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OLR Research Report


November 3, 2009

 

2009-R-0380

MEDICARE COVERAGE

By: Janet L. Kaminski Leduc, Senior Legislative Attorney

You asked for a detailed description of what Medicare covers and a comparison of Medicare coverage and recently proposed and enacted state health insurance benefit mandates.

SUMMARY

The tables that follow outline what benefits and services Medicare does and does not cover (Tables 1 to 4). Medicare typically pays the Medicare-approved amount for covered services, subject to copayment, deductible, or coinsurance. In 2009, the Part A hospital stay deductible is $1,068 and the Part B medical coverage annual deductible is $135.

The Medicare-approved amount is the amount a doctor or supplier that accepts Medicare “assignment” can be paid. It is the lower of the actual charge for the item or the fee that Medicare sets. It includes what Medicare pays and any copayment, deductible, or coinsurance that the patient pays. “Assignment” is a doctor's or supplier's agreement to accept the Medicare-approved amount as payment in full for the services rendered. Generally, a physician who does not accept assignment may not charge more than 115% of the Medicare-approved amount.

In Table 5 we compare certain recently proposed or enacted state health insurance benefit mandates (e.g., bone marrow testing, epidermolysis bullosa, lymphedema, ostomy supplies, prescription eye drop refills, prosthetic devices, and wigs) with Medicare coverage.

Table 1: Medicare Part A – Hospital Services Covered

Service

Coverage Description

Blood

If a hospital has to buy blood for a person, the person must pay for the first three pints of blood in a calendar year or have the blood donated. Often a hospital gets blood from a blood bank at no charge, in which case a person does not have to pay for it.

Home health care

Covered for a person who is homebound, which means leaving home takes a lot of effort. Coverage is limited to medically-necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology, or a continuing need for occupational therapy. Care must be ordered by a doctor and provided by a Medicare-certified home health agency. Services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment (DME), and medical supplies for use at home. Part A covers the cost of the first 100 home health visits following a hospital stay. There is no charge for home health care services, but see below for costs related to DME.

Hospice care

Covered for people with a terminal illness who are expected to live six months or less, as certified by a doctor. Coverage may include drugs for pain relief and symptom management, medical, nursing, social services, and other covered services as well as services not usually covered by Medicare (like grief counseling). Hospice care is usually given in the home (or other facility like a nursing home) by a Medicare-approved hospice. Medicare covers some short-term inpatient stays (for pain and symptom management that requires an inpatient stay) in a Medicare-approved facility, such as a hospice facility, hospital, or skilled nursing facility. Medicare also covers inpatient respite care (care given to a hospice patient so that the usual caregiver can rest) in a Medicare-approved facility up to five days for period of respite care. Medicare may pay for covered services for health problems that are not related to your terminal illness. A person can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that he or she is terminally ill. There is no charge for hospice services, but a person pays 5% of the Medicare-approved amount for inpatient respite care.

Hospital (inpatient)

Coverage includes semi-private room, meals, general nursing, drugs as part of inpatient treatment, and other hospital services and supplies. Examples include inpatient care in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care. Coverage does not include private-duty nursing, a television or telephone in the room, or personal care items like razors or slipper socks. It also does not include a private room, unless medically necessary. The doctor services received in a hospital are covered under Part B. A person pays $1,068 deductible and no coinsurance for days 1–60 each benefit period, $267 per day for days 61–90 each benefit period, $534 per “lifetime reserve day” after day 90 each benefit period (up to 60 days over your lifetime), and all costs for each day after the lifetime reserve days. Inpatient mental health care in a psychiatric hospital limited to 190 days in a lifetime.

Skilled nursing facility

Coverage includes semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a three-day minimum inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. To get care in a skilled nursing facility, the patient's doctor must certify that the patient needs daily skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care in this setting. A person pays $0 for the first 20 days each benefit period, $133.50 per day for days 21–100 each benefit period, and all costs for each day after day 100 in a benefit period.

Table 2: Medicare Part B – Preventive Services Covered

Service

Coverage Description

Abdominal aortic aneurysm screening

A one-time screening ultrasound for an at-risk person who is referred for it as a result of his or her “Welcome to Medicare” physical. The person pays 20% of the Medicare-approved amount.

