Medicare Coverage of Mental Health Services

Transcription

1 Medicare Coverage of Mental Health Services Medicare Coverage of Diabetic Services and Supplies July 2015 For Those Who Counsel People With Medicare

2 What is Diabetes? Chronic disease in which your body can t make or effectively use it s own insulin to regulate blood sugar Type 1 and Type 2 Diabetes Diabetes is the 7 th leading cause of death in the U.S. Approximately 29.1 million Americans have diabetes 26.9% are 65 and older Estimated 8.1 million are undiagnosed 1 in 3 people will develop diabetes in their lifetime 07/01/2015 Medicare Diabetic Services and Supplies 2

3 Medicare Coverage of Diabetes Services and Supplies Generally, Medicare Part B covers Diabetes screenings Diabetes self-management training Medical nutrition therapy services Hemoglobin A1c tests Foot exams & treatment Therapeutic shoes or inserts Glaucoma testing Blood sugar self-testing equipment and supplies Insulin pumps and insulin used with them Generally Medicare Part D covers Insulin Anti-diabetic drugs Certain diabetes supplies 07/01/2015 Medicare Diabetic Services and Supplies 3

4 Diabetes Screening Part B covers these screenings if your doctor determines you re at risk for diabetes You may be eligible for up to 2 diabetes screenings each year You pay nothing for the test if your doctor or other qualified health care provider accepts assignment Assignment an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. 07/01/2015 Medicare Diabetic Services and Supplies 4

5 Diabetes Self-Management Training Part B covers diabetes outpatient selfmanagement training to teach you to cope with and manage your diabetes May include tips for eating healthy, being active, monitoring blood sugar, taking medication, and reducing risks You must have diabetes and a written order from your doctor or other health care provider You pay 20% of the Medicare-approved amount, and the Part B deductible applies 07/01/2015 Medicare Diabetic Services and Supplies 5

6 Medical Nutrition Therapy Services Part B may cover medical nutrition therapy and certain related services if you have diabetes (or kidney disease) A registered dietician or nutrition professional who meets certain requirements can provide these services May include nutritional assessment, 1-on-1 counseling, and therapy services, either in person or through an interactive telecommunications system You pay nothing for these services if the doctor or other qualified health care provider accepts assignment 07/01/2015 Medicare Diabetic Services and Supplies 6

7 Hemoglobin A1c Test Is a blood test ordered by your doctor To measure your average blood sugar (also called glucose) over the past 2-3 months It helps your doctor gauge how well you re managing your blood sugar It is ordered twice a year, but can be ordered quarterly, for people having trouble managing their blood sugar 07/01/2015 Medicare Diabetic Services and Supplies 7

8 Foot Exam Part B covers a foot exam every 6 months for people with diabetic peripheral neuropathy and loss of protective sensation As long as you haven t seen a foot care professional for another reason between visits You pay 20% of the Medicare-approved amount after the yearly Part B deductible 07/01/2015 Medicare Diabetic Services and Supplies 8

9 Therapeutic Shoes and Inserts Medicare will pay for one pair of therapeutic shoes and inserts per calendar year if your doctor certifies that you have diabetes and you Have at least one of these conditions in one or both feet Partial or complete foot amputation Past foot ulcers Calluses that could lead to foot ulcers Nerve damage because of diabetes with signs of problems with calluses Poor circulation A deformed foot Are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes. Medicare also requires A podiatrist or other qualified doctor prescribes the shoes, and a doctor or other qualified individual fits and provides the shoes 07/01/2015 Medicare Diabetic Services and Supplies 9

10 Eye Exams for People With Diabetes Diabetes increases susceptibility to diabetic retinopathy and glaucoma Part B covers Yearly eye exam for diabetic retinopathy A glaucoma test once every 12 months for people at high risk for glaucoma These tests must be done or supervised by an eye doctor who's legally allowed to do this test in your state You pay 20% of the Medicare-approved amount and the Part B deductible applies In a hospital outpatient setting, you also pay a copayment 07/01/2015 Medicare Diabetic Services and Supplies 10

