Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
MARCH 2003 NICA NEWS
QUESTIONS AND ANSWERS
Q. Does Medigap insurance cover pre-existing conditions?A. An applicant could have a waiting period of up to six months for Medigap coverage of pre-existing conditions. However, the waiting period could be shortened or eliminated if the beneficiary previously had an insurance policy that qualifies as "creditable" coverage. In order to reduce the pre-ex waiting period, the beneficiary must have had the coverage within the 63 days prior to Medicare supplement coverage. Creditable coverage means one of the following types of insurance:
- Medicare Part A and Part B (only considered creditable during the first six months in which the beneficiary is both 65 years of age or older and enrolled in Medicare Part B)
- A group health plan (like an employer plan)
- COBRA
- Private health insurance coverage
- Medicaid
- CHAMPUS and TRICARE (health care programs for the uniformed military services)
- Federal Employees Health Benefit Plan
- A public health plan
- State health benefits risk pool
- A program of the Indian Health Service or Tribal Organization
- A health plan under the Peace Corps Act
- Medicare supplemental insurance or Medicare HMO plan Federal law defines a pre-existing condition as any condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage. Medigap insurers are required to reduce the pre-existing condition waiting period by the number of days an individual was covered under some form of "creditable" coverage (see above list) so long as there were no breaks in coverage of more than 63 calendar days.
Q. I bought a lift chair and Medicare has not approved the claim. They said I needed a doctor's order. Can I go back and get the order now and have Medicare pay for it?
A. Medicare's Durable Medical Equipment policy requires that the written order must be received prior to delivery in order for them to pay. That means that the "certificate of medical necessity" (CMN) needs to have been completed by the doctor with a date on it prior to the delivery date of the chair. Once the beneficiary accepts delivery of the chair they cannot go after the fact and obtain the written order.
Q. Can a non-participating Durable Medical Equipment (DME) provider accept assignment on some items and not others?
A. If a DME provider is participating it must accept assignment on all items. However, non-participating providers can pick and choose what items they will accept assignment on. The beneficiary pays 20% of the Medicare approved amount plus any extra amount the provider charges. The 15% limit on excess charges does not apply, so it is important to shop around. One provider may accept assignment on a particular piece of equipment and another may not.
Q. Do most people have an insurance policy to supplement Medicare?
A. According to Health Affairs, February 2002:
In 1999, 87% of all Medicare beneficiaries had some form of insurance to supplement Medicare.
- 33% - employer-sponsored
- 24% - Medigap policy
- 17% - Medicare + Choice
- 13% - no supplemental coverage
- 11% - Medicaid
- 2% - other public