Bone mass measurement (bone density)

Covered once every 24 months (more often if medically necessary) for a person with certain medical conditions or who meets certain criteria. The person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Cardiovascular screening

Covered every five years to test cholesterol, lipid, and triglyceride levels. No charge for the test, but the person generally has to pay 20% of the Medicare-approved amount for the doctor's visit.

Colorectal cancer screenings

One or more of the following tests may be covered:

Fecal Occult Blood Test—Once every 12 months if age 50 or older. No cost for the test, but a person generally has to pay 20% of the Medicare-approved amount for the doctor's visit.

Flexible Sigmoidoscopy—Generally, once every 48 months if age 50 or older, or for those not at high risk, 120 months after a previous screening colonoscopy. A person pays 20% of the Medicare-approved amount.

Colonoscopy—Generally once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. There is no minimum age. A person pays 20% of the Medicare-approved amount.

Barium Enema—Once every 48 months if age 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. A person pays 20% of the Medicare-approved amount.

Note: If a person has a flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, he or she pays 25% of the Medicare-approved amount.

Diabetes screening

Covered for a person with any of the following risk factors:

(1) high blood pressure (hypertension),

(2) history of abnormal cholesterol and triglyceride levels (dyslipidemia),

(3) obesity, or

(4) a history of high blood sugar (glucose).

Tests also covered if a person can answer “yes” to two or more of these questions:

 

(1) Are you age 65 or older?

(2) Are you overweight?

(3) Do you have a family history of diabetes?

(4) Do you have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than nine pounds?

Based on the results, a person may be eligible for up to two diabetes screenings every year. There is no charge for the test, but a person generally has to pay 20% of the Medicare-approved amount for the doctor's visit.

Diabetes self-management training

Covered for a person with diabetes with a health care provider's written training order. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Flu shots

Covered once a flu season in the fall or winter. There is no charge for the shot if the health care provider accepts Medicare assignment (which allows Medicare to pay the doctor directly).

Table 2: -Continued-

Glaucoma tests

Covered once every 12 months for a person at high risk for glaucoma, i.e., a person who (1) has diabetes, (2) has a family history of glaucoma, (3) is African-American and age 50 or older, or (4) is Hispanic and age 65 or older. Tests must be performed by an eye doctor who is legally authorized by the state. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Hepatitis B shot

Covered for people at high or medium risk for Hepatitis B. Risk increases if a person has hemophilia, end-state renal disease, or a condition that lowers resistance to infection, among other possible risk factors. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Mammograms

Screening mammograms are covered once every 12 months for a woman age 40 or older. One baseline mammogram is covered for a woman between age 35 and 39. A person pays 20% of the Medicare-approved amount.

Medical nutrition therapy services

Covered for a person with diabetes or kidney disease if referred for it by his or her doctor. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Pap test/pelvic exam (cancer screening)

Covers screening tests for cervical, vaginal, and breast cancers once every 24 months for a woman, but covers them once every 12 months for a woman at high risk and a woman of child-bearing age who had an exam that indicated cancer or other abnormalities in the past three years. There is no charge for the pap lab test, but a person pays 20% of the Medicare-approved amount for the pap test collection and pelvic and breast exams.

Physical exam (one “Welcome to Medicare” exam only)

Covers a one-time review of a person's health and education and counseling about preventive services, including certain screenings, shots, and referrals for other care is needed. Medicare covers the exam if a person gets it within 12 months of having Part B coverage. A person pays 20% of the Medicare-approved amount.

Pneumococcal shot

To prevent pneumococcal infections (e.g., certain types of pneumonia). Most people only need one shot in a lifetime. There is no charge for the shot if the health care provider accepts Medicare assignment.

Prostate cancer screening

Covers a digital rectal exam and prostate specific antigen (PSA) test once every 12 months for a man over age 50. There is no charge for the PSA test. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Smoking cessation counseling

Covers up to eight face-to-face visits in a 12 month period for a person (1) diagnosed an illness caused or complicated by tobacco use or (2) taking medicine that is affected by tobacco. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Table 3: Medicare Part B – Medical Services Covered

Service

Coverage Description

Ambulance services

Covers emergency ground transportation needed to transport a person to a hospital or skilled nursing facility for medically-necessary services and transportation in another vehicle could endanger the person's health. Covers airplane or helicopter transportation if a person requires immediate and rapid transport that ground transportation cannot provide.

