Fibromyalgia, a medical illness that causes musculoskeletal pain throughout the body, affects approximately 4 million people in the United States. While it is not an age-related disease, the symptoms are more severe in seniors. It can cause severe pain and make daily tasks difficult. There is still a lot of mystery surrounding this condition, but there’s been a lot of headway in the diagnosis and treatment process. So, if you have fibromyalgia, you may be asking what treatments are available to you and whether Medicare will pay for them.
What is Fibromyalgia?
Fibromyalgia is a chronic (long-term) condition. It causes symptoms such as soreness, fatigue, muscle tenderness, and even difficulty sleeping. The condition is very complex and shows in a variety of ways, so much so that even healthcare specialists struggle to completely understand the disorder. This is because its symptoms all mimic symptoms of other illnesses and there is currently no definitive test to confirm a diagnosis. So, Fibromyalgia is often misdiagnosed for years before being found.
In the past, some doctors even questioned if fibromyalgia was real. This resulted in widespread “lazy” and “dramatic” stereotypes of those suffering from fibromyalgia. However, as the disease has been examined more thoroughly, some of the stigmas that once surrounded it have faded. Doctors have been able to find medication, therapy, and lifestyle changes that can all help you manage your symptoms and live a better life.
Fibromyalgia Symptoms
Fibromyalgia has a long list of symptoms including:
Fatigue
Trouble sleeping
Nonrestorative sleeping (sleep without feeling rested)
Headaches
Difficulty focusing (called Fibro Fog)
Dry eyes
Rash
Itching
Pain in the lower abdomen
Bladder problems
Depression
Anxiety
The most noticeable sign of fibromyalgia is pain. Most fibromyalgia patients have small tender spots around but not in the joints. When pressure is applied to these spots they can cause anything from a dull ache to severe pain. These areas, known as the 18 fibromyalgia trigger points, are symmetrical, appearing on both sides of your body with 9 spots on each side.
Since there is no specific test for fibromyalgia doctors used to diagnose fibromyalgia based on the above symptoms combined with pain in at least 11 of the 18 trigger points. However, the American College of Rheumatology (ACR) modified clinical practice recommendations and removed the minimum trigger point limit from the diagnosis criteria.
18 Trigger Points
Behind the Neck
Fibromyalgia patients frequently have two trigger points in the back of their neck where their skull meets the neck. Fibromyalgia may also cause a stiff neck, cramping, and limited range of motion. However, keep in mind that neck pain and stiffness is not limited to fibromyalgia. As we noted most symptoms will mimic other conditions. Neck pain can be caused by arthritis, trauma, over-exertion, bad posture, or even sleeping on it at an odd angle.
Front of Neck
The trigger points on the front of the neck are above the collarbone on either side of your larynx. Pain in the front of the neck can also be caused by arthritis, injury or swollen glands. So before diagnosing fibromyalgia, your doctor will most likely order blood tests to rule out any rheumatological causes first.
Shoulders
Shoulder trigger points are around midway between the edge of your shoulder and the bottom of the neck, where the supraspinatus muscles attach to the shoulder blades. People with fibromyalgia may suffer scorching or throbbing pain in this area, as well as shoulder stiffness, in addition to pain when pressure is applied. Tendonitis, rotator cuff tears, and adhesive capsulitis (commonly known as frozen shoulder) can all produce pain in the supraspinatus muscles, which form part of the rotator cuff.
Chest
Fibromyalgia pain spots on the chest are found near the second rib on either side of the sternum (also known as the breast bone). That sore point is felt at the costochondral junction, the cartilage that links the rib to the sternum, a few inches below the collarbone. Some fibromyalgia patients may feel significant pain that begins at the tender point and radiates over the chest, a condition known as costochondritis.
Upper Back
Fibromyalgia pain points in the upper back are positioned immediately below the shoulder blades, where the trapezius muscles meet the scapula. In addition to the tenderness, you may experience discomfort across the trapezius. In fact, a 2013 study found that people with fibromyalgia have much higher trapezius muscle tension when exposed to mental stress than others. A spinal disk condition, arthritis, or an injury can also all cause pain in that area.
Elbows
Tender spots on the forearms associated with fibromyalgia are right below the elbow crease toward the outside of the arm. These trigger spots might appear on either one or both elbows. Fibromyalgia is often linked to lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow), both of which are forms of tendinitis. Both can result in discomfort and tingling down the forearm to the hands and fingers. Elbow discomfort can also be caused by injuries or illnesses unrelated to fibromyalgia, such as arthritis, gout, and lupus.
Lower Back
Lower back fibromyalgia pain sites are located towards the top of the buttocks, where the gluteus maximus and gluteus medius muscles connect. Fibromyalgia can also produce muscle pain, spasms, and stiffness across your entire back and buttocks. This type of pain is also common in people who do not have fibromyalgia. In the United States, one out of every four adults suffers from low back discomfort. It can be caused by problems with the vertebral disks, spinal misalignment, repeated stress injury, or an inflammatory condition.
Hips
The hip trigger points are located directly below the hip bone, roughly where the buttock muscles bend and connect the thigh muscles. In addition to the trigger points, people with fibromyalgia may have muscle soreness and limited range of motion in the hip area. Hip discomfort can be caused by osteoarthritis, muscular strains, and other injuries. When attempting to narrow down a diagnosis, X-rays and other imaging studies can sometimes rule out alternative illnesses. Imaging scans can assist distinguish between pain caused by joint degeneration, osteoarthritis, and myalgia (muscle pain).
Knees
Tender spots in the knee are found on the inside of the leg. The specific pain site lies directly above the side of the knee near the bottom of the vastus medialis muscle. Fibromyalgia-related knee pain may be accompanied by joint stiffness and cracking. Joint swelling, on the other hand, is not typical of fibromyalgia. If your knee is also swollen, it could be caused by another ailment such as knee osteoarthritis, a meniscus injury, bursitis, or an inflammatory disease.
