Pride TLC is Here to Help.

We take pride in serving the Wausau community, and in providing guidance to those who are struggling to navigate today’s complicated healthcare system. We are happy to help formulate the best transitional plan in order to ensure top-tier care with minimum financial burden to the patient- with no obligation to choose us as your provider.

Below are a few common questions asked.  If you have additional questions, please don’t hesitate to contact us any time.

What is Medicare?

Medicare is a federal health insurance program for qualified people who are:
•    Age 65 or older
•    Under age 65 but with certain disabilities
•    Any age but with end-stage renal disease (ESRD) or Lou Gehrig’s disease
Medicare includes the following four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (prescription drug coverage). Medicare also includes Medicare Supplement Plans (also called Medigap or MedSup).

How Does Medicare Work?

Medicare is a federal health insurance program that provides benefits to individuals age 65 and older and individuals of any age with a qualifying disability or illness. Most people are automatically enrolled into Original Medicare, Part A and Part B, when they become eligible at age 65. Medicare Part A and Part B cover costs associated with medically necessary hospital and medical services and supplies.

Beneficiaries who choose to enroll in a private Medicare plan have additional coverage options. Private coverage options such as Medicare Part D, Medicare Advantage, and Medicare Supplement policies may help cover the costs of prescription medications and other out-of-pocket costs not covered by Original Medicare. Some plans may require deductibles before Medicare pays its part and certain other out-of-pocket expenses, such as monthly premiums, copayments, and coinsurance payments.

Medicare has neither reviewed nor endorsed this information.

What is the "Welcome to Medicare Physical Exam" ?

The “Welcome to Medicare” physical exam is a one-time, preventive physical exam Medicare covers within the first 12 months that you have Part B. The exam will include a thorough review of your health, along with education and counseling about the preventive services you need, like certain screenings and shots, and referrals for other care.

This exam is a great way to get up-to-date on important screenings and shots and to talk with your doctor about your family history and how to stay healthy. During the Welcome to Medicare exam, your doctor will record your medical history and check your vision, blood pressure, and weight and height to measure your body mass index (BMI). Body mass index is a measure of body fat that applies to both adult men and women.

Your doctor will check that you are up-to-date with preventive screenings and services, such as cancer screenings and immunizations. Further tests may be ordered, if necessary, depending on your general health and medical history. For example, a person at risk for an abdominal aortic aneurysm may get a referral for a one-time screening ultrasound at his or her Welcome to Medicare physical exam. Your doctor will also give you advice to help you prevent disease, improve your health, and stay well. You will get a written plan (such as a checklist) when you leave, letting you know which screenings and other preventive services you should get in the future.

Your doctor will also talk with you about end-of-life planning, including advance directives. Advance directives are legal documents that let you put in writing what kind of health care you would want if you were too ill to speak and/or make decisions for yourself. Talking to your family, friends, and health care providers about your wishes is important, but these legal documents ensure your wishes are followed.

When do I get my Welcome to Medicare exam?

Once you enroll in Medicare Part B, schedule your Welcome to Medicare physical exam right away. Medicare will only cover this physical exam if it occurs within the first 12 months that you have Part B.

If you’ve had Part B for over 12 months, you can get a yearly “Wellness” visit instead. This visit is also covered and can help you and your doctor develop a personalized health plan.

How much does the exam cost?

Your Welcome to Medicare exam costs nothing if the doctor or health care provider accepts assignment. If you have additional tests or receive other services during this visit, you may have to pay coinsurance and the Medicare Part B deductible may apply.

What should I bring with me to the exam?

You should bring the following things with you when you go to your Welcome to Medicare physical exam:

  • Medical records, including immunization records if you are seeing a new doctor for the first time.
  • A list of prescription drugs that you currently take, how often you take them, and why.
  • Family health history. Try to learn as much as you can about your family’s health history before your appointment.
  • Any information you can give your doctor to help determine if you are at risk for certain diseases.

Medicare has neither reviewed nor endorsed this information.

