Medicare
Medicare is a federal health insurance program that pays a large part of the medical expenses of most Americans over the age of 65 and some younger, disabled persons who have received federal disability benefits for at least 24 months. Individuals with end-stage renal disease or ALS (amyotrophic lateral sclerosis, often called “Lou Gehrig’s Disease”) may qualify for Medicare without the 24-month requirement. Anyone over age 65 may apply for Medicare.
Most people get their Medicare coverage in one of two ways. The enrollee chooses either an Original Medicare Plan (which has Part A and Part B) + Part D (prescription drug coverage) + optional Medigap (Supplemental) insurance, or a Medicare Advantage Plan (called Part C), which combines Parts A, B, and D. Part A is premium-free to most people. Part B requires payment of a monthly premium. People with lower incomes pay lower premiums for Part B. If you are not yet on Social Security, you will be billed quarterly for Medicare premiums. Part C (Medicare Advantage plans) includes some benefits not available through Original Medicare. Part D is insurance for reducing prescription drug costs. It is optional and may require payment of a monthly premium to a private company.
Help with Medicare Premiums. Help is available for low-income enrollees who cannot afford to pay their Medicare premiums, copayments, or deductibles. To find out more about the Qualified Medicare Beneficiary (QMB), the Special Low-Income Medicare Beneficiary (SLMB), the Qualified Individuals 1 (QI1), or the Extra Help programs, or to enroll, see medical insurance and financing.
When to Apply for Medicare
To apply for Medicare benefits, you should contact Social Security three months before you turn 65, whether or not you are retired. If you do not sign up at that time, you may be charged higher premiums later, when you do sign up. Contact Social Security for details about when and how to apply. If you are receiving Social Security or Railroad Retirement when you turn 65, you are automatically enrolled in Medicare and will receive your Medicare card in the mail. The only way individuals may delay taking Part B without a penalty is if they are enrolled in an employer group health plan through their own or a spouse’s current or active employment.
If you continue to work after age 65 and are covered by your employer’s health insurance, Medicare will be the secondary payer for some hospital services under Part A. Contact Social Security promptly to enroll in Part B when you stop working or your employment-related health insurance terminates. Your premiums could be higher if you do not. You may have special rights to purchase a Medigap policy if your employment-related coverage is ending.
To learn about Medicare coverage, you can request pamphlets about Medicare benefits by telephone from Medicare Health Plans, or on the Internet at www.medicare.gov. The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare, sends a Medicare & You handbook to beneficiaries yearly. It contains the latest information about all of the ways to get your Medicare benefits and where to get help and additional information.
For reliable information about different ways of obtaining the Medicare benefits that you want, contact the local office of Tennessee State Health Insurance Assistance Program (SHIP) or call Senior Citizens Information & Referral Service.
Original Medicare
A. Part A: Hospital Insurance. Medicare Part A helps pay the cost of inpatient hospital care. In some instances, Part A helps pay for home health care, hospice care, and skilled nursing care in a nursing home. Per benefit period, the patient must pay the deductible—the cost of the first day in the hospital (set annually; $1,068 as of January 1, 2009). A benefit period begins when an individual is admitted as an inpatient to a hospital and ends when that person has been out of the hospital for 60 days. A new hospital deductible is charged only after that 60-day period. Some Medicare Supplement plans cover that cost.
Written material about patients’ rights under Medicare should be given to patients when they are admitted to the hospital.
Soon after a person is admitted to a hospital, the patient and family should be contacted by the discharge planner or social worker. If such contact is not made, ask about discharge planning. Plans for the care of the patient after discharge from the hospital should be made as early as possible. For scheduled procedures, basic planning can be done before even entering the hospital.
The amount Medicare will pay for a hospital stay is based on a patient’s diagnosis and whether care in a hospital is medically necessary. Once the doctor has decided that it is no longer medically necessary for a patient to remain in the hospital, the person will be discharged.
If the patient or the family disagrees with the doctor’s decision to discharge the patient, they can appeal the decision before having to leave the hospital. To appeal, contact QSource, Center for Healthcare Quality (page 132), Tennessee’s health-care quality improvement organization, for information and assistance in starting the appeal process within the time allowed. You may have to insist on your right to appeal.
B. Part B: Medical Insurance. Medicare Part B helps pay for medically necessary doctors’ care, outpatient hospital, and some other medical services. Enrollees pay a monthly premium and a yearly deductible for Part B. Ask Medicare for more information. Part B will pay 80 percent of the Medicare-approved amount for any eligible service. Doctors and durable medical equipment suppliers who accept as their full fee what Medicare allows are said to “accept Medicare assignment.”
