Medicare Most Frequently Asked Questions - Part 1

Understanding the Medicare system can be confusing. Here are answers to Frequently Asked Questions on Medicare. 

1. What is Medicare?

Medicare is the Federal health insurance program established in 1965 which is administered by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health Services. Medicare is health insurance for the following people:

  • Age 65 or older;

  • Under age 65 with certain disabilities who qualify for disability benefits from Social      Security or Railroad Retirement Board (RRB);

  • Any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant);

  • Diagnosed with ALS (Amyotrophic Lateral Sclerosis), also called Lou Gehrig's disease) the month your disability benefits begin.

2. How do I enroll in Medicare Part A (Hospital) and Part B (Medical)?

  • If you aren't getting Social Security or Railroad Retirement (RRB) benefits, you will need to sign up in one of three ways: 1) online at www.socialsecurity.gov; 2) call Social Security at 1-800-772-1213, or; 3) visit your local Social Security office.

  • In most cases, if you're already getting benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month.

  • If you're under 65 and disabled, you automatically get Part A and Part B after you get Social Security disability benefits (SSDI) or certain disability benefits from the RRB for 24 months.

  

3. What does Medicare Part A (hospital) cover?

  • Inpatient care in hospitals;

  • Inpatient care in a skilled nursing facility (not custodial or long-term care);

  • Home health care services;

  • Hospice care services;

  • Blood.

4. What does Medicare Part B (medical) cover?

  • Doctor's services and tests

  • Outpatient care

  • Home health care services

  • Durable medical equipment and other medical services  

  • Ambulance services

  • Chiropractic services

  • Diabetes supplies

  • Preventive services

5. What is NOT covered by Medicare Part A and Part B?

Medicare doesn't cover everything. If you need certain services that Medicare doesn't cover, you will have to pay for them yourself unless you have other insurance to cover the costs. Even if Medicare covers a service or item, you generally have to pay deductibles, coinsurance, and copayments. Some of the items and services that Medicare does not cover include the following:

  • Long-term care;

  • Routine dental care;

  • Dentures;

  • Cosmetic surgery;

  • Acupuncture;

  • Hearing aids;

  • Exams for fitting hearing aids.

6. What are Medicare Advantage (MA) plans (Part C plans)?

Medicare Advantage plans are offered by private insurance companies that contract with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan.  

7. What is Medicare Part D (Prescription Drug Plan)?

Medicare offers prescription drug coverage to everyone with Medicare. Even if you don't take a lot of prescriptions now, you should still consider joining a Medicare Prescription Drug Plan (PDP). To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. Take time and read the Formulary for each company.. If you decide not to join a Medicare drug plan when you're first eligible, and you don't have other creditable prescription drug coverage, you will likely pay a late enrollment penalty.

8. How can I get help paying for my prescription drugs?

Frequently Asked Questions by Medicare Beneficiaries I Senior Advocacy Services

You may qualify for "Extra Help", also called the low-income subsidy (LIS), from Medicare to help pay prescription drug costs if your yearly income and resources are below the following limits: Single Person: Monthly income less than $1,471 and resources less than $13,640; Married Person Living with a Spouse and no other Dependents: Monthly income less than $1,991 and resources below $27,250.

9. What other Low-Income programs are available?

You may qualify for the Medicaid program or any of the Medicare Savings Programs (MSP) if you meet certain monthly income and asset levels. 

10. What are Medicare Supplement plans (Medigap plans)?

A Medigap policy, sold by private insurance companies, can help pay some of the health care costs ("gaps") that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn't cover, like medical care when you travel outside the U.S.

If you have Medicare Parts A and B and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share. Medicare doesn't pay any of the premiums for a Medigap policy. 

11. What if I am still covered by my Employer Group Health Plan when I become eligible for Medicare (either while I am still working or now that I have retired)?

Do you have, or are you eligible for other types of health insurance or prescription drug coverage (like from a former or current employer or union)? If so, read the materials from your insurer or plan, or call them to find out how the coverage works with Medicare. If you have coverage through a former or current employer or union or other source, talk to your benefits administrator, insurer, or plan before making any changes to your coverage. If you drop your coverage, you may not be able to get it back.

In Part 2, I will answer additional questions. So be sure to send yours if you have particular ones. Be sure to watch for my next blog on how to qualify for Medicare Advantage Plans all year around.  Call (773) 614-3201 or e-mail me at bwillbar@gmail.com with your urgent questions.

