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  • Protecting Retiree Benefits
  • Supporting SRS Missions

Medicare
Information

Disclaimer: All references to SRS Medical Benefits after a retiree goes on Medicare are based upon current data.  The picture will be changed drastically when SRNS implements its plan to break its promises made as part of Early Retirement Incentives and to severely reduce medical benefits for retirees on Medicare beginning Jan. 1, 2013.  

NEW ITEM IMPORTANT INFORMATION ABOUT YOUR MEDICARE INSURANCE

Approaching 65 and Medicare

Issues To Be Aware of When You Go On Medicare

What You Need to Know About Opt-Out Providers

Changes in Medicare Procedures for Medical Summary Notices (MSNs)

SRSRA Advisory on Medicare Prescription Drug Plans

U. S. Government Medicare Web Site

Helpful Hints for Getting Your Health Care Expenses Reimbursed by Insurance

How to File a Medicare Claim Yourself

View Medicare Summary Notices (MSNs) on the Internet

Medicare Assistance


NEW ITEM IMPORTANT INFORMATION ABOUT YOUR MEDICARE INSURANCE

When you first signed up for a Medicare Supplement insurance policy, you used My Medicare Advocate to choose the company and policy.  Many retirees have had a policy for several years and wish to make changes. Please note: You MUST use My Medicare Advocate to make any changes to your Medicare Supplement policy or insurance company.  Failure to do so will result in the loss of the stipend.  This also applies to your spouse who receives a stipend.

If you are using Medicare Part D insurance policy, you should review your drug plan annually (during the sign up period).  The easiest way is to enter your list of drugs and other information by following the instructions on Medicare Find-a-Plan.   You may also review your plan by linking to MyMedicareAdvocate/SRS   and entering the PIN you were most recently issued by MMA.  Note that you DO NOT have to go through MMA to make changes to your Part D insurance policy, but you may do so if you choose.

You may also call My Medicare Advocate to get help with either your Medicare Supplement policy or your Part D policy, or use the SRS Resource Center. Your list of drugs may change and Medicare coverage for various drugs changes each year, so an annual review may save you money.

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Approaching 65 and Medicare

As you approach 65, make sure you are enrolled in Medicare and ready to transition from the Site medical plan to Medicare/Medicare supplement.  (Medicare coverage starts at the beginning of the month of your 65th birthday.)  If you are already drawing Social Security, then Medicare enrollment is automatic and you should receive a Medicare card showing enrollment in Part A and Part B about 3 months before eligibility.  If you are not drawing benefits, then you need to enroll for Medicare Parts A and B online or in person in the 3 month period before your birthday.  It is important to enroll early in this period to ensure coverage beginning the 1st of your birthday month and to allow time to set up your supplement and drug plans for continuous coverage.

Retirees will have to make unprecedented choices to use their site stipends wisely to purchase supplementary medical and drug insurance.  Some will see large cost increases because of changes in the system; others may see reduced costs; and some will see increased costs because they chose unwisely.

My Medicare Advocate (MMA) will be contacting you about 3 months before age 65 to sign you up for medical and drug insurance policies and can transfer you to a dental plan by phone, if you so desire. You should be getting a welcome kit and a PIN (personal identification number) from MMA. This will show you how to set up an account with MMA so that you can start making decisions as to which Medigap or Medicare Advantage policy is best for you.  You will have to enter your own list of drugs (Blue Cross did this for the initial transition, but no longer provides this service), which will enable MMA and you to choose which medical and drug plans that you may want.

Once you are registered with an account, you will be able to see the prices for you. (Prices are not shown on the MMA public website --- only on your personal, private website.) And be sure to ask your advocate for other prices, as some insurance companies do not allow their prices to be published anywhere.  So what is your deadline for purchasing a Medicare drug plan?  The Medicare Part D plans are required to get you ID cards or a letter you can take to your provider within 10 days of your application being approved.  The Medigap Plans take 2-3 weeks to get your ID cards.

As an example of the timing, if you were to turn 65 in May, in late January/early February, you should be receiving your Medicare card and MMA welcome kit and PIN.  With this information, you can set up an account online and start choosing your plan(s).  By March, you should have chosen your plan(s), assuming you have your Medicare card.

