Understanding Medicare: Benefit Plans, Coverage and Consumer Rights!

The Golden Years is a time of retirement and relaxation, but it is also a time for families to collaborate on long-term health care needs of aging adults. Aging in place is typically preferred, but this may present a challenge if there are health issues that impact independent living. Many believe that Medicare and social security is all that’s needed to manage our care needs as we get older, but this is often not the case.

What is Medicare?

Federal health insurance program for people who are 65 or older, or qualifying younger people who have been permanently disabled for 24 months, people with End-Stage Renal Disease – permanent kidney failure requiring dialysis or transplant, or people with ALS-Lou Gehrig’s disease.

Common Medicare Myths

MYTHFACT
Medicare covers all medical costMedicare covers 80% of many hospital and outpatient services.
Medicare covers hearing aids and denturesMedicare does not cover hearing aids or dentures. However, some Medicare Advantage plans may cover all or part of this cost.
Medicare covers eye examsMedicare does not cover eye exams, eyeglasses or contact lenses. However, some Medicare Advantage plans may cover all or part of this cost. Also, Medicare may cover certain costs for qualifying medical conditions such as glaucoma.
Medicare covers nursing home careMedicare covers temporary, short-term nursing home stays that typically occur after a qualifying hospital stay. However, certain criteria must be met and only the first 20 days are covered at 100%
Medicare guarantees nursing home coverage for 20 daysAny service must meet Medicare coverage criteria to be covered. If a beneficiary does not meet coverage criteria for 20 days, then Medicare will not cover the cost.
Medicare will pay for caregivers in the homeMedicare does not cover the cost of routine caregivers providing custodial care. Possible payment options include private pay, Medicaid (must qualify financially), VA benefits, or long term care insurance
Medicare pays for wheelchair ramps and chair liftsMedicare does not cover wheelchair ramps or chair lifts. However, there are certain programs that can help cover some or all of these costs. Check your local Department of Health and Human Services for options.

Benefit Plans

The A, B, C, D’s of Medicare

Medicare Part A:

Hospital Insurance

Inpatient hospital stays, temporary recovery in a skilled nursing facility, Hospice care, some home health care

Medicare Part B:

Medical Insurance

Certain physician services, outpatient services, medical supplies, preventive services

Medicare Part C:

Medicare Advantage

  • Offered by a private company that contracts with Medicare, provide all Part A and Part B benefits, most offer prescription drug coverage.
  • Medicare Advantage Plans include: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans, Special Needs Plans, Medicare Medical Savings Account Plans
  • NOTE: Medicare Advantage plans typically require prior-authorization and ongoing approval for medical services.

Medicare Part D:

Prescription Drug Coverage

  • Offered by insurance companies and other private companies approved by Medicare
  • Offered by some Medicare Advantage

Medigap:

 Supplemental Insurance (Medicare Plan D)

  • Supplements Medicare part A and B by “filling in the gaps”
  • Sold by private, insurance companies (Plans K and L pay 100% of out-of-pocket costs after part B deductible is met. You must have Medicare part A and B to secure a part D plan
  • Covers the percentage of Medicare covered expenses that Medicare does not (like co-pays, co-insurance, and deductibles). It does not cover expenses not covered by Medicare
  • Your monthly premium is paid separately from your Medicare premium. A Medigap policy only covers one person. Any standardized Medigap policy is guaranteed renewable even if you have health problems. Policies sold after January 1, 2006 do not include prescription drug coverage. So Medicare Part D would still be needed
  • It’s illegal for anyone to sell you a Medigap policy if you have a Medicare Medical Savings Account (MSA) Plan
  • Insurance Plans/Services that ARE NOT Medigap: Medicare Advantage Plans, Medicare Prescription Drug Plans, Medicaid, Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP), Tricare, Veterans’ benefits, Long-term care insurance policies, Indian Health Service, Tribal, and Urban Indian Health plans.
  • Generally, Medigap doesn’t cover long-term care, vision or dental, hearing aids, eyeglasses, or private-duty nursing services

WHAT MEDICARE COVERS

Health Care Settings:

Hospitals, Rehab Hospitals, Long Term Acute Care Hospital, Short-Term Skilled Nursing Stay, Home Health Medical Services, Outpatient health care services, Doctor’s office visits, Chiropractors, second opinion before surgery

Health Care Products/Services:

emergency ambulance, prescription drugs, medical treatments, drug testing/treatment, orthotic equipment, prosthetic equipment, oxygen and supplies (not always portable), nebulizer and supplies, passive nutrition, annual wellness visit, hearing and balance exams, cancer screenings, diabetic supplies/training, labs, respiratory equipment (i.e. CPAP/BiPAP for sleep apnea), some disposable supplies while receiving home health services (like intravenous supplies, gauze and catheters), mobility device (cane, walker, wheelchair, slide board), hospital bed, bedside commode, mechanical lift, lymphedema pumps, alcohol screening/counseling, vaccinations, smoking/tobacco cessation programs, PT, OT, ST, telehealth, transitional care services

WHAT MEDICARE DOES NOT COVER

Housing Assistance, Assisted Living, Nursing Home, Routine In-Home Caregivers, transportation to medical appointments, medical equipment to increase safety (i.e. grab bars, ramps, toilet risers, or other equipment for bathroom), eye exams (unless you have Diabetes or high risk for Glaucoma), Podiatry for routine footcare, dental procedures or supplies (i.e. cleanings, fillings, tooth extractions, dentures, etc.), incontinence products, compression leggings, homeopathic medicine, hearing aids, catheter supplies.

MEDICARE COSTS:

Part A (hospital insurance):

$0 – If you or your spouse paid Medicare taxes for 40 quarters (10 years) or more or you were a federal employee on January 1, 1983, or a state or local employee any time after March 31, 1986. The part A deductible is $1452.00.

$252 – If you or your spouse paid Medicare taxes between 30 and 39 quarters (7.5 and 10 years)

$478 – If you or your spouse paid Medicare taxes than 30 quarters (7.5 years)

Part B (health insurance):

$144.60 (6% increase), with a $198.00 deductible (was 135.50 in 2019 with a $185.00 deductible).

Part D (prescription drug insurance):

$30.50 – Average cost Nationwide

Medigap (Medicare supplement plan):

Average cost is $152.00 per month

– Need help paying for Medicare? There are 4 Medicare Savings Programs for those who meet certain conditions (not available in US VI or PR):

1) Qualified Medicare Beneficiary (QMB)

2) Qualifying Individual program (QIP)

3) Qualified Disabled and Working Individuals Program (QDWI)

4) The PACE Program (Program for the All-Inclusive Care of the Elderly)

CONSUMER RIGHTS

NOTE: There are now several Medicare programs designed to manage expenses, increase value, and ensure quality care. Examples include Value-Based Purchasing, Bundle Payments for Care Improvement and Medicare Shared Savings Program.

  • If you receive SS benefits, you will automatically enrolled in Medicare part A & B. If not, the open enrollment window begins 3 months before your 65th birthday to 7 months after.
  • Penalties are applied for those who fail to enroll on time that are without coverage
  • If you are dissatisfied with healthcare services, you may file a grievance at www.cms.gov and enter in the search box: Patient Request for Medical Payment form CMS-1490S
  • You may file an appeal about services not covered by a provider that you believe should be covered. There are 5 levels of appeals.
  • When denied Medicare coverage, you will receive an MSN (Medicare Summary Notice). Check your Medicare Summary Notice for information filing an appeal.

Are you a Veteran or are you Married to one? If so, thank you for your service! If you or your spouse served at least one day, active duty in the US Armed Forces during a congressionally recognized war (going off to war is not required, just service during war time), you may be eligible for the V.A. Aide and Attendance Grant that will provide funding for elder care services. For more info, visit: https://www.va.gov/pension/aid-attendance-housebound/

Financial advisors, senior care advisors, elder law attorneys and social workers can be excellent resources for providing guidance on long-term care planning, cost of care, and financial resources. Be sure to seek these essential support services so that you’ll have peace while meeting the healthcare challenges that often occur with aging during this bittersweet season of life.

Call 1-800-MEDICARE for questions regarding plans, benefits, and rights!

And that’s the tea!

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