Presented by Angela Free Associate Director, Benefits &
Payroll May 7, 2014 CSRA Medicare Presentation
Slide 2
Medicare Introduction Parts of Medicare What Medicare Covers
Transitioning to Medicare Who Pays When? Pharmacy Benefits Medicare
Appeals Answers to Submitted Questions New Questions? AGENDA
Slide 3
Medicare coverage is based on 3 main factors : Federal and
state laws National coverage decisions made by Medicare about
whether something is covered Local coverage decisions made by
companies in each state that process claims for Medicare. These
companies decide whether something is medically necessary and
should be covered in their area MEDICARE INTRODUCTION
Slide 4
Medicare covers services (like lab tests, surgeries, and doctor
visits) and supplies (like wheelchairs and walkers) considered
medically necessary to treat a disease or condition. PARTS OF
MEDICARE
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How to find out if Medicare covers what you need Talk to your
doctor or other provider about why you need certain services or
supplies, and ask if Medicare covers it. If you need something
that's usually covered and your provider thinks that Medicare won't
cover it, you'll have to sign a notice saying that you understand
you have to pay for that item, service, or supply yourself. Go here
to check for yourself. Enter all or part of the name of the
procedure, item or supply in the search field:
http://www.medicare.gov/coverage/your-medicare-coverage.html WHAT
MEDICARE COVERS
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Hospital care Skilled nursing facility care Nursing home care
(as long as custodial care isn't the only care you need) Hospice
Home health services WHAT DOES MEDICARE PART A COVER?
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Part B covers 2 types of services: Medically necessary
services: Services or supplies that are needed to diagnose or treat
your medical condition and that meet accepted standards of medical
practice. Preventive services: Health care to prevent illness (like
the flu) or detect it at an early stage, when treatment is most
likely to work best. You pay nothing for most preventive services
if you get the services from a health care provider who accepts
Medicare assignment. WHAT DOES PART B COVER?
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Clinical research Ambulance services Durable medical equipment
(DME) Mental health Inpatient care Outpatient care Partial
hospitalization Getting a second opinion before surgery Limited
outpatient prescription drugs PART B MEDICALLY NECESSARY:
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Abdominal aortic aneurysm screening Alcohol misuse screenings
& counseling Bone mass measurements (bone density)
Cardiovascular disease screenings Cardiovascular disease
(behavioral therapy) Cervical & vaginal cancer screening
Colorectal cancer screenings Depression screenings Diabetes
screenings Diabetes self-management training Glaucoma tests HIV
screening Mammograms (screening) Nutrition therapy services Obesity
screenings & counseling One-time Welcome to Medicare preventive
visit Prostate cancer screenings Sexually transmitted infections
screening & counseling Shots: Flu, Hepatitis B, Pneumococcal
Tobacco use cessation counseling Yearly "Wellness" visit PART B
PREVENTATIVE & DIAGNOSTIC:
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Medicare doesn't cover everything. If you need certain services
that Medicare doesn't cover, you'll have to pay for them yourself
unless you have other insurance or you're in a Medicare health plan
that covers these services. Even if Medicare covers a service or
item, you generally have to pay your deductible, coinsurance, and
copayments. Some of the items and services that Medicare doesn't
cover include: Long-term care, also called custodial care (remember
Part A covers it as long as thats not the only type of care you
need at the time) Most dental care Eye examinations related to
prescribing glasses Dentures Cosmetic surgery Acupuncture Hearing
aids and exams for fitting them Routine foot care WHAT'S NOT
COVERED BY PART A & PART B?
Slide 11
Part D adds prescription drug coverage to Original Medicare and
other Plans, like our USG plans. These plans are offered by
insurance companies and other private companies approved by
Medicare. Medicare Advantage Plans, Like our Kaiser Senior
Advantage Plan, may also offer prescription drug coverage that
follows the same rules as Medicare Prescription Drug Plans. WHAT
DOES PART D COVER?
