Preventive screenings are covered by Medicare at no cost to the patient, but sometimes there will be a bill to pay.  A colonoscopy is the example I use with my clients to explain how “free” tests and procedures sometimes turn out not to be free.

Last month, a client called me to complain about a bill she received for her colonoscopy. “Should I pay this bill?” she asked. “I thought this test was supposed to be free!”

My quick reply to her question was, “Yes, you must pay that bill”. Then I said, “They found polyps and removed them, didn’t they?”  She wondered how I could know the results of her colonoscopy, so I told her how a free screening can turn into a billable procedure.

A preventive screening colonoscopy is “free” to the patient – but when the doctor finds polyps and removes them, that preventive screening procedure turns into “outpatient surgery”. This client told me her bill was $250, and sure enough, her Medicare Advantage plan has a $250 co-pay for outpatient surgery. This is how I deduced that polyps had been found and removed during her colonoscopy.

Here is the list of preventive screenings covered by Medicare at no cost to the patient. I’ve highlighted the most common ones.

Abdominal Aortic Aneurysm Screening

Alcohol Misuse Screening and Counseling

Bone Mass Measurement (Bone Density Test)

Cardiovascular Disease (Behavorial Therapy)

Cardiovascular Screenings (cholesterol, lipids, triglycerides)

Colorectal Cancer Screenings

Depression Screening

Diabetes Screening

Flu Shot

Glaucoma Test

HIV Screening

Mammogram (screening for breast cancer)

Obesity Screening and Counseling

Pap Test and Pelvic Exam (includes a breast exam)

Prostate Cancer Screenings

An insurance agent was trying to help a senior citizen who was not sure if he gets help with his drug costs or his Medicare premium. The insurance agent, sitting with the senior, called Social Security (800-772-1213) and had the senior give permission to Social Security to talk to the insurance agent about what was in his record. The insurance agent knew what questions to ask to determine if the senior gets a low income subsidy for his drug costs.

The Social Security rep asked the insurance agent, “Are you going to sign this person up for a Medicare Advantage plan?”. The agent said she might do that, so the Social Security rep said, “Well, I’m not going to talk to you because you’re just trying to enroll this person in a Medicare Advantage plan”.

The senior then told the Social Security rep to talk to the agent because she was trying to help him.

The senior was already enrolled in a Medicare Advantage plan and wanted to change to a lower-cost plan. Most people are “locked into” their Advantage plan for the rest of 2013, but some people are allowed to change plans. These are folks who get the “Low Income Subsidy” for their drug costs (LIS).

Medicare allows people with LIS to change their Advantage plan or their Part D plan at any time during the year.

The Social Security rep said the senior should hang up and call back when the agent was not with him. The senior and the agent were shocked.

Is this a new Social Security policy? Are insurance agents officially presumed to be taking advantage of senior citizens? Is it a new rule that Social Security will not talk to an insurance agent who is sitting with a senior who is asking for help?

I only call Social Security if I’m helping someone get answers about enrolling in Medicare. I call Medicare when I need to get answers for a senior who is already covered by Medicare.  I know we can ask a Medicare rep if the senior’s record says he or she is enrolled in the Low Income Subsidy or the Medicare Savings Program. Sometimes a senior  has misplaced their Medicare card because they are enrolled in a Medicare Advantage plan. They need their Medicare card info if they want to change to another Advantage plan, and they can ask that a new card be sent to them.

The Medicare phone system (800-623-4227) tells you how much time you will wait until you will be able to talk to a person – and the wait is usually less than five minutes (except during the Open Enrollment Period). I’ve even called Medicare on the weekend and talked with very helpful representatives.

It seems odd that a Social Security representative would not agree to a senior’s request to allow an insurance agent to assist him. Did the Social Security rep think this senior was being held captive by the insurance agent and forced to make the call? The entire incident seems very odd.

How does Medicare work with other insurance coverage, such as a group health plan from a former employer or union? This is an important question because it determines whether your medical bills are paid correctly and on time.

Here is information from CMS (Centers for Medicare and Medicaid Services):

If you have Medicare and other insurance, always be sure to tell your doctor, hospital, and pharmacy. When there’s more than one insurance payer, certain rules determine which one pays first. This is what’s called “coordination of benefits.”

The “primary payer” pays what it owes on your bills first — and then sends the balance to the “secondary payer” to pay. In some cases, there may also be a third payer.

The primary payer pays up to the limits of its coverage. The secondary payer only pays if there are costs the primary insurer didn’t cover. But keep in mind that the secondary payer (which may be Medicare) may not pay all of the uncovered costs.

When Medicare is primary:

If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before that insurance will pay. (The Part B premium for most Americans in 2013 is $104.90 per month.) Here’s who pays first in various situations:

If you have retiree insurance (coverage from a former job), Medicare pays first.

Medicaid and TRICARE (the healthcare program for U.S. armed service members, retirees, and their families) never pay first for services that are covered by Medicare. They only pay after Medicare, employer plans, and/or Medicare Supplement Insurance (Medigap) have paid.

When Medicare is not Primary:

If you’re 65 or older, have group coverage based on your or your spouse’s current employment, and the employer has 20 or more workers, your group plan pays first. (If the company has fewer than 20 employees, Medicare pays first.)

Your group plan also pays first when you’re under 65 and disabled, have group coverage based on your or a family member’s current employment, and the employer has 100 or more employees. (Medicare pays first if the company has fewer than 100 employees.)

If you have Medicare because of end‑stage renal disease (permanent kidney failure), your group plan pays first for the first 30 months after you become eligible for Medicare. Medicare pays first after this 30‑month period.

Medicare may pay second if you’re in an accident or have a workers’ compensation case in which other insurance covers your injury or you’re suing another entity for medical expenses.

These types of insurance usually pay first for services related to each type:

·     No-fault insurance (including automobile insurance);

·     Liability (including automobile and self-insurance);

·     Black lung benefits;

·     Workers’ compensation.

For more information, visit www.medicare.gov/publications and read the booklet “Medicare and Other Health Benefits: Your Guide to Who Pays First.”