CSRA Medicare Presentation
Presented by Angela Free
Associate Director, Benefits & Payroll
May 7, 2014
AGENDA
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Medicare Introduction
Parts of Medicare
What Medicare Covers
Transitioning to Medicare
Who Pays When?
Pharmacy Benefits
Medicare Appeals
Answers to Submitted Questions
New Questions?
MEDICARE INTRODUCTION
Medicare coverage is based on 3 main factors :
• Federal and state laws
• National coverage decisions made by Medicare about whether something is
covered
• Local coverage decisions made by companies in each state that process claims for
Medicare. These companies decide whether something is medically necessary and
should be covered in their area
PARTS OF MEDICARE
Medicare covers services (like lab tests, surgeries, and doctor visits)
and supplies (like wheelchairs and walkers) considered medically
necessary to treat a disease or condition.
WHAT MEDICARE COVERS
How to find out if Medicare covers what you need
Talk to your doctor or other provider about why you need certain services or supplies, and
ask if Medicare covers it. If you need something that's usually covered and your provider
thinks that Medicare won't cover it, you'll have to sign a notice saying that you understand
you have to pay for that item, service, or supply yourself.
Go here to check for yourself. Enter all or part of the name of the procedure, item or
supply in the search field:
http://www.medicare.gov/coverage/your-medicare-coverage.html
WHAT DOES MEDICARE PART A COVER?
• Hospital care
• Skilled nursing facility care
• Nursing home care (as long as custodial care isn't the
only care you need)
• Hospice
• Home health services
WHAT DOES PART B COVER?
Part B covers 2 types of services:
Medically necessary services: Services or supplies that are needed to diagnose or treat
your medical condition and that meet accepted standards of medical practice.
Preventive services: Health care to prevent illness (like the flu) or detect it at an early
stage, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care
provider who accepts Medicare assignment.
PART B MEDICALLY NECESSARY:
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Clinical research
Ambulance services
Durable medical equipment (DME)
Mental health
Inpatient care
Outpatient care
Partial hospitalization
Getting a second opinion before surgery
Limited outpatient prescription drugs
PART B PREVENTATIVE & DIAGNOSTIC:
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Abdominal aortic aneurysm screening
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Mammograms (screening)
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Alcohol misuse screenings & counseling
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Nutrition therapy services
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Bone mass measurements (bone density)
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Obesity screenings & counseling
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Cardiovascular disease screenings
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One-time “Welcome to Medicare” preventive visit
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Cardiovascular disease (behavioral therapy)
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Prostate cancer screenings
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Cervical & vaginal cancer screening
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Colorectal cancer screenings
Sexually transmitted infections screening &
counseling
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Depression screenings
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Shots: Flu, Hepatitis B, Pneumococcal
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Diabetes screenings
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Tobacco use cessation counseling
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Diabetes self-management training
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Yearly "Wellness" visit
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Glaucoma tests
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HIV screening
WHAT'S NOT COVERED
BY PART A & PART B?
Medicare doesn't cover everything. If you need certain services that Medicare doesn't cover, you'll have to pay for them
yourself unless you have other insurance or you're in a Medicare health plan that covers these services. Even if Medicare
covers a service or item, you generally have to pay your deductible, coinsurance, and copayments. Some of the items and
services that Medicare doesn't cover include:
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Long-term care, also called custodial care (remember Part A covers it as long as that’s not the only type of care you
need at the time)
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Most dental care
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Eye examinations related to prescribing glasses
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Dentures
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Cosmetic surgery
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Acupuncture
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Hearing aids and exams for fitting them
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Routine foot care
WHAT DOES PART D COVER?
Part D adds prescription drug coverage to Original Medicare and other
Plans, like our USG plans. These plans are offered by insurance companies
and other private companies approved by Medicare.
Medicare Advantage Plans, Like our Kaiser Senior Advantage Plan, may also
offer prescription drug coverage that follows the same rules as Medicare
Prescription Drug Plans.
