- Health Care, Drugs & Insurance
Get Prepared Now
I am writing this Hub because I have dealt with the complicated Medicare A & B plans and Supplemental Insurance plan that the folks have every time a crisis happens and understand how difficult it is to understand. Fortunately, my dad was savvy and got a great group supplement plan so I do not have as much a problem as my cousins do with just the Original Part A and Part B Medicare Plans their folks have.
September is 'National Preparedness Month'so let's get prepared. I remember when I turned 40 how a particular over 50 group began flooding my mailbox with flyers on their discount program. My aunt said the same thing happen when she got close to age 65. Let us suppose that you are being bombarded with Supplemental Medicare plan information in the mail, and like me see a cacophony of television ads too. Your choices are many, wonder what does it mean? What should you do?
You can go on-line to http://www.medicare.gov/publications/pubs/pdf/10050.pdf to research the “Medicare & You” handbook but the 2011 booklet is 134 pages long. Fortunately, the booklet will be mailed to beneficiaries [people reaching age 65] in October and includes tips on selecting a plan and an overview of plan options. You could go to another website: http://www.cms.gov/OrigMedicarePartABEligEnrol/to do research as well, or call an insurance provider to see what benefits they have. But before you start calling, here is the skinny:
Medicare Enrollment Periods.
Initial Enrollment Period - Three months prior to the month you were born and three months after your birth month is the Initial Enrollment Period. You are suppose to get the Medicare Booklet and your Medicare Card in the mail three months before your birthday so you can take time to decide what you want to do. Most folks get Part A premium free. You pay a monthly premium for Medicare Part B. If you don't want to pay the premium for Part B, you have to follow instructions and send the card back so they do not charge you. However, there is a penalty of 10% per year if you declined Part B without a good reason and want it later. So you better be certain you don't want it.
Annual Enrollment Period - November 15 to December 31. Beneficiaries make changes to your current coverage, change plan coverage, change Advantage providers, return to original Medicare, change prescription drug plans, or become eligible for the first time.
General Enrollment Period - January 1 to March 31. If you did not enroll in Part B when you first became eligible for Medicare because of some unaccepted reason, you can sign up in 2012 from January 1 through March 31 each year and be effective July 1st, 2012. You will be penalized for not taking Part B when offered. Cobra does not defray Part B coverage penalty.
Open Enrollment Period January 1 through March 31 provides an opportunity to enroll, cancel, or change your Original Medicare Plan, Medicare Advantage plan or, Prescription Drug Plan. Changes made occur the next month. The beneficiary who wants to make changes must have both Medicare Part A and Medicare Part B and must live in the area served by the Medicare Advantage plan
Special Enrollment Period - Allow beneficiaries to make an enrollment change outside of the other enrollment period options Generally used for those who delayed enrolling in Part B because they were covered by employer-sponsored health insurance as an active worker or as a dependent of an active worker. Enrollment lasts 8 months from the time they (or their spouse) retire or they lose their health insurance.. Part B coverage starts the month after the election is made, and no late premium penalty is assessed
Medicare Part A and Part B are Fee-For-Service Plans driven by Benefit Periods. A benefit period begins the day you go into a hospital and ends 60 days after you have the last covered service. For each benefit period, you pay $1125.00 out of pocket expense. There is no limit to the number of benefit periods you have in any given year or the amount of out-of-pocket expense you pay annually in Original Medicare..
Medicare Part A
Part A effective date is determined on your birthday month when you turn age 65 and effective the 1st day of your birthday month if your birth day is day 2 through day 31 of the month. If however you are born the 1st day of the month, your Medicare effective date is the month preceding your birth month. So, Born September1st, Medicare effective date is August 1st. the year you turn 65.
Eligibility: Deemed eligible based on 10 years work or 40 quarters total work with Medicare deductions from their own earnings or those of a spouse, parent, or child. If you are deemed eligible, paid Medicare taxes or FICA, you pay no Part A monthly premium.
Note: You can purchase Part A at a monthly Premium cost if you or your family haven't earned eligibility by work credits. You can buy Part A for a monthly premium.
Part A Premium in 2011:
0-29 quarters - $450.00 a month
30-39 quarters- $248.00 a month
Medicare Part A Covers:
Hospitalization includes anesthesia charge.
Blood after the 1st 3 pints. Note: donated blood reduces or eliminates cost.
Skilled Nursing after 3 day hospital stay.
Home Health Care for Rehabilitation only
Pay less deductible.
Co-pay [out-of-pocket expense.
95% of Respite Care - You pay 5% of the cost
Prescription Drug in-patient cost less $5.00 co-pay for each drug
Hospice care less the Hospice Facility co-pay:
Days 1-100 - You pay no hospice skilled care co-pay
Note: Medicare does not pay room and board except in special circumstances
Medicare Part B
Monthly premium charge in 2011 of $115.40
Annual deductible in 2011 of $162.00.
