Lois Cornillaud was in her mid eighties and living in her own apartment in Clearwater, Fla., when her daughter, Barbara Kennedy, noticed that she was having trouble keeping track of her bills—double-paying some and not paying others. And she was getting a constant stream of medical bills and notices from Medicare. The paperwork was confusing, but Kennedy (then in her early sixties) was determined to figure it out. Besides wanting to help her mother, "I thought I'd be on Medicare soon, so I should understand this," says Kennedy, now 69.
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Kennedy became a student of Medicare, reading the Medicare & You handbook, scouring her mother's Medicare summary of benefits notices for unexpected charges and acting as her mother's advocate, sometimes with the help of the local Area Agency on Aging. For instance, after a hospital sent her mom a $1,700 bill for speech therapy she never had, Kennedy asked for an itemized bill. "The hospital dropped the charge, and I never heard about it again," she says. She also fought a miscoded ambulance bill, an unexpected rehabilitation charge and a $250 bill for an eye procedure the doctor had told her would be covered.
Now that Cornillaud is 92 and in a long-term-care facility, Kennedy has to monitor her care as well as her medical bills. After studying the Medicare system for almost a decade, "I'm more comfortable with it," she says.
Like Kennedy, you may find yourself getting a crash course in Medicare on your parents' behalf long before you qualify for benefits yourself. The paperwork can be overwhelming, especially if your parents have a lot of medical issues. You may also encounter a range of claims problems—from small billing or coding errors that can be fixed with a quick phone call to large charges that need to be appealed to an administrative law judge.
Here's how to help your parents' claims go smoothly and make sure they get all the coverage they deserve.
Know how it works
Most people 65 and over are covered by traditional Medicare. Medicare Part A (which has no premium) covers hospitalization, and Medicare Part B (typically $104.90 a month) covers doctors' visits and outpatient expenses. Together, parts A and B pay the bulk of seniors' medical expenses. Each part exacts co-payments and deductibles.
Traditional Medicare allows patients to use any doctor who accepts Medicare payments, but it can sometimes be difficult to find those doctors, especially in the case of psychiatrists and some specialists. You can search for doctors near your parent who accept Medicare assignment by going to www.medicare.gov and clicking on "Find doctors & other health professionals."
Many seniors buy a standardized Medicare supplement plan (sometimes called medigap) to pick up out-of-pocket expenses. These supplemental plans automatically fill in gaps in coverage, so claims problems are few. "Under federal law, the plans have to pay. There's no dispute about that," says Bonnie Burns, of California Health Advocates, who worked with the government to standardize medigap plans in the early '90s.
Medicare doesn't provide prescription-drug coverage. For that, most people buy a separate Medicare Part D plan, offered by private insurers. Seniors who have retiree health insurance can use it to fill the gaps in medical and drug coverage rather than buy a supplemental plan and Part D.
About one-fourth of seniors are enrolled in Medicare Advantage plans, which cover both medical and drug costs. These plans, provided by private insurers, follow the framework of traditional Medicare. Unlike traditional Medicare, however, patients are generally limited to a network of doctors and hospitals. Medicare Advantage premiums tend to be lower than the total premiums for Medicare plus medigap and Part D coverage, but you usually pay more in out-of-pocket costs than with Medicare, medigap and Part D combined. Confusion about network requirements can cause complications with claims you wouldn't have with traditional Medicare.
Pick the right plan. One way to help your parents avoid Medicare problems is to pick the right Part D or Medicare Advantage plan for their needs. You can help them do that during open enrollment, from October 15 to December 7 every year.
If your parents take expensive medications, for instance, be sure the plan continues to cover their drugs in the new plan year. Get a list of your parents' medications, and go to the Medicare.gov/find-a-plan tool to estimate the out-of-pocket costs for their drugs under each plan available in their area. "For a cancer patient who tends to take more-expensive drugs, this issue is very important," says Kirsten Sloan, of the American Cancer Society.
Two recent trends among Part D and Medicare Advantage plans are to shift drugs to more-expensive pricing tiers and make patients jump through hoops before some medications will be covered—for example, by requiring step therapy (which means they generally must try cheaper drugs first) or preauthorization (which means their doctor must prove their need for that drug). And many plans are switching from fixed-dollar co-payments to coinsurance, which is based on a percentage of the drug's cost. If a parent takes expensive cancer-treatment drugs, for example, the out-of-pocket costs could rise significantly.
If your parents have a Medicare Advantage plan, also make sure their key doctors, such as their primary-care doctor and, say, their oncologist, will be in the plan's network next year, says Sloan. "Don't assume that they stay from year to year," she says. Ask the plan about specific providers, and look carefully at the Annual Notice of Change, which Part D and Medicare Advantage plans must send to participants in September. The notice alerts them to plan changes for the following year, says Frederic Riccardi, director of client services for the Medicare Rights Center.