USG RX COVERAGE
The pharmacy benefits for Medicare Eligible Retirees enrolled in the BCBS plans are
provided through Express Scripts (formerly Medco) Medicare Part D prescription drug
plan for the University System of Georgia. This prescription drug plan generally
provides retirees the same prescription drug coverage as for active employees with very
few exceptions.
KAISER RX
Kaiser Senior Advantage Pharmacy coverage
If you enroll in the Kaiser Permanente Senior advantage plan, Kaiser Permanente will serve
automatically as your Part D provider.
If you are a new member selecting Kaiser Permanente Senior Advantage as your retiree
option for 2014, your application will include Part D enrollment information.
If you currently have an existing Part D Plan and enroll into Senior Advantage, your existing
Part D Plan will automatically be cancelled by Medicare.
IMPORTANT INFORMATION MEDICARE-ELIGIBLE
RETIREES NEED TO KNOW ABOUT THE OPEN ACCESS
POS PHARMACY PLAN COVERAGE:
• Medicare eligible retirees enrolled in the Open Access POS plan will be automatically
enrolled in the Express Scripts Medicare Part D plan through the University System of
Georgia as part of their pharmacy coverage
• If a retiree does not want to enroll in this Express Scripts Medicare Part D plan, the
retiree may waive coverage under the plan; however, if the retiree waives coverage,
he/she will no longer be eligible to participate in the Open Access POS plan. The retiree
will have the option to enroll in the HSA Open Access POS plan or the Kaiser Sr.
Advantage plan or cancel their retiree health coverage. If a retiree cancels their retiree
health coverage through the University System of Georgia, they will not be allowed to
re-enroll in coverage
(CON’T) IMPORTANT INFORMATION MEDICARE-
ELIGIBLE RETIREES NEED TO KNOW ABOUT THE
OPEN ACCESS POS PHARMACY PLAN COVERAGE:
• Retirees will receive a pre-enrollment letter from Express Scripts which will explain
the plan in detail
• Upon enrollment, Retirees will receive a Welcome kit and a new pharmacy ID card
with a new group number – it does not say Medicare, but the group number is a
Medicare group
• Retirees will be able to get their prescriptions from the same retail pharmacies as before
• Retirees with questions may contact the University System of Georgia Shared Services
Center toll-free at 1-855-214-2644 or e-mail helpdesk@ssc.usg.edu. For questions
about the benefits or how the plan works, contact Express Scripts Medicare Customer
Service at 1-877- 681-9875
HMO RX
Generic copay $10 for 30 day supply
Name brand $25
Mail order: Tier 1 $25 /Tier 2 $70
The HMO is subject to a formulary
Some drugs are subject to pre-authorization or step-therapy
OPEN ACCESS HSA POS Rx
(HIGH DEDUCTIBLE)
85% of network cost of drug
Not subject to formulary
Some drugs are subject to pre-authorization or step-therapy
Mail order is available
OPEN ACCESS POS RX
Generic $10, Preferred brand-name $35
Non-preferred brand-name 20% of the drug’s cost/$45 minimum copay /$125 max co-pay
Mail order: 31 - 90 Days supply: Generic $25, Preferred $87.50
Non preferred $112.50 minimum copay/$250 maximum copay
Annual out of pocket max (Non-preferred brand-name does not count toward this)
EE: $1000 EE + Ch or EE + Sp : $2000 Family (3 or more) $3000
This means the cost is waived for generic and preferred drugs after max is met in a year.
ACTIVE CHOICE
Choosing Mail Order or Retail:
A Message from the USG System Office
In 2014, members enrolled in the OA POS plan using maintenance medications at retail must
make a decision on how to receive maintenance prescription drugs – through home delivery
or retail prior to the third refill.
If a decision is not made by the third refill, members will be required to pay the full price of
the prescription until a decision is made. We want all of our employees and their dependents
to be aware of the savings and health benefits available to them through mail order!
