Insurance World

Medicare

    Medicare and how to get it? 

  Health care in the United States is very expensive and bureaucratically complex. The federal health insurance program, Medicare, for people 65 and older, as well as for people with certain chronic diseases and disabilities, is perhaps the most complex bureaucratic construct in American medicine, as it was created by layering older health programs on top of newer ones. As a result, to the layperson in this field, the health program looks like a chaotic and eclectic set of formulas and rules that are difficult to understand and make the best decisions about coverage. In this situation, the value of having an insurance agent's expertise to help you make decisions about which insurance coverage to choose is clear. 

 If you would like to receive a free consultation or purchase Medicare health insurance, please submit your request              .

  However, in the following description, we provide a general description of the Medicare health insurance program that will help you better navigate your decisions when choosing insurance coverage: 

   Medicare coverage is a federal government program created to help people 65 years of age or older with medical costs. The federally administered Medicare program took effect in 1966. Medicare has four parts of coverage: Part A is hospital insurance; Part B is medical insurance; Part C is Medicare Advantage; and Part D covers prescription insurance. Medicare Part A and Part B programs together make up the Original Medicare insurance program. They are provided by the federal government. Part C (Medicare Advantage) combines Parts A, B, and D and has additional insurance benefits.

   Hospital Part A (hospital care coverage) helps pay for a significant portion of your inpatient hospital care or skilled nursing facility stay (after you leave the hospital). In addition, Part A of the program pays for some home health care and hospice services.

   Medical Part B (health insurance) helps pay for many of the services of doctors and other health care providers, outpatient and home health care services, durable medical equipment, and some preventive services.

   Prescription Drug Part D provides coverage for prescription drugs. Insurance policies under this program are provided either as stand-alone drug coverage or as a component of Part C (Medicare Advantage). Different Part D insurance policies can vary significantly in the specific drugs covered (Formulary), the monthly cost of the plan (Premium), and the cost of the drugs covered. Part D plans do not cover all available drugs, but they are required to cover drugs in each therapeutic category. Therefore, it is very important to pay attention to details when choosing this insurance plan, especially if you take rare or expensive medications.

   Part C (Medicare Advantage) combines medical and drug coverage and may also cover glasses, gym memberships, dental care, and more. The main thing that Medicare Advantage provides over Original Medicare (Parts A and B) is a limit on the amount of your medical expenses. In other words, there is a ceiling above which you will not have any treatment costs, as the Maximum Out of Pocket is clearly indicated. Original Medicare does not have this option, and your costs can be any amount. Medicare Advantage plans vary depending on where you live, the type of plan, and benefits. Some of them have zero cost, some have a monthly cost. There are also Medicare Supplement plans, which are fundamentally different from Medicare Advantage. Which of these options is most appropriate depends on many individual factors and requires careful analysis. 

   Do you need to enroll in Medicare if you have health insurance through your job?

   It depends on a number of factors. Everyone has heard about the penalty for not signing up for Medicare on time and fears having to do so, even if they have good insurance through work. This is not always the case. Let's start by saying that Medicare doesn't require you to sign up for Parts A and B once you reach age 65 if you have comprehensive health insurance through your job. Part A is worth using because it's free and can benefit you when combined with your work health insurance. About half the time, it makes sense to switch to Medicare entirely and drop your work-based health insurance, and about half the time, it makes sense to stay on your work-based insurance but use Part A. The first factor is a comparison of the monthly cost of work insurance and Medicare, the second factor is a comparison of medical expenses, the third is the cost of drugs under different insurance options, and finally the fourth factor is whether only you, your spouse, or all family members use work health insurance. 

   How to get Medicare insurance?

   The first way is to apply through your Social Security account. Every legal U.S. resident has a Social Security Administration account, and registration can be done at secure.ssa.gov.

   The second option is to call Social Security and file a claim at 800-772-1213.

   The third way is to submit an application through an insurance agent.

   If you don't have employment insurance, you must enroll in Medicare health insurance at age 65. This is a must. People who fail to enroll in Part B insurance when they become eligible may have to pay a penalty of 10% of their premium for each year they are late in enrolling. The same goes for Part D insurance.

   Enrolling in Medicare Advantage (Part C):

  You must first sign up for Medicare Original coverage, and then choose a Medicare Advantage plan that suits you and switch to it. These insurance plans are provided by private insurance companies. All Medicare Advantage plans cover:

• All Part A services, except hospice care, which is covered directly under Part A.

• All Part B services and may cover Part D services.