Here is some information, thoughts and ideas to consider when choosing your Medicare supplement plan. This information is based on retirees' experience as we have transitioned from SRS coverage. If you are approaching 65 at other than the national annual enrollment period of October and November, hopefully you will not experience the extreme difficulty many of us had during the initial rush in late 2012 in contacting My Medicare Advocate. You can download a .pdf file of collected information by CLICKING HERE.   We hope you find this information useful.

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Issues To Be Aware of When You Go On Medicare

This is part of a communication sent by the SRNS Benefits Administration to the SRSRA Medical Benefits Committee, and dated February 1, 2011:

“When you become eligible for Medicare (Parts A&B) Medicare becomes your primary (first payer for) medical coverage. (However, if you are receiving Benefits as an active employee or a dependent of an active employee – the Plan will still be primary and you will not need to enroll in Medicare Part B until your employment ends.)  When Medicare is primary, claims should be submitted and paid by Medicare (Parts A&B) prior to their submission to Blue Cross Blue Shield (BCBS) for reimbursement from the Medical Benefits Plan. When Medicare (Parts A&B) is primary, BCBS calculates the normal benefit payable for a covered expense and then “ carves out” (or subtracts) what Medicare would pay for the expense. The difference between the normal SRS Plan benefit and the Medicare benefit is what BCBS would actually pay. You would then be responsible for the remaining amount up to the Medicare allowable amount. The SRS Plan should not be confused with what is referred to as a Medicare Supplemental or Medigap Plan.

It is important for you to understand when Medicare is primary that BCBS-SC will calculate the payment of a claim with the “carve out” approach as described below even if you have not enrolled in Medicare Part B coverage. When Medicare is primary and you do not enroll in Medicare Part B, the Plan will not pay for what would have been covered under Medicare Part B and your out of pocket cost will increase. You should also be aware that Medicare has penalties both in delayed coverage start dates and increased cost of coverage for not enrolling in Part B when you are first eligible after employment terminates. You may wish to contact your Social Security Office for more information on Medicare coverage and enrollment.

In January 1, 2006, new Medicare prescription drug coverage, Medicare Part D, became available to anyone eligible for Medicare. BCBS of South Carolina has determined the SRS prescription drug coverage, on average for all plan participants, and is expected to pay as much as the standard Medicare Part D will pay or defined as “credible coverage.” The “carve out” provision does not apply to Medicare Part D.”

Medicare Physicals

Update regarding Physicals for those of us on Medicare. This change began in January 2011. Medicare covers two types of physical exams – one when you’re new to Medicare and one each year after that. (Page 39 – Medicare & You booklet)

Within the first 12 months of our beginning on Medicare Part B we can receive a “Welcome to Medicare” physical exam and we pay nothing if we go to a physician who accepts Medicare assignment. You need to let the doctor know you are scheduling a “Welcome to Medicare” physical.

We are also entitled to a yearly “Wellness” exam if we have been on Part B for longer than 12 months. This yearly wellness visit is to develop or update our current health and risk factors. We pay nothing for this exam if the doctor accepts Medicare assignment. This exam is covered once every 12 months. The “Wellness” exam can not take place within 12 months of your “Welcome to Medicare” exam.

Please note that the 12 month interval between physicals must be a minimum of 12 months – 365 days. If you receive the wellness physical on day 364, Medicare will not pay for it. It is also very important to make sure your doctor knows that you are there for either the “Welcome to Medicare” or annual “Wellness” exams. The physician’s billing to Medicare must be specifically coded for these exams, and Medicare prescribes exactly what tests must be run for each and what they will pay for.

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What You Need to Know About Opt-Out Providers

(This information first appeared in an article in the SRSRA Newsletter, May, 2005

You can’t be asked to sign a private contract in an emergency situation or when you need urgent care.

A vexing situation appears to be repeating itself with greater frequency for SRSRA retirees age 65 and over. Vital health care needs are not always available from Medicare Providers. This may occur in one of two situations. One, Medicare does NOT cover the medically necessary test or treatment. Two, best practice providers have chosen to “Opt-Out” of Medicare.