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The pharmacy benefits for Medicare Eligible Retirees enrolled
in the BCBS plans are provided through Express Scripts (formerly
Medco) Medicare Part D prescription drug plan for the University
System of Georgia. This prescription drug plan generally provides
retirees the same prescription drug coverage as for active
employees with very few exceptions. USG RX COVERAGE
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Kaiser Senior Advantage Pharmacy coverage If you enroll in the
Kaiser Permanente Senior advantage plan, Kaiser Permanente will
serve automatically as your Part D provider. If you are a new
member selecting Kaiser Permanente Senior Advantage as your retiree
option for 2014, your application will include Part D enrollment
information. If you currently have an existing Part D Plan and
enroll into Senior Advantage, your existing Part D Plan will
automatically be cancelled by Medicare. KAISER RX
Slide 14
Medicare eligible retirees enrolled in the Open Access POS plan
will be automatically enrolled in the Express Scripts Medicare Part
D plan through the University System of Georgia as part of their
pharmacy coverage If a retiree does not want to enroll in this
Express Scripts Medicare Part D plan, the retiree may waive
coverage under the plan; however, if the retiree waives coverage,
he/she will no longer be eligible to participate in the Open Access
POS plan. The retiree will have the option to enroll in the HSA
Open Access POS plan or the Kaiser Sr. Advantage plan or cancel
their retiree health coverage. If a retiree cancels their retiree
health coverage through the University System of Georgia, they will
not be allowed to re-enroll in coverage IMPORTANT INFORMATION
MEDICARE-ELIGIBLE RETIREES NEED TO KNOW ABOUT THE OPEN ACCESS POS
PHARMACY PLAN COVERAGE:
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Retirees will receive a pre-enrollment letter from Express
Scripts which will explain the plan in detail Upon enrollment,
Retirees will receive a Welcome kit and a new pharmacy ID card with
a new group number it does not say Medicare, but the group number
is a Medicare group Retirees will be able to get their
prescriptions from the same retail pharmacies as before Retirees
with questions may contact the University System of Georgia Shared
Services Center toll-free at 1-855-214-2644 or e-mail
[email protected]. For questions about the benefits or how the
plan works, contact Express Scripts Medicare Customer Service at
1-877- 681-9875 (CONT) IMPORTANT INFORMATION MEDICARE- ELIGIBLE
RETIREES NEED TO KNOW ABOUT THE OPEN ACCESS POS PHARMACY PLAN
COVERAGE:
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Generic copay $10 for 30 day supply Name brand $25 Mail order:
Tier 1 $25 /Tier 2 $70 The HMO is subject to a formulary Some drugs
are subject to pre-authorization or step-therapy HMO RX
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85% of network cost of drug Not subject to formulary Some drugs
are subject to pre-authorization or step-therapy Mail order is
available OPEN ACCESS HSA POS Rx (HIGH DEDUCTIBLE)
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Generic $10, Preferred brand-name $35 Non-preferred brand-name
20% of the drugs cost/$45 minimum copay /$125 max co-pay Mail
order: 31 - 90 Days supply: Generic $25, Preferred $87.50 Non
preferred $112.50 minimum copay/$250 maximum copay Annual out of
pocket max (Non-preferred brand-name does not count toward this)
EE: $1000 EE + Ch or EE + Sp : $2000 Family (3 or more) $3000 This
means the cost is waived for generic and preferred drugs after max
is met in a year. OPEN ACCESS POS RX
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Choosing Mail Order or Retail: A Message from the USG System
Office In 2014, members enrolled in the OA POS plan using
maintenance medications at retail must make a decision on how to
receive maintenance prescription drugs through home delivery or
retail prior to the third refill. If a decision is not made by the
third refill, members will be required to pay the full price of the
prescription until a decision is made. We want all of our employees
and their dependents to be aware of the savings and health benefits
available to them through mail order! ACTIVE CHOICE
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To make the decision about mail order, visit the Express
Scripts website at www.Express- Scripts.com/Decide or call Express
Scripts at 877-603-1032, Monday Friday, 8:30 a.m. to 6 p.m.,
Eastern. Express Scripts will make the transition to mail order
easy by contacting your doctor to get a new 90-day prescription on
your behalf. Contact Express Scripts with your decision today!