Fibromyalgia Treatment
Unfortunately, there is currently no cure for fibromyalgia. Instead, medications, self-care practices, and lifestyle changes are used to reduce symptoms and improve quality of life.
Medications
Medications can help you sleep better and decrease pain. Pain relievers, anti-seizure medicines, and antidepressants are common fibromyalgia medications.
Pain Relievers
Fibromyalgia pain can be unpleasant and persistent enough to disrupt your everyday routine. If your discomfort is minor, you can take over-the-counter pain medicines such Tylenol, Aspirin, Motrin, or Aleve. These drugs can help you manage your disease by reducing your pain and discomfort. They may even help with your sleep.
Many of them also reduce inflammation. Inflammation is not a prominent symptom of fibromyalgia, although it may occur if you have a linked disorder such as rheumatoid arthritis (RA). Opioids have also been prescribed to treat fibromyalgia pain. However, research has revealed that they are ineffective over time. Furthermore, the dosage of narcotics is often increased rapidly, posing a health danger to those administered these prescriptions.
Anti Seizure Medication
Pregabalin (Lyrica), an anti seizure medication, was the first medication approved by the Food and Drug Administration (FDA) for fibromyalgia. It prevents nerve cells from delivering pain signals. Gabapentin (Neurontin) was developed to treat epilepsy, but it may also aid with fibromyalgia symptoms. Gabapentin is an off-label medicine that has not been approved by the FDA to treat fibromyalgia. Off-label drug use is when a medicine licensed by the FDA for one purpose is also used for a second, unapproved purpose.
A doctor can continue to prescribe the medicine for that unapproved purpose. This is due to the fact that the FDA regulates drug testing and ensures that the drug is safe to take but they don’t regulate what the drug can be used for. As a result, your doctor can prescribe a medicine in whatever way they believe is best for your treatment.
Antidepressants
Antidepressants such as duloxetine (Cymbalta) and milnacipran (Savella) are sometimes used to alleviate fibromyalgia pain and fatigue. These drugs may also assist to restore neurotransmitter balance and promote sleep. Both duloxetine and milnacipran have been approved by the FDA for the treatment of fibromyalgia.
Fibromyalgia Diet Changes
Some fibromyalgia patients claim to feel better when they follow a specific diet plan or avoid particular foods. There is no evidence that any specific diet changes will improve or cure fibromyalgia entirely but there are changes that are known to help some of the symptoms associated with fibromyalgia.
If you have fibromyalgia, aim to eat a well-balanced diet in general. Nutritious foods give you a steady amount of energy and help you keep your body healthy. They may also help to keep symptoms from worsening. Doing simple things like eating more fruit and lean proteins, and lowering sugar intake can all help balance your diet. Certain foods or substances, such as gluten or monosodium glutamate (MSG), may aggravate your symptoms. Keep a food diary to note what you eat and how you feel after each meal if this is the case. Share this journal with your doctor so they can assist you in determining which meals worsen your symptoms.
Natural Remedies
If drugs and dietary modifications do not completely improve your symptoms, you can explore other options. Many natural cures focus on stress reduction and pain relief, and they can help you feel better both psychologically and physically. They can be used alone or in conjunction with established medical treatments. Natural fibromyalgia treatments include:
Physical therapy
Acupuncture
Massage therapy
Meditation
Yoga
Tai Chi
General exercise
Therapy
Cognitive Behavioral Therapy
It’s worth noting that most alternative remedies for fibromyalgia haven’t been properly researched or confirmed to be effective. Before attempting some of these methods, consult with a healthcare practitioner about the advantages and dangers.
Medicare Coverage For Fibromyalgia
Medicare may cover some of the costs of your fibromyalgia treatment. Part B (Medical Insurance) can help pay the price of medical visits and diagnostic tests. If you are hospitalized for your disease, Medicare Part A may cover the costs of your hospital stay as well as any medicine you receive while in the hospital.
Part D, or prescription drug coverage, might help you save money on prescriptions you need. If you’ve been diagnosed with fibromyalgia in the last year and your current coverage isn’t meeting your needs, think about your alternatives during the Annual Election Period, which runs from October 15 to December 7. Pricing tiers will be established for each plan, based on generic, brand-name, and mail-order medications.
How EZ Can Help
If you need additional coverage, you can purchase an affordable Medicare Supplement Plan. Medicare Part B covers a lot, however it only covers 80% of your expenses, leaving you to pay the other 20% out of pocket. This can be rather costly, especially if you are on a fixed income, as many Medicare recipients are. However, by obtaining a Medicare Supplement Plan, you can save money on medical expenses while also receiving additional coverage.
There are ten Medicare Supplement Plans to choose from, each with its own set of coverage options and pricing. To save as much money as possible, it’s recommended looking into a Medicare Supplement Plan, so talk to an EZ agent about all of your alternatives. EZ’s agents work with the best insurance carriers in the country and can compare plans for you in minutes at no cost. Simply enter your zip code in the box below to get free instant quotes, or call 877-670-3602 to speak with an agent directly.
The Centers for Medicare and Medicaid (CMS) has begun covering genetic sequencing in 2018. It began when the FDA approved FoundationOne CDx, a test that can detect over 300 types of gene mutations. While Medicare does cover genetic testing to help detect possible health conditions it only covers a few types of genetic testing, and you have to meet certain criteria. Typically, genetic testing is used to screen, identify, or plan a specific treatment. That means without having certain symptoms or being at risk for certain health conditions Medicare won’t cover genetic testing. In most cases your doctor will be the one who advises you to get genetic testing done. For example, if you have a hereditary risk for a certain disorder. Along with testing to check the effectiveness of a new medication, this would help your doctor determine a better treatment plan.
Types Of Genetic Testing
Mainstream adult genetic testing covers several conditions. These are usually categorized by function:
Diagnostic, Predictive, or Presymptomatic – These tests are for patients who may have symptoms or know a certain medical condition runs in their family. A genetic test can show indicators for various cancers, polycystic kidney disease, and hemochromatosis. However, having indicators does not mean you will develop the disease. It just means you have the genes that can trigger it.
