Personal Medicare

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Medicare Advantage: Get To Know the 6 Types of Plans

Medicare Advantage Plans (Part C plans) are offered by private Medicare-approved companies.  These plans provide you with Original Medicare coverage, Part A and Part B, plus extra services -most also include Medicare Part D prescription drug coverage.  The amount you pay and your additional services vary by plan.  Here’s a basic overview of the 6 types of plans.

  1. Health Maintenance Organization (HMO) Plans  These Medicare Advantage Plans are available in some areas of the country.  Most HMO’s require you to use a select network of doctors and health care providers.  You are also required to use an in-network primary care physician to coordinate your overall care and refer you to any specialists as needed.
  2. Point of Service (POS) Plans  This is a second managed care option that allows you to see out-of-network doctors at a higher cost than in-network doctors.  Also, you can usually see in-network specialists without a referral from your primary care physician.
  3. Preferred Provider Organization (PPO) Plans  This is a third type of managed care plan –available in local or regional areas.  They don’t always require you to choose a primary care provider.  However, seeing an out-of-network doctor usually costs more.  Certain plans require you to pay a physician directly and then file a claim with your PPO.
  4. Private Fee-For-Service (PFFS) Plans  PFFS plans are not managed care plans, therefore they work without health care provider networks.  You can see any Medicare-eligible doctor or hospital that agrees to accept payment from your plan.  Some plans require you to pay the doctor directly and then submit a claim to your insurance company, which then pays you back.
  5. Medical Savings Account (MSA) Plans  These plans combine a High Deductible Health Plan (HDHP) and a special bank account fund (the MSA).  You can use the money in this account to pay for your health care costs, however, only Medicare-covered expenses count toward your deductible.  Once you’ve paid the deductible, the plan covers expenses normally covered under Medicare.  MSA plans do not include Medicare Part D prescription drug coverage, so policy owners need to purchase a stand-alone Part D plan.
  6. Special Needs (SNPs) Plans  These plans serve people with specific diseases or medical needs.  This can include people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid and some are for people who live in an institution (IE nursing home).  The plans customize benefits, health care provider choices, and covered drugs to best meet the specific needs of the groups they serve.

You can read about the basics of Medicare Advantage plans here.

Looking to browse Medicare Advantage plans in your state?  Click here.  Or, if you’re ready to compare plans based on your exact zip code and prescription drugs, click here.

Medicare Part A Explained

There are four basic parts of Medicare:  Medicare Part A, Medicare Part B, Part C, and Part D.  I’m going to break down Medicare Part A including how to qualify for it, when you get it, and what exactly it covers.

Qualifying for Medicare Part A

You qualify for Medicare Part A if you have worked at least 40 quarters (ten years) while paying Medicare taxes, or if you are the spouse of someone who has worked the ten years.  You may also qualify for Medicare Part A if you have a diagnosed disability for at least 24 months.  You will not have to pay for Medicare Part A if you meet these requirements.  Remember those Medicare taxes that were coming out of your check every month?  Well Medicare Part A is what you were paying for all those years.  If for some reason you only had worked over 30 quarters, but did not make it to 40 quarters you are still able to buy Medicare Part A for a reduced premium.  The current premium in 2017 is $227.  If you didn’t make it to even 30 quarters, or if you don’t qualify any other way, you will have to pay the full premium of $413 in 2017.

When Can I Enroll Into Medicare Part A

You will likely be able to enroll into Medicare Part A when you turn 65 years of age, or if you have been diagnosed with a disability, and have received benefits for at least 24 months.  I write in more detail about this subject in my post about qualifying for Medicare.

Medicare Part A Coverage

Medicare Part A is not complete Medicare coverage.  You will want Medicare Part B and Medicare Part D as well.  In some cases you may even elect to enroll into Medicare Part C.  Medicare Part A is known as hospital coverage.  Don’t think that this means that it covers an entire hospital stay because is does not.  Medicare Part A covers the following:

  • Inpatient Hospital Care – this is for things like a semi-private room, supplies, and drugs as part of your treatment
  • Skilled Nursing Care – in a skilled nursing facility under certain conditions for a limited time
  • Hospice
  • Home Health Services – intermittent skilled nursing care along with some therapy and continued occupational services

Expect to pay the following:

  • Inpatient Hospital Deductible – $1316 for 2017 – Can be applied multiple times for different occurrences and covers days 1-60
  • Hospital Co-pay – Days 61-90 is $329/day in 2017
  • Skilled Nursing Facility – Days 1-20 is $0; Days 21-100 is $164.50/day in 2017
  • Hospice – $0
  • Home Health Services – $0

Notice what is lacking from your hospital coverage is doctor services.  If you require surgery, that cost falls under Medicare Part B, along with any other doctor provided services.  This is why Part A is not enough and must have Part B included with it.  Also, notice that you still have out of pocket costs with Medicare Part A.  You will still have some substantial costs to pay when you go to utilize your Medicare Part A coverage.  This is why you may want to consider some other kind of supplemental coverage along with your Medicare coverage.