HOW TO CONTACT EXPRESS SCRIPTS
To make the decision about mail order, visit the Express Scripts website at www.ExpressScripts.com/Decide or call Express Scripts at 877-603-1032, Monday – Friday, 8:30 a.m. to 6 p.m.,
Eastern.
Express Scripts will make the transition to mail order easy by contacting your doctor to get a new
90-day prescription on your behalf.
Contact Express Scripts with your decision today!
Thank you!
University System of Georgia/Board of Regents Human Resources
TRANSITIONING TO MEDICARE
I’ll be 65 soon, what do I need to do?
 Sign up for Medicare Parts A & B (online at medicare.gov, by phone, or in person)
 Contact CSU Benefits Office or Shared Services with your Medicare Claim Number
 After you are enrolled, contact Medicare for coordination of benefits (more later)
 If you are already retired and turning 65, you need to make sure you are in an eligible health plan.
If you are currently enrolled in the Blue Cross HMO – you must change plans because it is not
Medicare compatible.You may choose High Deductible HSA POS Plan or Regular POS HSA Plan.
You will receive a kit from the SSA 60-90 days before your birthday. If you are still active and enrolled
in a USG medical plan, it is considered credible coverage, and you can put off enrolling in Medicare
parts B and D until you retire without paying a penalty. If you do choose to enroll while active, your
USG plan will remain primary, and your Medicare B plan will be secondary.
MEDICARE CLAIM NUMBER
WHEN CAN I SIGN UP?
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When you turn 65 - your Initial Enrollment Period
During Medicare annual enrollment between January 1–March 31 each year
When you lose employer sponsored group health coverage (8 months from end of
employment or end of coverage, whichever occurs first)
There is a penalty for signing up late – 10% for each full 12 month period past your
initial enrollment deadline, but if you remain enrolled in your CSU plan as an active
employee until you retire and then enroll, the penalty is waived.
HOW MEDICARE WORKS WITH OTHER INSURANCE
If you have Medicare and other health insurance or coverage, each type of
coverage is called a "payer." When there's more than one payer,
“coordination of benefits " rules decide which one pays first.
PRIMARY PAYER
The "primary payer" pays what it owes on your bills first, and then sends the rest to the
"secondary payer" to pay. In some cases, there may also be a third payer.
Paying "first" means paying the whole bill up to the limits of the coverage. It doesn't
always mean the primary payer pays first in time. If the insurance company doesn't pay the
claim promptly (usually within 120 days), your doctor or other provider may bill
Medicare. Medicare may make a conditional payment to pay the bill, and then later recover
any payments the primary payer should've made.
If you have questions about who pays first, or if your insurance changes, call the Medicare
Coordination of Benefits Contractor at 1-855-798-2627.
COORDINATION OF BENEFITS BETWEEN
MEDICARE AND A SECOND PAYER
Question: How does Medicare pay as a secondary payer?
SECOND PAYER
Answer: When Medicare is primary, Part A and B, the member has a Medicare deductible (which is usually met
before BCBS) and BCBSGA deductible to meet before Blue Cross plan cover’s member’s Medicare’s 20%
coinsurance.
Also, if the member has not met their deductible for BCBS, the provider can bill the member for an amount
that Medicare states is the patient's responsibility.
*If the member uses an in network provider, the BCBS’s deductible is $300.00; once the deductible is met, BCBS will pick up the
member’s Medicare coinsurance.
*If the member uses an out of network provider, the BCBSGA’s deductible is $400.00; once the deductible is met,
Blue Cross will pick up the member’s Medicare coinsurance. However, since the provider is not participating, the
member will be subject to balance billing because out of network providers do not take provider’s write-offs
because they are not contracted to.
DEFINITION OF BALANCE BILLING:
The dollar amount charged by a provider that is in excess of the plan’s
allowed amount for medical care or treatment. Amounts that are
balance billed by a provider are the member's responsibility. Member
costs incurred for balance billing will not apply toward the annual
deductible or toward the annual maximum out-of-pocket limits.