Carrier – Even if a person never gets sick or shows signs of a disease, they may be a genetic carrier for that disease. A test that looks for DNA markers that show a person is a carrier of an inherited disease can tell them if they could pass this gene on to a child or if they already have. If the other parent is also a carrier, this test can also tell them if they have already passed this gene onto a child.
Pharmacogenomic – The study of genetics is a big part of learning how the body breaks down drugs or responds to them. In some cases, a person’s genes can show whether or not a certain treatment will work or cause a bad response. This can help doctors tailor their treatment plan to the patient’s needs. Which can improve the chances of the patient’s health and healing going well.
Are There Risks To Genetic Testing?
Most genetic tests have very few risks and may be as easy as swabbing the inside of a patient’s cheek. Other tests may need a sample of blood. Which can cause some of the usual side effects of having blood taken. This could lead to redness or soreness in the place where the injection was given. Genetic testing, like any test, can also lead to changes in your mental health. Depending on how bad the scenario is, genetic testing can take an emotional toll. This could happen while deciding if a genetic test is needed, while waiting for the results, or after a genetic problem has been confirmed. This is natural since the possibility of serious medical conditions can be scary.
Keep in mind, genetic tests might be able to find out if a person has genetic markers linked to hereditary conditions. But they don’t tell us how likely it is that a person will get the disease. Or how signs might change or get worse over time. The health care worker who does the genetic test can tell you if there are any limits to the test and what it is usually used for.
Genetic Testing With Medicare
As we noted before, Medicare will pay for only a few types of genetic testing if you meet Medicare’s standards. If your doctor suggests that you get a genetic test it will most likely be covered because it will stem from a set of symptoms you’ve been showing. These are the genetic tests Medicare will cover:
Molecular Diagnostic Genetic Test (MDT) – Involves looking at gene sequences for changes that could cause certain illnesses.
Next Generation Sequencing (NGS) – NGS is a type of genetic testing that looks at many different parts of a person’s DNA at once. It helps doctors figure out how changes (mutations) in your DNA can show risk factors. And help them figure out what’s wrong with you.
Pharmacogenomics (PGx) – As we noted above, this is a type of test designed to learn how your body will react to certain types of medication.
Medicare also pays for NGS genetic tests for both acquired cancer (caused by gene mutations) and germline cancer (which is passed down from parent to child). Medicare will also cover some types of genetic tests that are used to diagnose cancer. These tests help find biomarkers, which are signs of abnormal cell activity in your body. For example, Medicare pays diagnostic tests for breast cancer, prostate cancer, ovarian cancer, and pancreatic cancer for people who have never been tested for specific mutations (BRCA).
BRCA Testing
Medicare pays for genetic tests that look for changes in the BRCA 1 and BRCA 2 genes. Which are the breast and ovarian cancer genes. Medicare also pays for other genetic tests that can tell if someone has a BRCA gene. Research shows that both men and women with the BRCA 1 or BRCA 2 gene mutations are much more likely to get breast and ovarian cancer than people who don’t have these gene mutations. A test like NGS that looks at many genes at once can find changes in BRCA 1, BRCA 2, and other genes. This can help doctors figure out if someone has cancer or not. There is criteria to get testing for BRCA 1 and BRCA 2:
You have to have pre-testing genetic counseling
Testing must be relevant to your family history of cancer
National Comprehensive Cancer Network rules say that you must meet certain standards to be eligible for testing for breast cancer or another type of cancer and one other type of inherited cancer.
When Does Medicare Cover Genetic Testing?
Medicare will pay for genetic testing for certain conditions and PGx for medications. As long as your doctor orders it and it is done in a lab that is approved by the Clinical Laboratory Improvement Amendments (CLIA).
Medicare covers genetic diagnostic testing for specific gene changes and NGS multi-gene panel testing if you have been diagnosed with cancer. If you meet Medicare’s requirements, NGS testing is also covered for other inherited diseases. Such as heart problems (cardiomyopathy, which is a problem with the heart muscle) and arrhythmia. Coverage for the Individual Plan may change based on where you live. For some medicines, PGx testing is also covered. Many medicines are broken down in the liver by enzymes like CYP2C19, CYP2D6, and CYP2C9. Doctors and pharmacists can better focus your medication therapy by testing your genes for these enzymes.
Medicare will pay for PGx testing for certain drugs like warfarin, clopidogrel, amitriptyline, and others if certain conditions are met. Your doctor can tell you more about the perks of PGx testing for you. The company that gives you your Medicare plan can tell you which PGx tests are covered by your plan. Medicare also lets MACs decide if they will cover NGS genetic tests that are not FDA-approved and other types of NGS genetic tests. For instance, for other types of cancer and other health problems.
Cost Of Genetic Testing
How much a genetic test will cost you varies based on the type of test, how it’s done (saliva or blood sample), and whether or not you meet the requirements for Medicare coverage. If your test is covered, you won’t have to pay anything as long as your provider accepts Medicare assignment. This means they agree to the payment terms set by Medicare. Costs for genetic tests can range from a few hundred to a few thousand dollars. So, it is important to make sure that Medicare pays for the test. Medicare has rules about who can get testing, and your doctor must give you an order for it. Medicare Administrative Contractors (MACs) may also have eligibility standards based on where you live.
Counseling With Genetic Testing
Medicare rules say that a “cancer genetics professional” like a doctor can give genetic advice. Which is covered, but you have to be a patient of that doctor. Certified genetic counselors are not yet seen as health care experts by Medicare. So, if you see a genetic counselor who is certified, your visit may not be paid. Certified genetic counselors have special training in genetics and therapy, so they can help you understand how your genes affect your chances of getting diseases like cancer. Based on the rules in place, Medicare doesn’t pay for genetic advice for any screening or prevention tests. Your Medicare plan provider can tell you more about the coverage standards for genetic counseling.
