Medicare: A Basic Understanding

by Michael on December 8, 2009

in Health insurance,Insurance Newswatch,Long Term Care,Medicare

Sometimes people will continue working primarily due to feeling the need for health insurance. This is understandable, in view of the uncertainty today.

When a person does reach Medicare age, questions often arise. Questions like:

1) What is original Medicare?

2) What are Medicare Advantage Plans?

3) What about prescription drugs? And finally …

4) What about Long Term Care?

Original Medicare is broken into two parts, Part A (Hospital) and Part B (Doctors and other things). Part “A” comes with Social Security and you do not pay for it. Part “B” you do pay for, as it is subtracted from your Social Security Check. Some people qualify for help with this premium, while others pay more (due to large incomes). Most people pay $96.50 for Part “B”. Some people elect not to enroll in this, but I believe that almost everyone should enroll in Part “B”. It is the best deal in health care today.

Medicare Supplement Plans (sometimes called MediGap policies), pay on the deductibles and co-pays that Medicare does not pay. They only pay on expenses that are “covered” by Medicare. In other words: if Medicare pays something for the service, then MediGap policies have a benefit. Conversely, if Medicare does not cover the expense at all, then neither does any MediGap policies.

Medicare Supplement polices are standardized. Each policy has a letter designation, and every company who sells that “letter designation’ has the same policy. So a “Plan F” from company XYZ is the same policy and has the same benefits as a “Plan F” from company ABC. The only difference is the premium and how well a company serves your needs.

I am a big advocate of original Medicare combined with a good supplement. In my view, and in most cases, a person will have the lowest overall medical expenses choosing this option. (Ask me and I will help you decide if this would be true for you). But the best part is a person’s medical expenses are predictable using this option.

You are allowed to enroll without health questions when you enroll in Part “B” of Medicare. The legal time frame is three months prior to three months after (a total of seven months). Some companies choose to allow more time. And some companies allow this at any time on some plans. And in CA, a person can change companies but keep the same plan in their birthday month without health questions.

Choosing Original Medicare with its Part “A” and Part “B” along with a MediGap policy is felt by many (including myself) to be best for people who wish to know exactly what their health costs will be or for those who travel a lot.

Medicare Advantage Plans are also known as Medicare Part “C”. It is essentially the privatization of Medicare. A person still pays for Part “B”, but could pay anywhere from Zero dollars to around a hundred dollars per month for the plan. It is different in each County. Although it is Medicare, these plans work a little more like a person may be use to coming off a group health plan. Typically, you will have co-pays and the like, with a maximum out of pocket. You do not know what your total costs will be, but you do know the maximum it could be (which is typically considerably higher than staying with Original Medicare and a supplement). These plans differ somewhat in that a doctor may choose to accept it or not, and may in fact, choose to accept you this week, but not next week. He may choose to accept your best friend, but not accept you. A physician cannot do this with original Medicare, but it is legal for him to do this with Medicare Advantage Plans. They refer to it as “deeming”. A decision to accept you does not establish a policy, but rather a decision made on each visit. Just so you know, it is not common for Physicians to do this, but it can and does happen for reasons beyond anything you have control over.

Medicare Advantage Plans operate under very strict enrollment procedures, but a person needs to know that each year, for the last six weeks of the year, a person can change their plan, or return to Original Medicare, if they choose. There are other times, under various rules that allow changes. Ask me for it, and I will give you the complete rules regarding this.

The important thing to understand is that a person does not give up Medicare when enrolling in one of these plans. However, there are rules that must be followed and it is in a person’s best interest to review this each year, as under current CMS (Center for Medicare and Medicaid Services) rules, the plans may change each year. I cannot stress enough the need to do this if a person chooses a Medicare Advantage Plan. The changes can be drastic.

Medicare Advantage Plans, in my view, are not a good option. However, there are exceptions to this statement. If appropriate, they are usually best for people; 1) who wish to keep premiums low, 2) do not mind taking a risk on the total potential out of pocket, and 3) do not travel a lot.  Some counties still have zero premium plans available, which covers a person as well as they may be use to under their group insurance plan (of course, each plan is different and a comparison should be made).

Prescription Drugs are covered under Medicare Part “D”. These plans are typically sold nationally (as opposed to by County). They can be included in Medicare Advantage Plans or purchases separately. It takes quite a lot to explain these, but suffice it to say that there are quite a few differences between plans. The design of these plans came out of Congress, and I cannot explain the rationale behind the design, as I find the design illogical. However, I can show you, not only a good plan for you, but also how to utilize the plan to best serve your interests which means, to save you money.

Long Term Care is really a separate subject. Although Medicare does have a Limited Benefit for Skilled Nursing, the two operative words are “Limited” and “Skilled”. It is good for short stays while a person is recovering and making progress. Basically, it is for those instances where a person is not sick enough to be in the hospital, but still needs some care while recovering. It is not for long-term convalescent care. This type of coverage can be handled in a lot of different ways, and which way is best for an individual will depend on their financial situation, married or not, and a host of other factors. The only constant is planning is needed. The decision cannot be made at the time of need, or at least not made well.

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