Medicare now covers an annual “Wellness” visit to a primary care physician at  no cost to the patient. But, as with the “Welcome to Medicare” visit, the list of what is covered “for free” is very limited. Anything beyond the list (provided below) will result in a bill.

Medicare.gov provides the following information:

• Yearly “Wellness” visits: If you’ve had Part B for longer than 12 months, you can get this visit to develop or update a personalized prevention help plan to prevent disease and disability based on your current health and risk factors. Your provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your provider develop a personalized prevention plan to help you stay healthy and get the most out of your visit. It also includes:
  • A review of your medical and family history
  • Developing or updating a list of current providers and prescriptions
  • Height, weight, blood pressure, and other routine measurements
  • Detection of any cognitive impairment
  • Personalized health advice
  • A list of risk factors and treatment options for you
  • A screening schedule (like a checklist) for appropriate preventive services. Get details about coverage for screenings, shots, and other preventive services.

This visit is covered once every 12 months (11 full months must have passed since the last visit).

Your costs in Original Medicare

You pay nothing for the “Welcome to Medicare” preventive visit or the yearly “Wellness” visit if your doctor or other qualified health care provider accepts assignment. The Part B deductible doesn’t apply.

However, if your doctor or other health care provider performs additional tests or services during the same visit that aren’t covered under these preventive benefits, you may have to pay coinsurance, and the Part B deductible may apply.

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Wellness visit vs Sickness visit

If a person has a health issue, whether major or minor, Medicare will cover the doctor visit – but deductibles, 20% co-insurance, and Medicare Advantage co-pays will be charged to the patient.

In this situation, the patient must have a new health issue, or be seeing the doctor to assess an ongoing health problem.

Medicare will pay for the three parts of a standard office visit:  taking a HISTORY; performing a PHYSICAL EXAM, and developing an ASSESSMENT/PLAN.

As I wrote yesterday regarding the Welcome to Medicare Visit, the patient might expect to get a “free exam”, but he could end up with a bill.  The bill will depend on the patient’s Medicare coverage.  Does he have only Medicare?  Does he have a Medicare supplement, and which one?  Is he enrolled in a Medicare Advantage plan?

For a quick overview of your Medicare choices, take a look at this short video: Intro to your Medicare Choices

Every day 10,000 American baby-boomers turn 65 .  Most will enroll in Medicare, but many will not.

Not everyone needs to enroll in Medicare because some people continue working and are covered by their employer’s health insurance.  A person who works for a large employer with good health insurance (that probably includes coverage for a younger spouse) can keep that coverage and does not need to enroll in Medicare.  When that person retires, he/she will face no penalty for late-enrollment in Part B of Medicare.

People who are self-employed, or work for a small company with lousy health insurance (with high deductibles, co-pays, and ridiculous premiums), will be thrilled to get into the Medicare system.  I have said to many people in this category, “You may be getting older, but you’ll finally get good health insurance!”

How you enroll in Medicare depends on your current situation related to Social Security.

1) If you are receiving Social Security payments, you will automatically be enrolled in Medicare A and B. Part B has a monthly premium which will be deducted from your Social Security check at the start of the month in which you turn 65.  Your Medicare card will be sent to you three months before your birthday month.

2) If you are not drawing Social Security payments, you will need to contact Social Security to tell them you want Part B.

The Social Security phone number is 800-772-1213. Or you can go to Medicare.gov and enroll online. You will also need to make arrangements to pay your Part B premium, which is $104.90 per month in 2013. If your income is above $85,000/yr, you will pay a higher Part B premium.  You have to pay 3 months at a time at the start, but you can set up automatic bank withdrawals to pay the premium each month.

You should make sure you are signed up for Medicare three months before you turn 65.  So if your birthday is in July, now is the time to get started on your Medicare Part B enrollment. If your birthday is in May or June, you really need to get on the ball.

Once you’ve enrolled in Part B, you will get your Medicare card.  Your Medicare card has important information that is required when you go to sign up for a Medicare supplement, Part D plan, or a Medicare Advantage plan. Your Medicare claim number is usually your Social Security number with a letter after it.  People who don’t use Medicare when they turn 65 will have different start dates for Part A and Part B.

