Will Medicare Pay for Injections Given in a Doctor’s Office?

Toni: 

I am turning 65 in January 2020 and understand that Medicare is making changes especially with Medicare Supplements. My under 65 individual health plan has a $4,000 deductible which I meet every year due to shots of Lucentis for Macular degeneration which is over $2500 per shot given at the doctor’s office. I also have allergy shots given each week from another doctor.  Does Medicare pay for that?

My concern is how will Medicare pay for this charge in 2020. Look forward to your answer. Tabitha from Sugar Land area

Great question, Tabitha:

Most Americans do not realize what is covered under Medicare Part B, which is the medical part of Medicare.

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

You mentioned that you have a concern about whether expensive macular degeneration injections for your eyes 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. Your out of pocket is the $185 Medicare Part B deductible.

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

“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.”

In the handbook under “Doctor and other health care provider services”, it 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.The 2019 Part B medical/doctor deductible is $185 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 $185 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, Tabitha, you will have low or no out of pocket for Medicare medically necessary approved amounts depending on which Medicare Supplement plan you are enrolled.

The Medicare handbook states that “if you’re in a Medicare Advantage Plan (like a 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.

For a Medicare checkup call the Toni Says Medicare call center at 832/519-8664 regarding your Medicare plans and options.

Toni Says Confused about Medicare Open Enrollment Workshops begin in September:

• Thursday September 19-Champion Forest Baptist Church 6:00PM-8:00PM
• Tuesday September 24-Sugar Creek Baptist Church, 6:30-to 8:30
• Wednesday, October 2- St Paul’s Methodist Church, 400 to 7:00 PM
• Tuesday October 15-Westbury Baptist Church 6:00-8:00 PM

Toni King, author of the Medicare Survival Guide® iswhich is a simple guide that puts Medicare in people terms isgiving a $5 discount on the  Medicare Survival Guide® Advancedbook at www.tonisays.com. Have a Medicare question? Email Toni atinfo@tonisays.com.