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Understanding Medicare Healthcare

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Understanding Medicare

Health Insurance is Important for Peace of Mind

We know that, as you age, you want to begin to focus on the things that truly matter. Do not waste any more time worrying about what will happen should health issues arise. Knowing you have a safety net available in the event of a health emergency will provide a sense of ease, which means you can begin to focus on enjoying this rewarding time in your life.

Senior Couple on the couch

Learning About the Plans at a glance

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.

To be eligible for Medicare, you must earn at least forty (40) quarters of employment. During employment, Social Security payments are deducted from your salary. The forty quarters will qualify you for Medicare Part A at no cost. If interested, you must be 65 years of age or possess certain disabilities as defined by Medicare. You can contact the Social Security Administration online or go to a Social Security Office in your community to sign up or ask questions. You may also work through a Medicare advisor who works for a private company. When you enroll in Medicare, you also enroll in the Original Government Medicare plan. However once enrolled, you can then choose a Medicare Advantage Plan from a private company.

For clarity purposes, Medicare Part A covers Hospital Care and Medicare Part B covers doctor visits and charges a monthly premium for its coverage. Individuals must accept or decline Part B coverage when applying. In addition, enrollment for the Original Medicare Plan in most cases must be at a certain time of the year.

When enrolled in the Original Government Medicare Plan, you can go to any doctor or hospital in the United States that accepts Medicare. The Original Government Medicare Plan does not maintain a formalized “network” of Doctors and Hospitals. To see a Doctor, Specialist, or healthcare entity, Medicare enrollees simply make an appointment.

The Original Government Medicare policy requires a monthly premium for Part B coverage, which covers doctors for medical care. Additional charges include deductibles, coinsurance, and co-pays. The Original Government Medicare plan does not include a maximum out of pocket expense cap on healthcare coverage. However, with the Original Government Medicare plan, you can purchase Part D drug coverage and a Medigap plan separately.

The Original Government Medicare Plan maintains services that continually stay the same. Basically, it covers medically necessary healthcare. The Original Government Medicare Plan does not provide coverage for prescription drugs; however, it can be purchased. With the Original Government Medicare Plan, you may want to purchase a Medigap plan to defray costs. Additionally, you may want to purchase the Medicare Part D Prescription Drug Plan. Medicare Advantage plans must offer a benefits package similar or at least equal to the Original Government Medicare Plan’s, Medicare Advantage must also cover everything the Original Government Medicare Plan covers.

Medicare Advantage plans offer additional services to the Original Government Medicare Plan. These services may include:

Dental
Hearing
Vision care
Health club memberships
Prescription drug coverage

Medicare Advantage (MA) plans provide a specific type of Medicare health insurance. To enroll in an MA plan, you must be enrolled in the Medicare program and purchase from a private organization. Those in the healthcare industry refer to this plan as “Part C” of Medicare or “MA Plans.”

MA Plans provide an alternative to the Original Government Medicare plan by offering additional coverage. Our guide will cover the pros and cons of MA Plans. It provides information about different options and why you may need this kind of insurance.

To enroll in a Medicare Advantage program, you must specifically request Medicare coverage through a Medicare Advantage Plan and have reached the age of 65. Age exceptions exist, but those are for individuals with special needs. When applying, you must enroll in the Original Government Medicare Plan, Part A, and B to qualify for the Medicare Advantage Plan. Medicare Advantage benefits are administrated and provided through a private insurance company and not the government.

For those enrolled in a Medicare Advantage plan, your health care will be provided at no extra charge by those in the specific network. Because Medicare Advantage is comprised of a network of health care professionals, sometimes you must obtain a new primary care doctor, obtain referrals to see health care specialists and obtain authorization for certain services. Some Medicare Advantage plans allow you to obtain care outside the network and allow payment directly to those health care professionals. If you travel out of the service area and need to see a health care provider, most Medicare Advantage plans will cover the emergency and urgent care required. The follow-up and continued care must be conducted in the service area.

In network medical staff can join or leave a Medicare Advantage network anytime during the year. The Medicare Advantage plan can change doctors and hospitals in the network at any time during the year.

Medicare Advantage plans do not contain a co-payments provision that exceeds those for the Original Government Medicare for chemotherapy administration services, renal dialysis services, and skilled nursing. All Medicare Advantage plans maintain a Maximum Allowable Out-Of-Pocket (MOOP) limit on the amount of cost-sharing they can charge for Part A and Part B services. Once the yearly limit of out-of-pocket expenses has been reached, you will incur no further health care costs for the rest of the year. Medicare Advantage plans may change benefits, premiums, and co-pays every year.

Medicare Advantage plans vary in cost, and thus, applicants should conduct all necessary due diligence.

Questions to ask:
Explain any additional monthly premium.
Does the plan charge for a yearly deductible?
Explain the charges for a visit or service (co-payments or co-insurance).
What does the health plan offer?
Explain the healthcare network.

