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Medicare Coverage For Mammograms

Breast cancer. Those two words can be terrifying, especially for older women. The median age for a breast cancer diagnosis is 61 years old, with 41% of breast cancer cases diagnosed in women age 65 and older. In addition, the median age of death from breast cancer is 68 years old. These are scary statistics for older women, but there is one simple thing you can do to minimize your risk. This Breast Cancer Awareness Month, we want older women with Medicare to understand how mammograms can help detect (and successfully treat) breast cancer, as well as how they are covered under Medicare.

The Different Types Of Mammograms

A mammogram is generally scheduled every year for women aged 50 and older to help with early detection of breast cancer. It is a simple procedure: once you remove your clothing from the waist up, you will place each breast between two specialized plates on the machine. The breast is then compressed for imaging. It might be uncomfortable and there might be some pain involved, but the compression does not last longer than a few seconds each time. The 3 types of mammograms are:

Film Mammograms– Conventional 2-D X-rays record black and white images on large sheets of film.
Digital Mammograms– 2-D black and white images of the breast are taken and then recorded into a computer. This allows the doctor to zoom in and enlarge the picture to take a closer look.
3-D Mammograms– 3-D images of the breast are taken in thin slices. This type of mammogram has been shown to improve the diagnosis of cancer in dense breast tissues.

Screening Vs Diagnostic Mammograms

The mammograms you get at your doctors office are classified in two different ways: screening and diagnostic. Screening mammograms are administered as part of a routine checkup to detect breast cancer in women who have no apparent symptoms. Diagnostic mammograms, on the other hand, are used after abnormal results on a screening mammogram, or if there are signs of breast cancer, such as a lump, that alerts a physician that there may be a problem.

Doctors use the same machines for both screening mammograms and diagnostic mammograms. Screening mammograms usually consists of taking two or more images of each breast while diagnostic mammograms involve taking a higher number of images from different angles.

Medicare Part B

If you have Medicare Part B, both screening and diagnostic mammograms are covered, but there are different coverage levels and out-of-pocket costs depending on your situation. Medicare will pay for:

One screening mammogram every 12 months if you’re 40 or older.

Medicare will pay for one screening mammogram every 12 months if you’re 40 or older.
One or more diagnostic mammograms, if necessary, to diagnose breast cancer
Both conventional and 3-D mammogram costs, if the provider offers 3-D mammograms.
Transportation costs if you need to get to your mammogram appointment

You will pay nothing for a screening mammogram as long as your doctor accepts Medicare assignment. However, if your doctor recommends more frequent tests or additional services, you might have to pay co-pays and other out-of-pocket costs. For example, as with many services, Medicare will cover 80% of the costs of diagnostic mammograms and you will pay the other 20% of the medicare-approved amount. You can avoid these out-of-pocket costs if you have a Medicare Supplement Plan. As long as you pay your monthly premium, many of these plans will cover your share of the costs.

If you are looking for ways to help pay for mammograms or any other Medicare costs, a Medicare Supplement Plan is a great option for you. There are 10 different types of Medicare supplement plans to choose from, so it can be a lot of work trying to determine which one is best for your needs. EZ is here to help make the process as painless as possible: we will provide you with a personal agent who will compare all available plans in your area, and sign you up with a Medicare Supplement Plan that is within your budget. To get started simply enter your zip code in the bar above or to speak to one of our highly-trained licensed agents, call 888-753-7207.

What Medicare Covers After A Stroke

According to the National Institute of Neurological Disorders and Stroke, over half a million people over the age of 65 suffer from a stroke every year. A stroke can be very serious, and can have long lasting effects on balance, hearing, and vision. It can also cause decreased mobility or even paralysis. Recovery after a stroke can be a long and difficult process, especially if you don’t have the proper insurance coverage. Thankfully, Medicare covers a lot of the aftercare related to recovery from a stroke, including both inpatient and outpatient care, as well as some medical equipment. There are gaps, however, which can be filled by a Medicare Supplement Plan.

Medicare Part A Coverage

If you suffer a stroke, you might need to go to an Inpatient Rehab Facility afterwards to recover and get the therapy that you need. As long as your doctor deems your stay medically necessary, Medicare Part A will cover this inpatient rehabilitation. Medicare will cover the cost of treatment in an inpatient facility for a limited time; if you need to stay longer than 60 days you will have to pay $352 per day for days 61-90. For days 91 and beyond, you will pay $704 in coinsurance per “lifetime reserve day.” You have 60 reserve days over your whole lifetime; after that, you will need to pay the full cost of your stay.