Know These Three Health Care Terms Before Obtaining Obamacare

Until Obamacare is repealed and replaced, you are stuck with it unless the new President is a Republican. 

If Hillary becomes President, Obamacare will continue and both the cost and the penalties will just get worse along with your choice of doctors and hospitals being seriously diminished. 

Nevertheless, here are the three health insurance terms you need to know before buying an Obamacare policy or just a regular health insurance policy.

Premium

The total amount paid to the insurance company for health insurance coverage. This is typically a monthly charge. Within the context of group health insurance coverage, the premium is paid in whole or in part by the employer on behalf of the employee or the employee's dependents. Unearned premium is the portion of a premium already received by the insurer under which protection has not yet been provided. The entire premium is not earned until the policy period expires, even though premiums are typically paid in advance.

Deductible

The amount of loss paid by the policyholder. A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for service or claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans may or may not typically require a deductible, while most Indemnity and PPO plans do. In general, the bigger the deductible, the lower the premium charged for the same coverage.

Coinsurance

The amount that you are obliged to pay for covered medical services after you've satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance. After paying 80 percent of losses up to a specified ceiling, the insurer starts paying 100 percent of losses.


Call (773) 641-3201 for answers to your health care questions or to get a quote. 

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Medicare Fundamentals: Part A and Part B

Over 47 million seniors age 65 and older, and people with certain disabilities and medical conditions, get their health care coverage through Medicare. While Medicare covers many health care services, it does not cover everything. Below is what you should know.

If you have Original, Fee-for-Service Medicare, the following applies to you:

Medicare Part A ("Hospital Insurance") does over: 

Inpatient care in a skilled nursing facility for a limited number of days, following a qualifying three-day minimum inpatient hospital stay for a related illness or injury

Home health services as ordered by a doctor (or other health care provider), including nursing care; physical, speech or occupational therapy; medical social services; home health aide services and medical supplies for use at home

Hospice care if you have a terminal illness with a life expectancy of 6 months or less, as certified by doctor, at home or facility where you reside. Limited coverage for stays in a hospice facility, hospital or skilled nursing facility for pain or symptom management

Services Medicare Part A does not cover include:

Custodial care or long-term care in a skilled nursing facility or nursing home. Custodial care includes non-skilled personal care, such as help with  bathing, dressing, eating, getting in and out of a bed or chair, or toileting.

Medicare does not pay for room and board costs or non-skilled personal(custodial) care in a nursing home, or long-term care or assisted living facility. It does cover Medicare-approved medical care and services, ordered and rendered by a Medicare-enrolled health care provider, such as a doctor or physical therapist, to the beneficiary who is a resident.                                                                            

    Services Medicare Part B ("Medical Insurance") does cover:         

• Doctors' visits, services and tests; outpatient care and services; some home health   services       not covered under Part A; Medicare-cove red durable medical equipment (DME), prosthetics, orthotics and supplies
• Medicare-covered services provided by non-physician health care providers, such as nurse practitioners, physician assistants, social workers, psychologists, physical therapists, and other
• Many preventive services and test
• Outpatient mental health care
• Kidney dialysis services and supplies
• Ambulance transport for medically-necessary services (limited)
• Chiropractic services (limited)
• Eyeglasses (limited to after-cataract surgery that implants an intraocular lens)
• Some prescription drugs (i.e. injections in doctor's office, certain oral cancer drugs
• Transplants and immunosuppressive drugs

Things that are not covered by Medicare, under either Parts A or B, include: routine dental care, dentures, hearing aids and exams for fitting hearing aids, cosmetic surgery and acupuncture.

For those who get coverage through a Medicare Advantage Plan (Medicare Part C), the story is a bit different. Medicare Advantage Plans are offered by Medicare-approved private insurers, and must cover all the services covered under Original Medicare, except hospice care, which continues to be covered by Original Fee-for­-Service Medicare even when a person is enrolled in a Medicare Advantage Plan.

These plans, which may charge a premium, deductible and co-insurance, may include extra benefits and services not covered under Original Fee-for- Service Medicare, such as dental and vision care, glasses, hearing aids and health and/or wellness programs. Most plans also include prescription drug coverage, available to those in OriginalMedicare under Part D.

 E-mail your Medicare questions to me at Ask Will at wwillbar@gmail.com