How Do I Get a New Medicare Card?

Most people are automatically enrolled into the Original Medicare (Part A and Part B) and receive their Medicare card in the mail three months before turning 65. If you are under 65 and disabled, you will also be automatically enrolled into Medicare Part A and Part B after 24 months of receiving disability benefits from Social Security or the Railroad Retirement Board (RRB). If you do not qualify for automatic enrollment, you can file through the Social Security website and will receive your Medicare card within 30 days of enrollment.

If your Medicare card is stolen, lost, or damaged, you can apply for a new one via the Social Security website. To make an online request for a new Medicare card, be prepared to provide:

  • Your name as it appears on your most recent Medicare card
  • Your Social Security number
  • Your date of birth

Your new card will arrive in the mail around 30 days after you apply for a replacement and will be sent to the address that Social Security has on file. If you have moved and did not change your address on file, you must report this change before requesting a new card.

If you are unable to use the online request or would rather talk to someone directly, you can also speak with a Social Security representative by calling toll-free at 1-800-772-1213 (TTY 1-800-325-0778). You may also visit your local Social Security office.

If you need proof that you have Medicare sooner than 30 days, you can also request an entitlement letter which you should receive within 14 days. If you need proof immediately for your doctor or for a prescription, visit your nearest Social Security office for assistance.

Medicare has neither reviewed nor endorsed this information.

How Do I Contact Medicare?

Beneficiaries or caregivers who have questions or concerns regarding their Medicare coverage have a few options for contacting Medicare. Depending on your need, you can:

  • Log in to your MyMedicare.gov account to access billing-related information, including your claims, expenses, or medical records. If you are having issues accessing your account, then you may want to consult the customer service department.
  • Speak with a customer service representative through online Live Chat support.
  • Call a Medicare customer service representative at 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048), 24/7.
  • Call MyMedicare.gov technical assistance at 1-877-607-9663.

Additionally, if you have general questions about your Medicare coverage and wish to contact Medicare by mail, you may send any inquiries to:

Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Be aware that, for security purposes, no one will be able to contact Medicare on your behalf without filling out a “Medicare Authorization to Disclose Personal Health Information” form. This form can be found on Medicare.gov and is necessary if you wish to have someone make inquiries on your behalf.

Medicare has neither reviewed nor endorsed this information.

How Do I Change My Address Through Social Security?

If you get Social Security benefits, you can change your Medicare address online at the Social Security website. If you change your address online, you will be asked a series of questions to verify your identity. Your answers must match the information Social Security has in its records. You can only change your address online if you have established a permanent password, which can be created by visiting My Social Security.

If you do not want to answer the questions online or you do not have a permanent password, you cannot submit a change of address online. Instead, you can call the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778) and speak to one of their representatives or visit your local Social Security office.

If you received a Social Security Statement with an incorrect address, this is probably due to the fact that those addresses came from the Internal Revenue Service, so you must make the correction with them, not Social Security. You can download the change of address form at the IRS website, or you can call the IRS toll-free telephone number at 1-800-829-3676 and ask for Form 8822.

Medicare has neither reviewed nor endorsed this information.

How Do I Report a Medicare's Beneficary's Death?

When the death of a Medicare beneficiary occurs, the family member or person responsible for the beneficiary’s affairs should promptly notify Social Security. He or she can do so by calling Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

If monthly benefits were being paid via direct deposit, the bank or other financial institution also needs to be notified of the beneficiary’s death. Any funds received for the month of death and any later months must be returned to Social Security as soon as possible.

If benefits were being paid by check, do not cash any checks received for the month in which the beneficiary died or thereafter. Return the checks to Social Security as soon as possible. A one-time payment of $255 is payable to the surviving spouse if he or she was living with the beneficiary at the time of death or if the surviving spouse was living apart from the beneficiary, but was receiving Social Security benefits from the beneficiary’s earnings record. If there is no surviving spouse, the payment is made to a child who was eligible for benefits from the beneficiary’s earnings record in the month of death.

Medicare has neither reviewed nor endorsed this information.