Get Covered With EZ
Medicare is great, but sometimes it can be hard to understand. Even after you sign up, you’ll still have to make some decisions about your health care. Don’t worry about asking questions. Talk to an EZ agent who can tell you what you need to do to sign up and explain everything to you. EZ can help you sign up, buy a Medicare Supplement Plan, or just think about your choices. Our insurance brokers work with the best firms in the country. You can get a free review of all the plans in your area from them. We’ll talk with you about your medical and financial needs and help you find a plan that meets them all. Call one of our certified agents at 877-670-3602 to get started.
When you think of Medicare you likely think of the health insurance system designed for people over 65, but there are some cases where younger people are also on Medicare. Some people with disabilities who are younger than 65 can get Medicare. These people must have been getting disability payments from Social Security for at least 24 months or have End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease). So, if you have one of these conditions, it’s important to not only look into and compare all of your plan choices, but also make sure you sign up for Medicare at the right time.
ESRD
End-stage renal failure, also called end-stage renal disease (ESRD), is the last and final stage of chronic kidney disease. In this stage, the kidneys’ function has gotten so deficient that they can’t function on their own anymore. A person with end-stage renal failure needs dialysis or a kidney donation to live longer than a few weeks. As kidney failure worsens, patients may feel a wide range of symptoms. Some of these are tiredness, drowsiness, less urination or not being able to pee, dry skin, itchy skin, headache, weight loss, nausea, bone pain, changes in skin and nails, and being easy to bruise.
If you have been told you have end-stage renal disease and need a kidney donation or are getting dialysis, you can sign up for Medicare on the first day of your fourth month of dialysis. If you are taking part in a program to help you do your own dialysis, you will be qualified for Medicare right away. However, if you stop doing self-dialysis and start going to a dialysis center, your Medicare benefits will stop and you will have to go through 4 months of dialysis before you can start getting them again.
ESRD Medicare Coverage
A doctor must tell you that you have ESRD before you can get ESRD Medicare. Also, you must have enough work history to qualify for Social Security Disability Insurance (SSDI) or Social Security retirement benefits. You can also apply based on your spouse’s or parent’s work history. Depending on your treatment plan, Medicare for ESRD will start when:
If you start a training program for home dialysis, which is sometimes called “self-dialysis,” you can get Medicare as of the first day of the first month of the program. Before your third month of dialysis, you must start the program. Your doctor must also say that they think you can finish the program and that you will keep doing home dialysis after the program is over.
If you get dialysis at a center for inpatients or outpatients, you can get Medicare starting on the first day of the fourth month you get dialysis. For instance, if you start dialysis on May 10, your ESRD Medicare coverage can begin on August 1.
If you need a kidney transplant, you can get Medicare starting the month you are admitted to a Medicare-approved hospital for the transplant or for health services you need before the transplant. If you need a kidney transplant, you can get Medicare starting the month you are admitted to a Medicare-approved hospital for the transplant or for health services you need before the transplant.
What’s Covered?
As long as you meet the requirements, you won’t have to pay a premium for Medicare Part A, but you will have to pay a monthly premium and meet a yearly deductible for Medicare Part B coverage, just like everyone else who has Medicare. Parts A and B of Medicare will pay for:
Dialysis
Kidney transplant
Transplant drugs after a covered transplant
Dialysis-related drugs
Part B covers outpatient dialysis, which is why you should sign up for Medicare as soon as possible so that this expensive treatment is covered. Immunosuppressant drugs used after a kidney donation are now covered by Medicare, thanks to a law passed in 2019. Before this law was passed, many Medicare recipients couldn’t afford to pay for these drugs out of pocket.
ALS
Amyotrophic lateral sclerosis is a motor neuron illness that kills people. It is defined by the loss of nerve cells in the brain and spinal cord over time. It is often called Lou Gehrig’s disease after the famous baseball player who died from it. ALS is one of the most debilitating diseases that affect how nerves and muscles work. ALS does not affect the brain or the senses, like being able to see or hear. It is also not infectious. There is no cure for this sickness right now. People of any race or ethnicity are most likely to get ALS between the ages of 40 and 70, though it can happen at a younger age.
If you have been identified with ALS, you will automatically be enrolled in Medicare the month you start getting disability payments from Social Security. If you have Amyotrophic Lateral Sclerosis (ALS), you are automatically enrolled in Medicare the first month you get Social Security Disability Insurance (SSDI) or a train disability annuity.
Once you know you have ALS, you should fill out an application for SSDI or a railroad disability annuity and send it to Social Security or the Railroad Retirement Board. Before you can start getting disability payments, you will have to wait five months. Make sure to say that you have ALS in a clear way on your application for disability payments. Once you’ve waited five months, your Medicare will start the same month as your unemployment payments. Coverage includes services like:
Physical and occupational therapy
Speech-language therapy
Medicines used in intravenous infusions
After you sign up for Parts A and B, you can choose between a Medicare Supplement Plan and a Medicare Advantage plan. You can save money on Part B out-of-pocket costs with a Medicare Supplement Plan.
Medicare Costs Under 65
Original Medicare (Parts A and B) costs the same for both people over 65 and people under 65 who are disabled, but the prices of Medicare Supplement plans are very different in big ways. Most of the time, Medicare supplement plans cost a lot more for disabled Medicare recipients under 65 than for Medicare recipients over 65. Many people with Original Medicare buy Medicare Supplement insurance to cover care that isn’t covered by Medicare Parts A (hospitalization and inpatient care) and B (outpatient care). Parts A and B cover about 80% of the costs, so you need extra insurance.
Most states do not offer Medicare Supplement insurance to Medicare recipients under the age of 65, or they are too expensive for this age group. For example, a Medicare Supplement Plan G insurance costs $179 a month for a 65-year-old woman who doesn’t smoke and lives in the Tampa, Florida, area. However, if she were under 65, that same plan would cost $479 a month.