Medicare Part B Covers:
Physician services in and out of the hospital.
Ambulance and air lift charges to the hospital.
Out patient Mental Health Coverage less a 45% co-pay.
Hospital deductible and co-pay:
Days 1-60 you pay your first inpatient hospital deductible amount, currently $1125.00.
Days 61-90 you pay $283.00 co-pay every day.
Days 91-150 you have a lifetime benefit of $566.00 Once used is gone forever.
Skilled Nursing Facility [SNF] co-pay after 3 day hospitalization:
Day 1-20 you pay nothing for the first 20 days.
Day 21-100 you pay $141.50 co-pay for each day.
Over 101 you pay 100% of the cost.
You pay a co-pay of 20% after deductible for most covered expenses however, some physician visits have a zero co-pay like the initial 'wellness visit.' Consult the 'Medicare and You' handbook for specific services.
Note, in 2011 The Affordable Care Act providespreventive care assistance to those on Medicare Part B. For more information visit: http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf
Medicare Part C
Medicare pays private insurance companies a capitation rate to provide health care to people with Medicare Part C. Part C is known as the ‘Advantage Plan.’ it is regulated by The Centers for Medicare & Medicare Services. In order to have an Advantage Part C plan, you have to have Part A and Part B coverage. Many people choose an Advantage plan because it has a maximum amount out-of-pocket dollar amount. For 2011, that dollar amount is$6700.00 or less for most Advantage plan participants. There is a plethora of providers selling Advantage Plans to those who qualify. Check out the government website for more information at: https://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx
There are three main types of Advantage Plans on the market are the HMO, PFFS, and PPO plans. Medicare Advantage Plans must be equal to or better than the Original Medicare [Part A & Part B combined]. They offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Part D coverage as part of their package and those who select a Part C Plan pay an additional fee for the extra coverage and out-of-pocket protection provided.. Here is Plan C information in a nut shell:
Medicare Part C Generally Covers
Medicare Part A & Part B services
365 days hospitalization.
The first 3 pints of blood.
Formula prescription drugs like Part D, plus.
HMO Plans - Health Maintenance Organization is service network of primary care doctors, specialists, hospitals and other providers you must go to in order to secure reimbursement unless it is an emergency situation. If you are out of the service area for 6 months you may be dropped from this plan.
HMO PPS Plans - An Health Maintenance Organization Point of Service Plan has a service network of primary care doctors, specialists, hospitals and other providers but they may allow you to get some services out-of-network at a higher out-of-pocket cost.
PPO Plans - Preferred Provider Organization of primary care doctors, specialists, hospitals and other providers that you may go to. You have the flexibility to go to any doctors, specialists, or hospitals that aren't on the plan’s list, but it will usually cost more. Medicare PPO Plans are either Regional Preferred Provider Organization Plans serving one of 26 regions established by Medicare or, Local Preferred Provider Organizations Plans serving counties the PPO Plan chooses to include in its service area.
PFFS Plans [Medicare Look Alike Plans] - Private Fee-For-Service A Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan. The insurance plan, rather than the Medicare Program decides how much it will pay and what you pay for the services provided. You may pay more or less for Medicare covered benefits and may have extra benefits that aren't covered under the Original Medicare Plan
MSA Plan - Medical Savings Account Plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less the deductible). You can use the money to pay for your health care services during the year.
SN Plans - Special Needs plans are limited to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formula (list of covered drugs) to best meet the specific needs of the groups they serve. Requirements include: You have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, a mental health condition, or HIV/AIDS). You live in an institution (like a nursing home), or you require nursing care at home. You have both Medicare and Medicaid.
Medicare Part D
Medicare prescription Drug Coverage covers a formulary prescription drugs only. If you want other drugs you pay out of pocket. There is a Co-pay [out-of-pocket expense] for drugs listed on the formulary.
Note, in 2011 The Affordable Care Act changed Medicare Part D. More discounts for routine prescription drugs. Visit www.medicare.com If nothing else, hopefully I have alerted you to the need to do your research and help your seniors when it comes time to research Medicare Options.
12 policies are offered A-N each with a different premium cost. The coverage provided is roughly proportional to the premium paid. Each standardized Medi-gap policy mustcover basic benefits. Medi-gap Plans A through G have one set of basic benefits, and Plans K, L, M and N have a different set of basic benefits. Some plans are not offered everywhere due to the offering.
SelectMedi-gap during the open enrollment period which begins within 6 months of turning 65 Most plans must have Medicare Part A and Part B, If you have Medicare Part B you may obtain a Medigap plan on a guaranteed issue basis requiring no medical screening. Outside the Open Enrollment Period, the issuing insurance company may require medical screening and may obtain an attending physician's statement if necessary.
Medi-gap Generally Covers:
Medicare co-payments cost.
365 days of hospitalization.
The first 3 pints of blood.