The first situation involving a Medicare non-covered item is not too problematic. Medicare requires the provider to inform you that Medicare probably will not pay and have you sign an Advanced Beneficiary Notice, ABN. Sometimes the Medicare non-covered item is still covered by the SRS Team Health coverage being administered by BCBS. Medicare may not cover an item at all, only at specified frequencies, or only when medically necessary. On occasion reports have been noted that ABNs are being used for medically unnecessary items that serve only to protect the provider from liability.

The second situation involving providers that have chosen to Opt-Out of Medicare is most problematic. Opt-Out providers can gouge out whatever the market will bear.

In this situation, as prescribed by US Code, Our Health Choice self-insured plan is still only the “secondary” insurance. As such, when the benefit coordination occurs the portion that Medicare (“primary”) would have paid (called the Medicare “limiting” amount) is first subtracted. This is sometimes referred to as the “carve-out”.

Recently a SRSRA member reported a case where the only successful health care option was from a provider that has chosen to Opt-Out of the Medicare system. Medicare refers to this as a “Private Contract”. See page 64 of Medicare & You 2012.

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Changes in Medicare Procedures for Medical Summary Notices (MSNs)

Medicare only sends Medical Summary Notices (MSNs) to participants on a quarterly schedule provided there were claims Processed in the participant's account during the quarter.  Participants may receive an Explanation of Benefits Summary from Blue Cross on a claim before receiving their quarterly MSN.  Retirees should carefully review their Medicare and Blue Cross statements until they become familiar with this change in notification procedure.

As a result of these cost saving administrative changes, retirees may find it more difficult to track their medical expenses. If a retiree needs information about a medical claim they should not hesitate to contact Customer Service at Medicare.   The Medicare Helpline telephone number is 1‑800‑633‑4227

Please note that you can also view your MSNs online at the Medicare.gov link listed below on this page.

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MEDICARE PRESCRIPTION DRUG COVERAGE OPTION

If you are currently, or will soon become, eligible for Medicare , you will receive solicitations to sign up for Medicare prescription drug coverage (Part D) annually.  During November, 2009, SRS mailed retirees a letter entitled:

"SRNS &SRS health choice 2010 Medical Participant information for SRNS & SRS retirees."

You should read this letter carefully before you enroll in any other Part D plan.  To obtain a copy of this letter, or a more recent one, click on the following links: Nov. 1, 2009,   or   Nov. 10, 2011 .

NOTE:      • The Site BCBS prescription drug plan is better than any of the Medicare prescription drug plans for all but exceptional cases The figure below shows the out-of-pocket cost for prescription drugs for three options:

(1) No insurance
(2) SRS-BCBS plan
(3) Medicare Part D coverage
The figure below clearly shows that the out-of-pocket cost for prescription drugs is lowest for the SRS-BCBS plan.

Rx Drug Costs

     Additionally, WSRC/BSRI has already sent you a notice stating that our Prescription Drug coverage under the WSRC Team Health Choice Plan already meets Medicare’s standards for retirees on Medicare.   YOU SHOULD KEEP THAT LETTER FOREVER!

      [IMPT. NOTE:You can download a copy of that vital letter here.]

     An on-line tool that you may want to use is at:

           Results of a search of the Medicare.gov site for Medicare Prescription Drug Coverage


Also, check the Medicare.gov site (see first link in next section below) where you can do you own searches.

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The U.S. Government Medicare web site has more information about the Medicare Part D Prescription Drug plan and other information about Medicare.

The Medicare State Health Insurance Assistance Program (SHIP) web site has links to counselors in every State and several Territories who are available to provide free one-on-one help with your Medicare questions or problems..

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Helpful Hints for Getting Your Health Care Expenses Reimbursed by Insurance

In the complex world of getting reimbursement for your Health Care expenses, the following Helpful Hints will help you get the correct insurance reimbursements due you under the SRS Health Benefit Plans.

In general, Blue Cross/Blue Shield (BC/BS) won’t consider your claim for payment until they have the related Medicare Summary Notice (MSN). Most providers will file Medicare for you. In case they don’t or won’t, it is up to you to file for Medicare payment, even if the amount to be paid by Medicare is zero or small, because BC/BS won’t consider your claim unless they have the MSN from Medicare. (See the next section below about how to file a Medicare claim yourself.)