There are no federal laws that say insurance companies have to sell Medicare Supplement policies to people under 65, and most states do not have laws about how much the plans can charge Medicare recipients under 65. Insurance companies don’t want to sell these plans to people with disabilities because they are high-risk customers. Because of this, Medicare Supplement Plans for Medicare recipients under 65 can be hard to find and can cost a lot more than in other states.
States with guaranteed issue and pricing regulations
In these states, Medicare Supplement policies must be sold to Medicare users under 65 with disabilities. These states also require insurance companies to keep policy costs low.
States where all 10 plans are available but cost more
In these states, insurance companies are required to offer all Medicare Supplement Plans to people under 65, but the states let insurance companies charge high rates.
States with variable availability and alternatives
In these places, Medicare enrollees who are under 65 and have a disability and don’t qualify for a full Medicare plan are not required to get a supplemental policy. However, these states have other kinds of insurance, like high-risk insurance pools, that can cover them.
Knowing that having ESRD or ALS won’t stop you from joining Medicare or getting coverage for your treatment should put your mind at ease. Depending on your condition, you may have to wait for coverage, but once you are ready for Medicare, you will have choices for more help. For example, you can sign up for a Part D plan to cover your prescriptions, and you can buy a Medicare Supplement Plan to help pay for your Part B out-of-pocket costs, since Part B only covers 80% of your medical bills.
While shopping for Medicare Supplement Plans you might see something called a Part B excess charge. You’ll specifically see this term in the discontinued Medicare Supplement Plans C and F. Providers who take Medicare usually also take Medicare assignment, which is the amount Medicare will pay for certain services. So, thankfully, excess charges don’t happen very often for most Medicare recipients. However, a doctor may choose to accept Medicare insurance, but not Medicare assignment which means they can charge more in some cases. The difference between the higher charge and the Medicare-approved amount for medical services, supplies, or equipment is the excess charge.
Medicare Assignment
There’s no guarantee that a doctor or hospital will only charge Medicare-approved amounts for their patients just because they take Medicare patients. All of the services and procedures that Medicare agrees to pay for have set prices that they will pay. In other words, the medical service provider must “accept Medicare assignment”. Which means they agree to take the Medicare-approved amount as payment for the service or equipment. After that, the provider sends a bill for the amount owed straight to Medicare. Medicare usually pays 80% of the bill, leaving the patient to pay the last 20%. If a provider doesn’t “accept assignment,” they can charge up to 15% more than the Medicare-approved amount for Part B.
If you go to a participating provider, all you have to pay for approved services is your Medicare deductible and coinsurance. This is the case even if the provider charges people with other types of health insurance more. Your participating provider will also send your bills to Medicare.
There are also providers who won’t take Medicare assignment. These are called “nonparticipating providers.” If your provider doesn’t participate, they might or might not agree to accept Medicare assignment for specific services. There are usually limits on how much doctors and other medical workers can charge when they don’t accept Medicare assignment. However, there is usually a limit on how much more they can charge for the service.
Part B of Medicare usually pays for care and services given in clinics and other outpatient settings. Medicare Part B pays for a range of medically necessary outpatient services and care. The Centers for Medicare & Medicaid Services say that medically necessary services are “services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.”
The Part B deductible must be paid before Part B will pay for most medically necessary treatments during the year. For most covered services, you have to pay 20% of the cost out of pocket through Part B. Part B of Medicare also covers services and care that keep you from getting sick. Such as cancer and some other diseases’ screenings, tests, shots, and guidance. For most preventive services, you don’t have to pay anything, but for most medically important services, you have to pay 20% of the cost.
How Much Is The Excess Charge?
“The limiting charge” is the most that non-participating providers can charge you for some medical services and products that Medicare covers. This limit says that Medicare-accepting providers who are not participating can charge you up to 15% more than Medicare’s amount for the same services. This is an example: Medicare has agreed to pay providers $300 for a service you need. Your provider won’t work with Medicare, and they’ll charge you the full legal amount, which is 15%. In this case, the extra charge for you would be $45.
In another instance, Medicare pays $100 for another service you receive. Your provider doesn’t take Medicare assignments, but they’ll only charge you an extra 6%. In this case, the extra charge is $6. It’s important to note that not all services have a limit and there is no cap on how much non-participating suppliers of durable medical equipment can charge you for goods and equipment. Make sure your doctor accepts assignments before you get any durable medical equipment.
How Common Are Excess Charges
A 2020 issue report from the Kaiser Family Foundation says that 99% of doctors who aren’t pediatricians accept Medicare. Also, 98% of doctors who take Medicare are participating providers, which means that most Medicare-approved visits shouldn’t have an excess charge. Although there are many medical providers in the United States, even a small number of providers who don’t accept assignments can add up. This is why you should always check with your provider to see if they take assignments before making appointments or buying medical supplies and equipment.
Does Every State Allow Excess Charges?
It can be a pain to deal with Part B extra charges, but luckily some states are against them. The state has to allow excess charges to happen. If they don’t, Medicare recipients in those places won’t be charged more than the Medicare approved amount. Because Part B excess charges are different in each state, it’s important to know what’s going on if you don’t want to have extra Medicare charges added to your bill. Some states either don’t allow extra charges or put some kind of cap on them, but not all of them do.
Connecticut – People who are in the Medicare Savings Program at the Qualified Medicare Beneficiary (QMB) level are the only ones who can’t be charged extra. Everyone else in Connecticut who has Medicare Part B can face excess charges.
Massachusetts – Balance billing is illegal in the state, so doctors who take Medicare can’t charge their patients more than the approved amount.
Minnesota – Under Minnesota law, Medicare excess charges are not allowed. However, there is an exception that ambulance services and medical equipment are able to have excess charges.
New York – The Balance Billing Law of New York says that excess charges can’t be more than 5% above what Medicare allows.
Pennsylvania – Pennsylvania does not allow excess charges.
Rhode Island – This is another state that does not allow excess charges.
Vermont – This state also prohibits excess charges entirely.