Medicare Supplements

Medicare Supplements -- or Medigap -- are designed to help an individual pay for any costs that cannot be covered by Original Government Medicare (OGM). In order to be able to purchase and keep a Medigap policy, you must be enrolled in Medicare Parts A and B. If you meet this criterion, you are able to join the Medigap plan during your Open Enrollment Period (OEP), which lasts for six months and begins the month you enroll in Part B. This also applies to those who have group health insurance through their employer or union. During your OEP, an insurance company cannot use medical underwriting. According to Medicare.gov, 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 change or be repeated. This means that the best time to get Medigap is during your OEP. After this period ends, you may be unable to buy a Medigap policy at a later time. If you are able, an insurance company can deny you a Medigap policy based on your health. You may also have to incur late penalty fees, just like you would with the Original Government Medicare plan.

If you are eligible for Medicare under the age of 65 due to a disability, it does not mean that you are guaranteed eligibility for an accompanying Medigap policy. Insurance companies aren’t obligated to sell you a Medigap policy if you are under 65 because of End Stage Renal Disease (ESRD) 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

If you have a pre-existing health condition, there are instances in which insurance companies can withhold Medigap coverage for out-of-cost expenses for up to six months. After six months, Medigap policies will begin to cover your pre-existing condition.

A Medigap policy is different from a Medicare Advantage Plan. In addition, policies don’t cover drug prescriptions. The difference lies within what the two 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 Original Government Medicare plan. These benefits include vision, dental and hearing insurance. Medigap, however, lowers your share of costs for the approved Parts A and B with the OGM plan. If you want additional drug coverage, then it is something you must purchase.

You must also know that Medigap can only be applied to the Original Government Medicare. This means that you cannot have a Medigap policy if you’re already enrolled in a Medicare Advantage Plan unless you go back to OGM. This is 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 Medicare.gov:

  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 plan that will best 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.

Choosing a healthcare plan is no easy task, which is why most seniors seek the help of Medicare specialists who do not charge a fee. Make sure you understand what each plan offers, the restrictions if any, the cost of each plan, and how the plan may interact or interfere with any active health insurance plan.

For instance, if you retire and have health insurance, a possibility exists that you may lose your present coverage when purchasing a Medicare Advantage plan. Please note that your former employer could offer you a Medicare Advantage plan. With that, both you and the company receive a win-win.

During the process of choosing one of the Medicare plans, you should also consider buying a Medigap policy, a prescription drug plan. Make sure you are clear on premiums, deductibles, co-payments, and yearly out-of-pocket maximums for both plans. Since not all Medicare Advantage plans work the same way, the following needs to be included in due diligence.

As of 2020, Medicare Advantage plans are authorized to offer innovation benefits, including transportation to doctor’s appointments. Medicare Advantage is another way to get your Medicare Part A and Part B benefits through a private insurance company approved by Medicare. To find out if your plan covers this, or if you are eligible to add a plan including transportation please contact our advisors, who are glad to assist at no charge.

Original Medicare (Part A and Part B) generally does not cover transportation to get 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. Your doctor must provide a written order verifying that ambulance transportation is medically necessary because of your health condition.

If you do not qualify for non-emergency ambulance transportation, there may be non-Medicare transportation services available in your immediate area through local organizations. For instance, 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 Program of All-Inclusive Care for the Elderly (PACE), these organizations may also provide transportation for routine medical care. Visit www.Medicaid.gov or www.Pace4you.org for more information.

While original Medicare does not cover gym memberships or fitness programs, these may be part of the extra coverage offered by Medicare Advantage Plans, other Medicare health plans, or Medicare Supplement Insurance (Medigap) plans.

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

Unlike Medicare Advantage plans, Medicare Supplement insurance plans do not typically include gym memberships. Medicare Supplement insurance plans may cover most of your Medicare Part A and Part B coinsurance and copayments, as well foreign travel emergencies.

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

You may want to compare plans to see if one in your area offers coverage for health club membership costs. Feel free to contact our advisors, who are glad to explain your benefits and help you find an option at no charge.

Medicare Advantage Plans, sometimes called Part C, combine Original Medicare Part A and Part B into one complete plan. These plans are offered through private insurance companies approved by the government Medicare program. These plans may also offer extra programs and services not covered by Original Medicare, such as dental coverage. Some plans may also include Part D prescription drug coverage and vision.

Medicare Advantage Plans work similarly to traditional health plans in cost and coverage. For example, there are HMOs, PPOs, POS plans, and more. These can include deductibles, copays, and coinsurance, but not all Medicare Advantage Plans cover dental. Before you sign up, make sure to read the details of what the plan covers. If you want dental coverage under Medicare, then make sure the Medicare Advantage Plan you choose includes the dental coverage that fits your needs and budget.