Choosing your Medicare coverage:

Once you’ve got your Medicare card, you need to choose your Medicare coverage.  Will you have only Medicare? (A financially risky choice.)  Will you get a Medicare supplement and a stand-alone Part D plan?  Will you enroll in a Medicare Advantage plan that includes Part D drug coverage?  On my website I provide a short video presentation, Intro to Your Medicare Choices.  Click here to to go that page.

At this time of year, people enrolled in a Medicare Advantage plan cannot change their plan, or dis-enroll from their plan – unless they meet certain requirements such as: they are moving to a new state; they qualify for a chronic illness plan; they get help with their prescription costs through the Low Income Subsidy (LIS). These people get a “special election period” to enroll in a new Medicare Advantage plan at this time of year.

So how did a client of mine get changed from one Medicare Advantage plan to another when she did not qualify for a “special election period”? The answer is that her husband made a mistake by using an on-line application for a product he did not understand.

Bill was trying to help his wife, who is disabled and under 65. She has been enrolled in a Medicare Advantage plan since she got her Medicare last summer. But because Medicare Advantage plans pay 80% of the cost for durable medical equipment, Bill went on-line to see if he could get some kind of supplement to cover 20% of the cost of the expensive wheelchair his wife will need soon.

Bill is a smart guy, but he made a mistake by filling out an enrollment form on the Humana website. Bill thought he was signing his wife up for some sort of supplement that would fill the gaps in his wife’s Medicare Advantage plan. He put in his wife’s Medicare information and hit the submit button. Then he realized he had made a mistake, so he called Humana and asked them to cancel the application he had just submitted electronically.

The Humana representative told him she would cancel his on-line application, so he thought he was okay. That was near the end of February. Last week, Bill got a $177 bill for the Humana Gold Choice Private-Fee-For-Service (PFFS) Medicare Advantage plan. Uh, oh.

Bill called Humana and they said his wife is enrolled in their Advantage plan. He called Health Net, the plan his wife had been in, and was told she had been dis-enrolled from their plan.

Bill called me and I couldn’t understand how his wife got enrolled in the Humana plan because she is not allowed to change her plan at this time of year. Even though Bill made a mistake by submitting an on-line application, it should have been rejected because his wife does not have a “special election period” (SEP) to change her plan. Humana should have realized this and rejected the application. Additionally, Medicare should have rejected the application.

So what SEP code did Humana use to get this application through Medicare’s enrollment period rules? And why did someone at Humana tell Bill she would cancel the application and then not do it?

Bill and I called Medicare and were told by a representative that there was nothing Medicare could do about the Medicare Advantage plan change because it was done on-line.   The Medicare rep said Bill’s wife is stuck in the Humana PFFS plan until next January.

After some discussion, the Medicare rep got a supervisor who gave us a different answer.  The supervisor said she would put in a “complaint” to Humana and Health Net and ask them to cancel the Humana enrollment and re-instate the Health Net enrollment for Bill’s wife.

All this happened a week ago, last Friday. On Monday of this week, Health Net called Bill.  On Wednesday, Bill got a call from Humana. They said they will try to fix the enrollment mistake. So we’ll wait and see if the Medicare Advantage companies can fix a problem Medicare said it could not fix.

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The lesson here is that even smart people like Bill can make mistakes when they fill out important applications on-line. Enrolling in Medicare Part D, or a Medicare Advantage plan is too important to do on-line. Bill did not understand what he read about the Humana Gold Choice PFFS plan, but he figured it couldn’t hurt to put in an application.

Yikes!  Bill had no idea about the consequences of that application. He did not realize it would cancel his wife’s Health Net Medicare Advantage plan and replace it with a very expensive Humana PFFS plan that requires higher co-pays than the Health Net plan and the same 20% co-pay for an expensive electric wheelchair.

But how did the application get through to Medicare and get approved by Medicare? It should have been rejected by both Humana and Medicare. Hopefully this all gets fixed, but we’ll have to wait and see.