HOW CLAIMS ARE PAID BY USG IF PROVIDERS
OPT OUT OF MEDICARE
As of 2014, members will pay a lower premium to USG when they have
Medicare primary so they must find a provider who accepts both Medicare
and Blue Cross OA POS. If a member uses a provider that has “opted-out” of
Medicare, Blue Cross will not pay as primary, as they have done in the
past. Blue Cross will process the claims as secondary and any amounts above
the plan’s payment can be held as the patient’s liability.
This means that Blue Cross will only cover the 20% of Medicare’s
coinsurance.
HOW CLAIMS ARE PAID WHEN THE CLAIMANT
HAS MEDICAID AND MEDICARE
Blue Cross do not coordinate with Medicaid
If the claimant has Medicare, Medicaid and Blue Cross, Medicare pays
first, Blue Cross pays and if there is a balance of Medicaid allowable
charges, Medicaid pays.
If the claimant has Medicare and Medicaid only, Medicare pays first and
Medicaid pays second.
APPEALS
Here are some basic steps for challenging Medicare coverage denials under Part A
(including hospitalization, nursing homes and hospice services) and Part B (doctor visits,
tests, home health care, durable medical equipment).
In most cases, it is not necessary to hire a lawyer. Advocates say to be sure to write your
Medicare or member number on all documents, and to keep copies.
You have to be committed and tenacious.
FIVE LEVELS OF APPEALS
Level 1: Redetermination by the company that handles claims for Medicare
Level 2: Reconsideration by a Qualified Independent Contractor (QIC)
Level 3: Hearing before an Administrative Law Judge (ALJ)
Level 4: Review by the Medicare Appeals Council (Appeals Council)
Level 5: Judicial review by a Federal District Court
FIRST APPEAL
For the first appeal, called redetermination:
• Make the request within 120 days of receiving the denial
• Any dollar amount can be appealed
• Circle the questionable item on your quarterly Medicare statement, called the
Medicare Summary Notice, and follow the mailing instructions on the form.You can
also complete an appeals form found here: www.medicare.gov/claims-andappeals/file-an-appeal/original-medicare/original-medicare-appeals.html
SECOND APPEAL
If you get denied again, you can make a request for second appeal, called reconsideration:
• Make the request within 180 days of receiving notice that the first appeal was denied.
• In a letter, explain the services or items that you received and why payment is in dispute.
• Include a copy of the initial denial or fill out the reconsideration form available at
www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/originalmedicare-appeals-level-2.html.
THIRD APPEAL
To request a hearing before an Administrative Law Judge , which usually is conducted
via conference call with patients, doctors and others:
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Make the request within 60 days of receiving the denial of the second appeal.
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To be eligible for a hearing, the amount in dispute must be at least $140.
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In your letter, provide your name, address, Medicare number, document control
number from previous denial, dates of services or items in dispute and why you are
appealing.
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Include any other information to support your request, or complete a hearing request
form available at www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level3.html.
FOURTH APPEAL
If you get denied again, you can make a request for consideration by the
Medicare Appeals Council:
• Make this request within 60 days of receiving the hearing decision.
• In a letter, cite which parts of the decision you dispute and the date of the
decision, or complete the hearing review request form available at
www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-4.html.
FIFTH AND FINAL APPEAL
Beneficiaries who are still not satisfied can file an appeal in Federal Court, but
the amount in dispute must be at least $1,350.
ANSWERS TO QUESTIONS
Question: My Medicare part B deductible for 2013 is $147. Is this
something BCBS covers? OR am I responsible for the $300 BCBS annual
deductible in addition to the Medicare Part B deductible?
Answer: You must first meet your $300 deductible with us before we will
consider any amounts for processing. For example, Medicare processes a
claim with the $147.00 of the total claim amount applying towards your
Medicare deductible.You have not met your BCBS deductible. However,
BCBS will apply that $147.00 as a CREDIT towards your BCBS deductible.