How Excess Charges Can Affect You
Say you go to a doctor who isn’t a participant to get a few moles removed that look odd. Medicare will only pay $400 for this treatment, so the dermatologist could charge you $460. If you’ve already met your Part B deductible, the treatment would cost you $140 out of pocket. This includes your $80 coinsurance payment of 20% plus the $60 Part B extra charge. With a participating provider, the most you would have to pay out of pocket is $80. It’s important to remember that excess charges do not count toward your Part B payment.
However, a doctor who isn’t participating can add extra charges to your bill as many times as they want. If you often see a provider who doesn’t take assignments, you could end up paying hundreds of dollars more each year than you should.
Medicare Supplement Plans That Cover Excess Charges
There are only two Medicare Supplement plans that protect you from Medicare Part B extra charges– Plans F and G are those plans. In the past, Medicare Plan F gave the most benefits of all the Medicare Supplement plans. Many people thought it was worth the extra cost because it filled in some of the holes in Medicare Parts A and B.
The main thing that makes Plan F better than other Medicare Supplement plans is that it pays for the yearly Medicare Part B deductible. However, in 2015, this changed. People who became eligible for Medicare after January 1, 2020, can no longer get Plan F. People who already had Plan F before the change have the option of keeping it. If you could have gotten Medicare before January 1, 2020, but chose not to, you might also still be able to sign up for Plan F.
Plan G is now the most popular Medicare Supplement Insurance plan that anyone, regardless of when you enroll in Medicare, can get. Plan G pays for the “gaps” in Medicare benefits, which are the costs you have to pay for yourself after Medicare pays its share of the bill. More of these costs are covered by Plan G than by any other Medicare Supplement Insurance plan for new Medicare users.
Why Is Plan F Discontinued?
The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in 2015. This law made it illegal to sell any Medicare Supplement plans that covered Part B deductibles for people who became eligible after January 1, 2020. There are only 2 of 10 Medicare Supplement Plans that have this benefit, Plan F and Plan C. The new law did not change anything about the plans themselves. If you had or were eligible for one of these plans before January 2020 then the coverage is still the same. The only thing that changed was that new enrollees can no longer purchase the plans and eventually the plans will be entirely phased out once nobody on Medicare is eligible or has one of these plans.
Working With EZ
It is very important to compare the pros and cons of each Medicare Supplement Plan before choosing one. That takes a lot of work because you have to call a lot of insurance companies to get rate quotes, which can take a long time. You can check prices in half the time if you work with an EZ agent. When you work with a qualified agent, you can compare Medicare Supplement Plans from a number of different companies and plans all in one place.
Your agent can tell you about the changes between each plan and compare prices for you. Your adviser can also help you compare out-of-pocket costs and premium costs to find the plan that will save you the most money in the long run. Call us at 877-670-3602 right now to start looking for a Medicare Supplement Plan. To see online quotes you can also type your zip code into the box below.
Even if you have Medicare Parts A and B coverage, you may still need extra coverage for your prescription drugs. So, like a lot of people with Medicare, you might be looking at Medicare Part D, especially Medicare Silverscript, which is the cheapest way to cover prescription drugs on the market. It’s not surprising that many Medicare recipients are choosing a Silverscript plan as a way to save money. Could one fit your needs?
Part D of Medicare is the plan for prescription drugs. Some of a Medicare recipient’s medicine costs are covered by these drug plans. Medication costs can add up quickly, and if you don’t have insurance, you may have to pay a lot out of pocket. Medicare Part D plans help pay for the prices of prescription drugs so that people who need them can get them.
Medicare is made up of different parts, or sections, that cover different types of health care. Part A and Part B are the parts of Original Medicare. Prescription drugs are not covered by either of these plans. On the other hand, there are Medicare Advantage Plans, also called Medicare Part C, that are given by private insurance companies. Some of these plans may cover Part D, but not all of them do. If someone with Original Medicare or a Medicare Advantage Plan without a Part D plan wants coverage for prescription drugs, they would need to sign up for a different Medicare Part D plan, like SilverScript.
SilverScript
SilverScript is a private insurance company that merged with Aetna in January of 2020 and offers Medicare Part D plans. It covers prescription drugs for people with Original Medicare. Coverage choices are available in all 50 states and Washington, D.C. People who are qualified for Medicare Part D can choose from three different plans from SilverScript. Each plan has a different fee and covers prescription drugs in a different way. To figure out which plan is best for you, you should make a list of the prescription drugs you take and compare it to the formularies of each plan.
Depending on the plan you choose and the medicines you need, SilverScript’s Medicare Part D plans offer a range of fees and copays that can fit almost any budget. Also, these plans cover you at thousands of pharmacies across the country. Even though the SilverScript formulary changes every year, this provider’s prescription drug plans offer full coverage and reasonable prices.
A formulary is a list of all the prescription drugs that a certain insurance will pay for. When looking for coverage for your prescription drugs, you should know what drugs you take and how the Medicare Part D plans in your area cover them. So, you can sign up for a plan that will cover your medicines. There are times when a Medicare Part D plan might not cover the medicine you need. There could be a formulaic option, though. Your doctor may think about a change if they think it would be a good idea. If not, you could ask for a list exception, which means that the plan may cover your drug if it is approved.
SilverScript may change its formularies from time to time, so it’s important to check your prescription drug benefits every year during the Annual Enrollment Period. This will make sure that you get the right coverage every year. There are five tiers of drugs, and each tier may have its own fees or copayments for coverage. Here’s how the tiers are broken up:
Tier 2 – Generic drugs that usually cost more than tier 1 drugs
Tier 3 – Preferred brand-name drugs with no generic version
Tier 4 – Less commonly prescribed non-preferred drugs
Tier 5 – Expensive specialty drugs that may require monitoring
In the formulary you will also see information about any restrictions or terms for coverage that apply to each drug. These rules are listed at the beginning of the formulary. They can include things like needing Aetna’s authorization first or limits on how many drugs can be covered at once. There’s a chance that a SilverScript formulary might be a little different based on where the plan is sold.