11 Blood Sugar Self-testing Equipment & Supplies Blood sugar (also called blood glucose) selftesting equipment and supplies are covered as durable medical equipment for all people with Medicare Part B who have diabetes, even if you don t use insulin Self-testing supplies include: Blood sugar monitors Blood sugar test strips Lancet devices and lancets Glucose control solutions for checking the accuracy of testing equipment and test strips 07/01/2015 Medicare Diabetic Services and Supplies 11

12 Insulin Pumps and the Insulin Used in the Pumps Covered for people with Medicare Part B who have diabetes and meet certain conditions Medicare covers the cost of insulin pumps and the insulin used in the pumps when medically necessary Injectable insulin not associated with the use of an insulin infusion pump and inhaled insulin are covered under Medicare Part D drug plans 07/01/2015 Medicare Diabetic Services and Supplies 12

13 Part D Coverage for Insulin and Supplies Covered for all people with Medicare Part D Medical supplies include the following: Syringes, needles, alcohol swabs, gauze, and inhaled insulin devices Injectable insulin not associated with the use of an insulin infusion pump Anti-diabetic drugs Insulin Pen Insulin Vials & Syringe 07/01/2015 Medicare Diabetic Services and Supplies 13

14 What Do I Need From My Doctor to Get Supplies? Medicare will only cover your blood sugar self-testing equipment and supplies if you get a prescription from your doctor. The prescription should include Whether you have diabetes What kind of blood sugar monitor you need and why you need it If you need a special monitor because of vision problems, your doctor must provide an explanation Whether you use insulin How often you should test your blood sugar How many test strips and lancets you need for one month 07/01/2015 Medicare Diabetic Services and Supplies 14

15 Two Ways to Get Diabetic Testing Supplies If you have Original Medicare there are 2 ways to get diabetic testing supplies 1. Delivered directly to your home by a national mail-order contract supplier (mail-order) 2. Picked up in person from any Medicare-enrolled supplier of diabetic testing supplies (non-mailorder) which could be a pharmacy 07/01/2015 Medicare Diabetic Services and Supplies 15

16 Home Delivery of Diabetic Testing Supplies You can use the Medicare National Mail Order Program No matter where you live, you ll need to use a Medicare national mail-order contract supplier for Medicare to pay for diabetic testing supplies that are delivered to your home The National Mail-Order Program doesn't require you to change your testing monitor. If you're happy with your current monitor, look for a mail-order contract supplier or local store that can provide the supplies you need 07/01/2015 Medicare Diabetic Services and Supplies 16

17 Medicare.gov Supplier Directory 07/01/2015 Medicare Diabetic Services and Supplies 17

18 Pharmacy Choice May Affect Cost Ask the supplier or pharmacy if they are enrolled in Medicare and if they accept Medicare assignment If yes to both, Medicare will pay the pharmacy or supplier directly People pay just their coinsurance amount when they get supplies from a pharmacy or supplier for assigned claims If the pharmacy or supplier doesn t accept assignment, prescription costs may be higher People may have to pay the entire charge at the time of service, and wait for Medicare to send its share of the cost If there are no local suppliers or pharmacies enrolled in Medicare that accept assignment, you may want use the mail order option This may save you money 07/01/2015 Medicare Diabetic Services and Supplies 18

19 What s Not Covered? Original Medicare and Medicare drug plans don t cover everything. Diabetes supplies and services not covered include Continuous glucose monitors Eye exams for glasses (called refraction) Orthopedic shoes (shoes for people whose feet are impaired, but intact) Cosmetic surgery 07/01/2015 Medicare Diabetic Services and Supplies 19

20 What If I Have a Medicare Advantage Plan? If you have a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, your plan must give you at least the same coverage as Original Medicare, but it may have different rules Your costs, rights, protections, and choices for where you get your care might be different if you re in one of these plans You might also get extra benefits Read your plan materials, or call your benefits administrator for more information about your benefits 07/01/2015 Medicare Diabetic Services and Supplies 20

21 Rights and Protections All Medicare beneficiaries including those covered by the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program have certain rights and protections You can find more information about your rights and protections in the following: Supplier Quality Standards and Beneficiary Protections Fact Sheet [PDF, 327KB] Your Guide to Medicare s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program [PDF, 720KB] 07/01/2015 Medicare Diabetic Services and Supplies 21