You will not be responsible for BCBS $300.00 deductible plus the $147.00
deductible from Medicare.Your responsibility would be your $147 which
would be payable to the provider who rendered the service.
Note:You will be responsible for paying the remainder $153 needed
towards the deductible with BCBS before BCBS plan would pay.
Question: What are the planned changes to the BOR/USG Health Benefit Plan
and the impact on retirees?
Answer: I am not aware of any. I posed the question to the system office and they
indicated they had nothing to share at this time that would have an impact on
retirees.
Question: Does Medicare cover Pap tests? If so, how often is the test covered?
Answer:Yes.
Once every 24 months for all women
Once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of
childbearing age and have had an abnormal Pap test in the past 36 months
Question: What are the procedures now covered by Medicare not covered by University
System Health Insurance (now BCBS)?
Answer:
Acupuncture (discounts provided through BCBSGa’s Special Offers Program)
Air-fluidized beds (discounts provided through BCBSGa’s Special Offers Program)
Bariatric surgery
Canes (discounts provided through BCBSGa’s Special Offers Program)
Cosmetic Surgery
Gym membership and fitness programs (discounts provided through BCBSGa’s
Special Offers Program)
Hearing Aids
Hospital Beds
Adult diapers (discounts provided through BCBSGa’s Special Offers Program)
Question: If Medicare denies a procedure or test, at present, when will
University System Health Insurance pick up coverage?
Answer: If Medicare does not cover the services and the services are covered by
Blue Cross, a denial EOB from Medicare must be submitted to Blue Cross to show
it is non-covered under the primary provider. At that point, Blue Cross would pay.
Question: In the future, if Medicare cuts kick in and coverage is denied for tests
and procedures now covered, does the University System plan to cover these tests
and procedures? Probably would require an increase in premium.
Answer: The intent of the USG plan is to cover the Medicare 20% coinsurance
once deductibles have been met. At this time there is not a plan to change the
structure and provide additional or different coverage.
Question: It is constant guesswork what they have covered following a
procedure? Is there a way a covered individual can electronically access
his or her records--hopefully, not just a telephone number?
Answer:Yes! “Blue Button” allows you to download your health data.
Here is the link to an online demonstration of registration:
https://mymedicare.gov/Help/VirtualTour/WBT_Register_V2.aspx
Another useful like with how to demos for several other functions:
https://mymedicare.gov/help/virtualtour.aspx#
Question: My physical therapist advised me that there was a federal bill in
motion--don't know if it is house or senate--to cover additional services,
including
a) therapeutic massages,
b) personalized gym training,
c) acupuncture and dry needle therapy.
What is the status of that bill?
Answer: We could not find evidence that it ever existed. The system office,
our Blue Cross Account Manager and a couple of researchers in the HR office
tried to help find it but could not.
Question: One healthcare provider I see is registered dietitian/nutritionist. She does
not accept insurance or Medicare, but will provide diagnosis code sheet. I filed her sheet
with BCBS and they paid 100%. Should I have also submitted to Medicare--if so, how,
since they don't seem to have a system of direct patient input?
Answer: Submit via the claim form, The Patient’s Request for Medical Payment
Found here:
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1490S-ENGLISH.pdf
Question: Medicare so far has proven to be a retirement penalty costing $209.80
per month. Having retired July 1, 2013, spouse and I are now paying $104.90
each per month for part B which we had never paid before. We had been under
BCBS high deductible family plan of $132/month and continue with that plan in
retirement. So far Medicare has paid $0. At this rate, it appears we will be out of
pocket rest of our lives $209.80 per month (plus any Medicare Part B
increases). Please provide numeric illustrations of what CMS/Medicare will
provide. We realize that BCBS will help with some of the drug/pharmacy since we
don't have Part D, but to get any other benefits from CMS/Medicare it appears we
may have to drop BCBS to get those. Are we over-insured and under-benefitting?
