supplemental to Medicare is explained on page 17 in your Retiree Insurance Information Booklet. If you do not enroll in Medicare at age 65, AlaskaCare will estimate the amount Medicare would have paid and deduct that amount before paying your claim, which means you will pay a larger part of your bill.

You may have coverage that would be primary to Medicare, including a plan provided to you or your spouse as an active employee. While you can delay Medicare until that coverage ends, the retiree plan will estimate what Medicare would have paid before it will make a payment and you will be responsible for paying the amount Medicare would have paid.

There are three different “Enrollment Periods” for Medicare:

The Initial Enrollment Period, a 7-month window, begins three months before your 65th birthday month and ends three months after.
The Special Enrollment Period, available if you are covered as an employee or the dependent of an employee when you turn 65 and want to delay enrollment. You have up to 8 months after your health insurance terminates, which you’ll need to document, to avoid a penalty for not being enrolled when you were eligible.
The General Enrollment Period is January-March for anyone that missed their initial enrollment period and didn’t have a Special Enrollment Period. The coverage begins July 1. Enrolling during this period, rather than when you were first eligible, means you will pay a penalty through higher Medicare premiums.

You will also be offered Medicare Part D—the prescription drug plan. You are not required to enroll in the plan as your AlaskaCare drug coverage is the same or better than the Medicare plan. By not enrolling in Part D, you can avoid unnecessary premiums and coordination between Medicare and AlaskaCare for your prescription drugs. If you have questions regarding the AlaskaCare Retiree Health Plan, you should contact the Division of Retirement and Benefits. For questions regarding your Medicare eligibility, please call the Medicare Information Office at (800) 478-6065 or if you’re in Anchorage (907) 269-3680.

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Ambulance coverage under Medicare

Many people have questions regarding what Medicare will cover in terms of ambulance services. What follows is some guidance from Medicare.

Ambulance services may be covered under Medicare Part B (outpatient medical) to the nearest appropriate medical facility that is able to give you the care you need if you meet certain conditions. This might include ambulance service to or from a hospital, including a critical access hospital, skilled nursing facility, or dialysis facility. Types of ambulance transportation include emergency ground (vehicle), emergency air (airplane or helicopter), and non-emergency ground (when you need transportation to diagnose or treat your health condition and transportation in any other vehicle would endanger your health).

If you think that Medicare should have covered a claim for ambulance service that it did not cover, carefully check your Medicare Summary Notice (MSN) or go to MyMedicare.gov to review the claim and detailed explanation of why Medicare didn’t pay. There are two common reasons for denials:

The ambulance company didn’t fully document why you needed ambulance transportation. If this happens, contact the doctor who treated you or the discharge social worker to get more information about your need for ambulance transportation. Send this information to the company that handles bills for Medicare or ask your doctor to send it.
The ambulance company didn’t file the proper paperwork. In this case, ask the ambulance company to refile the claim and don’t pay the bill until the company has done so. In lieu of this, ask the company that handles bills for Medicare to contact the ambulance company on your behalf to make it aware of its responsibility to file a Medicare claim. If refiling your claim doesn’t result in payment, you may file an appeal. (An appeal is an action you take if you disagree with a Medicare decision.) Your MSN will tell you why the bill wasn’t paid, how long you have to file an appeal, and what appeal steps you can take. Keep a copy of everything you send to Medicare as part of your appeal. If you need more help, visit Medicare.gov/Publications to review the following publications or call (800) 478-6065 for more assistance.

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Travel and medical coverage under Medicare

Many people have questions regarding what Medicare will cover in terms of travel inside or outside the United States. What follows is some guidance from Medicare.

Travel for routine medical needs Medicare does not generally cover travel for routine medical needs. If your health provider in Alaska recommends another provider or specialist in Seattle or elsewhere, it is possible that the cost of the medical procedures or supplies will be covered (through Medicare Part B, outpatient medical). Medicare does not cover travel costs unless travel meets guidelines for ambulance travel. (Please see travel coverage under the AlaskaCare Health Plans.)

