posted
I just learned that beginning in 2016, unless a provider is enrolled in Medicare Part D, then their prescriptions are not covered by Medicare Part D plans. I just spoke with Dr. Js clinic in DC and was told that they do not participate in any part of Medicare, even though best I can figure out is that Medicare Part D enrollment is just paper work without cost to the provider. This would seem to mean that the top LLMDs are off limits to all but wealthy Medicare patients.
I live in MA but can move anywhere for care. Does anyone know of a top ILADS LLMD who participates in at least Medicare Part D, even if not Part B?
FYI: I no longer live in 'northeast ohio' and have emailed the webmaster to see if my screen name can be changed.
Posts: 18 | From MA | Registered: Jun 2009
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TF
Frequent Contributor (5K+ posts)
Member # 14183
posted
I did a quick search and found that a doctor must either accept Medicare or opt out of Medicare in order for their prescriptions to be covered by Part D of Medicare.
Here is the Medicare website that says this:
"Part D Prescriber Enrollment - Home
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans"
Read the entire paragraph and you will see where it says this is effective Jan. 2016, etc.
So, you just need to find out if the lyme doctor has opted out of Medicare or not. If they have opted out, then your prescriptions will be covered.
To opt out, the physician has to file a paper with the Medicare agency saying that they do NOT participate in Medicare. This way, any patient that comes to that doctor cannot file any claim with Medicare for coverage of that doctor's services.
So, call Dr. J back and ask if he has opted out of Medicare. If he has, you will get prescriptions covered by Part D.
If he has not opted out, let us know. Then I will find out if the doc I recommend has opted out. If so, you could go to him.
That website also tells doctors how to opt out of Medicare. Many have not opted out and they also will not take Medicare. So, what they have to do is refuse to take any patient who has Medicare.
Opting out is some work and hassle for the doctor. I believe they have to file their paperwork yearly and Medicare can write to them and demand to see their paperwork, including a form signed by the patient understanding that the doc has opted out of Medicare.
One of my husband's doctors (not a lyme doc) opted out of Medicare and Medicare was writing to me as if the doc took Medicare. I called them and told them he had opted out. Then "all hell" broke loose! They faxed paperwork to the doc making him prove that my husband is informed YEARLY that the doc has opted out of Medicare. The doc was so upset with me! He was scared to death that Medicare was going to embroil him in a big paperwork controversy or worse.
So, believe me, there are reasons doctors don't opt out of Medicare. It is definitely an easier life for them if they just don't take Medicare patients.
I'll bet Dr. J. has opted out because I think he takes Medicare patients. Hopefully, if you want to go to him, I am right.
Posts: 9931 | From Maryland | Registered: Dec 2007
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posted
Thanks so much for your reply and help. I have been away from Lymenet since about 2008 and thought I would get an email notifying me of any replies but didn't get one. Is there some way to set that up?
I spoke with his office on Monday. She double checked and said they don't participate in any part of Medicare. Tuesday, I sent another message with the information about opting out, including the paragraph from the documents with instructions for doctors. Haven't heard back. If even opting out is a hassle, then that might explain why doctors don't want to do it.
When I am feeling better, I may call back to ask whether they have opted out.
Posts: 18 | From MA | Registered: Jun 2009
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TF
Frequent Contributor (5K+ posts)
Member # 14183
posted
There is no way to set up your profile to get notified by email when someone replies PUBLICLY to one of your public posts.
But, you can be notified by email if someone sends you a private message. To set that up:
Go to My Profile.
Hit Edit Profile
Go down the page until you see:
"Be notified by email when someone sends you a private message?"
Put a check mark next to that option. Then, you will get an email alerting you that someone has sent a message to your inbox.
Regarding Dr. J, if he takes any patients who have Medicare Part B, then he must have opted out of Medicare. So, basically, if he takes anyone over the age of 65, he most likely has opted out of Medicare.
If a doc has not opted out of Medicare and takes a patient with Part B, they are required by law to submit their bill to Medicare and accept as full payment the amount that Medicare sends them.
Sounds like you are going to have to talk to his office manager. That is the person who would know if Dr. J has opted out of Medicare.
Or, you can decide to see the doc I recommend. He is cheaper and not right inside D.C. which is a hassle for traffic and parking.
Posts: 9931 | From Maryland | Registered: Dec 2007
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posted
I will have to call them at some point and ask if they have opted out of Part D. When I told her I had Medicare, she did not say I could not be a patient so you must be right that they must have opted out of that.
I do not live in DC, but have lived there in the past, and if I can't get care here, wouldn't mind moving back there. So if you could tell me about your doctor, that would be great.
Posts: 18 | From MA | Registered: Jun 2009
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TF
Frequent Contributor (5K+ posts)
Member # 14183
posted
Don't ask if they have opted out of Part D. Just ask if they have opted out of the Medicare program period.
You can't opt out of various parts of Medicare. You opt out of the entire program or you don't.
Notice the wording on the Medicare site.
I will send you the doctor's name.
Posts: 9931 | From Maryland | Registered: Dec 2007
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<< .... Together, these rules require virtually all physicians and other eligible professionals, including dentists, who write prescriptions for Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, except in very limited circumstances. >>
-------------------- Suzanne who no longer lives in northeast ohio Posts: 18 | From MA | Registered: Jun 2009
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