SilverScript Plans
There are three different SilverScript coverage choices for Medicare beneficiaries:
SilverScript SmartSaver
This choice is for people who are active, prefer generic drugs, and are generally healthy. It has the lowest national average of monthly premiums at $5.92. It includes $0 deductibles for Tier 1 drugs, and $505 deductible for Tiers 2-5. The copays for preferred pharmacies by tier are:
Tier 1 – $2 copay for 30-day prescriptions and $6 for 90-day prescriptions
Tier 2 – $15 for 30-days’ worth and $45 for 90-days
Tier 3 – 25% coinsurance
Tier 4 – 50% coinsurance
Tier 5 – 25% coinsurance for 30-day prescriptions
SilverScript Choice
This plan covers more than the SmartSaver plan, but it has a $505 deductible and a $33.60 monthly premium. If you qualify for the Extra Help program, you can get a $0 monthly premium instead. The copays for preferred pharmacies are:
Tier 1 – $2 copay for 30-day prescriptions and $6 for 90-day prescriptions
Tier 2 – $7 for 30-days’ worth and $21 for 90-days
Tier 3 – 17% coinsurance for a 30-day supply; 22% for 90
Tier 4 – 30%-40% coinsurance
Tier 5 – 25% coinsurance for 30-day prescriptions
SilverScript Plus
This plan has even better coverage than the first 2, with a $75.58 monthly fee, a $0 deductible on all tiers, and a coverage gap for Tier 1 and 2 drugs. I also has$0 copays on Tier 1 and 2 drugs for the other tiers the copays are:
Tier 3 – $47 copay for a 30 day supply; $141 for 90
Tier 4 – 50%-40% coinsurance for both supply amounts
Tier 5 – 33% coinsurance for 30-day prescriptions
What Pharmacies Accept SilverScript?
SilverScript lets you get your prescription drugs from thousands of pharmacies across the country. There are more than 65,000 pharmacies in the United States that are part of the SilverScript drugstore network. Your SilverScript Medicare Part D plan will be accepted at most chain pharmacies. But not all shops are in the “preferred category”. With a preferred pharmacy, you can get the drugs for the least amount of money. These pharmacies include:
Walmart
CVS
Wegmans
Kroger
Publix
Even though they cost a little more than preferred pharmacies, standard network pharmacies still offer service. These pharmacies include:
Walgreens (for most SilverScript plans)
Sam’s Club
There are also many local pharmacies that fall into either of those categories so be sure to check your plan for your area’s local pharmacies.
How To Choose
There are a few things to think about when choosing the right Part D plan, whether it’s SilverScript or any other plan, for you. The major things you should think about are cost, coverage, and how flexible the plan is. Cost is always a factor when choosing a Part D plan. Different plans come with different costs. Coverage gaps, fees, deductibles, copayments or coinsurance, and premiums all affect your overall cost. If you are in good health and prefer to take generic drugs, you may want to choose a plan with a lower premium and benefits for tier 1 or tier 2 drugs. You can choose a plan with a higher cost and more benefits to help with your health care needs if you need specific drugs, have serious health problems, or need more specific coverage.
You also need to know how much coverage you need. If you don’t need a lot of coverage, you may want to save money by getting a plan with less coverage. But if you need more coverage because of your health or for your own peace of mind, you may want to look into plans with more coverage that cost more. Choosing the best Part D plan will also depend on how flexible you are about the drugs and pharmacies you want to use. If you don’t mind taking generic or recommended generic drugs, you may have more plan choices. Also, if you are willing to get your drugs from different pharmacies you will have more plans to choose from. However, if you have specific drug plans or pharmacies in mind, you may need to look at better coverage plans to see what works best for you.
Call EZ
If you want to compare SilverScript drug plans, you should think about the prescription drugs you take and how much of them you take. You should also think about how much you are willing to pay for premiums and a yearly deductible. As we’ve already said, if the cost of your medicines is getting too high for you, a SilverScript plan could help you by putting all of your monthly costs into one payment.
You should also look into a Medicare Supplement Plan if you want to save even more money. There are 10 Medicare Supplement Plans to choose from, and each one has different rates and coverage choices. Talk to an EZ agent about all of your choices. The agents at EZ work with the best insurance companies in the country, and they can review plans for you for free in just a few minutes. Enter your zip code in the box below to get free instant quotes for plans that cover your present doctors, or call 877-670-3602 to talk to a licensed agent.
The Medicare Annual Enrollment Period (AEP) is a set period of time where you can change your Medicare benefits. Every year, the AEP lasts from October 15 to December 7. If you didn’t sign up for a Medicare Advantage plan or a Medicare prescription drug plan when you first became eligible for Medicare (during your Initial Enrollment Period), the AEP is usually your chance to do so, unless you apply for a Special Election Period (SEP). It also allows you to make any changes you need to tailor your Medicare coverage to your specific needs.
If you are eligible or already enrolled in any Medicare product you can use the AEP to move to a different Medicare plan, sign up for an entirely new plan, or drop out of a plan. This includes the ability to move from Original Medicare to Medicare Advantage, switch between different Medicare Advantage plans, and sign up for or change Medicare prescription drug coverage.
Your AEP Options
During the Medicare AEP, you can move from Original Medicare (Parts A and B) to Medicare Advantage (Part C), or vice versa, if you already have Medicare. However, if you want to switch, you may also have to make some other choices. Depending on what kind of plan you’re switching to and from, you’ll have to make different decisions.
In this case, you have Original Medicare and want to move to a Medicare Advantage plan. You may also have a separate Part D plan for prescription drugs. Most Medicare Advantage plans include everything that you need. They pay for your Medicare Part A and Part B benefits, as well as Part D prescription drugs and other health services and things that Original Medicare doesn’t cover. Some of these other things are dental, vision, and hearing care, as well as gym memberships. There is also an annual out-of-pocket limit on Medicare Advantage plans to keep you from paying too much.
