Archive for the ‘Medicare News’ Category

Medicare home health care is a service Medicare provides to homebound patients who need intermittent skilled nursing care or therapy services. It includes skilled nursing care, physical therapy, speech-language pathology, occupational therapy, and home health aide services. To be eligible for Medicare home health care, patients must meet specific criteria, including seeing a physician or authorized health care provider, being homebound, and needing intermittent skilled nursing care or therapy services. The care must be provided by or under arrangements with a Medicare-certified provider.

Medicare can cover home health care if it meets the following criteria:

  1. The patient must see a physician or authorized health care provider. The physician/provider must write a brief narrative describing the patient’s clinical condition and how the patient’s condition supports homebound status and the need for skilled home health services.
  2. A physician/authorized provider has signed or will sign a plan of care.
  3. The patient is homebound. This standard is met if leaving home requires a considerable and taxing effort, which may be shown by the patient needing personal assistance, or the help of a wheelchair crutches, or other supportive device. Occasional but infrequent “walks around the block” and outings are allowable. Attending an adult day center or religious services is not an automatic bar to meeting the homebound requirement.
  4. The patient needs skilled nursing care intermittently (at least once every 60 days) or physical or speech-language pathology. (Occupational therapy can continue Medicare home health care but not begin coverage.)
  5. The care must be provided by or under arrangements with, a Medicare-certified provider.

Robocall scams can often seem random, but that’s not always true. Sometimes, robocalls targeted to older Americans whose Medicare eligibility opens the door to health insurance fraud.

It is essential to know that Medicare does not call you uninvited and ask you for personal or private information. Medicare usually sends a written statement in the mail before you get a phone call from a government agency. Medicare advises that calls you receive requesting health insurance information should not be trusted.

Here are some additional tips from Medicare.gov to help you avoid scammers. 

  • Never give your Medicare card, Medicare Number, Social Security card, or Social Security Number to anyone except your doctor or people you know who should have it (like insurers acting on your behalf or people who work with Medicare, like your State Health Insurance Assistance Program (SHIP). Get the contact information for your local SHIP.
  • Do NOT accept offers of money or gifts for free medical care.
  • Don’t allow anyone, except your doctor or other Medicare providers, to review your medical records or recommend services.
  • Never Join a Medicare health or drug plan over the phone unless YOU called Medicare.
  • If someone asks you for your information or money or threatens to cancel your health benefits if you don’t share your details, hang up and call 1-800-MEDICARE (1-800-633-4227) or visit medicare.gov.

Additional Tips for Avoiding Scammers 

  • Don’t answer calls from unknown numbers.
  • If you answer and the caller isn’t who you expected, hang up immediately.
  • Never give out personal information such as account numbers, Social Security numbers, mother’s maiden name, passwords, or any other self-identifying response to an unexpected call.
  • Use caution if you are being pressured for information immediately.
  • If a caller claims to represent a health insurance provider or a government agency, hang up. You can then call back using a phone number on an account statement, phone book, or official website to verify the caller’s authenticity.

Don’t be a victim of scammers. Keep these tips in mind, as scammers can be persuasive. 

Ten companies manufacturing some of the costliest prescription drugs to participate in first-ever direct negotiations with Medicare. The Biden-Harris Administration announced that all ten drug companies whose drugs were selected for price negotiation with Medicare for the first cycle of the program have decided to participate in those negotiations. These companies manufacture some of the costliest and most commonly used prescription drugs.

These selected drugs accounted for $50.5 billion in total Part D gross covered prescription drug costs, or about 20% of total Part D gross covered prescription drug costs between June 1, 2022, and May 31, 2023, which is the period used to determine which drugs were eligible for negotiation. Medicare enrollees taking the ten drugs covered under Part D selected for negotiation paid $3.4 billion in out-of-pocket costs in 2022 for these drugs.

The ten companies participating in the Medicare Drug Price Negotiation Program Drug NameParticipating Manufacturer:

Eliquis/Bristol Myers Squibb
Jardiance/Boehringer Ingelheim
Xarelto/Janssen Pharms
Januvia/Merck Sharp Dohme
Farxiga/AstraZeneca AB
Entresto/Novartis Pharms Corp
Enbrel/Immunex Corporation
Imbruvica/Pharmacyclics LLC
Stelara/Janssen Biotech, Inc.
Fiasp; Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill/Novo Nordisk Inc.