22 Problems With Service And Supplies If you have a problem getting needed DMEPOS items or services, or if you are concerned about the quality of the supplies and services you re getting Contact your supplier Call MEDICARE ( ) to get help TTY users should call /01/2015 Medicare Diabetic Services and Supplies 22

23 Competitive Acquisition Ombudsman (CAO) If you have contacted the supplier and MEDICARE, but still need help Ask the MEDICARE representative to submit your issue to the CAO The CAO Helps to ensure that DMEPOS issues are resolved Provides CMS with data that can be used to improve the Competitive Bidding Program Identifies systemic issues to help CMS ensure that people have access to high-quality DMEPOS 07/01/2015 Medicare Diabetic Services and Supplies 23

24 Diabetic Testing Supplies Fraud Schemes It may be a scam if The pharmacy bills diabetic supplies only, no medications You get unsolicited telemarketing calls from a pharmacy You re asked to purchase products you didn t order Your contacted and told to call your doctor for an order when you don t need supplies Your physician is asked to sign orders he didn t authorize You re billed for supplies that you didn t request or receive 07/01/2015 Medicare Diabetic Services and Supplies 24

25 Check Your Knowledge Question 1 Which part of Medicare covers diabetic testing supplies? a. Part A b. Part B c. Part C d. Part D 0% 0% 0% 0% a. b. c. d. 07/01/2015 Medicare Diabetic Services and Supplies 25

26 Casework Discussion Scenario 1 Agnes was just diagnosed with diabetes. How would you explain her options for getting supplies? She has Medicare Parts A, B, and D. 07/01/2015 Medicare Diabetic Services and Supplies 26

27 Casework Scenario 1 Question 1 What part of Medicare will cover her insulin? a. Part A b. Part B c. Part D d. Depends on whether she has an insulin pump 0% 0% 0% 0% a. b. c. d. 07/01/2015 Medicare Diabetic Services and Supplies 27

28 Casework Scenario 1 Question 2 Agnes received lancets and syringes in the mail that she didn t order. What part of Medicare should pay for them? a. Medicare won t pay for supplies she didn t order and her doctor didn t prescribe b. Part D c. Part B lancets and Part D syringes d. Part B 0% 0% 0% 0% a. b. c. d. 07/01/2015 Medicare Diabetic Services and Supplies 28

29 Casework Scenario 1 Question 3 All mail-order deliveries of diabetic supplies are fraudulent? a. True b. False 0% 0% a. b. 07/01/2015 Medicare Diabetic Services and Supplies 29

30 Casework Scenario 1 Question 4 Agnes tells you she saw a large box of diabetic test strips for sale cheap online from a woman who found them in a closet at her late mother s house. What would you say to Agnes? a. Great, you got a deal. b. This isn t a good idea. c. Just be sure they match your meter. 0% 0% 0% 0% a. b. c. d. 07/01/2015 Medicare Diabetic Services and Supplies 30

31 Casework Scenario 2 Sandy is enrolled in Medicare Parts A and B She has insulin dependent diabetes and tests 3 times daily Recently, Sandy s doctor determined it was medically necessary for Sandy to test more frequently 07/01/2015 Medicare Diabetic Services and Supplies 31

32 Casework Scenario 2 Question1 Sandy s supplier said Medicare won t pay for additional testing supplies even if it s medically necessary. a. True b. False 0% 0% a. b. 07/01/2015 Medicare Diabetic Services and Supplies 32

33 Casework Scenario 3 Anton has insulin dependent diabetes and has some nerve related symptoms in his feet. He asks you for information about what Medicare might cover. He has Medicare Parts A, B, and D. 07/01/2015 Medicare Diabetic Services and Supplies 33

34 Casework Scenario 3 Question 1 Anton may be eligible for a. Part B diabetes selfmanagement training b. Part B foot exams and treatment c. Therapeutic shoes and inserts d. All of the above 0% 0% 0% 0% a. b. c. d. 07/01/2015 Medicare Diabetic Services and Supplies 34

35 Casework Scenario 4 Bill has Medicare Parts A, B and D. He uses an insulin pump. His doctor has just prescribed an insulin pen with long-acting insulin for Bill to use when he s off his pump for an extended time. 07/01/2015 Medicare Diabetic Services and Supplies 35

