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Understanding Medicare Healthcare

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Understanding Medicare

Why is Health Insurance Important?

Focusing on what matters becomes more important as you age. Having health insurance allows you to spend time on those things that matter. Having a safety net, like a Medicare plan, close to you will bring peace of mind. One of the greatest Medicare benefits is that it will aid you in nearly every health-related situation.

Senior Couple on the couch

WE ARE DEDICATED TO INFORMING AND EDUCATING YOU ABOUT HEALTHCARE AND OTHER FINANCIAL SERVICES.

You want answers to your questions regarding insurance and financial products. Since selecting the best product to meet your needs can be complicated, we hope our information will help you understand your options.

Because your needs are varied and ever-changing, we continually monitor various government and private programs and products. We will update this site continually and are happy to keep you informed on changes. Be sure to complete the form on any of our pages so we can send a free guide and keep you informed in areas of interest to you.

First and foremost, Medicare eligibility requires an individual to be of Medicare age (at least 65 years old) or qualified through disability guidelines set by the Social Security Administration (SSA). Additionally, those eligible for Medicare have earned at least 40 quarters of employment, in which Social Security payments are deducted from their salary. An individual can earn up to four credits per year, meaning an individual must put at least 10 years’ worth of work toward Social Security payments. Once enrolled in Medicare, you are enrolled in the Original Government Medicare (OGM) plan. The OGM plan offers separate add-ons, such as Medicare supplements. If you have questions about your eligibility, you can visit the SSA website, visit your local SSA office or visit with a Medicare adviser.

Everyone who has earned at least 40 quarters will qualify for Medicare Part A at no cost. Medicare Part A covers hospital care while Medicare Part B covers doctor visits. There are monthly premiums associated with Part B, unlike Part A. These charges cover the doctor visits as well as deductibles, coinsurance and copays. It’s important to note that the OGM plan does not include a maximum out of pocket expense gap on health care coverage, meaning there is no limit to how much you can pay in medical bills. Individuals must accept or decline Part B’s coverage when enrolling in a Medicare plan.

When enrolled in the OGM plan, you can go to any doctor or hospital in the U.S. that accepts Medicare. The OGM does not maintain a formalized “network” of doctors and hospitals, but it maintains its services, meaning OGM is designed to cover any necessary medical health care. However, it does not cover prescription drugs. Coverage for prescription drugs, otherwise known as Medicare Part D plans, is another example of a separate add-on that can be purchased through OGM. You may want to consider purchasing the Medicare Part D {prescription Drug plan because it will offer a benefits package equal to the OGM and Medicare Advantage plans.

Medicare Advantage (MA) plans provide a specific type of Medicare health insurance that is separate from the OGM plan. It is also known as Medicare Part C coverage. Enrollment eligibility requires that an individual must be enrolled in Parts A and B of the OGM program with plans to purchase MA from a Medicare-approved private company. An individual must also be of Medicare age, 65, or qualified through disability guidelines set by the SSA. Once in the MA program, benefits will be administered through the private insurance company instead of the government.

Health care will be provided at no extra cost for those in a specific network with Medicare Advantage. However, because MA consists of a network of health care professionals, you should expect to get a new primary care doctor, receive new referrals to see health care specialists and get authorization for certain services. There are some MA plans that allow you to receive care outside of the network and pay those health care professionals directly. Additionally, MA plans will cover emergency care that takes place outside of your network, though follow-up and continued care must take place in the service area. In-network medical staff can join or leave a Medicare Advantage network anytime during the year. This also means that the MA plan can change doctors and hospitals in the network at any time throughout the year.

Medicare Advantage plans offer additional services to the OGM plan. These services may include:

  • Dental,
  • Hearing,
  • Vision care,
  • Health club memberships and
  • Prescription drug coverage

MA plans are similar to health plans in cost and coverage. There are HMOs, PPOs, POS plans and more. These can include deductibles, copays, and coinsurance, but not all Medicare Advantage plans cover dental. Make sure to read all of the details about what is covered in your plan before signing up. If you want dental coverage as a Medicare benefit, ensure the plan you choose includes this coverage in a way that fits both your needs and budget. An OGM plan will not cover dental work unless you have suffered a traumatic unjust that has also affected your jaw, teeth or mouth and requires hospitalization.

Medicare Advantage plans don’t contain a co-payments provision that exceeds those for the OGM for chemotherapy administration services. Renal dialysis services, and skilled nursing. All MA plans maintain a Maximum Allowable Out-of-Pocket (MOOP) limit on the amount of cost-sharing they can charge for Parts A and B services. You will receive no further health care costs for the rest of the year once the yearly limit of out-of-pocket expenses has been reached MA plans may change benefits. Premiums and copays each year. It is also important to note that Medicare rates for MA plans will vary in cost between applicants.

