Should I be paying for this? And more of your Medicare questions

Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.

Moeller is a research fellow at the Center on Aging & Work at Boston College and co-author of “How to Live to 100.” He wrote his latest book, “How to Get What’s Yours: The Secrets to Maxing Out Your Social Security,” with Making Sen$e’s Paul Solman and Larry Kotlikoff. He is now working on a companion book about Medicare. Follow him on Twitter @PhilMoeller or e¬mail him at medicarephil@gmail.com.

Your Medicare Questions

Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP). It is funded by the government but is otherwise independent and trains volunteers to provide consumer Medicare counseling in state and local offices around the country. The nonprofit Medicare Rights Center is also providing on¬going help.

Julia – Fla.: I have sleep apnea, a sleep disorder in which my breathing repeatedly stops and starts. I have been through sleep studies, and a pulmonologist recommended a dental sleep apnea device. I went to a specialist who agreed and said that his patients had been approved for payment by Medicare. Several months after I paid my very large portion of the bill, my health insurer said that Medicare does not pay for this, and therefore they would not approve my claim, because they follow Medicare rules. My dentist was very surprised, as was I. Did the rules for coverage change for this type of durable medical device?

Phil Moeller: Julia has my sympathies on multiple levels. Sleep apnea is a serious problem and it’s clear by her work in sleep studies that Julia is doing what she can to learn about her condition and remedy it. In doing so, however, she also has entered into the world of what Medicare calls “durable medical equipment” devices, known as DMEs. Many of these devices have become famous as staples of late-night cable TV ads. I laughed at many of them myself when I was younger. Can anyone forget Mrs. Fletcher and her memorable line—“I’ve fallen and can’t get up”? Actor Wilford Brimley’s testimonials for a diabetes products company have made him a cult figure. There are lots of others available on YouTube.

Today, of course, I don’t laugh at Mrs. Fletcher. I am Mrs. Fletcher, or close to it.

Medicare pays for an enormous range of DMEs. They are covered under Part B of Medicare, generally require a doctor’s prescription, and must meet these four tests: they are durable, or long-lasting; they are used for medical purposes; they are usually not useful to someone who isn’t sick or injured; and they are used in your home.

Medicare works with thousands of equipment providers around the country. Not surprisingly, there always seems to be a shady outfit that would like to exploit these rules with a product that seems like the real deal to untrained eyes but isn’t. Beyond guarding against fraud, Medicare has developed a big regulatory structure to also hold down costs, oversee doctors and other healthcare providers in how they recommend DMEs, and make sure beneficiaries get what they need. The system is inherently fighting with itself, of course, because some of these objectives may be at odds with others.

Sleep apnea devices are covered by Medicare along with other Continuous Positive Airway Pressure items, known as CPAP devices. We asked folks at Medicare (technically, they’re at the Centers for Medicare & Medicaid Services, or CMS) if there have been any recent changes to CPAP coverage rules. The simple answer is no, but as faithful readers and you other insomniacs out there already know, there is little that is simple in Medicare.

Medicare hires Medicare Administrative Contractors (MACs) to run its various insurance programs. There are four DME MACs, and the one that oversees Florida is named CGS Administrators, LLC. According to CMS, each of the four DME MACs has discretion on whether or not to cover sleep apnea devices based on what the agency calls “local medical necessity criteria.” These criteria have not been changed, a CMS spokesman said, and provided this link to the Florida criteria. I took a look, and while I did stay once at a Holiday Inn Express, had absolutely no clue what the document was talking about. If you would like to get in touch with the DME folks at CGS, here’s their contact information.

This leads us to other possible glitches, and they’re just that. The first one is whether or not your sleep apnea device was properly prescribed by a doctor, and whether or not he or she is enrolled as a participating Medicare physician. Most doctors are but if yours is not, Medicare will not cover the item.

Another possible glitch is that your device was mistakenly coded for the wrong DME category. Imagine that! A coding mistake! According to the folks at the Medicare Rights Center who help with these answers, CPAP devices for sleep apnea therapy are not purchased items but are covered by DME as rental equipment. Medicare pays the MAC that supplied the device to rent it for 13 months, after which you will own it.