Medicare may cover limited non-emergency transportation if a person has orders from a doctor. Only covers services to the nearest appropriate medical facility able to give a person the care needed. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Ambulatory surgical centers

Covers facility fees for approved surgical procedures provided in an ambulatory surgical center (where procedures are performed and the patient is released on the same day). A person pays 20% of the Medicare-approved amount (25% for flexible sigmoidoscopies and screening colonoscopies), and the Part B deductible applies. A person must pay all facility charges Medicare does not allow in ambulatory surgical centers.

Blood

If a health care provider has to buy blood for a person, the person must pay for the first three pints of blood in a calendar year or have the blood donated. Often a provider gets blood from a blood bank at no charge, in which case a person does not have to pay for it. A person pays 20% of the Medicare-approved amount for additional pints of blood a person receives as an outpatient, and the Part B deductible applies.

Chiropractic services (limited)

Covers services to correct a subluxation (when one or more bones of the spine move out of position) using spinal manipulation. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Clinical research study costs

Covers some costs, like doctor visits and tests, in qualifying clinical research studies. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Defibrillator (implantable automatic)

Covered for some people diagnosed with heart failure. A person pays 20% of the Medicare-approved amount, but no more than the Part A hospital stay deductible if he or she is a hospital outpatient, and the Part B deductible applies.

Diabetes Supplies

Covers blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes (in some cases). Covers insulin only if used with an insulin pump. (Insulin and certain medical supplies, such as syringes, may be covered by Medicare Part D (prescription drug coverage). A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Diagnostic tests and clinical laboratory services

Covers x-rays, MRIs, CT scans, EKGs, and some other diagnostic tests. If received as a hospital outpatient, a person pays a specified copayment, but no more than the part A hospital stay deductible.

Covers clinical laboratory tests, including certain blood tests, urinalysis, and some screening tests. There is no charge for clinical laboratory tests.

Dialysis services and supplies

Covers dialysis for people with End Stage Renal Disease either in a facility or at home when a doctor orders it. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Doctor services

Covers services that are medically necessary (includes outpatient and some inpatient doctor services) or covered preventive services. Excludes routine physicals, except for the one-time “Welcome to Medicare” exam. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Table 3:- Continued-

Durable medical equipment (DME)

Covers:

Air fluidized beds

Blood glucose monitors

Bone growth stimulators*

Canes (except white canes for the blind)

Commode chairs

Crutches

Home oxygen equipment and supplies*

Hospital beds for use in the home when a doctor orders it

Infusion pumps and some related medicines

Lymphedema pumps and pneumatic compression devices*

Nebulizers and some related medicines (if reasonable and necessary)

Patient lifts*

Scooters

Suction pumps

Traction equipment

Transcutaneous electronic nerve stimulators*

Ventilators or respiratory assist devices

Walkers

Wheelchairs (manual and power)

* Certificate of medical necessity is required for this equipment.

A person generally pays 20% of the Medicare-approved amount, and the Part B deductible applies. But the amount a person pays may vary because Medicare pays for different kinds of DME in different ways. A person also may have to rent or buy DME. A person must obtain covered DME from a supplier enrolled in Medicare.

Emergency room services

A person pays a specified copayment for the hospital emergency room visit, 20% of the Medicare-approved amount for the doctor's services, and the part B deductible applies.

Eye exams (limited)

Covered for people with diabetes to check for diabetic retinopathy once every 12 months. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Eyeglasses (limited)

Covers one pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery with intraocular lens implant. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Federally-qualified health center (FQHC) services

FQHCs provide a broad range of outpatient primary care and preventive services. A person pays 20% of the Medicare-approved amount.

Foot care and podiatrist services (limited)

Covered for people with diabetes-related nerve damage or who meet certain conditions. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Hearing and balance exams

Covered if a doctor orders it. (Hearing aids and exams to fit hearing aids are not covered.) A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Home health services

Covered for a person who is homebound, which means leaving home takes a lot of effort. Coverage is limited to medically-necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology, or a continuing need for occupational therapy. Care must be ordered by a doctor and provided by a Medicare-certified home health agency. Services may also include medical social services, part-time or intermittent home health aide services, DME, and medical supplies for use at home. There is no cost for home health services, but see above for costs related to DME.

Table 3:- Continued-

Hospital (outpatient)

A person pays a specified copayment for each outpatient service received as part of doctor's care, but no more than the Part A hospital stay deductible, and the Part B deductible applies.

