Page 2 - Cover Letter and Medicare Evaluation for Jamie Marshall

Finally, enroll in the stand-alone drug plan that has the lowest costs for the Rx
drugs you take. As described below, the lowest-cost plan is the Humana Walmart
Value Rx Plan, which you can enroll in by calling (800) 281-6918. When you do
this, you will be signing up for Part D coverage.

Your physicians’ network affiliations

Dr. Pruzan is listed in the Medicare provider directory (Appendix A1), but it’s not clear whether
she accepts Medicare-approved rates. Doctors who accept Medicare but not its approved rates
may charge up to 15% more than the approved rates. Medigap Plans G and N in your evaluation
covers that excess charge, but Plan L does not.

Your other two physicians – Drs. Lithgow and Williams – are not listed in the Medicare
directory. But you should verify this because the Medicare directory information is not always
current. Also, in some cases, providers are not listed individually, but the medical group that
they belong to is listed.

Dr. Lithgow is affiliated with the Yale New Haven Health System, which does accept Medicare,
but it is possible that some of its affiliated providers may not accept Medicare. And Dr. Williams
is affiliated with Brookside Gynecology, which according to its website opted out of Medicare
last August. Again, though, it’s a good idea to independently verify this information.

When a physician opts out of Medicare, neither Medicare nor a Medigap policy will pay for
services provided by that physician. But Medicare and the Medigap policy should cover referral
services ordered or prescribed by the doctor (assuming they are services that Medicare would
cover in other situations).

As an example, if a doctor who does not accept Medicare refers you to an imaging service or
physical therapy center that accepts Medicare, those secondary services should be covered.
Still, it is important to verify this with the secondary provider. And if you are asked to sign an
“Advance Beneficiary Notice,” it is an indication that the provider has reason to believe that
Medicare may not cover the service. Appendix A2 is an explanation from the Medicare web
site of how the opt-out process works.

Finally, in rare cases a doctor or medical group that does not accept Medicare will be in the
network of an Advantage plan. And even they are not, they may be covered as an out-of-
network service by an Advantage PPO plan. But in some PPO’s, referrals for secondary services
that are made by an out-of-network doctor may not be covered, depending on the PPO’s rules.

How Medigap policies work

Perhaps the most desirable attribute of Medigap policies is the flexibility they offer. There are
no networks, and you will usually not need referrals to see specialists. You will be covered when

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