   So, the Medicare Advantage insurance program (known as Part C) combines three parts of Medicare (A+B+D). That is, when you sign up for Medicare Advantage, you can immediately get coverage for hospital expenses, general practitioner/specialist services, and medications, and usually additional coverage for glasses, hearing aids, a gym membership, a dentist, healthy eating, etc. These insurance plans have a relatively low monthly cost or no cost (zero premium).

   There are a wide variety of these insurance plans such as HMO, PPO, Special Needs Plans, etc. Medicare Advantage Plans are Medicare provided by an approved Health Maintenance Organization or Preferred Provider Organization.

   Another choice is a Private Fee For Service (PFFS) Plan. In this type of plan an individual may go to any Medicare-approved doctor or hospital that accepts Medicare payments. The insurance plan, rather than the Medicare Program, decides how much it will pay and what the Medicare enrollee pays for the services rendered. The plan could include extra benefits that are not covered under the original Medicare plan.

• HMO's, PPO's, and Private Fee-For-Services are all types of a Medicare Advantage Plan.

• In addition to the premium, Medicare Advantage enrollees normally must pay a small copayment per visit or per service.

• Medicare Part C does NOT cover long-term care.

   Health Maintenance Organization (HMO) Plans:

  In most HMOs, you can only go to doctors, other health care providers or hospitals in the plan’s network except in an emergency. You may also need to get a referral from your primary care doctor in order to see a specialist.

   Preferred Provider Organization (PPO) Plans:

   In a PPO, you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. There is out of network coverage, but you pay more if you use doctors, hospitals, and providers outside of the network.

   Medicare Advantage Special Needs Plans (SNP):

  Medicare Advantage specialty plans provide more focused health care for people with specific disabling (chronic) conditions in addition to standard health care services. SNPs are typically for individuals who are insured under Medicare and Medicaid.

     Medicare Medical Savings Account (MSA) Plans:

   A consumer-directed Medicare Advantage Plan similar to Health Savings Account Plans available outside of Medicare. Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs.

   Medicare Supplement:

   Original Medicare covers approximately 80% of medical costs. To expand your coverage, you can switch to Medicare Advantage insurance or enroll in the Medicare Supplement program. This insurance, often referred to as Medigap, provides additional coverage for the insured person's out-of-pocket expenses for services not covered under Medicare Plans A and B. Its cost depends on the type of plan, your age and the state you live in.

   Medigap has 10 standardized insurance configurations and is offered by private insurance companies. These plans provide varying amounts of coverage for hospital expenses, skilled nursing facility stays, blood transfusions (first 3 pints), up to 365 additional days of hospitalization, hospice care, and emergency medical care for international travel, up to the plan's limit.

   Medigap does not cover: medications, routine dental, vision and audiology services, eyeglasses, contact lenses and hearing aids, nursing care (assistance with bathing, eating, dressing), long-term care.

   Medicare Supplement plans offer different premiums to meet your budget or financial needs. Two Medicare Supplement plans offer a high deductible for a lower cost premium.

   Other supplemental medical insurance:

   Supplemental insurance is separate from Medicare and pays lump sum benefits in case of specific coverage such as cancer, critical illness, and accidents. Depending on the insurance company and the insurance policy, you still may be able to enroll in these supplemental policies at the age of 65.

   As beneficial as Medicare and Medicare supplement insurance are to the elderly in protecting them against the costs of medical care, neither of these programs cover long-term custodial or nursing home care. Medicaid covers some of the costs associated with long-term care, but a person is ineligible for Medicaid until he or she is practically destitute. How can these costs be paid? The solution for many is long-term care insurance.

   Enrollment periods for any type of insurance coverage can be difficult to navigate. Medicare is no different. There are several enrollment periods that enable you to receive or change how you receive the Medicare coverage you’re entitled to as a Senior.

   These include:

• Initial Enrollment Period (IEP);

• Special Enrollment Period (SEP);

• Annual Election Period (AEP);

• Medicare Advantage Open Enrollment Period (MA OEP).

   Understanding the differences between each enrollment period is often a point of confusion for Seniors. First, to better understand MA OEP, we’ll briefly discuss what you can do during IEP, SEP, and AEP.

   1. Initial Enrollment Period (IEP):

  You are first able to sign up for Medicare during your Initial Enrollment Period (IEP), which takes place when you turn 65 years old and lasts for seven months total:

• The three months prior to the month you turn 65,

• The month you turn 65, and

• The three months after you turn 65.

