This is the third of a four-part series regarding Medicare insurance. We’ll also respond to questions from Dr. Palombo about the enrollment period for the Affordable Care Act (ACA) (“Obamacare”) insurance.
Medicare has four parts: A, B, C and D. You can sign up for Medicare three months before turning age 65, the month of your birthday and three months after (assuming you’ve paid into Social Security/Medicare during your working years). If you have a disability before age 65, you may be entitled to Medicare.
It’s generally wise to enroll in Medicare during the 7-month window by setting up an appointment at your local Social Security office or online (the former is preferable, so you can get advice). If you enroll late, there are penalties in the form of higher premiums.
Medicare Part A, Part B, Part C and Medigap Explained
Part A Medicare covers a good portion of hospitalization, but there is usually a deductible for each hospital stay. Most of us don’t have to pay a monthly premium for Part A if you (or your spouse) paid Medicare taxes while working. Medicare pays most, but not all, of the costs during a “benefit period” which begins when admitted to a hospital and up to as many as 90 days.
Part B Medicare pays for outpatient visits to your doctor (or primary care provider). It usually pays 80% of Medicare’s “approved” fee. If you choose a Medicare Advantage Plan or supplemental insurance (Medigap), it usually pays a large portion, if not all the remaining 20% (depending on which plan you select).
You can get Part A and Part B Medicare benefits through original Medicare or a Medicare Advantage Plan (Part C). These Medicare Advantage health plans are purchased from private insurance companies who contract with Medicare to provide the Part A and Part B benefits, plus additional services not provided by Medicare. Claims are submitted and processed by these companies.
Medicare Advantage Plans include Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs), or Private Fee-for-Service (PFFS), Special Needs (SNPs) plans, and HMO Point-of-Service (HMOPOS) plans. Availability depends on the state in which you live. Most plans offer drug coverage, so a separate Part D plan does not need to be purchased. The services that are provided vary depending upon the plan you select. Monthly premiums and out-of-pocket limits, deductibles and co-payments apply.
Another option for more coverage is to purchase a Supplement Plan (also known as Medigap) from a private insurance company. Original Medicare is the primary insurance carrier. Providers of coverage under this plan bill their services to Medicare directly, then whatever Medicare doesn’t pay is submitted to your Medigap carrier. The amount the Medigap carrier covers depends on the Plan you purchase. Insurance companies offer Plans A thru N. Availability varies state by state. Medigap policies cover more of the out-of-pocket expenses than Medicare Advantage plans, but the monthly premiums are higher, and you must purchase a separate Part D drug plan.
Medicare publishes a book annually, Medicare & You, which itemizes the plans available in each area of your state. It also provides additional details regarding deductibles and copayments.
Part D is Medicare’s drug plan. Please refer to our September 2018 medical forum for additional information on Plan D specifics.
Beginning in January 2019, insurers selling Medicare Advantage plans have the option of including a variety of other benefits for those needing home health aides, home delivered meals, transport to a doctor’s office, etc. So, it pays to select a plan that best meets your needs. If you can afford a supplemental plan, it gives you peace of mind should you become seriously ill and protects you from having to dip into your life savings. Here is a helpful chart comparing various plans.
Answering Your Questions
We’re very grateful to our readers who post questions to us. Last month, Dr. Palombo suggested that with open enrollment soon approaching, we provide a brief guide to the process and to also address how the Trump administration is making enrollment more difficult:
The Trump administration has continued to undermine the ACA by drastically reducing funding for helpers (facilitators) to assist Americans to enroll or re-enroll in a high-quality ACA insurance plan through the insurance exchanges during the yearly enrollment period that starts November 1 and ends December 15 (45-day window). The administration has also tried to reduce the number of days to enroll. But many states (like California) have been able to extend the enrollment period to allow more time to select insurance for 2019.
The Trump administration has also re-introduced access to short-term, “cheap” insurance plans for as little as $69/month that will appeal to healthy young people. These inferior policies often don’t cover pre-existing medical conditions nor treatment of those with mental illness or drug abuse.
Be wary of how these policies are advertised because naïve purchasers may confuse them with quality ACA policies. We advise staying away from cheap Trumpcare insurance unless you decide having some insurance is better than having no insurance.
Next month we will share some interesting and amusing insights about what it’s like to enter one’s 7th decade (we like to think of it as being the new 5th decade).
Please send us your questions about this month’s forum or other problems you are grappling with in securing quality healthcare from our complex healthcare system. Answers to some of your questions will be posted next month. We will respond personally to other questions if you provide your email address.
Post questions and comments below and please follow and like us on Facebook at: www.facebook.com/QualityAffordableHealthcare. We cannot answer questions about personal medical issues because of medical/legal restrictions, and because they are best addressed by your doctor.
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Please watch for updates about our forthcoming book: (Revised title) “The Insider’s Guide to Quality Affordable Healthcare: Practical Strategies to Navigate Our Complex Healthcare System” – with an expected publication in December 2018.