Does Medicare Cover “Expensive” Injections in Doctor’s Office?

Does Medicare Cover “Expensive” Injections in Doctor’s Office?

Toni: 

I have been laid off this week with my current employer’s benefits ending August 31.  I turn 65 in August and will be enrolling in Medicare.  My employer group health plan currently has an HSA with a high deductible of $3,000 which I meet early in the year due to my health issues.  The biggest medical expense is shots that I receive from 2 doctors.

One is a shot for macular degeneration which is over $2,000 per shot.  It does not take me too many treatments to make the $3000 deductible.

The other is for allergy shots taken monthly from my allergist that are not too expensive.

My concern is how does Medicare pay for these 2 medical procedures? Sherry from San Antonio, TX.

Great question, Sherry:

In the Medicare and You handbook, it discusses “What does Medicare Part B cover?”  It states that Medicare Part B “helps to cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment and other medical services.

Many preventative services and other medical services covered under Part B are discussed in the Medicare and You handbook.

Sherry, you mentioned that you have a concern about whether the expensive macular degeneration shot for your eye and the allergy testing and shots can be covered under Medicare Part B.  If these procedures are medically necessary, then Medicare will pay for those procedures.

“Medically necessary” as defined by Medicare means “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

Under “Doctor and other health care provider services”, the handbook states that “Medicare covers medically necessary doctor services (including outpatient services and some doctor services you get when you’re a hospital inpatient) and covered preventative services. Medicare covers other health care providers like physician assistants, nurse practitioners, social workers, physical therapists and psychologists.

During a Toni Says® Medicare consultation, we always verify that your prescriptions included medical injections during an office visits such as your expensive macular degeneration medications are covered on your Medicare Part D plan if for some reason, Medicare will not allow the medical injection to be covered during an office visit.

Discuss your macular degeneration eye procedure with your doctor’s office manager because you may not need to order the prescription from a pharmacy preventing using your Medicare Part D prescription drug plan and possibly going into the Donut Hole.

The Medicare handbook states that “if you’re in a Medicare Advantage Plan (like an HMO or PPO) or have other insurance, your costs may be different. Contact your plan to find out the costs.” Verify if your Medicare Advantage Plan will cover your injections or shots or will it be covered in that specific MAPD plan’s Medicare Part D plan.

The 2020 Part B medical/doctor deductible is $198 with Medicare paying 80% of the Medicare approved amount and you (the Medicare beneficiary) paying 20% of the Medicare approved amount.

To help pay for the 20% out of pocket after the $198 deductible, many enrolled in Medicare chose a Medicare Supplement to help defray the Medicare Parts A and B deductibles and out of pocket charges. With a Medicare Supplement, Sherry, you will have low or no out of pocket for Medicare medically necessary approved amounts

Have questions regarding Medicare plan changes, email the Toni Says® team at info@tonisays.com.

In August, due to America’s social distancing issues, the Toni Says Confused about Medicare workshops will be conducted via online webinars (zoom meetings). More information coming soon.

Toni King, author of the Medicare Survival Guide® is giving a $5 discount on the  Medicare Survival Guide® Advanced book and bundle packages for the Toni Says® newspaper article readers at www.tonisays.com