Medical and surgical services and supplies (outpatient)

Covers approved procedures (e.g., x-rays, cast, stitches). A person pays a copayment for each service received in an outpatient setting, but no more than the Part A hospital stay deductible, and the Part B deductible applies.

Mental health and substance abuse care

Covers services generally given outside a hospital or in a hospital outpatient department, including lab tests and visits with a doctor, psychiatrist, clinical psychologist, or clinical social worker. Certain limits and conditions apply.

For a health care provider to diagnose a person or monitor prescriptions, a person pays 20% of the Medicare-approved amount. For outpatient treatment of a mental health treatment (including therapy), a person pays 50% of the Medicare-approved amount. The Part B deductible applies.

Occupational therapy

Covers evaluation and treatment to return a person to his or her usual activities (e.g., dressing, bathing) after an illness or accident when a doctor certifies the person needs it. Beginning in 2009 “there may be limits” on these services. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Physical therapy

Covers evaluation and treatment for injuries and diseases that change a person's ability to function when a doctor certifies the person needs it. Beginning in 2009 “there may be limits” on these services. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Practitioner services (non-doctor)

Covers services by practitioners (e.g., physician assistants and nurse practitioners). A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Prescription drugs (limited benefit)

Covers a limited number of prescriptions such as those one receives in a hospital outpatient department under certain circumstances, injected drugs received in a doctor's office, certain oral cancer drugs, and drugs used with certain DME (e.g., nebulizer or infusion pump). A person pays 20% of the Medicare-approved amount, and the Part B deductible applies. (Other than these examples, a person pays 100% of most prescription drugs, unless he or she has Part D—prescription drug coverage—or other drug coverage.)

Prosthetics and orthotics

Covers:

Arm, leg, back, and neck braces;

Artificial limbs (and replacement parts) and eyes;

Breast prostheses, including a surgical brassiere, after a mastectomy;

Ostomy supplies for people who have had a colostomy, ileostomy, or urinary ostomy (coverage is based on the amount of supplies a doctor says is needed for the condition);

Prosthetic devices needed to replace an internal body part or function; and

Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease, one pair per calendar year. (The treating doctor must certify the need for therapeutic shoes or inserts. A podiatrist or other qualified doctor must prescribe the shoes and inserts. A doctor or other qualified person—e.g., a pedorthist, orthotist, or prosthetist—must fit and provide the shoes.)

A person pays 20% of the Medicare-approved amount, and the Part B deductible applies. Amounts may be different is the supplier does not accept Medicare assignment.

Table 3:-Continued-

Rural health clinic services

Rural health clinics provide a broad range of outpatient primary care services. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Second surgical opinions (SSOs)

SSOs are covered in some cases for non-emergency surgeries. In some cases, a third surgical opinion will also be covered. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Speech-language pathology services

Covers evaluation and treatment to regain and strengthen speech and language skills including cognitive and swallowing skills when a doctor certifies the need. Beginning in 2009 “there may be limits” on these services. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Surgical dressing services

Covers the treatment of a surgical or surgically-treated wound. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Telemedicine (limited)

Covers medical or other health services given to a patient using a communications system (e.g. computer, telephone, television) by a provider in a location different from the patient's. Available in some rural areas, under certain conditions and only in a provider's office, hospital, or FQHC. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Transplants and immunosuppressive drugs

Covers doctor services for heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and only in a Medicare-certified facility. Bone marrow and cornea transplants are covered under certain conditions.

Immunosuppressive drugs are covered if the transplant was paid for by (1) Medicare or (2) an employer or union group health required to pay before Medicare. (Otherwise, Part D—prescription drug coverage—may cover the drugs.)

A person must have been entitled to Part A coverage at the time of the transplant and Part B coverage at the time of receiving the immunosuppressive drugs. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Travel (health care outside the United States)

Medicare generally does not cover health care while a person is traveling outside the United States. In rare cases, Medicare may pay for inpatient hospital, doctor, or ambulance services in a foreign country in the following situations:

If an emergency arose in the United States and the foreign hospital is closer than the nearest U.S. hospital that can treat the medical condition.

If traveling in Canada without unreasonable delay by the most direct route between Alaska and another U.S. state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency.

If a person lives in the United States and the foreign hospital is closer to his or her home than the nearest U.S. hospital that can treat the medical condition, regardless of whether an emergency exists.