Pros:

  • MA plans maintain lower cost-sharing expenses than the OGM plans. For instance, a MA plan may require a co-payment of $10. The OGM co-payment consists of 20% of the cost, which may exceed $10.
  • MA plans maintain maximum limits for our out-of-pocket expenses. As a result, once a policyholder reaches the maximum, there are no further costs for any services. Moreover, this exemption will last for the remainder of the insurance year. Unfortunately, the OGM plan does not offer this very important benefit.
  • MA plans coordinate among the health care providers.
  • MA plans serve as a “one-stop” center for all health and prescription drug coverage needs.

Cons:

  • There are a limited number of MA networks to choose from. In most cases, if you go out of network for care without authorization or a referral, your medical care may not qualify for reimbursement, and you may need to pay the costs yourself.
  • Authorizations and referrals: Hospital stays, medical equipment and visits to specialists all require a referral from the primary physician. Therefore, without authorization, medical care may not qualify for reimbursement, and you may need to pay the costs yourself.
  • Regional limitations: most MA plans require that you live within a network’s region for at least 6 months prior to enrolling.
  • Plan Options: the available options for MA plans will vary depending on the region and the approved plan of providers.

Understanding the advantages and disadvantages of MA plans should incite questions for an individual to ask professionals. Below is a list of questions you should ask when inquiring about these plans:

  • Can you explain any additional monthly premium?
  • Does the plan charge for a yearly deductible?
  • Can you explain the charges for a visit or service (co-payments/ci-insurance)?
  • What does the health plan offer?
  • Can you explain the health care network?

Visit the Medicare website to learn more insight on a Medicare Advantage plan

Medicare Supplements -- or Medigap plans -- are designed to help an individual pay for any costs that cannot be covered by an Original Medicare plan, especially when it comes to costs associated with Medicare Part D. An individual must be enrolled in Medicare Part A as well as Medicare Part B in order to be eligible to purchase and keep a Medigap policy. If you meet this criterion, you are able to join the Medigap plan during your Medicare Open Enrollment Period (OEP), which begins three months before you reach Medicare eligibility age and ends three months after your birthday. Medigap coverage will begin the month you enroll in Part B. It is important to note that you are still qualified for Medigap if you have group health insurance through your employer or union. During your OEP, an insurance company cannot use medical underwriting. According to the Medicare website, this means that a company cannot do the following because of health issues:

  • Refuse to sell you Medigap policies they offer.
  • Make you wait for coverage to start -- unless it has to do with pre-existing health conditions, which we will discuss at a later time.
  • Charge you more for a Medigap policy.

It is important to note that your open enrollment cannot be changed or repeated, meaning the best time to get Medigap is during your Medicare enrollment period. You may be unable to buy a Medigap policy once this period ends. If you are able, an insurance company can deny you a policy based on your health. You may also receive late penalty fees, just like you would with the OGM plan.

The eligibility for a Medigap policy is tricky. You must be at least 65 in order to receive a Medigap policy. Those who are younger than the Medicare age, but still qualify for Medicare, are not guaranteed eligibility for a Medigap policy. Insurance companies are not obligated to sell you a Medigap policy if you are under 65 because of End Stage Renal Disease (ESDR) or a disability. However, the following states do require insurance companies to offer at least one Medigap policy for those under 65 with Medicare:

  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • New Hampshire
  • New Jersey
  • New York
  • North Carolina
  • Oklahoma
  • Oregon
  • Pennsylvania
  • South Dakota
  • Tennessee
  • Texas
  • Vermont
  • Wisconsin

There are instances in which insurance companies can withhold Medigap coverage for out-of-cost expenses for up to six months for those who have a pre-existing health condition. After six months, Medigap policies will begin to cover those with these conditions.

Medigap policies are different from Medicare Advantage plans. The difference between the two lies within what they provide. A Medicare Advantage plan will combine Medicare Parts A and B, and usually Part D, into one plan. It will also offer benefits that an individual would not receive through the OGM plan, which were mentioned above. Medigap, however, lowers your share of costs for the approved Parts A and B with the OGM plan. Any desired additional drug coverage must be purchased. Additionally, Medigap can only be applied to the OGM plan and not the MA plan because Medigap is meant to fill in coverage for what the OGM does not cover.

To enroll in a Medigap policy, there are three steps that have been outlined by the Medicare website:

  1. Decide which plan you want. Policies are standardized with Plans A through N (unless you live in Massachusetts, Minnesota, or Wisconsin, where you will have different standardized plans). During this step, you should compare the benefits that each plan will help pay for and choose the best plan that will cover what you need.
  2. Pick your plan/policy, Find the policies that are available in your area. You will find that the biggest variation between policies with the same letter (A - N) is the prices.
  3. Contact the company. You will be able to get an official quote through the company you decide to contact for your policy. Prices will be subject to change at any time based on the time in which you purchase your policy, as well as your health conditions and more.