Medicare Qualifications

Ever wonder what it takes to qualify for Medicare?  I’m breaking it down for you here in a very easy to understand way so you’ll be ready to go when it comes time to enroll into Medicare!

Turning 65

As you may already know, turning 65 is one of the qualifications for receiving Medicare.  Many people will qualify for Medicare this way; however, there are ways to qualify for Medicare without being 65 years old which I’ll discuss later.  This isn’t just another birthday as you’ll soon discover.  Several months before your 65th birthday you will start to be inundated by mail soliciting you to sign up for Medicare insurance.  Expect to find seminar requests, direct mail wanting you to fill out applications, and mail asking you to fill out a card and send it in along with many other solicitations.  The main piece of mail you’ll want to look out for is your actual Medicare card from Social Security.  It will be in a larger envelope instead of your typical letter size envelope.

Much has been said recently about whether or not Medicare will even be there for you when you need it.  It’s no secret that Medicare is running out of money at an alarming rate.  One of the many suggestions to alleviate this problem is to raise the age at which you would qualify for Medicare.  As of now, 65 is the magic number to qualify for Medicare.

Disabled

As I mentioned earlier, it is possible to qualify for Medicare without having to be 65 years old.  One way of doing this is through being disabled.  While you do have to go through the process of qualifying for disability benefits, typically you will received Medicare automatically after being on disability for 24 months.

ESRD

ESRD or End Stage Renal Disease also qualifies you for Medicare.  You will need to be receiving dialysis on a regular basis, or have had a kidney transplant in order to qualify.  You also will need to apply for Medicare since you won’t be automatically enrolled.  Your coverage begins under these circumstances:

  • The 3rd month after the month in which a regular course of dialysis begins; or
  • The first month a regular course of dialysis begins if the individual engages in self-dialysis training; or
  • The month of kidney transplant; or
  • Two months prior to the month of transplant if the individual was hospitalized during those months in preparation for the transplant.

When you qualify, you typically are qualifying for Medicare Part A at no cost, and the ability to enroll into Medicare Part B for a monthly premium.  In most cases, you will automatically be enrolled into both Part A and Part B.  It is up to you to decline Part B if you don’t want to pay the monthly premium.  Personally, I would discourage you from declining Part B unless you have some special circumstance that makes sense for you to decline it.  An example would be if you are still working and have coverage under an employer group plan.

Social Security Extra Help Program Explained

The Social Security Extra Help program is also known as Low Income Subsidy or (LIS).  This is one of the best and easiest to qualify programs available through Social Security.  If you haven’t already, I’m going to walk you through the program and application process to make sure you are receiving all of the benefits that you are entitled to.

What Is The Extra Help Program?

LIS, also known a Extra Help is a federal subsidy program that helps low income Medicare eligible consumers pay for healthcare costs associated with prescription drug costs such as premiums, annual deductibles, and copay and coinsurance costs associated with the prescription drugs.  Almost 1 in 3 Medicare consumers have Low Income Subsidy!

What Are the Qualifications For Extra Help?

To qualify for extra help, you must meet the following requirements:

  1. Have Medicare Part A and/or Part B
  2. Reside in one of the 50 states or the District of Columbia
  3. Meet current income and asset requirements
    1. Your resources must be limited to $13,820 for an individual or $27,600 for a married couple living together. Resources include such things as bank accounts, stocks, and bonds. We do not count your home, car, or any life insurance policy as resources – socialsecurity.gov
    2. Your annual income must be limited to $18,090 for an individual or $24,360 for a married couple living together. Even if your annual income is higher, you still may be able to get some help. Some examples where you may have higher income and still qualify for Extra Help include if you or your spouse: —Support other family members who live with you; —Have earnings from work; or —Live in Alaska or Hawaii. – socialsecurity.gov

What Are the Levels of Extra Help?

