What Are My Medicare Rights?
Many older adults are being offered insurance by managed care organizations, for example, Health Management Organizations (HMO), Managed Care Organizations (MCO), and Preferred Provider Organizations (PPO). While these insurance plans may offer good benefits, the buyer must understand what is and is not covered by each plan.
Having so many health care insurance options to consider can be somewhat overwhelming. The APPRISE Program helps persons who have Medicare or Medicaid health insurance questions.
All APPRISE services are provided free of charge. To talk to an APPRISE counselor in your area, contact Philadelphia Corporation for Aging, or call APPRISE at 800-783-7067. Also, if you need help with Medicare, you can call KePro (Medicare Insurance), 800-332-1914.
Every Medicare beneficiary has the right to:
- Receive good quality health care.
- Be admitted to the hospital when it is medically necessary.
- Stay in the hospital until it is medically safe to leave.
Medical Assistance
Many older adults aren't aware that they may be eligible for programs to help with their medical expenses.
Health Horizons is a program that helps with the medical expenses of adults 65 or over who have low income. The program will pay for medical benefits including prescriptions, doctor or clinic visits, dental and eye care. For more information on the program call Department of Public Welfare County Assistance Office 215-560-2900 or the Philadelphia Corporation for Aging 215-765-9040.
Prescription Drug Coverage
The cost of medication can be a huge barrier for many older adults in need of help. Unfortunately, many older adults will decrease their medication or stop taking it if it is too expensive. Here are some ways to get medication coverage or medication that is more affordable.
- Medical Assistance (MA): Depending on income and resources, many older adults may be eligible to have all prescription needs paid with no cost to them. The program can be reached at 800-842-2020.
- Explore Pharmaceutical Assistance Contract for the Elderly (PACE) or PACENET: If you are over 65, PACE is available to cover prescriptions (after a co-payment) for individuals with 2001 annual incomes below $14,000 for single persons and $17,200 for married couples.
PACENET is available to cover prescriptions, after a co-payment, for individuals with 2001 annual incomes between $14,000 and $17,000 for single persons and between $17,200 and $20,200 for married couples who have spent $500 on their prescriptions.
The PACE program can be reached at 800-225-7223.
Programs From Companies That Make or Distribute the Drugs
Most pharmaceutical companies have patient assistance programs through which people can get their prescriptions filled.
The first step is to find out the name of the manufacturer of the medication. Second, call the pharmaceutical manufacturer and ask if it has a patient assistance program. Ask what the requirements are for receiving free prescription drugs. Some companies require that the applicant have limited income or no insurance coverage at all in order to qualify for the program. Many companies require the applicant's physician to request participation in the program, and also to play a role in completing the application. Two Web sites offer information on contacting pharmaceutical companies: www.rxhope.com and www.phrma.org
Private Prescription Services
People can also obtain low-cost prescription drugs through a private prescription service. There are several. One is called www.needymeds.com and is an online service. The other is called Indigent Patient Services (IPS) and can be reached at 727-821-7333. These services usually charge a one-time registration fee and a cost per prescription and refill. For example, there might be a one-time registration fee of $25 and a $10 fee per prescription filled. The services require people to submit a request for each specific prescription drug that they need. They take phone requests and generate formal request forms that applicants and their doctors must sign and send to each pharmaceutical company. The pharmaceutical company will then send the medication to the doctor, who gives it to the applicant.
Discount Mail-order Services
Another way of getting lower cost medication is by contacting discount mail-order medication services. Here are just a few of the mail-order services to explore:
- Preferred Prescription Plan: 800-881-6325
- Managed Healthcare Systems: 954-938-7984
- RXUSA: 800-798-7248
- U-Save: 888-817-3784
Medicare HMOs
Some offer prescription coverage, but policies vary in their degree of coverage. Before changing HMOs, make sure to ask a lot of questions. Some questions to ask are:
- Is there a monthly premium and how much?
- Does the HMO include my doctor in its network?
- What pharmacies would I have to use?
- Does the HMO cover my present prescription drugs on the formulary?
- If not, what is the cost to me for drugs that are not covered?
- Is there an annual limit on brand-name drugs?
- How is the limit calculated?
- Explain how the limit would be calculated in my case, given the drugs I take.
Medigap Policies
Many insurance companies offer policies that cover the gaps in Medicare coverage. These are called Medigap policies. The average Medigap policy covering prescription medications in Pennsylvania runs about $142 per month.
Veterans Administration
All veterans who have served on active duty in the Armed Forces, wartime or peacetime, and received an Honorable or General Discharge are eligible for medical care through the Department of Veterans Affairs, 800-827-1000.