The landmark Inflation Reduction Act allowed Medicare to negotiate prescription drug prices for the first time. In late August, the U.S. Department of Health and Human Services (HHS) announced the ten drugs covered under Medicare Part D selected for the first negotiation cycle. Drug companies that manufacture these drugs have indicated that they will participate in talks with Medicare during the remainder of 2023 and 2024, and any agreed-upon negotiated prices will become effective beginning in 2026.

When shopping for an HMO dental insurance plan or a dental discount plan, you must ensure they have an in-network provider (dentist) you wish to visit. However, continue beyond one dental provider in a plan. You want to ensure that the dental insurance or plan has at least two to three dental providers that would work for you. You want to ensure that you have more than one provider so you can change dental providers or get a second dental opinion when needed.

Both dental HMO and dental discount plans require you to pick a plan provider or go to plan providers. There are no benefits or savings when going to a dental provider not an in-network dentist on the plan.

When selecting a dental provider from a plan, there are a few things to consider:

  1. Location: Choose a dentist that is convenient for you to visit. The closer the dental provider is to your home or workplace, the easier it will be to keep your dental appointments.
  2. Reputation: Look for online reviews and ratings of the dental provider. You want to choose a dentist with a good reputation for quality dental care.
  3. Services: Verify that the dental provider offers the services you need. For example, if you need orthodontic treatment, ensure the dentist is an orthodontic specialist.
  4. Availability: Check the dental provider’s availability, including their hours of operation and appointment availability. You want to choose a dentist that can accommodate your schedule.
  5. Cost: Find out your out-of-pocket costs for services, such as copays and deductibles. Make sure that the dental provider is affordable and fits within your budget.

Considering these factors, you can choose a dental provider from your plan that meets your needs and helps you maintain good oral health.

Medicare Advantage is a program that offers an alternative way to receive your Medicare benefits. Under this program, you can choose from a few dental services companies. It is essential to review your options carefully and compare them to buying a separate dental insurance plan.

When reviewing your options, take the time to review each plan’s benefits for dental services. The coverage can be limited, and you want to ensure you know and understand the coverage available for dental care. Some Medicare Advantage plans may cover preventive care such as cleanings, X-rays, and exams but may not cover other procedures such as root canals or crowns.

After reviewing what is available for dental care, compare what they offer against buying a separate dental insurance plan. You may pay more for your dental insurance plan, but finding coverage and cost savings are better and save you money on your dental care needs. A separate dental insurance plan can offer more comprehensive coverage and help you save money on costly dental procedures.

In conclusion, it’s essential to review your options carefully when it comes to dental care. Whether you choose to enroll in a Medicare Advantage plan offering dental services or buy a separate dental insurance plan, it’s essential to ensure you have the coverage you need to maintain good oral health and avoid costly procedures.

In most cases, Medicare does not cover dental services like routine cleanings, fillings, tooth extractions, or items like dentures. In addition, Medicare Advantage may not provide enough coverage when you need it.

Some Dental Services Medicare May Cover:

  • Certain dental services you get when you’re admitted as a hospital inpatient for your dental procedure, either because of your underlying medical condition or the severity of the procedure. 
  • Specific inpatient or outpatient dental services directly related to certain covered medical treatments. In these cases, you must get the dental service because it’s linked to the success of the medical treatment you need, like:
    • An oral exam and dental treatment before you get a heart valve replacement or a bone marrow, organ, or kidney transplant. 
    • A procedure (like a tooth extraction) to treat a mouth infection before you get cancer treatment services like chemotherapy.
    • Treatment for a complication you experience while getting head and neck cancer treatment services.

Regarding your primary and overall dental care needs, consider shopping for a dental insurance plan that better fits your dental needs. Having good dental healthcare helps maintain good overall health. You can contact our member service line at 310-534-3444, where our team of experts will help you understand each plan’s different options and benefits. They will guide you in selecting the best plan to provide your family with the necessary coverage at a price that fits your budget.

As a person with diabetes, it’s essential to keep an eye on your eye health. High blood sugar levels can damage the tiny blood vessels in the retina, leading to diabetic retinopathy. This condition can cause vision loss or even blindness if left untreated. Therefore, regular eye exams are crucial to catch any issues early on and prevent further damage. So, it’s highly recommended to have more frequent eye exams if you have diabetes.