Medicare Part B Coverage

Medicare Part B will cover any outpatient rehabilitation needed, such as physical therapy, at 80%. You will be responsible for the other 20% coinsurance. As with any service, your doctor must deem your rehab medically necessary in order for it to be covered. If there is any durable medical equipment that is medically necessary, then Part B will also cover the cost of that at 80%. This includes equipment such as wheelchairs, walkers, or canes. Any of this equipment will need a prescription from your doctor.

Skilled Nursing Facilities

If you are moved into a skilled nursing facility from the hospital or from an inpatient rehab facility, Medicare will only pay for your stay if you have satisfied the “3-day rule.” This means that you need to have been admitted as an inpatient into the hospital for three days, and not classified as an “observation care” patient. With Medicare, staying at one of these facilities is free to you for the first 20 days, and $176 per day for the next 80 days after that.

Long-Term Care Facilities

Medicare does not cover any long-term care facilities, even if your doctor deems it medically necessary. These services are not covered because care at these facilities includes things like bathing, feeding, and assisting with the bathroom, which Medicare does not consider medical care services.

Medicare Supplement Plans

There are obviously gaps in what Parts A and B cover when it comes to recovery from a stroke. A Medicare Supplement Plan can help to fill those gaps. Most plans will cover your Part A coinsurance and allow you to extend hospitalization days up to 365 days over your lifetime. A Medicare Supplement Plan will cover part or all of your Part A deductible, and approximately 8 out of 10 plans will cover the skilled nursing facilities coinsurance. Some also provide coverage for long-term care. There are 10 different types of plans to choose from, with different coverage and different price points. EZ’s highly trained, licensed agents can help you compare these plans, and can provide quotes to you within minutes.

We hope you never need to test the limits of Medicare’s coverage for stroke care. Speak to your doctor about your risk factors, such as high blood pressure, high cholesterol, diabetes, smoking, and drinking, and see if there are ways you might be able to lower your risk through healthy lifestyle changes. Suffering a stroke can be scary and life-changing, but if it does happen to you, Medicare will cover the majority of your costs for treatment and rehabilitation. And whatever it does not cover, you can always count on a Medicare Supplement Plan to help you pay your medical bills. To be better prepared and to save money, compare Medicare Supplement Plan quotes by entering your zip code in the bar above, or to speak directly to an agent call 888-753-7207.

CMS To Begin Medicare Audits: What This Means For Providers

In order to ensure that hospitals, clinics, and other healthcare providers are not being overpaid for Medicare services, CMS usually conducts on-going audits. However, CMS suspended most fee-for-service claim audits and medical reviews by Medicare Administrative Contractors (MACs) on March 30th of this year due to the coronavirus pandemic. Suspension continued through most of the summer, but the agency resumed auditing providers’ Medicare claims on August 3rd. CMS stated this summer that the audits will continue “regardless of the status of the public health emergency.”

The Audits That Have Been Resumed

CMS has resumed both prepayment and post-payment medical reviews conducted by:

The Medicare Administrative Contractors
The Supplemental Medical Review Contractors (SMRC)
The Recovery Audit Contractor (RAC)
Any contractors under the Targeted Probe and Educate (TPE) program

What This Means For Healthcare Organizations

As states began to reopen this summer, CMS made it clear that they did not expect to extend the enforcement discretion period for audits any longer. At this point, all organizations should be taking the appropriate steps to be prepared for an audit in case it happens, including notifying all staff involved. If an organization is selected for review and they have any hardships related to the pandemic, they can discuss them with their contractors.

doctors dressed head to toe with protective gear seeing an elderly man with a mask on. — *CMS indicated that hospice care providers will most likely be selected for audits.*

CMS noted that “auditors will be applying any waivers and flexibilities in place during the emergency period, otherwise all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements.”

According to CMS, hospices are among the most utilized Medicare services. Because of this, CMS indicated that hospice care providers will most likely be selected for audits. When they are selected, they will have a chance to speak with their contractor about any hardships in replying related to the pandemic.

Many hospice care providers are worried about getting through an audit during this difficult time, especially since being subject to one would redirect focus away from patients, families, and hospice caregivers. “Staff are already being pushed to the limits. We’re operating with constraints in terms of how we can access patients. We’re operating mostly virtually right now, which is cumbersome,” Peter Brunnick, president and CEO of Hospice & Palliative Care Charlotte Region told Hospice News. “To add the audit process, which would require getting staff in-house pulling records and sitting down with auditors, is counter to everything we’re doing now trying to be socially distant and practice safety.”