   2. Special Enrollment Period (SEP):

  Special Enrollment Periods (SEPs),allow those on Medicare Advantage or a Medicare drug plan to make changes to your Medicare Advantage plan and Medicare prescription drug coverage provided certain events occur in your life. Each SEP has its own rules about when and what type of changes you can make. An uncomprehensive list of life events that may prompt an SEP include:

• A change in where you live;

• A loss of your current coverage;

• A chance to get other coverage arises;

• The contract your plan has with Medicare changes.

   3. Annual Election Period (AEP):

  The Annual Election Period (AEP) occurs every year from October 15 to December 7. It allows Medicare beneficiaries to make these changes to the way they receive Medicare benefits:

• Change from a Medicare Advantage plan back to Original Medicare.

• Change from Original Medicare to a Medicare Advantage plan.

• Switch from one Medicare Advantage plan to another Medicare Advantage plan with or without prescription drug coverage.

• Drop, switch, or join a Medicare Part D (prescription drug) plan.

    4. Medicare Advantage Open Enrollment Period (MA OEP):

   MA OEP takes place every year from January 1 to March 31. MA OEP allows Seniors enrolled in a Medicare Advantage plan to make a one-time change to the way they receive their Medicare benefits by choosing one of the following:

• Switch to Original Medicare (Medicare Part A and Part B) and add a Medicare Part D (prescription drug) plan if desired: Medicare Advantage plan → Original Medicare.

• Switch to a different Medicare Advantage plan with or without prescription drug coverage: Medicare Advantage plan → Medicare Advantage plan.

   If you have Original Medicare (with or without Medicare Part D prescription drug coverage), you can’t make any changes to your Medicare coverage during MA OEP like you can during AEP.

   Now that we know the two changes you can make during MA OEP, let’s discuss why you might want to make either of those changes.

   Why might I switch from a Medicare Advantage plan to Original Medicare?

   Medicare Advantage plan → Original Medicare:

   1. Cost – Some Medicare Advantage plans may provide additional benefits at lower premiums. However, you can’t get any additional supplemental coverage like a Medicare Supplement insurance policy if you have a Medicare Advantage plan. This could leave you without financial protection against many unexpected out-of-pocket expenses like copayments and deductibles. In this case, some may want to switch to Original Medicare and add a Medicare Supplement insurance policy.

   2. Doctor and hospital choice – Generally, you have to stick to a network of providers when you are enrolled in a Medicare Advantage plan. With Original Medicare paired with or without a Medicare Supplement insurance policy, you get to choose any doctor or hospital that accepts Medicare. This can be helpful for snowbirds or Seniors who may travel out of their Medicare Advantage plan networks throughout the year.

   3. Your plan is not renewed – Medicare Advantage plans are not guaranteed renewable. This means you may have coverage one year but not the next.

   4. Changes in network – Medicare Advantage plans usually have a network you have to stay in. The doctor, hospital, and specialist you prefer, however, have the ability to leave your Medicare Advantage plan or exit your plan’s network meaning you may need to search for a new provider in the network.

   5. Your Medicare Advantage plan is no longer available – Your Medicare Advantage plan’s carrier could exit marketing. In this case, enrollees would need to find new coverage for the coming coverage year.

   This is not a comprehensive list of reasons you might change from one Medicare Advantage plan to Original Medicare with or without a Medicare Supplement insurance policy during MA OEP.

   Why might I switch from one Medicare Advantage plan to another Medicare Advantage plan?

   Medicare Advantage plan → Medicare Advantage plan:

   Reasons you may want to switch from one Medicare Advantage plan to another Medicare Advantage plan during MA OEP include:

   1. Your Medicare Advantage plan carrier has decided to stop participating in Medicare – You might be happy with your plan, however, if your plan carrier stops participating in Medicare, it will no longer be available. You might seek out a Medicare Advantage plan with similar features in this case.

   2. You want a plan with more, fewer, or different features – A common instance follows: You may have a Medicare Advantage plan that does not include prescription drug coverage, and want to switch to one that does include prescription drug coverage. Prescription drug coverage options vary by Medicare Advantage plan, as each Medicare Advantage plan is privately managed by the insurance carrier. Evaluate the drug coverage that’s included in the Medicare Advantage plan you’re considering to make sure your prescription drug coverage needs are met and continue to be met.

   This is not a comprehensive list of reasons you might change from one Medicare Advantage plan to another Medicare Advantage plan during MA OEP.

   The coverage you need is entirely dependent on your lifestyle and factors like budget, age, and health. Learn more about Medicare, including enrollment periods, at medicare.gov. Or, speak to a licensed insurance agent to ensure you get one-on-one guidance tailored to your needs.

   If you need to purchase Medicare, please submit your request               .