Medicare Part B (Medical Insurance) covers annual eye exams for diabetic retinopathy if you have diabetes. The exam must be conducted by an eye doctor legally authorized to perform the test in your state.

It is important to note that your healthcare provider may suggest that you receive services more frequently than what Medicare covers. Additionally, they may recommend services that are not covered by Medicare, which means you may have to pay some or all of the costs. To better understand why your doctor recommends certain services, you should ask questions and determine how much Medicare will pay for them.

If you are a Medicare beneficiary, it is important to know that Medicare does not cover routine eye exams for eyeglasses or contact lenses. However, some Medicare Advantage Plans may offer additional benefits that Original Medicare does not cover, such as vision, hearing, or dental services. If you are interested in these plans, you should contact the plan provider for more information on their benefits.

Alternatively, consider purchasing a separate vision insurance plan, such as VSP Vision. With VSP Vision, you can enjoy a routine eye exam for just $15.00 co-pay. Moreover, the plan offers benefits for frames with prescription lenses or contacts and extra savings on glasses/sunglasses. What’s more, the plan has no waiting periods for services and a broad range of providers in their network. Call our member services at 310-534-3444 M-F, 8 am-4 pm, if you have questions about the VSP vision insurance we offer.

So, if you need vision care services, you have several options. Whether you prefer a Medicare Advantage Plan or a separate vision insurance plan, it is essential to research and choose a plan that meets your specific needs and budget.

In short, Medicare does not cover routine eye exams for eyeglasses or contact lenses. Medicare also does not cover the cost of glasses or contacts unless you’ve just had cataract surgery.

However, our office offers a vision insurance plan by VSP that provides benefits for eye exams and eyeglasses or contact lenses. VSP Vision Insurance is a comprehensive insurance plan that provides benefits for eye exams, eyeglasses, and contact lenses. The plan covers eye exams with a low copay and includes eyeglasses or contact lenses allowances. VSP has an extensive network of eye doctors and retailers, so finding a provider or a retail location for eyewear is easy. Additionally, VSP offers additional savings on lens enhancements and other vision-related needs. VSP Vision insurance could be an excellent option for those who want to maintain their eye health and save money on vision-related expenses.

I live in California and am looking for dental insurance. What are some excellent dental insurance companies to get dental insurance with?

Answer: There are several excellent dental insurance companies to consider, depending on your needs and budget. Some of the top dental insurance providers are Delta Dental, Cigna, Humana, MetLife, and UnitedHealthcare. Each of these companies offers a range of plans with varying coverage levels and premiums, so it’s important to compare their options to find the best fit for you. You can research their plans and benefits online or speak with a representative to learn more about their offerings. If you have any questions about our dental insurance plan options, please call our member services line at 310-534-3444

We offer over 30 dental insurance plans from several different insurance companies. Out of our dental insurance plan options, more than half are dental PPO insurance plans. We are giving you a broad range to review and choose from. Our member services at 310-534-3444 are here to help you if you have any questions about our dental insurance plan options. We strive to offer as many dental insurance options as possible so that you can pick the best dental insurance that fits your and your family’s dental care needs.

Medicare is a government-funded health insurance program for people over 65 with specific disabilities or end-stage renal disease. It is divided into parts – A, B, C, and D – each covering different aspects of healthcare services. While Medicare Part A covers hospital insurance, Part B covers medical insurance, which includes doctor visits, outpatient care, and some preventive services. However, it’s important to note that Medicare Part B does not cover some services.

Some of the services not covered by Medicare Part B include:

  • Drug coverage is covered by Medicare Part D. 
  • Hearing aids, 
  • Dental and vision services are not covered by Medicare Part B, but rather by Medicare Part C or Medicare Advantage plans. 
  • Additionally, Medicare Part B does not cover long-term care.

Medicare Advantage plans, as mentioned earlier, bundle Parts A, B, and D and often include additional dental, eye, and hearing services and fitness programs. If you’re looking for more comprehensive coverage than what Medicare Part B offers, you may want to consider a Medicare Advantage plan.

Question: What is affordable dental insurance? 

Dental insurance is a type of insurance coverage that helps to cover the cost of dental services. It’s an essential component of overall health coverage, as good oral health is critical for overall health and well-being. Affordable dental insurance in California is a popular topic of discussion for many people. Affordability depends on the person. If you are looking for a lower-cost dental insurance option, start your search for dental insurance by reviewing dental HMO insurance plan options. HMO dental insurance plans are usually more affordable than PPO and Indemnity dental insurance plans. 