“We recognize that oversight, even in a pandemic, is important, and we have no patience or tolerance for fraud and abuse. On the other hand, asking a compliant provider to take time out of providing care to their population in the middle of a global pandemic is not the best idea,” said National Hospice & Palliative Care Organization President and CEO Edo Banach. “There is a lot of consternation out there about the possibility that individuals are going to be pulled out of the field into the office and sift through records at a time when really all hands are needed on deck.”

CMS claims that they are taking the pandemic into consideration while doing these audits, so that they will not interfere with healthcare providers providing care to those who really need it.

Medicare’s Expansion Of Telehealth

Over the past few months, many people have gotten used to seeing their doctor virtually, or being able to call them from the comfort of their own home. Access to telemedicine was greatly expanded during the recent pandemic, and this has been especially beneficial for seniors. Having access to telehealth services means that older adults are not forced to jeopardize their health by going to a doctor’s office, and that they can access care even if they live in rural areas or are unable to get to a doctor’s office.

Now, in order to continue to protect older adults, both CMS and Congress are proposing actions to continue the expansion of telehealth. CMS Administrator Seema Verma announced that telehealth and telemedicine will be expanded to Medicare beneficiaries even after the pandemic is over. “I can’t imagine going back,” said Verma of returning to normal doctor’s visits. Now Medicare beneficiaries won’t have to. Congress is also trying to continue the expansion of telehealth services with their bipartisan Helping Ensure Access to Local TeleHealth (HEALTH) Act. If passed, this bill would mean that community health clinics and clinics in rural areas would continue to get reimbursement for telehealth services.

clack and white picture of congress — *CMS and Congress are looking into passing a bill to expand telehealth services for Medicare.*

The Temporary Expansion

CMS has been allowing telehealth services to cover more than 100 medical services since the CARES Act was signed into law in March of this year. This piece of legislation included provisions that removed restrictions on a patient’s location when receiving telehealth services, and permitted CMS to waive any Medicare reimbursement requirements.

Both providers and patients across the country have been taking advantage of the availability of telehealth services since the beginning of the pandemic. Medicare patients have been able to safely access both physical and mental health services throughout these hard times. But as state and federal governments enter their reopening phases, some of the expanded access to telehealth services is beginning to expire.

“Through the temporary telehealth changes thus far, community health center patients have been able to access primary care and behavioral health services while physically distancing to limit spread of coronavirus. However, patients and providers alike will benefit from permanent telehealth access even once the virus is under control,” Chris Shank, CEO and president of the North Carolina Community Health Center Association said in a statement.

Possible Changes Ahead

As state and federal governments enter their reopening phases, some of the expanded access to telehealth services is beginning to expire. CMS is seeking to stop this expiration and to:

Allow telehealth services to be covered under Medicare permanently
Remove “originating site facility and location requirements for distant site telehealth services.” In other words, community health centers and clinics would be able to service anyone in any location.
Reimburse community health centers and rural clinics for telehealth services

Congress is also trying to make sure that telehealth is accessible to seniors who could have trouble reaching a provider, as well as to those who receive care through federally qualified health centers. If passed, the HEALTH Act would mean that these community health centers and rural health clinics will continue to be reimbursed by Medicare for telehealth services. The HEALTH Act would provide “permanent cost-related payments for telehealth services furnished by federally qualified health centers [FQHC] and rural health clinics under the Medicare program.”

“The changes that we can make through the standard rule-making process, actions such as adding services to the telehealth list and making those permanent, those will appear in the physician fee rule,” said Emily Yoder, an analyst in CMS’ Division of Practitioner Services, while speaking during the American Telemedicine Association’s virtual conference.

Telehealth has become the new normal, and many Medicare beneficiaries have become dependent on it, especially those who have trouble accessing in-person care. The proposal to expand some telehealth services even after the pandemic is over is a welcome one for seniors who rely on telemedicine to get the care they need.

Trump Cuts The Cost Of Insulin For Medicare Beneficiaries

One in three Medicare beneficiaries has diabetes, which is more than 3 million people nationwide. Unfortunately, Medicare does not provide coverage for insulin. In May, President Trump announced that his administration is going to cut the price of insulin for Medicare beneficiaries to $35 for a one month supply. This would be a drastic reduction in price of about 66%. For older adults struggling to pay for their necessary supply of insulin, this could be a life-saving development.

Insulin Costs Skyrocket Every Year

The cost of insulin therapy tripled between 2002 and 2013, and it has increased another 55% since 2014. Diabetics have been expressing concerns over the out-of-control cost of insulin for many years. In fact, insulin has become so unaffordable that some people have either opted to get their insulin abroad from Canada, or go without it.

To make insulin more attainable, some manufacturers offer copay cards and assistance programs to help lower the out-of-pocket costs. These measures do help, but the costs of insulin copays and coinsurance for those on a Part D plan are still astronomical.

