Marci's Medicare Answers for April 2007

Dear Marci, I was diagnosed with breast cancer and my doctor recommended a mastectomy. Before I schedule the surgery, I'd like to get another doctor's opinion. Will Medicare cover this? Claire Dear Claire, Yes, Original Medicare will cover a second opinion because your doctor recommended surgery. In fact, Medicare will cover a second opinion after your doctor recommends just about any major procedure. If the second doctor disagrees with the first, Medicare will even cover a third opinion. As with most Part B-covered services, Medicare will generally cover 80 percent of the appointment's cost. If you have a Medicare private health plan, you might need a referral from your primary care doctor before a second opinion will be covered. Also, you may have to pay the appointment's full cost if you see a doctor who is not in your plan's network. Call your plan to find out whether a second opinion will be covered and at what cost, and whether you need to get a referral. Marci Dear Marci, My dad had a stroke and now needs outpatient occupational therapy. Is it true that Medicare limits the amount he can get? Ron Dear Ron, In many cases, but not all. In 2007, Medicare covers up to $1,780 for occupational therapy annually after the Part B deductible is paid. It also covers up to $1,780 of physical and speech therapy combined. It will cover 80 percent of the cost of these types of therapy if they are medically necessary, your doctor or therapist sets up the plan of treatment and your doctor periodically reviews the plan. If you have certain conditions, like Multiple Sclerosis the coverage limits do not apply. If your father reaches the coverage limit but does not have a condition that would automatically allow him to get more therapy covered, his therapist or doctor can ask Medicare to cover more outpatient therapy if it is medically necessary. You can learn more about how to request an extension at www.cms.hhs.gov/apps/media/press/release. as p?Counter=1782 or call 800-MEDICARE. Marci Dear Marci, I used to have an employer health plan that covered all my prescriptions. Now I have a Medicare private drug plan, but it doesn't cover one of my drugs. My doctor said that no other prescription will work for me. Is there anything I can do? Wendy Dear Wendy, As long as the medication is not excluded from Medicare coverage by law, you can ask your drug plan to cover a drug not on its list of covered drugs (formulary) by asking for an exception. Your doctor must send your drug plan a written statement that explains why the prescription is medically necessary and that other drugs covered by your plan will not work or may actually harm you. Your drug plan must respond within 72 hours of receiving your doctor's statement, unless your health is in jeopardy. In this case, you can ask for an expedited request which your drug plan must respond to within 24 hours. Every drug plan has its own exception process, so call your drug plan. If the plan denies your exception request, you can appeal. If you need help getting a drug covered, call the Medicare Rights Center's Drug Plan Appeals Hotline at 888-466-9050. Marci Marci's Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation's largest independent source of information and assistance for people with Medicare. To subscribe to "Dear Marci," MRC's free educational e-newsletter, simply e-mail dearmarci@medicarerights.org.