A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Urgent care services

Covers treatment of a sudden illness or injury that is not a medical emergency. A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Table 4: What is Not Covered by Medicare Part A and Part B

Items and services that Medicare does not cover include, but are not limited to:

Acupuncture

Chiropractic services, except as specifically allowed

Cosmetic surgery

Custodial care, except when a person also get skilled nursing care in a skilled nursing facility, at home, or as part of hospice care

Deductibles, coinsurance, or copayments. People with limited income and resources may get help paying these costs.

Dental care and dentures

Eye exams (routine), eye refractions, and eyeglasses, except as specifically allowed

Foot care (routine), like cutting corns or calluses

Hearing aids and exams to fit a hearing aid

Hearing tests not ordered by a doctor

Laboratory tests (screening), except as specifically allowed

Long-term care

Orthopedic shoes, with few exceptions under diabetes supplies

Physical exams (routinely or yearly), except one time “Welcome to Medicare” exam

Prescription drugs, with few exceptions.

Shots to prevent illness, except as specifically allowed

Surgical procedures given in ambulatory surgical centers that are not included on Medicare's list of ambulatory surgical center covered procedures.

Syringes or insulin, except insulin used with an insulin pump is covered by Part B.

Travel (health care outside the United States), except as specifically allowed.

Table 5: Recently Proposed or Enacted State Benefit Mandates vs. Medicare Coverage

Item or Service

Proposed Mandate

Medicare

Bone marrow testing

Requires policies to cover human leukocyte antigen testing for bone marrow transplant purposes. It permits a policy to limit coverage to one test in a person's lifetime. Prohibits a policy, except for an individual high-deductible policy, from imposing a coinsurance, copayment, deductible, or other out-of-pocket expense for the testing that exceeds 20% of the cost for testing per year.

Requires a policy to (1) require bone marrow testing be done at a facility certified under the federal Clinical Laboratory Improvement Act and accredited by the American Society for Histocompatibility and Immunogenetics, or its successor, and (2) limit coverage to people who enroll in the National Marrow Donor Program when being tested. (SB 290 (2009)).

It appears that Medicare does not pay for bone marrow testing as conceived in the proposed state law.

When OLR posed the coverage question to the Centers for Medicare & Medicaid Services (CMS), we were informed that Medicare will make a coverage determination after a health care provider submits a claim to Medicare and that it will only pay for medically necessary services.

Table 5: -Continued-

Item or Service

Proposed Mandate

Medicare

Clinical Trials

Requires policies to cover routine patient costs incurred while a patient is participating in a clinical trial treating serious or life-threatening diseases (SB 299 (2009)). (The bill did not specify payment criteria for the clinical trials, other than to require coverage.)

“Routine patient care costs” are medically necessary services resulting from the patient's treatment during the clinical trial that the policy would cover if the person were not in the trial. These include physicians' services, diagnostic and laboratory tests, hospitalization, and other services rendered for a patient's condition, or a complication related to it, that are consistent with the usual and customary standard of care. The covered costs also include those for off-label cancer drugs.

A “clinical trial for treating serious or life-threatening diseases” is an organized, systematic, scientific study of interventions to treat, palliate, or prevent a serious or life-threatening disease. It excludes certain clinical trials for treating cancer, the costs of which policies must cover pursuant to a separate law (CGS 38a-504a to 504g and 38a-542a to 542g). But it apparently includes cancer clinical trials not otherwise covered under that law, including Phase I and Phase II clinical trial for cancer prevention.

Medicare covers routine health care costs for enrollees involved in a clinical trial. Medicare also pays for standard costs including hospital and physician visits, routine lab tests, and costs that are due to medical problems as a result of being part of a clinical trial. In most cases, Medicare does not pay for the experimental item being investigated.

A person pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Epidermolysis bullosa

Require policies to cover wound care supplies that are medically necessary to treat epidermolysis bullosa (EB) and administered under a physician's direction (PA 09-51)

When OLR posed the coverage question to CMS, CMS did not specify whether Medicare covers wound care supplies specifically for EB. Rather, CMS indicated that Medicare covers wound care supplies for certain severe, chronic ulcers, including a stage 3 or 4 pressure ulcer, neuropathic ulcer, venous or arterial insufficiency ulcer, or ulcer of mixed origin.