If you have a provider who lives in your state of residence, the provider will in most cases file Medicare for you in the state of residence, and Medicare will send the MSN to BC/BS in your state of residence, thus enabling BC/BS to provide you with payments under the contract.

If the provider is outside your state of residence, the provider will in most cases file Medicare for you in the provider’s state, not your state of residence, and in general neither Medicare nor the provider will file the MSN with your state of residence BC/BS. It is therefore generally up to you to forward the MSN to BC/BS in your state of residence in order to receive appropriate payment.

However, as of January 1,2006, if the provider is outside your state of residence, your Medicare claim information will be automatically crossed over electronically to your SRS Health Benefit Plan for secondary payment consideration.  This process eliminates the need to have your medical summary notice sent to the BCBS in your state of residence.  Upon completion of processing under your SRS Plan, you will receive an Explanation of Benefits.

If a provider does not accept assignment under Medicare Part B for a Medicare covered procedure, then provider charges are capped by law at 15 % above Medicare Part B payments.

For claims to BC/BS where there is a dispute whether services rendered are under medical or mental health coverage, BC/BS generally won’t consider your claim for payment until they have the related Medicare Summary Notice and a Statement of Denial from Value Options (VO), the mental health coverage carrier. This latter Statement of Denial is a formal letter stating VO's refusal to pay.

Finally, do not sign any waivers and do not pay anything until you receive an Explanation of Benefits (EOB) from Blue Cross Blue Shield.


Problems with BCBS software system

For those on Medicare it is important to be conscientious about reviewing your MSN’s (Medicare Summary Notices) against your BCBS EOB’s (Explanation of Benefits) especially for those living outside the State of South Carolina. Apparently there is a flaw in the transfer of information between the Medicare and the BCBS software systems when initiated out-of-state. On your BCBS EOB, you will be notified that your charges are out-of-network and are not paid. You need to contact the retirees’ customer service representative listed on our Website to get clarification. Sending an email is very effective - gari.howard@bcbssc.com

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CLICK HERE TO FIND OUT HOW TO FILE A MEDICARE CLAIM YOURSELF if your provider will not do so.

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View your Medicare Summary Notices (MSNs) on the Internet

Viewing your Medicare Summary Notices (MSNs) on the Internet has become very important because of changes in the way Medicare and BCBS send hard copies of the MSNs and EOBs, respectively. As of Sept. 18, 2006, the SC Medicare has moved their records to the Federal Medicare site. (This move is explained here). To access your records, go to the following link:
Federal Medicare MSNs on the Internet   The page will tell you how to register and login.

NOTE: You may become infuriated trying to use this site. It is particularly ill-equipped to deal with Mac computers using the Safari or Firefox browser (actually, the Firefox browser won't work on PCs either for this web site).  You may have to use Internet Explorer as your browser, although Netscape Navigator has worked recently. None of the Medicare "help desk" seem to understand, let alone be able to solve, this problem.  We have contacted CCME (below) to enlist their help in getting this improved for you.

Open a new Browser window, and type in, or just copy from here and paste into the address bar, the following URL:
https://myportal.medicare.gov

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Medicare Assistance

You can call the national 24-hour customer service number 1-800-MEDICARE (1-800-633-4227), or visit http://www.medicare.gov. If members have a state-specific question, the customer service representative at the above number should be able to refer members to the state-specific Medicare number. (The one for South Carolina is 1‑800‑583‑2236.) This may be a useful starting contact to resolve Medicare issues if the regular Medicare office of your state is not providing satisfactory service.

There is a Medicare Advice Counseling Service out of the South Carolina Lieutenant Governor’s office.  The contact at this office is Gloria McDonald.   The number is 803-734-9900 or 1-800-868-9095 or email askus@aging.sc.gov. Their web site is http://www.aging.sc.gov

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Send e-mail to: Board of Directors

US Mail: SRS Retiree Association
P.O. Box 5686
Aiken, S.C. 29804

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SRS Retiree Association, Inc.
Aiken SC

Revised: January 2, 2015


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