It’s always a smart option for a senior to seek the help of Medicare specialists who do not charge a fee when selecting a Medicare plan. Understand what each plan offers, any restrictions, costs and how the plan may interact or interfere with any active health insurance plan.

For example, if you retire and have health insurance, there is a possibility that you may lose your present coverage when purchasing a Medicare Advantage plan. However, it is possible that a current employer could offer you an MA plan, in which you and the company would receive a win-win.

You should also consider buying a Medicare Supplement policy during the process of choosing one of the Medicare plans. Ensure that you’re clear about premiums, deductibles, copayments and yearly out-of-pocket maximums for both plans.

Additionally, like we mentioned before, there are benefits included in a Medicare Advantage plan that would otherwise not be offered with the OGM plan, like vision care. There are Medicare benefits included in the OGM that are not present in an MA plan, like access to almost any doctor, hospital, or health care facility in the nation.

Medicare Advantage plans are authorized to offer innovation benefits as of 2020, including transportation to doctor’s appointments. Medicare Advantage is another way an individual can get his or her Medicare benefits with Parts A and B through a private insurance company approved by Medicare. Our advisers will be happy to discuss with you whether your Medicare plan covers this or if you are eligible to add a plan that includes transportation.

OGM generally does not cover transportation to routine health care. However, it may cover non-emergency ambulance transportation to and from a health-care provider. You need to have a health condition diagnosed or treated and other forms of transportation could endanger your health. However, your doctor must provide a written order verifying that ambulance transportation is medically necessary because of your health condition.

If you don’t qualify for non-emergency ambulance transportation, there may be non-Medicare transportation services available in your immediate area through local organizations. One example could be your local Area Agency on Aging (AAA) may be able to help you find transportation to and from your health care provider.

If you are eligible for Medicaid or the Program of All-Inclusive Care for the Elderly (PACE), these organizations may also provide transportation for routine medical care. Visit Medicaid or PACE for more information.

Although the Original Government Medicare does not cover gym memberships or programs, these may be considered extra coverage by Medicare Advantage programs, other Medicare health plans or Medicare Supplement (Medigap) insurance plans.

It’s possible that your health insurance may include a free fitness membership for adults aged 65 and older called SilverSneakers. SilverSneakers eligibility and membership includes access to roughly 16,000 gym and fitness centers across the country, meaning there are more participating SilverSneakers locations than there are Starbucks.

Medicare Supplement insurance plans don’t include gym memberships. Medicare Supplement insurance plans may cover most of your Medicare Part A and Part B coinsurance and copayments, as well as foreign travel emergencies.

These Medicare plan options are offered through private, Medicare-approved companies, meaning their availability and benefits may differ by location.

You will want to compare plans to see if one in your area offers coverage for health club membership costs. Our advisers will be glad to discuss your benefits with you and help you find an option at no charge.

The dental coverage that is offered by Medicare Advantage plans can include:

  • Teeth cleaning,
  • Routine X-Rays,
  • Extractions,
  • Fillings and more

Plans may differ based on the insurance company as well as your locations. Dental coverage often comes with limits on how many services are covered in a plan year, maximum cost allowances and more.

In addition to dental services, a Medicare prescription drug plan or a Medicare Advantage plan may cover certain products related to vision care, like eye drops or other vision medications prescribed by a doctor.

Medicare Part B covers some vision care, but not routine vision exams. You’re not covered for vision correction, like eyeglasses or contact lenses under Part B unless you need vision correction after cataract surgery. Additionally, Part B also does not cover eye refractions.

Part B covers yearly glaucoma screenings if an individual is at high risk. High-risk patients include those with a family history of glaucoma, African Americans over the age of 50, Hispanic Americans over the age of 65 and people with diabetes. State-approved vision care specialists are the only providers who can perform yearly vision screenings for glaucoma. Individuals are expected to pay the 20% Medicare coinsurance for the vision care costs approved by Medicare, subject to his or her annual Medicare deductible.

Medicare Part B vision benefits cover cataract surgery and the cost of the replacement artificial lens, as well as the cost for vision correction products, such as glasses with standard frames, following cataract surgery. You pay the 20% Medicare coinsurance for the amount approved by Medicare, subject to your annual Medicare deductible.