Your level of LIS is determined by your qualifications.  You will automatically qualify for extra help if you are a full benefit dual eligible consumer, if you receive Supplemental Security Income (SSI) benefits, or if you are a partial dual eligible consumer meaning you belong to a Medicare Savings program.  There are 4 levels of LIS that you can qualify for which will determine the benefits that you will receive:

  • Level 4 LIS – Not eligible for Medicaid
    1. Reduced Deductible
    2. Member pays 15% or less for each drug and low flat copay upon reaching catastrophic coverage level
    3. Varying premium subsidy of 0%, 25%, 50%, 75%, or 100%
  • Level 1 LIS – May be eligible for Medicaid
    1. No deductible
    2. Member pays low flat copay for each drug and 0 copay upon reaching catastrophic coverage level.
    3. 100% premium subsidy
  • Level 2 LIS – Must be eligible for Medicaid
    1. No deductible
    2. Member pays lowest flat copay for each drug and 0 copay upon reaching catastrophic coverage level.
    3. 100% premium subsidy
  • Level 3 LIS – Must be eligible for Medicaid and institutionalized
    1. No deductible
    2. Member pays $0 copay for each drug
    3. 100% premium subsidy

Plan premium is based upon your level of LIS (100%, 75%, 50%, 25%,  premium subsidy)

How Do I Apply for Extra Help?

There are several way that you can apply for extra help.  I’ll list them in the order of best to worst:

  • Apply online at socialsecurity.gov.  Click on the link to go directly to the application process!  This is the fastest and easiest way to apply.
  • Apply over the phone by calling 800-772-1213.  This process will require some patience as you will likely be forced into an automatic phone system asking you for a bunch of information.  In many cases you can bypass the auto system by saying “representative” 3 or more time in a row when it asks you something.
  • Finally, you can simply go to you local Social Security office and apply in person.  Make sure you bring all possible identification, and pack a lunch because you’ll likely be there most of the day!

All Good Things Must Come to an End

Congratulations!  You’ve successfully applied and been approved for extra help!  Now you can sit back, relax, and do nothing!  Not exactly!  Approval is not a lifetime guarantee.  Here is how the process works once you’ve been approved:

  • SSA determines who qualifies, their benefit level, and processes LIS applications.
  • SSA periodically contacts Medicare beneficiaries to review their LIS status.
  • A form must be completed and returned within 30 days. Extra Help is terminated the following January if it is not returned.
  • SSA reviews are done each year, usually at the end of August. Any changes take effect the following January. Changes include:
    1. No change in the amount of Extra Help
    2. An increase in the amount
    3. A decrease in the amount
    4. Termination of Extra Help

There you have it!  An all inclusive guide to extra help that explains what it is, tells you if you qualify, gives you the best way to apply, and even explains how to keep it.  If you haven’t do so already, get started now!

Dental Coverage for Seniors: What Medicare Offers… and Doesn’t!

One of the most frustrating aspects of Medicare is figuring out what’s covered and what isn’t. Today, we’re going to address the issue of dental care and other oral health coverage. Is it available or not?

Seniors, it isn’t good news!

When trying to understand your Original Medicare benefits, that’s Part A (hospital) and Part B (medical), it’s important to understand that it’s for your major medical only. That means it covers anything about your overall health condition. And, as far as the government is concerned, that does not include your teeth or any other aspect of oral health.

There is an exception to the hard-and-fast, no dental coverage rule. Medicare will pay when your primary care physician or specialist determine that oral surgery, or another dental procedure, is “medically necessary”. This only happens in the treatment of another health condition, such as oral cancer. Curiously, Medicare may pay to have all of your teeth pulled, but they won’t pay for your dentures or implants.

How-to Get Coverage?

We all have a different situation, so, thank goodness, there are different solutions. For some luck people, Medicare Advantage is a solution. But, it’s a real crap shoot, because so many things need to match up (primary care doctor, specialists, prescription coverage, etc). Good luck finding the right plan that also offers dental.

The next option is an individual dental plan. Here’s where you’d think the government could have done some good, because dental plans are available through the federal healthcare exchange, but only if you’re enrolled in a health plan on the exchange. Where was Obama on that one? Okay, gripe over.

If you want traditional dental insurance, you’ll have to go to a private health exchange or an individual plan o get it. Plans start at about $25 per month, but be careful. These cheap-o dental plans are just that, and they come with a long list of caveats, like a 6+ month waiting period, annual limits or a lifetime limit. If you want a plan that does not have these limitations, then you’re looking at more money, on up to $60 to $70 per month. And, you still have deductibles and co-pays, driving the cost up even more.

The third option is to pay out of pocket and find the discounts. Hey, we’re seniors, right? We know how to get discounts! And, as far as I can see, there’s none better than the discount dental cards available from a wide variety of players, including CVS, Aetna, Cigna and man more.

If you’re not familiar with these cards, it’s a really simple concept. For a flat fee each year you get 40% to 60% off standard dental rates. I guess the dentists and specialists can afford to give these discounts because it reduces their advertising costs, or something like that. Whatever it is, it’s a great deal for us. Click here for a list of all savings plans.

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