Thank you! University System of Georgia/Board of Regents Human
Resources HOW TO CONTACT EXPRESS SCRIPTS
Slide 21
Ill be 65 soon, what do I need to do? Sign up for Medicare
Parts A & B (online at medicare.gov, by phone, or in person)
Contact CSU Benefits Office or Shared Services with your Medicare
Claim Number After you are enrolled, contact Medicare for
coordination of benefits (more later) If you are already retired
and turning 65, you need to make sure you are in an eligible health
plan. If you are currently enrolled in the Blue Cross HMO you must
change plans because it is not Medicare compatible. You may choose
High Deductible HSA POS Plan or Regular POS HSA Plan. You will
receive a kit from the SSA 60-90 days before your birthday. If you
are still active and enrolled in a USG medical plan, it is
considered credible coverage, and you can put off enrolling in
Medicare parts B and D until you retire without paying a penalty.
If you do choose to enroll while active, your USG plan will remain
primary, and your Medicare B plan will be secondary. TRANSITIONING
TO MEDICARE
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MEDICARE CLAIM NUMBER
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When you turn 65 - your Initial Enrollment Period During
Medicare annual enrollment between January 1March 31 each year When
you lose employer sponsored group health coverage (8 months from
end of employment or end of coverage, whichever occurs first) There
is a penalty for signing up late 10% for each full 12 month period
past your initial enrollment deadline, but if you remain enrolled
in your CSU plan as an active employee until you retire and then
enroll, the penalty is waived. WHEN CAN I SIGN UP?
Slide 24
If you have Medicare and other health insurance or coverage,
each type of coverage is called a "payer." When there's more than
one payer, coordination of benefits " rules decide which one pays
first. HOW MEDICARE WORKS WITH OTHER INSURANCE
Slide 25
The "primary payer" pays what it owes on your bills first, and
then sends the rest to the "secondary payer" to pay. In some cases,
there may also be a third payer. Paying "first" means paying the
whole bill up to the limits of the coverage. It doesn't always mean
the primary payer pays first in time. If the insurance company
doesn't pay the claim promptly (usually within 120 days), your
doctor or other provider may bill Medicare. Medicare may make a
conditional payment to pay the bill, and then later recover any
payments the primary payer should've made. If you have questions
about who pays first, or if your insurance changes, call the
Medicare Coordination of Benefits Contractor at 1-855-798-2627.
PRIMARY PAYER
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COORDINATION OF BENEFITS BETWEEN MEDICARE AND A SECOND PAYER
Question: How does Medicare pay as a secondary payer?
Slide 27
Answer: When Medicare is primary, Part A and B, the member has
a Medicare deductible (which is usually met before BCBS) and BCBSGA
deductible to meet before Blue Cross plan covers members Medicares
20% coinsurance. Also, if the member has not met their deductible
for BCBS, the provider can bill the member for an amount that
Medicare states is the patient's responsibility. *If the member
uses an in network provider, the BCBSs deductible is $300.00; once
the deductible is met, BCBS will pick up the members Medicare
coinsurance. *If the member uses an out of network provider, the
BCBSGAs deductible is $400.00; once the deductible is met, Blue
Cross will pick up the members Medicare coinsurance. However, since
the provider is not participating, the member will be subject to
balance billing because out of network providers do not take
providers write-offs because they are not contracted to. SECOND
PAYER
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Slide 29
The dollar amount charged by a provider that is in excess of
the plans allowed amount for medical care or treatment. Amounts
that are balance billed by a provider are the member's
responsibility. Member costs incurred for balance billing will not
apply toward the annual deductible or toward the annual maximum
out-of-pocket limits. DEFINITION OF BALANCE BILLING:
Slide 30
HOW CLAIMS ARE PAID BY USG IF PROVIDERS OPT OUT OF MEDICARE As
of 2014, members will pay a lower premium to USG when they have
Medicare primary so they must find a provider who accepts both
Medicare and Blue Cross OA POS. If a member uses a provider that
has opted-out of Medicare, Blue Cross will not pay as primary, as
they have done in the past. Blue Cross will process the claims as
secondary and any amounts above the plans payment can be held as
the patients liability. This means that Blue Cross will only cover
the 20% of Medicares coinsurance.