If covered, Medicare covers up to 15 dressing kits per wound, per month, unless a doctor documents that the wound size needs more than one kit for each dressing change. Supplies are not covered in certain circumstances, including when there is present in the wound (1) dead skin if wound cleaning is not attempted, (2) untreated bone or bone marrow infection, or (3) cancer.

Table 5: -Continued-

Item or Service

Proposed Mandate

Medicare

Lymphedema

Requires policies to cover supplies prescribed by a physician for the treatment of lymphedema, and such supplies must be considered durable medical equipment under the policy (HB 5691 (2008)).

“Lymphedema” means a chronic condition in which excess fluid or lymph collects in tissues of the body and causes edema, deformity, skin changes and infection in such tissues due to missing, impaired or damaged channels or ducts that transport lymph.

Medicare covers pumps and pneumatic compression devices for the treatment of lymphedema under the durable medical equipment benefit.

Medicare requires a “certificate of medical necessity” for this equipment. A “certificate of medical necessity” is a form required authorizing the use of certain durable medical items and equipment prescribed by a physician. This form is completed by the patient's doctor or the doctor's employee.

A person generally pays 20% of the Medicare-approved amount, and the Part B deductible applies.

Ostomy supplies

Require policies to cover $5,000 annually, up from $1,000 currently required by law, for medically necessary ostomy appliances and supplies, including collection devices, irrigation equipment and supplies, and skin barriers and protectors (HB 5021 (2009) and HB 5541, as amended by House A (2008)).

“Ostomy” includes colostomy, ileostomy and urostomy.

By law, amount covered does not count against any durable medical equipment maximum.

Medicare covers ostomy supplies under its prosthetics and orthotics benefit. It covers ostomy supplies for people who have had a colostomy, ileostomy, or urinary ostomy. The amount of supplies covered is based what the amount of supplies a doctor says is needed for the condition. A person pays 20% of the Medicare-approved amount after paying his or her Part B deductible for the year. Medicare pays the other 80%. These amounts may be different if the supplier does not accept Medicare assignment.

Prescription eye drop refills

Prohibit policies that provide prescription eye drop coverage from denying coverage for prescription renewals when (1) the refill is requested by the insured less than 30 days from either (a) the date the original prescription was given to the insured or (b) the last date the prescription refill was given to the insured, whichever is later, and (2) the prescribing physician indicates on the original prescription that additional quantities are needed and the refill request does not exceed this amount (PA 09-136).

Medicare includes a limited prescription drug benefit (see Table 3 above).

When OLR posed the coverage question to CMS, we were informed only that the drug plan must send a person its drug formulary upon enrollment and at least annually thereafter.

Preventive Care

Prohibit policies from imposing copayments, deductibles, or other out-of-pocket expenses for preventive care services (SB 459 (2009) and SB 478 (2008)).

Medicare covers a variety of preventive care services with a range of payment requirements (see Table 2 above). For most, a person pays 20% coinsurance. For some, the Part B deductible also applies. Some tests are provided at no charge.

Table 5: -Continued-

Item or Service

Proposed Mandate

Medicare

Prosthetic devices

Requires health insurance policies to cover prosthetic devices, and repairs and replacements to them, subject to specified conditions. It defines a “prosthetic device” as an artificial device to replace all or part of an arm or leg. It excludes a device that (1) contains a microprocessor or (2) is designed exclusively for athletic purposes.

The coverage must be at least equivalent to the coverage Medicare provides for such devices, but may be limited to a prosthetic device that the person's health care provider determines is most appropriate to meet his or her medical needs (HB 5093 (2009)).

Prohibits policies from considering a prosthetic device as durable medical equipment.

See Table 3 above for a full description of what Medicare covers regarding prosthetics and orthotics.

A person pays 20% of the Medicare-approved amount after paying his or her Part B deductible for the year. Medicare pays the other 80%. These amounts may be different if the supplier does not accept Medicare assignment.

Medicare treats prosthetics separately from DME.

Wigs

Require coverage for a licensed physician- or advanced practice registered nurse-prescribed wig for a person with hair loss caused by a diagnosed medical condition, except androgenetic alopecia (e.g., male-pattern baldness) (HB 5673 (2009). The coverage must be subject to the same terms and conditions applicable to all other policy benefits, but be at least a yearly benefit of $350. By law, oncologist-prescribed wigs are covered for people who suffer from hair loss due to chemotherapy, up to $350 a year (CGS 38a-504 and 38a-542).

Medicare does not pay for wigs.

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