Medicare Covers…
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Abdominal aortic aneurysm screening
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Cardiac rehabilitation programs
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Dental services
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Acupuncture
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Depression screenings
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Air-fluidized beds
Cardiovascular disease (behavioral
therapy)
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Diabetes screenings
Alcohol misuse screening & counseling
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Cardiovascular disease screenings
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Diabetes self-management training
Ambulance services
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Cataract surgery
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Diabetes supplies & services
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Ambulatory surgical centers
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Cervical & vaginal cancer screenings
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Anesthesia
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Chemotherapy
Diagnostic tests, X-rays, and clinical
laboratory services
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Artificial eyes & limbs
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Chiropractic services
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Dialysis (children)
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Bariatric surgery
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Clinical research studies
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Dialysis (kidney) services & supplies
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Blood
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Colorectal cancer screenings
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Blood processing & handling
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Commode chairs
Doctor & other health care provider
services
Blood sugar (glucose) test strips
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Drugs
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Blood sugar monitors
Continuous passive motion (CPM)
machine
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Durable medical equipment (DME)
coverage
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Bone mass measurement (bone density)
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Braces (arm, leg, back, and neck)
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Breast prostheses
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Canes
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Cosmetic surgery
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Crutches
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Custodial care
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Defibrillator (implantable automatic)
Medicare Covers…
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Diabetes screenings
Diabetes self-management training
Diabetes supplies & services
Diagnostic tests, X-rays, and clinical
laboratory services
Dialysis (children)
Dialysis (kidney) services & supplies
Doctor & other health care provider
services
Drugs
Durable medical equipment (DME)
coverage
EKG (electrocardiogram) screening
Emergency department services
Enteral nutrition supplies & equipment
(feeding pump)
Eye exams
Eyeglasses/contact lenses
Flu shots
Foot care
Foot exam
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Glaucoma tests
Glucose control solutions
Gym membership & fitness programs
Health education & wellness programs
Hearing and balance exams & hearing
aids
Hepatitis B shots
HIV screening
Home health services
Home oxygen equipment & supplies
Hospice & respite care
Hospital beds
Hospital care (outpatient)
Humidifiers
Incontinence supplies & adult diapers
Infusion pumps
Inpatient hospital care
Insulin
Kidney disease education
Kidney transplants (adults)
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Kidney transplants (children)
Laboratory services (clinical)
Lancet devices & lancets
Long-term care hospitals
Macular degeneration
Mammograms
Massage therapy
Mental health care (inpatient)
Mental health care (outpatient)
Mental health care (partial
hospitalization)
Nebulizers & nebulizer medications
Nursing home care
Nutrition therapy services (medical)
Obesity screening & counseling
Medicare Covers…
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Orthotics & artificial limbs
Osteoporosis drugs for women
Ostomy supplies
Outpatient hospital services
Oxygen therapy
Pancreas transplants (adults)
Patient lifts
Physical therapy/occupational
therapy/speech-language
pathology services
Pneumococcal shots
Prescription drugs (outpatient)
Preventive & screening services
Preventive visit & yearly wellness
exams
Prostate cancer screenings
Prosthetic devices
Pulmonary rehabilitation program
Radiation therapy
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Religious non-medical health care 
institution (RNHCI)
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Rural health clinic & federally
qualified health center services
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Second surgical opinions
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Sexually transmitted infections
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(STI) screening & counseling
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Shingles shot
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Shots (vaccinations)
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Skilled nursing facility (SNF) care
Sleep apnea & Continuous Positive 
Airway Pressure (CPAP) therapy
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Sleep study
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Smoking & tobacco use cessation
(counseling to stop smoking or
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using tobacco products)
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Substance-related disorders
Suction pumps
Supplies (you use at home)
Surgery (estimating costs)
Surgical dressing services
Tdap shot (tetanus, diphtheria, &
pertussis shot)
Telehealth
Therapeutic shoes or inserts
Traction equipment
Transplants (adults)
Transportation
Travel (when you need health care
outside the U.S.)
Urgently needed care
Walkers
Wheelchairs & power mobility
devices
X-rays
Yearly eye exam
New Questions?