Slide 31
HOW CLAIMS ARE PAID WHEN THE CLAIMANT HAS MEDICAID AND MEDICARE
Blue Cross do not coordinate with Medicaid If the claimant has
Medicare, Medicaid and Blue Cross, Medicare pays first, Blue Cross
pays and if there is a balance of Medicaid allowable charges,
Medicaid pays. If the claimant has Medicare and Medicaid only,
Medicare pays first and Medicaid pays second.
Slide 32
Here are some basic steps for challenging Medicare coverage
denials under Part A (including hospitalization, nursing homes and
hospice services) and Part B (doctor visits, tests, home health
care, durable medical equipment). In most cases, it is not
necessary to hire a lawyer. Advocates say to be sure to write your
Medicare or member number on all documents, and to keep copies. You
have to be committed and tenacious. APPEALS
Slide 33
Level 1: Redetermination by the company that handles claims for
Medicare Level 2: Reconsideration by a Qualified Independent
Contractor (QIC) Level 3: Hearing before an Administrative Law
Judge (ALJ) Level 4: Review by the Medicare Appeals Council
(Appeals Council) Level 5: Judicial review by a Federal District
Court FIVE LEVELS OF APPEALS
Slide 34
For the first appeal, called redetermination: Make the request
within 120 days of receiving the denial Any dollar amount can be
appealed Circle the questionable item on your quarterly Medicare
statement, called the Medicare Summary Notice, and follow the
mailing instructions on the form. You can also complete an appeals
form found here: www.medicare.gov/claims-and-
appeals/file-an-appeal/original-medicare/original-medicare-appeals.htmlwww.medicare.gov/claims-and-
appeals/file-an-appeal/original-medicare/original-medicare-appeals.html
FIRST APPEAL
Slide 35
If you get denied again, you can make a request for second
appeal, called reconsideration: Make the request within 180 days of
receiving notice that the first appeal was denied. In a letter,
explain the services or items that you received and why payment is
in dispute. Include a copy of the initial denial or fill out the
reconsideration form available at
www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-
medicare-appeals-level-2.html.
www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-
medicare-appeals-level-2.html SECOND APPEAL
Slide 36
To request a hearing before an Administrative Law Judge, which
usually is conducted via conference call with patients, doctors and
others: Make the request within 60 days of receiving the denial of
the second appeal. To be eligible for a hearing, the amount in
dispute must be at least $140. In your letter, provide your name,
address, Medicare number, document control number from previous
denial, dates of services or items in dispute and why you are
appealing. Include any other information to support your request,
or complete a hearing request form available at
www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-
3.html.www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-
3.html THIRD APPEAL
Slide 37
If you get denied again, you can make a request for
consideration by the Medicare Appeals Council: Make this request
within 60 days of receiving the hearing decision. In a letter, cite
which parts of the decision you dispute and the date of the
decision, or complete the hearing review request form available at
www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-4.html.
www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-4.html
FOURTH APPEAL
Slide 38
Beneficiaries who are still not satisfied can file an appeal in
Federal Court, but the amount in dispute must be at least $1,350.
FIFTH AND FINAL APPEAL
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ANSWERS TO QUESTIONS
Slide 40
Question: My Medicare part B deductible for 2013 is $147. Is
this something BCBS covers? OR am I responsible for the $300 BCBS
annual deductible in addition to the Medicare Part B deductible?
Answer: You must first meet your $300 deductible with us before we
will consider any amounts for processing. For example, Medicare
processes a claim with the $147.00 of the total claim amount
applying towards your Medicare deductible. You have not met your
BCBS deductible. However, BCBS will apply that $147.00 as a CREDIT
towards your BCBS deductible. You will not be responsible for BCBS
$300.00 deductible plus the $147.00 deductible from Medicare. Your
responsibility would be your $147 which would be payable to the
provider who rendered the service. Note: You will be responsible
for paying the remainder $153 needed towards the deductible with
BCBS before BCBS plan would pay.
Slide 41
Question: What are the planned changes to the BOR/USG Health
Benefit Plan and the impact on retirees? Answer: I am not aware of
any. I posed the question to the system office and they indicated
they had nothing to share at this time that would have an impact on
retirees.