During the AEP you can move from Original Medicare to a Medicare Advantage plan. Depending on the Medicare Advantage plan you choose, you may no longer need a separate Part D plan if you already have one. With Medicare Advantage, you usually don’t need a separate Part D prescription drug plan because drug coverage is built in.
If you switch to a Medicare Advantage plan, the plan will work with Medicare to move your benefits over. You don’t have to get in touch with Medicare on your own. On January 1, your new plan will start to cover you. If you have a stand-alone Part D prescription drug plan or another private Medicare plan, you’ll need to call the plan provider directly to drop out. Just call the number on the back of your member ID card. During the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31, you can choose a different Medicare Advantage plan or switch back to Original Medicare.
Medicare Advantage To Original Medicare
Original Medicare only has Part A (coverage for hospital stays) and Part B (coverage for medical care). It doesn’t give you some of the things your Medicare Advantage plan might have, like coverage for prescription drugs, dental, vision, or fitness. Original Medicare also doesn’t have an annual out-of-pocket cap, so there is no built-in financial protection.
If you still want these things, you will need to buy extra coverage. For example, if you want coverage for prescription drugs, you will now have to find a stand-alone Part D plan and sign up for it. If you decide you need more coverage, you will need to choose a Medicare Supplement Plan and sign up directly with the plan provider. To make the switch to Original Medicare, you will need to call your Medicare Advantage plan provider or Medicare directly.
Medicare advantage plans are pretty comprehensive, but there are still times you may want to switch to a different plan. Such as:
Moving to a plan that offers drug coverage
Moving to a plan without drug coverage
Switching to a plan that has dental or vision coverage
Aside from the AEP there are other times you can change your Medicare Advantage plan. During the Medicare Advantage open enrollment period, which runs from January 1 to March 31 every year, you can make changes to your plan at any time. The changes you make will go into action on the first of the month after you make them. You can also change your Medicare Advantage plan during a Special Enrollment Period if you have a big change in your life. Medicare may give you a special enrollment period if you move to a new place, if your coverage choices change, or if certain other things happen in your life.
You can apply for a Medicare Supplement Plan at any time of the year, not just during the AEP. However, unlike Part D and Medicare Advantage plans, Medicare Supplement Plans don’t have to offer a yearly enrollment period like Part D and Medicare Advantage plans do. If you apply for a Medicare Supplement Plan after your six-month initial enrollment time has ended, the insurer is likely to use a process called “medical underwriting” to decide if you are eligible and how much you will have to pay. Some states have passed laws that make it easier for seniors to switch from one Medicare Supplement Plan to another by applying birthday rules or guaranteed issue rights. Both allow a specific amount of time where you can change your Medicare Supplement Plan without going through underwriting.
Guaranteed Issue Rights
New York and Connecticut – Medicare Supplement Plans are guaranteed issue all year.
Massachusetts – There is a 2 month period every year between February and March where plans are guaranteed issue
Maine – Participants can move to a different Medicare Supplement plan with the same or less benefits at any time during the year, and all carriers must set aside one month each year when Medicare Supplement Plan A is guaranteed to be available to all participants.
Missouri – There is an Anniversary Guaranteed Issue Period. Anyone with a Medicare Supplement plan has 60 days around the anniversary of their plan each year to switch to the same plan from a different insurance company.
Birthday Rules
California – The rule goes into effect 30 days before their birthday and stays in place for 60 days after. During this time, customers in The Golden State can switch to any plan with the insurance company of their choice that has the same or less benefits.
Oregon – The birthday rule starts on your birthday and lasts for 30 days after that. This gives you 31 days to change plans. It works like California’s and lets customers switch to any insurance company or plan with the same or less benefits.
Idaho – This rule goes into effect on your birthday and lasts for 63 days. You will be able to sign up for any plan with the same or less benefits. Also, the plan could be with any provider.
Illinois – This birthday rule only applies to people who are 65 to 75 years old. During this time, you can switch plans with your current insurance company. But the benefits of your new plan can’t be better than those of your old plan. This open registration period starts on your birthday and goes on for 45 days.
Louisiana – The time for the birthday rule starts 30 days before your birthday and ends 63 days after it. So, you have 93 days to change the plan you have now. During this time, you can switch to a policy with the same or less benefits through your present provider.
Maryland – The birthday rule for Medicare Supplement starts on your birthday and ends 30 days after that. Giving residents 31 days to sign up for a plan with the same or less worth.
Nevada – For at least 61 days, you can make changes to your plan. This window opens on the first of your birthday month. You can switch carriers or plans during this time, but the benefits of the new plan must be the same or less than what you get from your present plan.
Oklahoma – The 60-day window for the birthday rule starts on your birthday. During the 60 days, you can change your plan or provider. However, you can only switch to a plan with the same or less value than the one you have now.
Need Help?
Medicare is great, but sometimes it can be hard to understand. Even after you sign up during the AEP, you’ll still have to make some decisions about your health care. Don’t worry about asking questions. Talk to an EZ person who can tell you what you need to do to sign up and explain everything to you. EZ can help you sign up, buy a Medicare Supplement Plan, or just think about your choices. Our insurance brokers work with the best firms in the country. You can get a free review of all the plans in your area from them. We’ll talk with you about your medical and financial needs and help you find a plan that meets them all. Call one of our certified agents at 877-670-3602 to get started.
Knees
Most genetic tests have very few risks and may be as easy as swabbing the inside of a patient’s cheek. Other tests may need a sample of blood. Which can cause some of the usual side effects of having blood taken. This could lead to redness or soreness in the place where the injection was given. Genetic testing, like any test, can also lead to changes in your mental health. Depending on how bad the scenario is, genetic testing can take an emotional toll. This could happen while deciding if a genetic test is needed, while waiting for the results, or after a genetic problem has been confirmed. This is natural since the possibility of serious medical conditions can be scary. 
Medicare will pay for genetic testing for certain conditions and PGx for medications. As long as your doctor orders it and it is done in a lab that is approved by the Clinical Laboratory Improvement Amendments (CLIA).