Remember that with HMO dental insurance, you will need to choose a dental office that is a part of the plan network of providers, and unlike a PPO plan, there are no plan benefits if you go to a dentist who is not a provider of the plan.

Question: Costco sells a Delta Dental plan, Delta Care, but you have to be a member of Costco, which I am not. I know about it because my friend told me. Can I get this plan or one like it for myself? 

Answer: We offer Delta Care HMO plans for individuals to buy directly. I can’t say it is the same as Costco’s offering, but it is an HMO dental insurance plan offered through Delta Dental. Call our member services at 310-534-3444. We will gladly assist you with these options if you have questions about our dental insurance plans.

Medicare Part B provides coverage for many routine and preventative services – some of which may be surprising, like bariatric surgery. However, strict medical criteria must be met before being approved for gastric bypass surgery and laparoscopic banding surgery.

Check out the numerous services covered through Medicare Part B:

Medical services covered:

  • Acupuncture.
  • Advance care planning, such as advance directives.
  • Ambulance services.
  • Ambulatory surgical centers.
  • Behavioral health integration services (like depression, anxiety, or other mental health conditions).
  • Chemotherapy.
  • Chiropractic services.
  • Chronic care management services (if you have two or more serious, chronic conditions).
  • Clinical research studies.
  • Cognitive assessment and care plan services.
  • CPAP devices and therapy.
  • COVID-19 vaccines.
  • Defibrillators.
  • Diabetes equipment, supplies, and therapeutic shoes.
  • Durable medical equipment like hospital beds, oxygen, walkers, wheelchairs, etc.
  • Electrocardiogram (EKG) screenings.
  • Emergency department services.
  • E-visits allow you to talk to your doctor virtually.
  • Eyeglasses (if you have cataract surgery).
  • Foot care.
  • Hearing and balance exams.
  • Home health services.
  • Home infusion therapy and supplies.
  • Kidney dialysis and supplies.
  • Kidney disease education.
  • Laboratory tests.
  • Mental health outpatient care.
  • Nutrition therapy services.
  • Occupational therapy.
  • Opioid use treatment services.
  • Oral anti-cancer drugs.
  • Outpatient hospital services.
  • Outpatient medical and surgical services.
  • Outpatient rehabilitation services.
  • Physician’s services – primary care and specialty.
  • Physical therapy services.
  • Prostate cancer screenings.
  • Prosthetic-orthotic items.
  • Pulmonary rehabilitation programs.
  • Rural health clinic services.
  • Second surgical opinions.
  • Telehealth.
  • Transplants and immunosuppressive drugs.
  • Travel care: There are certain exceptions when traveling outside the US.
  • Virtual check-ins.
  • Annual wellness checks.

Tooth decay is a common dental problem that affects people of all ages. However, children are more susceptible to it, and as the study done by Delta Dental suggests, a significant number of children are at a higher risk of tooth decay. According to a study done by Delta Dental, a third of children ages 6-18 are at higher risk for tooth decay, and of those children. 

* More than 70 percent are not receiving two fluoride treatments a year

* More than 60 percent of ages 6-9 did not receive sealants on their first molars

* More than 80 percent of ages 11-15 did not receive sealants on their second molars

While having dental insurance can help save money on dental care expenses, it is equally important to use it effectively. Many people with dental insurance do not understand their plan’s benefits and miss out on treatments that could prevent future dental problems. 

You should review your dental insurance plan’s coverage, including preventive care services like fluoride treatments and dental sealants, which can significantly reduce the risk of tooth decay. By taking advantage of your dental insurance benefits, you can help ensure that you and your family receive the proper dental care you need to maintain a healthy smile.

Question: I have health insurance through my employer, and although it offers dental benefits, it is limited in coverage of dental care services. Can I buy another individual dental plan and use that instead? 

Answer: If you have health insurance through your employer that includes dental benefits but is limited in coverage for dental care services, consider purchasing an individual dental plan. You also may be able to coordinate benefits. It will depend on what you have currently and if you are going to a dentist who will coordinate dual plans. It is, however, worth asking about at your dental office. 

If you are considering purchasing an individual dental plan, it is essential to review your options carefully. We currently offer 46 different dental insurance and plan options for your review. Our member services at 310-534-3444 will gladly assist you with these options if you have any questions about our dental insurance plans.

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