Slide 42
Question: Does Medicare cover Pap tests? If so, how often is
the test covered? Answer: Yes. Once every 24 months for all women
Once every 12 months if youre at high risk for cervical or vaginal
cancer, or if youre of childbearing age and have had an abnormal
Pap test in the past 36 months
Slide 43
Question: What are the procedures now covered by Medicare not
covered by University System Health Insurance (now BCBS)? Answer:
Acupuncture (discounts provided through BCBSGas Special Offers
Program) Air-fluidized beds (discounts provided through BCBSGas
Special Offers Program) Bariatric surgery Canes (discounts provided
through BCBSGas Special Offers Program) Cosmetic Surgery Gym
membership and fitness programs (discounts provided through BCBSGas
Special Offers Program) Hearing Aids Hospital Beds Adult diapers
(discounts provided through BCBSGas Special Offers Program)
Slide 44
Question: If Medicare denies a procedure or test, at present,
when will University System Health Insurance pick up coverage?
Answer: If Medicare does not cover the services and the services
are covered by Blue Cross, a denial EOB from Medicare must be
submitted to Blue Cross to show it is non-covered under the primary
provider. At that point, Blue Cross would pay.
Slide 45
Question: In the future, if Medicare cuts kick in and coverage
is denied for tests and procedures now covered, does the University
System plan to cover these tests and procedures? Probably would
require an increase in premium. Answer: The intent of the USG plan
is to cover the Medicare 20% coinsurance once deductibles have been
met. At this time there is not a plan to change the structure and
provide additional or different coverage.
Slide 46
Question: It is constant guesswork what they have covered
following a procedure? Is there a way a covered individual can
electronically access his or her records--hopefully, not just a
telephone number? Answer: Yes! Blue Button allows you to download
your health data. Here is the link to an online demonstration of
registration:
https://mymedicare.gov/Help/VirtualTour/WBT_Register_V2.aspx
Another useful like with how to demos for several other functions:
https://mymedicare.gov/help/virtualtour.aspx#
Slide 47
Question: My physical therapist advised me that there was a
federal bill in motion--don't know if it is house or senate--to
cover additional services, including a) therapeutic massages, b)
personalized gym training, c) acupuncture and dry needle therapy.
What is the status of that bill? Answer: We could not find evidence
that it ever existed. The system office, our Blue Cross Account
Manager and a couple of researchers in the HR office tried to help
find it but could not.
Slide 48
Question: One healthcare provider I see is registered
dietitian/nutritionist. She does not accept insurance or Medicare,
but will provide diagnosis code sheet. I filed her sheet with BCBS
and they paid 100%. Should I have also submitted to Medicare--if
so, how, since they don't seem to have a system of direct patient
input? Answer: Submit via the claim form, The Patients Request for
Medical Payment Found here:
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1490S-ENGLISH.pdf
Slide 49
Question: Medicare so far has proven to be a retirement penalty
costing $209.80 per month. Having retired July 1, 2013, spouse and
I are now paying $104.90 each per month for part B which we had
never paid before. We had been under BCBS high deductible family
plan of $132/month and continue with that plan in retirement. So
far Medicare has paid $0. At this rate, it appears we will be out
of pocket rest of our lives $209.80 per month (plus any Medicare
Part B increases). Please provide numeric illustrations of what
CMS/Medicare will provide. We realize that BCBS will help with some
of the drug/pharmacy since we don't have Part D, but to get any
other benefits from CMS/Medicare it appears we may have to drop
BCBS to get those. Are we over-insured and under-benefitting?
