Medicare Coverage While Traveling Within the U.S.

August 9, 2016

When people retire they often have more time to travel.  Although Medicare coverage is generally not available when beneficiaries are overseas, what about coverage for those exploring our own varied and scenic land?

If you have original Medicare, the answer is easy: you can travel anywhere in the U.S. or its territories and receive health services from any doctor or hospital that accepts Medicare.  (“Territories” includes Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.) The amount you will pay depends on whether the provider “accepts assignment.”  Those that take assignment agree to accept the approved Medicare amount as payment in full, although in the case of outpatient visits you or your Medigap insurer may be left with a 20 percent coinsurance, as would be the case for care at home.

Providers that don’t accept assignment may charge you up to 15 percent above the Medicare-approved amount, although this percentage may be lower in some states. In the case of providers that don’t accept Medicare at all, you will have to pay the entire cost of care.

If instead of original Medicare you are in a Medicare Advantage plan (a privately run managed care plan), the answer to the question of coverage is more complicated. Depending on your post-retirement goals, this could be a consideration in whether you choose original Medicare or an Advantage plan.

For enrollees traveling for less than six months outside their plan’s service area, Medicare Advantage plans must cover emergency and urgent care, and charges for such care that is out-of-network cannot exceed $65 or whatever you would have paid for an in-network provider.  Whether you will be covered for anything more than emergency or urgent care depends on the plan’s geographic service area, its rules about travel outside of that area, and what type of plan it is.

If your plan is of the PPO (Preferred Provider Organization) variety, it must cover care delivered by providers who aren’t in the plan’s network or service area, although you will usually pay more for out-of-network care.  Plans that follow the HMO (Health Maintenance Organization) model usually do not cover care from out-of-network providers.  If your HMO plan does cover out-of-network providers, be sure to follow the plan’s rules or you may find that you’re not covered, and you will likely pay more for the care in any case.

If you are outside your plan’s service area for six months or more, most plans must automatically disenroll you and you will be returned to original Medicare unless you choose another Medicare Advantage plan.  However, some plans will allow you to travel outside the service area for up to a year. Even if your plan has such a travel benefit, check what geographic areas and types of care are covered.  If you get care from providers not covered in the plan’s network, you may pay more or not be covered at all.

The Medicare Rights Center advises Medicare Advantage enrollees to “look at your plan benefits carefully to see what costs and rules apply when you travel within the United States or its territories.”  For more from the Medicare Rights Center on Medicare Advantage coverage if traveling within the U.S., click here.

If your plan denies you coverage, you can always appeal.  For more on Medicare Advantage appeals.

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What Is Undue Influence?

Saying that there has been “undue influence” is often used as a reason to contest a will or estate plan, but what does it mean?

Undue influence occurs when someone exerts pressure on an individual, causing that individual to act contrary to his or her wishes and to the benefit of the influencer or the influencer’s friends. The pressure can take the form of deception, harassment, threats, or isolation. Often the influencer separates the individual from their loved ones in order to coerce. The elderly and infirm are usually more susceptible to undue influence.

To prove a loved one was subject to undue influence in drafting an estate plan, you have to show that the loved one disposed of his or her property in a way that was unexpected under the circumstances, that he or she is susceptible to undue influence (because of illness, age, frailty, or a special relationship with the influencer), and that the person who exerted the influence had the opportunity to do so. Generally, the burden of proving undue influence is on the person asserting undue influence. However, if the alleged influencer had a fiduciary relationship with your loved one, the burden may be on the influencer to prove that there was no undue influence. People who have a fiduciary relationship can include a child, a spouse, or an agent under a power of attorney. For more information on contesting a will, go here.

When drawing up a will or estate plan, it is important to avoid even the appearance of undue influence. For example, if you are planning on leaving everything to your daughter who is also your primary caregiver, your other children may argue that your daughter took advantage of her position to influence you. To avoid the appearance of undue influence, do not involve any family members who are inheriting under your will in drafting your will. Family members should not be present when you discuss the will with your attorney or when you sign it. To be totally safe, family members shouldn’t even drive or accompany you to the attorney’s office. You can also get a formal assessment of your mental capabilities done by a medical professional before you draft estate planning documents. For more information on preventing a will contest, go here.

July 14, 2016

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