What if a Person Has a Concern About the Quality of Care Received While on Medicare?

If you feel that you did not receive the proper care and are concerned about it, you may contact your local Quality Improvement Organization (QIO). This group of doctors and other health care providers works to improve quality of care for Medicare beneficiaries.

To get contact information for the QIO:

or

  • Call 1-800-Medicare (1-800-633-4227)

As a Medicare beneficiary, you may use the Find Affordable Medicare Insurance tool on our Comparing Medicare Advantage Plans page to compare Medicare Advantage (MA) plans and Prescription Drug Plans (PDP) in your area. The quality of each plan is determined using a five-star rating system with the higher quality plans having a higher number of stars. These ratings are based on things like such as how they help you stay healthy, how they manage chronic conditions, the plan’s customer service options, and more. By using these star ratings, you may determine how these MA and PDPs compare to Original Medicare (Part A and Part B).

Medicare has neither reviewed nor endorsed this information.

What if a Person Disagrees With a Decision Medicare Makes About Coverage or Payment for a Service?

If you are a beneficiary do not agree with a coverage or payment decision made by Medicare, your Medicare Prescription Drug Plan, or your Medicare Advantage health plan, you can file an appeal. Beneficiaries have the right to file an appeal if Medicare denies:

  • A request for a certain health care item, service, supply, or prescription drug for which you believe you should receive coverage.
  • A request for payment of a health care item, service, supply, or prescription drug that you already received.
  • A request to change what you pay for a health care item, service, supply, or prescription drug.

The Medicare appeal process has five levels, and if you disagree with decision made at any level of the process, you can usually move on to the next level. After you file an appeal, your Medicare plan will send you a decision letter that tells you how to move on to the next level of appeal.

To file an appeal or get more information, do any of the following:

  • Look in your plan’s informational materials for instructions.
  • Contact your Medicare plan.
  • Call your local State Health Insurance Assistance Program (SHIP).

Medicare has neither reviewed nor endorsed this information.

How Do I Report Medicare Fraud?

Medicare fraud is about a doctor, supplier, or other individual using the Medicare system dishonestly. Here are some examples of Medicare fraud:

  • Someone uses your Medicare card to receive health services or products. You may not lend your card to anyone. If you think your card was stolen, call 1-800-MEDICARE immediately.
  • Medicare gets a bill for a service or product you didn’t receive.
  • A company sells you a “Medicare” prescription drug plan, and it isn’t really Medicare-approved.

If you suspect that a Medicare provider is committing, or has committed, Medicare fraud, we recommend that you first talk to the organization in question (for example, your doctor’s office) about the problem. If, after contacting the provider, you feel as though your concerns have not been addressed, or you suspect any type of fraudulent activity, you should report it to Medicare.

Before reporting fraud, make sure you have the following information available (or as much of it as possible):

  • Your name and Medicare number
  • The provider’s name and any identifying number you may have
  • The service or item you’re questioning
  • The date the service or item was supposedly given or delivered
  • The payment amount approved and paid by Medicare
  • The date on your Medicare Summary Notice (MSN)
  • The reason you think Medicare shouldn’t have paid

To report fraud or suspicious activity, you may contact any of the agencies listed below.

Medicare

Call 1-800-MEDICARE, or go to http://www.stopmedicarefraud.gov/.

Mail: Medicare Beneficiary Contact Center
P.O. Box 39
Lawrence, KS 66044

Department of Health and Human Services, Office of the Inspector General

Call 1-800-447-8477 (TTY: 1-800-377-4950), or go to http://www.hhs.gov/.

Mail: HHS Tips Hotline
P.O. Box 23489
Washington, DC 20026-3489

Centers for Medicare & Medicaid Services (CMS)

Call 1-800-633-4227 (TTY 1- 877-486-2048), or go to http://www.cms.gov/.

Medicare has neither reviewed nor endorsed this information.

How Do I Report Disability Fraud?