“Having more predictable out-of-pocket costs will help seniors adhere to their doctor’s orders,” White House counselor Kellyanne Conway said.

The Long Battle

This step toward addressing the crisis of rising insulin costs is long overdue. Diabetics, who are dependent on insulin to control their glucose levels and to prevent stroke or even death, have understandably been voicing their concerns about this issue for years. Their voices carried, reaching lawmakers who ended up taking pharmaceutical companies to court over the soaring costs of insulin. The House Committee on Energy and Commerce Oversight and Investigations Subcommittee held a total of 4 congressional hearings on this subject in 2019. In response to the hearings, pharmaceutical companies offered to lower prices and make generic brands available, but their promises were not enough.

Finally Being Heard

The Trump administration realized just how much insulin costs were affecting seniors and decided to take action. On Tuesday, May 26, the president stated, “Today I’m proud to announce that we have reached a breakthrough agreement to dramatically slash the out-of-pocket cost of insulin.”

CMS Administrator Seema Verma added, “President Trump has forged partnerships with pharmaceutical manufacturers and plans to deliver lower priced insulin to our nation’s seniors. This market-based solution, in which insulin manufacturers and Part D sponsors compete to provide lower costs and higher quality for patients, will allow seniors to choose a Part D plan that covers their insulin at an average 66 percent lower out-of-pocket cost throughout the year.”

She continued, “Trump’s Part D seniors savings model plan will go effective January 2021 and will save seniors about 66%, or an average of $446 each year, on insulin copays.” Verma also noted that if this model for lowering costs is successful, then they will try to expand the program to include other expensive prescription drugs.

Does Medicare Cover Ambulance Rides?

Ambulance rides are not cheap, they can range anywhere from hundreds to thousands of dollars. During a medical emergency, the last thing you want to worry about is if Medicare will cover the large ambulance bill. Thankfully, Medicare does cover ambulance rides so you don’t have to worry about anything but receiving the care you need. In fact, Medicare pays over $5 billion for ambulance service claims every year. However, to receive these benefits, there are stipulations you should be aware of first.

Eligibility Under Medicare Part B

Medicare Part B covers emergency ambulance services, and in some cases will also cover non-emergency services. An emergency is considered any situation in which your health is in serious danger. If you schedule your ambulance ride, then it is not considered an emergency. To receive coverage from Medicare:

The ambulance service must be medically necessary, and the only way to safely transport you to the hospital.
The transportation supplier (meaning nursing care facility or any provider asking for ambulance services) must meet Medicare ambulance requirements.
The reason for the trip must be to receive a Medicare-covered service during transportation or to return from receiving Medicare-covered care.
if it is not an emergency, then your doctor must provide a written order ahead of your scheduled trip.

If the situation is not an emergency, then ambulance services will only be covered if:

You are confined to your bed and unable to get up.
You need medical services during the trip that are only available in an ambulance.
You live in a skilled nursing facility and your doctor has written an order for an ambulance. You might be required to produce the order within 48 hours of the transport.
Your doctor deems that ambulance transport is medically necessary and provides a written order ahead of your scheduled trip.

Be aware that if you ask first-responders to take you to a hospital or facility other than the one that is closest to you, Medicare will only cover the cost of a ride to the nearest hospital or facility. You will be responsible for paying the rest of the bill out-of-pocket.

Ambulance Flights

Medicare will also cover other modes of emergency transportation, including ambulance flights. In order for Medicare to cover an ambulance flight, a ground ambulance must be unable to make it to your location. Medicare will also approve a flight if a ground ambulance can make it to the location but the situation is unsafe for the crew.

Your Costs

As with many services, Medicare Part B covers 80% of ambulance services, leaving you to pay 20% coinsurance out-of-pocket after you meet your Part B deductible ( $198 in 2020). It is illegal for ambulance companies to apply excess charges to your bill.

Some Medicare Supplement Plans will cover your coinsurance payments, so if you have certain letter plans, then ambulance rides will be covered 100%.

Ambulance rides are mostly covered by Medicare, but if you are worried about coinsurance payments, then consider a Medicare Supplement Plan. These plans mean that you won’t have to face Medicare bills alone, allowing you peace of mind, while at the same time putting money back in your wallet. There are different types of plans to choose from, with different coverage options at different price points. If you’re unsure where to begin, EZ can give you free quotes and a breakdown of all the plans. One of our agents will compare all of your options and find the perfect plan for your budget and needs. To get your free Medicare Supplement Plan quotes, simply enter your zip code in the bar above, or to speak to an agent, call 888-753-7207.

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