Slide 50
Medicare Covers Abdominal aortic aneurysm screening Acupuncture
Air-fluidized beds Alcohol misuse screening & counseling
Ambulance services Ambulatory surgical centers Anesthesia
Artificial eyes & limbs Bariatric surgery Blood Blood
processing & handling Blood sugar (glucose) test strips Blood
sugar monitors Bone mass measurement (bone density) Braces (arm,
leg, back, and neck) Breast prostheses Canes Cardiac rehabilitation
programs Cardiovascular disease (behavioral therapy) Cardiovascular
disease (behavioral therapy) Cardiovascular disease screenings
Cataract surgery Cervical & vaginal cancer screenings
Chemotherapy Chiropractic services Clinical research studies
Colorectal cancer screenings Commode chairs Continuous passive
motion (CPM) machine Continuous passive motion (CPM) machine
Cosmetic surgery Crutches Custodial care Defibrillator (implantable
automatic) Dental services Depression screenings Diabetes
screenings Diabetes self-management training Diabetes supplies
& services Diagnostic tests, X-rays, and clinical laboratory
services Diagnostic tests, X-rays, and clinical laboratory services
Dialysis (children) Dialysis (kidney) services & supplies
Doctor & other health care provider services Doctor & other
health care provider services Drugs Durable medical equipment (DME)
coverage Durable medical equipment (DME) coverage
Slide 51
Medicare Covers Diabetes screenings Diabetes self-management
training Diabetes supplies & services Diagnostic tests, X-rays,
and clinical laboratory services Diagnostic tests, X-rays, and
clinical laboratory services Dialysis (children) Dialysis (kidney)
services & supplies Doctor & other health care provider
services Doctor & other health care provider services Drugs
Durable medical equipment (DME) coverage Durable medical equipment
(DME) coverage EKG (electrocardiogram) screening Emergency
department services Enteral nutrition supplies & equipment
(feeding pump) Enteral nutrition supplies & equipment (feeding
pump) Eye exams Eyeglasses/contact lenses Flu shots Foot care Foot
exam Glaucoma tests Glucose control solutions Gym membership &
fitness programs Health education & wellness programs Hearing
and balance exams & hearing aids Hearing and balance exams
& hearing aids Hepatitis B shots HIV screening Home health
services Home oxygen equipment & supplies Hospice & respite
care Hospital beds Hospital care (outpatient) Humidifiers
Incontinence supplies & adult diapers Infusion pumps Inpatient
hospital care Insulin Kidney disease education Kidney transplants
(adults) Kidney transplants (children) Laboratory services
(clinical) Lancet devices & lancets Long-term care hospitals
Macular degeneration Mammograms Massage therapy Mental health care
(inpatient) Mental health care (outpatient) Mental health care
(partial hospitalization) Mental health care (partial
hospitalization) Nebulizers & nebulizer medications Nursing
home care Nutrition therapy services (medical) Obesity screening
& counseling
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Medicare Covers Orthotics & artificial limbs Osteoporosis
drugs for women Ostomy supplies Outpatient hospital services Oxygen
therapy Pancreas transplants (adults) Patient lifts Physical
therapy/occupational therapy/speech-language pathology services
Physical therapy/occupational therapy/speech-language pathology
services Pneumococcal shots Prescription drugs (outpatient)
Preventive & screening services Preventive visit & yearly
wellness exams Preventive visit & yearly wellness exams
Prostate cancer screenings Prosthetic devices Pulmonary
rehabilitation program Radiation therapy Religious non-medical
health care institution (RNHCI) Religious non-medical health care
institution (RNHCI) Rural health clinic & federally qualified
health center services Rural health clinic & federally
qualified health center services Second surgical opinions Sexually
transmitted infections (STI) screening & counseling Sexually
transmitted infections (STI) screening & counseling Shingles
shot Shots (vaccinations) Skilled nursing facility (SNF) care Sleep
apnea & Continuous Positive Airway Pressure (CPAP) therapy
Sleep apnea & Continuous Positive Airway Pressure (CPAP)
therapy Sleep study Smoking & tobacco use cessation (counseling
to stop smoking or using tobacco products) Smoking & tobacco
use cessation (counseling to stop smoking or using tobacco
products) Substance-related disorders Suction pumps Supplies (you
use at home) Surgery (estimating costs) Surgical dressing services
Tdap shot (tetanus, diphtheria, & pertussis shot) Tdap shot
(tetanus, diphtheria, & pertussis shot) Telehealth Therapeutic
shoes or inserts Traction equipment Transplants (adults)
Transportation Travel (when you need health care outside the U.S.)
Travel (when you need health care outside the U.S.) Urgently needed
care Walkers Wheelchairs & power mobility devices Wheelchairs
& power mobility devices X-rays Yearly eye exam