36 Casework Scenario 4 Question 1 Which part(s) of Medicare will cover Bill s insulin? a. Part B covers the insulin used in the insulin pump and in the insulin pen b. Part D covers the insulin used in the insulin pump and in the insulin pen c. Part D covers the insulin used in the insulin pump and Part B covers the insulin in the insulin pen d. Part B covers the insulin used in the insulin pump, and Part D covers the insulin in the insulin pen 0% 0% 0% 0% a. b. c. d. 07/01/2015 Medicare Diabetic Services and Supplies 36

37 Resources American Diabetes Association diabetes.org/ MedlinePlus nlm.nih.gov/medlineplus/ Call MEDICARE ( ). TTY users should call State Health Insurance Assistance Programs (SHIPs) Medicare.gov/contacts/ If you live in a rural area contact a Federally Qualified Health Center (FQHC), visit CMS.hhs.gov/center/fqhc.asp 07/01/2015 Medicare Diabetic Services and Supplies 37

38 Publication Resource Medicare s Coverage of Diabetes Supplies & Services CMS Product No /01/2015 Medicare Diabetic Services and Supplies 38

39 CMS National Training Program To view all available NTP training materials, or to subscribe to our list, visit CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html For questions about training products

40 Appendix 1 Supply/service What s covered What you pay Anti-diabetic drugs Diabetes screenings Hemoglobin A1c Tests Diabetes self-management training 07/01/2015 Part D covers anti-diabetic drugs for maintaining blood sugar (glucose). Part B covers these screenings if your doctor determines you re at risk for diabetes. You may be eligible for up to 2 diabetes screenings each year. Part B covers outpatient training for people at risk for complications from diabetes or recently diagnosed with diabetes to teach them to manage their diabetes, with a written order to a certified diabetes self-management education program. Coinsurance or copayment; Part D deductible may also apply No coinsurance, copayment, or Part B deductible; Generally, 20% of the Medicare-approved amount for the doctor s visit 20% of the Medicareapproved amount after the yearly Part B deductible Medicare Diabetic Services and Supplies 40

41 Appendix 1.2 Supply/service What s covered What you pay Diabetes equipment & supplies Uses insulin, they may be able to get up to 300 test strips and lancets every month, and 1 lancet device every 6 months. Doesn t use insulin, they may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months. Diabetes supplies Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. These supplies include: Blood glucose monitors; Blood glucose test strips; Lancet devices and lancets; Glucose control solutions for checking the accuracy of testing equipment and test strips. Part D covers certain medical supplies for administration of insulin (like syringes, needles, alcohol swabs, gauze, and inhaled insulin devices). 20% of the Medicareapproved amount after the yearly Part B deductible If your doctor says it s medically necessary, Medicare will allow you to get additional test strips and lancets. Coinsurance or copayment Part D deductible may also apply 07/01/2015 Medicare Diabetic Services and Supplies 41

42 Appendix 1.3 Supply/service What s covered What you pay Foot exams & treatment Therapeutic shoes or inserts Part B covers a foot exam every 6 months for people with diabetic peripheral neuropathy and loss of protective sensation, as long as they haven t seen a foot care professional for another reason between visits. Part B covers therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease. The doctor must certify your need for therapeutic shoes or inserts. The shoes and inserts must be prescribed and provided by a qualified doctor. 20% of the Medicareapproved amount after the yearly Part B deductible 20% of the Medicareapproved amount after the yearly Part B deductible 07/01/2015 Medicare Diabetic Services and Supplies 42

43 Insulin Appendix 1.4 Supply/service What s covered What you pay Insulin pumps Medicare Part D covers insulin that isn t administered with an insulin pump. Medicare Part B covers external insulin pumps and the insulin that the device uses under durable medical equipment for people who meet certain conditions. Coinsurance or copayment Part D deductible may also apply 20% of the Medicareapproved amount after the yearly Part B deductible Medical Nutrition Therapy Part B may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, and your doctor refers you for the service. No copayment, coinsurance, or Part B deductible if your doctor or health care provider accepts assignment 07/01/2015 Medicare Diabetic Services and Supplies 43