If you suspect any sort of disability fraud, you can report it to the Social Security Administration (SSA) via Internet, phone, or mail. You may remain anonymous during the process if you believe that the disclosure of your identity will cause problems, but keep in mind that this anonymity may limit the SSA’s ability to completely investigate your allegations.

To report fraud, waste, or abuse online, fill out the form on the Social Security website.

To report it via mail, send to:
Social Security Fraud Hotline
P.O. Box 17785
Baltimore, MD 21235

To report via telephone, call the Fraud Hotline at 1-800-269-0271 from 10AM to 4PM. If you cannot reach a representative during this time, you may also report disability fraud at your local Social Security office during regular business hours.

Medicare has neither reviewed nor endorsed this information.

How is Medicare Funded?

Medicare is paid for through two federally funded trusts, both of which are held by the U.S. Treasury. The Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund disburse funds that may only be used for the Medicare program.

Hospital Insurance is largely funded by revenue from a 2.9% payroll tax, levied on both workers and their employers. HI is additionally funded by the collection of income taxes, Social Security benefits, interest earned on trust fund investments, and Medicare Part A premiums from those who aren’t eligible for premium-free Medicare Part A.

Supplementary Medical Insurance funds Medicare Part B and Medicare Part D plans, and is bankrolled by premium payments from those plans in addition to funds authorized by Congress and interest earned on investments.

Medicare has neither reviewed nor endorsed this information.

What are the Centers for Medicare and Medicaid Services (CMS)?

The Centers for Medicare and Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS oversees and administers the Medicare program. In addition to the Medicare program, CMS coordinates jointly with state governments on Medicaid, the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA), and the Clinical Laboratory Improvement Amendments (CLIA).

The Centers for Medicare and Medicaid Services contract private health care professionals across all necessary professions (billing, customer service, fraud) to function as intermediaries between the government and the health-care industry.

In addition, the Chief Actuary of CMS is responsible for briefing the Medicare Board of Trustees on cost-projection and accounting data needed for evaluating the financial prosperity of the program.

As a Medicare insurance plan broker, eHealth works according to the rules and requirements set forth by the CMS. You can take a look at our available Medicare plans through the links on this page.

Medicare has neither reviewed nor endorsed this information.

How Does Obamacare Effect Medicare?

There are some Obamacare impacts on Medicare worth noting:

  • More affordable preventive services. Medicare Part B now includes more preventive coverage and at less cost. Services such as colonoscopies and mammograms are available for free or at a low cost. Beneficiaries are also eligible for a free yearly “Wellness” exam.
  • Potential for prescription drug cost savings. The Affordable Care Act will ensure that the coverage gap (also called the “donut hole”) in Medicare Part D, where the beneficiary is responsible for the full cost of his or her prescriptions, will be closed completely by 2020. Between now and then, the government provides an increasing discount on brand-name drugs each year while a beneficiary is in the coverage gap. You do not have to do anything to receive this discount; it is applied at the pharmacy automatically.
  • Better support for doctors. Obamacare provides doctors with additional resources to better coordinate care for patients. This ensures that treatments are timely and consistent.
  • Extends the Medicare program’s longevity. Because of the ACA, the Medicare Trust Fund will be extended to at least 2029. Efforts have been made to greatly reduce fraud, waste, and abuse within the program to secure this extension.

Obamacare and Medicare Advantage plans

Medicare Advantage plans (MA or Medicare Part C) are sold by private insurance providers across the nation, and Obamacare aims to reward the companies that offer the highest quality care. These are the plans that top the Centers for Medicare and Medicaid Services 5-Star Rating system.

Obamacare and Medigap plans

The Affordable Care Act does not affect the medical underwriting process. If beneficiaries enroll in Medicare Supplement (also known as Medigap) Plans outside of their Medigap Open Enrollment Period (a six-month period beginning on the first day of the month that they are 65 or older and enrolled in Medicare Part B), then they are subject to the medical underwriting process. This assesses all beneficiaries and could result in higher costs or even a denial of coverage.

Medicare has neither reviewed nor endorsed this information.