Travel outside the United States

In most cases, Medicare does not cover health care if you are living abroad or while you’re traveling outside the U.S. (the “U.S.,” according to Medicare, includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). There are some exceptions, including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following rare situations:

If an emergency arises within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition.
If you’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency.
If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.
Medicare may cover medically-necessary ambulance transportation to a foreign hospital only with admission for medically-necessary covered inpatient hospital services.

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Protect your health with medicare preventive services

The AlaskaCare Retiree Health Plan provides limited preventive care benefits including one routine mammogram, pap smear and/or prostate specific antigen test per benefit year. But retirees who are eligible for Medicare can utilize Medicare’s preventive benefits such as flu shots, diabetes screening, HIV screening, smoking cessation counseling, and bone mass measurement.

Preventive Services overview: View a complete list of preventive services and access resources at Medicare.gov
Preventive Services checklist: Take this checklist to your doctor or other health care provider, and ask which preventive services are right for you.
View list of medicare publications: Access approximately 120 publications related to Medicare
A Healthier US Starts Here [PDF]: This brochure has a handy checklist of each benefit, what it does, and how often it’s covered by Medicare.
Medicare & You Handbook: This handbook is the best and official source of answers to your Medicare questions.

Medicare encourages you to get a one time “Welcome to Medicare” physical exam in the first 12 months of your enrollment in Medicare Part B. You’ll get a complete review of your health and medical history and the information gathered will be useful for comparison purposes in the future.

Find out more by visiting MyMedicare.gov to:

request future eHandbooks
track preventive benefits you’ve used each year
remind you of benefits for which you are eligible
review or print claims

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Understanding the ABC's of Medicare

Medicare consists of four parts – A, B, C, and D – and knowing those parts is key to having a smooth transition to Medicare, avoiding late enrollment penalties, and receiving full benefits from your AlaskaCare Retiree Health Plan.

Part A covers inpatient hospital stays, skilled nursing care, home health care, and hospice care. It is generally provided free of charge beginning at age 65. If you are receiving Social Security benefits at age 65, you will be automatically enrolled in Part A. If not, you must contact Social Security in the three months before your 65th birthday to ensure your Medicare Part A begins promptly when you turn 65.

Part B covers outpatient provider services, emergency room care, diagnostic testing and preventive care. The 2013 premium for Part B is $104.90 (some exceptions apply for high income members). As with Part A, you will be automatically enrolled in Part B if you are receiving Social Security at age 65 and the premium will be withheld from your Social Security benefit. If you are not receiving Social Security, you must enroll in Part B during the 3 months before your 65th birthday, at the same time as you enroll in Part A, and arrange to pay the premium directly.

Part C plans are Medicare Advantage plans provided by private insurers for members who live outside the State of Alaska. They cover the same services as Medicare Part A and B combined as well as some supplemental benefits but are Preferred Provider Organizations (PPO) or Health Maintenance Organizations (HMO). These plans may not the best choice for AlaskaCare members who already have the Retiree Plan to supplement Medicare.

Part D provides prescription drug coverage through private insurers. AlaskaCare members have prescription drug coverage which is as good as, and in most cases, better than Part D.

AlaskaCare Retiree Health Plan members need both Medicare Parts A and B at age 65 because the Retiree Health Plan becomes supplemental to Medicare at that time (per State statute). When paying a claim, the health plan will assume the member has coverage under Parts A and B and will deduct the amount Medicare would have paid prior to making payment. This is true even if the member has another health plan provided through the employment of the member or the spouse. Without Part A and B, the Retiree Plan member will be responsible for the portion Medicare would have paid, regardless of any other coverage they have. (Members who are not eligible for premium-free Part A should obtain a confirmation letter from Social Security and the Retiree Health Plan will remain primary for Part A expenses.)

AlaskaCare Employee Health Plan members may enroll in Part A as soon as they are eligible and it will pay secondary to the Employee Plan. They can delay enrolling in Part B until they terminate employment but must do so immediately when their employee health coverage ends in order to avoid a penalty or a delay in the start of Part B and less than full benefits from the Retiree Plan if they are moving to that plan.

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