Original Medicare is composed of Part A, which is hospital insurance, and Part B, medical insurance. The only instance in which Original Medicare might cover any dental work, is if you suffered a traumatic injury that also affected your jaw, teeth, or mouth and had to be hospitalized. Then, Original Medicare may cover some of that dental care. Understanding exactly what your plan would cover is important to know before accidents occur.

When it comes to dental and vision, only Medicare Advantage Plans (Part C) may offer coverage and not all of them do. The dental coverage is typically basic and could include:
• Teeth cleaning
• Routine X-rays
• Extractions
• Fillings
• And possibly more
Plans may differ based on the insurance company and even your location. Dental coverage often comes with limits on how many services are covered in a plan year, maximum cost allowances, and more.

A Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan may cover certain products related to vision care, like eye drops or other vision medications prescribed by a doctor.

Medicare Part B is medical insurance. Medicare Part B covers some vision care, but not routine vision exams. You are not covered for vision correction such as eyeglasses or contact lenses under Medicare Part B unless you need vision correction after cataract surgery. Medicare Part B also does not cover eye refractions.

Medicare Part B covers yearly glaucoma screenings if you are at high risk. High-risk patients include those with a family history of glaucoma, African Americans age 50 and older, Hispanic Americans age 65 and older, and people with diabetes. State-approved vision care specialists are the only providers that may perform yearly vision screenings for glaucoma. You pay the 20% Medicare coinsurance for the vision care costs approved by Medicare, subject to your 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 Part B vision benefits cover eye prostheses for patients with absence or shrinkage of the eye due to birth defect, trauma, or surgical removal. Medicare 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 of 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.

Medicare Part C (or Medicare Advantage) offers an alternative way to receive your Original Medicare benefits. Medicare Advantage plans are offered by private, Medicare-approved insurers. All private insurers must offer at least 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 charged by Medicare Advantage plans that do not offer routine vision benefits.

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

Pros:
• The Medicare Advantage (MA) program provides more benefits than the government’s Original Medicare program. Additional coverage typically includes routine dental care, prescription drugs, hearing aids, routine vision care, and membership to gyms and fitness centers.
• MA plans maintain lower cost-sharing expenses than the original Government Medicare Plans. For instance, a Medicare Advantage Plan may require a co-payment of $10. The Original Government Medicare co-payment consists of 20% of the cost, which may exceed $10.
• MA Plans maintain maximum limits for out-of-pocket expenses. As a result, once a policyholder reaches the maximum, there are no further costs for any covered services. Moreover, this exemption will last for the remainder of the insurance year. Unfortunately, the original Government Medicare plan does not offer this very important benefit.
• MA Plans coordinate care 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 Medicare Advantage Plans require that you live within a network’s region for at least 6 months prior to enrolling.
• Plan Options: The available options for Medicare Advantage Plans will vary depending on the region and the approved plan providers.

This guide should help you have a better understanding of which plan will be better for you and your family. If you want the financial protection of a limit on healthcare spending and set costs for procedures, as well as prescription benefits and extra benefits like dental and vision all rolled into one plan, Medicare Advantage can be a great option depending on the cost difference.

Health Insurance Costs

At a glance, it may seem as though the costs and premiums for 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 or fee.

Fortunately, for Part A, most people don’t pay a premium and can be automatically enrolled. 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 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 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 for Part A but didn’t.

Unlike Part A, you are expected to pay a premium for Parts B, C and D. The standard Part B premium is around $148.50/month. However, this amount could be higher if your income is higher. You are able to sign up for Medicare Part B beginning three months from your 65th birthday until three months after. If you do not enroll during this time, you will have to pay a late enrollment penalty in addition to your monthly payment for the remainder of your life. You must also know that your monthly premium will increase 10% for every year in which you could have been enrolled in Medicare Part B but didn’t do so.

For Parts C and D, the standard premium will vary by your plan. You can compare costs for specific Part C and D plans on Medicare.gov. However, with Part D, it is expected that the higher income you have, the more you will pay in your premium. There is no late enrollment penalty for Medicare Part C because you are able to switch to this plan at any point during specific enrollment periods. However, if you enroll for 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 premium cost.

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

  1. Pay online through your Secure Medicare account.
  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 usually on the 20th each month.
  4. Mail your payment 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. You will not have to do anything.
  2. “First Bill.” This mean that 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 for the current month.
  4. “Delinquent Bill.” Think of this as 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.

Although your health insurance costs may seem overwhelming, that doesn’t mean that they aren’t manageable. Medicare will assist individuals who need help in making payments. The Best Senior Service 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.

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

Just about anyone is approved

No matter your health or financial situation, there are a variety of services available to you. 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.

Since programs vary by state (and sometimes by county) and since each person’s situation is different, we recommend using our resources along with guidance from a licensed representative in your state. When you request a free guide we are happy to connect you with a qualified expert who can help you find the program best fitting for your needs.

Senior Couple in the kitchen