Your note suggests you paid a big chunk of the bill. This leads me to think that in your mind at least, you purchased the sleep apnea device and now own it. According to the MRC, you don’t. You should ask your insurer if this might be the source of its non-coverage decision.

You also said your insurance company rejected the claim, which makes me think you have a Medicare Advantage policy. Private insurers must include Part B coverage in these policies but it’s always possible that your insurer has some wrinkles. Maybe your doctor was not in its provider network. This could be a big problem. Traditional Medicare is a fee-for-service system that lets you use whatever participating doctors you wish. Medicare Advantage plans use their own care networks—it’s how they can afford to offer benefits beyond those of traditional Medicare.

You can appeal your insurer’s denial of your claim. Millions of appeals are filed every year. You’ll need to work with the office of the doctor who prescribed your device, making sure he or she confirms your need for it and providing you with the documentation your plan requires. If you need help with your appeal, get in touch with a SHIP or MRC counselor.

The American Sleep Apnea Association has resources that might help you, including several local chapters in Florida. You should be able to find people just like you and get help from them to find out the next steps you should take. The association also has an assistance program for people who cannot afford one.

Julia, if your brain hasn’t short-circuited by this point, good luck!

L.B. – Ga: Is enrollment in Part A mandatory? I know it is automatic when one signs up for Social Security before age 65. I believe one can then decline it at 65. I was told the law changed in 2011 to make Part A mandatory. Is this true?

Phil Moeller: The law did not change, although there was an unsuccessful lawsuit in 2011 that challenged it. If you are receiving Social Security benefits prior to age 65, you will be automatically covered for Medicare when you turn 65. If you are covered at that time by an employer group health insurance plan from your own employer or your spouse’s employer, and the employer has more than 20 employees, you do not need to sign up for Medicare Part B. Check this out with your current health insurer.

However, while you can reject Part B, you can only reject Part A by effectively withdrawing from Social Security and ending your benefits. In some cases, you also would have to repay any Social Security benefits you had received. People receiving Social Security have also worked long enough to qualify for free Part A of Medicare, which covers hospital and other qualifying institutional care. Because this is free and because you are already taking Social Security, I can’t think of any reason why you would be disadvantaged by taking Part A. You probably wouldn’t use it, although, again, it would be a good idea to check this out with your current health insurer.

Carol – Ariz.: I have Medicare Parts A and B as well as a retiree insurance plan from the federal government, where I worked. I am considering full time employment again at age 66 and will have employer group coverage again. Can you tell me whether Medicare will be secondary to the new employment policy and what role my retirement plan will play?

Phil Moeller: The sequence of payment responsibility will depend on the size of your new employer. If the employer has more than 20 employees, your new plan will be the primary payer and Medicare will be secondary. If the employer has fewer than two employees, Medicare will be the primary payer and the employer plan will be secondary. In both cases, your retirement plan will be third in line to pay (tertiary).

Carol might not have thought about this, but if her new plan would be the primary payer, will she even need Medicare? It might be possible for her to stop using the program and thus stop making her monthly premium payments for Part B. Social Security, which handles a lot of Medicare administrative work, is the agency that would process such a termination. Its rules require that she have a personal interview with an agency representative to review her decision and make sure there are no adverse consequences.

Nancy – Mass.: I will turn 66 this summer. I was employed and had health insurance until I lost my job in January. My current health coverage is an extension of COBRA through my carrier. It will be ending at the end of June. Have I missed my Medicare signup deadline? If so, do I have to wait until next January to apply for Part B?

Phil Moeller: No, you can still sign up for Medicare without a late enrollment penalty, but you need to do so by the end of July. As an earlier Ask Phil explained, COBRA is not considered creditable insurance under Medicare rules. This means that the eight-month Medicare enrollment period for new subscribers was triggered last January when you lost your job. Also, it might be best if you signed up for Medicare right now. There’s a good chance that your COBRA policy pays secondary to Medicare and that you could be on the hook for more of your health expenses if you have a claim and do not have Medicare. Check with your COBRA insurer to find out whether it pays primary or secondary to Medicare.