Medicare B vision benefits cover eye prostheses for patients with absence or shrinkage of the eye due to a birth defect, trauma, or surgical removal. Part B also covers the polishing and resurfacing of vision prostheses twice per year under its vision benefits, as well as one enlargement or reduction in size prostheses without documentation. Additional enlargements or reductions are only covered when medically necessary. Medicare covers the cost for vision prosthesis replacement if the vision prosthesis is lost, stolen or irreparably damaged within the first five years.

Medicare Part B covers ocular photodynamic therapy, which is a treatment for patients with macular degeneration, a vision problem associated with age.

MA offers an alternative way to receive your Original Government Medicare benefits. MA plans are offered by private, Medicare-approved insurers. All private insurers must offer the same benefits as Original Medicare (except hospice care, which Medicare Part A covers), but they may include other benefits, such as routine vision, routine dental and Medicare prescription drug coverage. When routine vision benefits are available through a Medicare Advantage plan, your premiums could be higher than those with MA plans that do not offer routine vision benefits.

Some MA plans include full coverage for routine vision exams, vision correction products and other vision care. Review the specific MA plan’s vision benefits to be sure.

It may seem as though the costs and premiums and Medicare in 2021 are high. That’s why it’s important to understand the premiums for each part of Medicare now, so that you don’t get a late penalty fee.

Fortunately, for Medicare Part A, most people don’t pay a premium and have automatic Medicare eligibility coupled with automatic Medicare enrollment. This is because they have worked enough in their lifetime to get this service at no cost. However, if the number of hours you’ve worked do not meet the criterion, you may still purchase Part A and pay monthly Medicare premiums. How much you pay depends on how long you have been paying Medicare taxes. If you have been paying taxes for less than 30 quarters, the standard cost is typically around $471/month. However, if you paid taxes for anywhere between 30 to 39 quarters, your standard drops to around $259/month. If you enroll late, you will be penalized with an additional 10% cost of your monthly premium. This cost will be due for twice the number of years in which you could have enrolled in Part A but didn’t.

Unlike Part A, you are expected to pay a premium for Parts B, C and D. The standard Medicare Part B premium is around $148.50/month. However, this amount could be higher if your income is higher. There is no late enrollment penalty for Medicare Part C coverage, also known as Medicare Advantage, because you are able to switch to this plan at any point during specific enrollment periods. However, if you enroll in Part D late, you will have to pay a late enrollment fee in addition to your monthly premium. This fee is the number of months you were late to enroll multiplied by 1% of the average monthly prescription Medicare cost.

There are four ways in which you can pay your Part A and B premiums, as listed by the Medicare website:

  1. Pay online through your Secure Medicare account through the Medicare website.
  2. Pay directly from your savings/checking account through your bank’s online bill payment service
  3. Sign up for Medicare Easy pay, a free service that automatically deducts your premium payments from your savings or checking account each month. You can expect this to happen on the 20th of each month.
  4. Mail your payments to Medicare via check, money order, credit card or debit card. There will be a coupon that will come in your bill. You must fill this out, or else your payments could be delayed. If you pay with credit or with debit card, fill out your account information and the expiration date, as well as sign the coupon.

Mail your payment -- and your coupon -- to:
Medicare Premium Collection Center
PO Box 790355
St. Louis, MO 63179-0355

Make sure to look closely at the upper right corner of your bill. There are four things your bill could possibly state:

  1. "This is not a bill.” This means you are on Medicare Easy Pay, and you will not have to do anything.
  2. “First Bill.” This means this is either your first Medicare bill, or you’ve paid your last bill in full. This is a bill stating that you are to send in the payment for your total amount due. Medicare must receive this bill by its due date, or it is considered late.
  3. “Second Bill.” This is a notification from Medicare stating that it did not receive your full payment from your previous bill, and that it is around 60 days late. This is the time for you to pay the remainder of your bill from the previous month, as well as the premium of the current month.
  4. “Delinquent Bill.” This is your final warning from Medicare. At the 90-day mark, you have one last chance to send in your payment. Failing to do so means you will lose your Medicare coverage.

Medicare will assist individuals who need help in making payments. The Best Senior Services is also here to assist you, by connecting you with a local licensed agent who will help you better understand Medicare services and what is right for you.

You can appeal unfavorable decisions regarding coverage of services for both the Original Government Medicare plan and the Medicare Advantage plan. Different rules and regulations exist for each Medicare plan, and you should look into details of each policy to understand certain deadlines.

Anyone can be Approved

There are a variety of services available to you, no matter your health or financial situation. For some programs, it is important to enroll at a specific time. However, we understand that your first priority is selecting an option that not only works for your current situation, but also anticipates your future needs.

We recommend using our resources along with guidance from a licensed representative in your state because programs vary by state (or county) and each person’s situation is different. We will connect you with a qualified expert who can help you find the program best fitting for your needs when you request a free guide.

Senior Couple in the kitchen