C. Part D: Prescription Drug Insurance. Medicare Part D helps pay for medically necessary prescription drugs for beneficiaries. Medicare Part D is optional; however, there is a penalty for beneficiaries who do not enroll when they first become eligible but later decide to enroll. The annual open enrollment period is November 15 to December 31 each year. Enrollees must participate in Part A, B, or both and may pay a Part D monthly premium and yearly deductible. There are some limits in what Part D covers. These limits are described in the annual Medicare & You handbook.
Enrollees eligible for both Medicare and Medicaid (“dual eligibles”) will receive prescription drug coverage through Medicare, not Medicaid.
D. Help with Medicare Premiums and Deductibles. Help is available for low-income seniors who cannot afford to pay their Medicare premiums, copayments, or deductibles. To find out more about the Qualified Medicare Beneficiary (QMB), the Special Low-Income Medicare Beneficiary (SLMB), the Qualified Individual (QI), or the Extra Help programs, or to enroll, see medical insurance and financing.
E. Medigap (Medicare Supplement Insurance). Medigap policies are health insurance sold by private insurance companies to fill “gaps” in Original Medicare plan coverage. Medigap policies help pay your share (coinsurance, copayments, and deductibles) of the costs of Medicare-covered services, and some policies cover certain costs not covered by Original Medicare. In Tennessee, you may choose from up to 12 different standardized types of Medigap policies (Plans A-L). Medigap policies must follow federal and state laws. These laws protect you. A Medigap policy must be clearly identified as “Medicare Supplement Insurance.” You need only one Medigap insurance policy. Before purchasing a policy, be sure that the plan provides the coverage that you want and can afford. For more information contact the State Health Insurance Assistance Program (SHIP), Senior Citizens Information & Referral Service, page 117, or Affordable Medicine Options for Seniors (AMOS).
State and federal law guarantees your right to purchase the Medicare supplement insurance policy of your choice during an open enrollment period that begins when you are enrolled in Parts A and B. You cannot be refused or charged more based on your health, medical history, or claims experience.
New guarantees of access, called Guaranteed Issue Rights, to some Medigap (supplement) policies are available outside the initial open enrollment period for people in the following situations:
- Your employer-provided retiree group health insurance that supplemented Medicare is terminated,
- you dropped your supplement insurance when you enrolled in any Medicare Advantage plan for the first time and elect to leave the plan within 12 months of enrolling,
- you move out of the geographic area served by your Medicare Advantage plan, or
- your Medicare Advantage plan’s contract with Medicare is not renewed.
Very quick action is required: Enrollees must choose a Medigap policy within 63 days of losing previous coverage. Access is offered to the Medigap you had before, if available, or to Plans A, B, C, and F. Price is not controlled, meaning enrollees might have to pay more for the same coverage than they paid before. For more information or assistance, contact Affordable Medicine Options for Seniors, or the State Health Insurance Assistance Program).
Medicare Advantage Plans
Medicare Advantage plans (Medicare Part C) are approved by Medicare but run by private companies. When you join a Medicare Advantage plan, you are still in Medicare, but you must choose to be in either Original Medicare or Medicare Advantage—you cannot be in both. If you have a Medicare Advantage plan, you probably do not need a Medigap policy, too. In many cases, the premiums or the costs of services (copays) can be lower in a Medicare Advantage Plan than they are in Original Medicare or Original Medicare with certain Medigap policies.
Medicare Advantage Plans provide all of your Part A and Part B coverage and must cover medically necessary services. They generally offer extra benefits (such as dental care, routine eye exams, and preventive care), and many include Part D drug coverage. However, you are still responsible for paying your Medicare Part B premiums in addition to any premiums charged by the Medicare Advantage Plan. The kinds of Medicare Advantage Plans available in our area are:
- Health Maintenance Organizations (HMO)
- HMOs with a Point of Service (POS) Option
- Preferred Provider Organizations (PPO)
- Private Fee-For-Service Plans (PFFS)
- Special Needs Plans
- Medical Savings Account Plans (MSA)
Medicare Advantage Plans are private insurance. These plans often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services. In many cases, your costs for services can be lower than in the Original Medicare Plan. Some of these plans coordinate your care using networks and referrals. This can help manage your overall care and result in savings to you.
Although Medicare Advantage plans can have many advantages, consumers should also understand that providers are encouraged to provide care at the most cost-effective level possible. Sometimes requested services are denied. If you are denied services, an appeal is worth pursuing. Each plan has a member-services telephone number; it connects you with a person who will help you work within the plan’s appeal process.
Medicare Advantage Plans available in Tennessee are listed in the Medicare & You handbook, or call Medicare, or go online.
Factors to Consider with Choosing Coverage in Knox County
To decide whether to enroll in a Medicare Advantage plan (HMO, PFFS, PPO, Special Needs, or MSA), or remian in Original Medicare, evaluate their advantages and disadvantages for yourself.
In an HMO, you are limited to using only the doctors, hospitals, and other health-care providers that have signed contracts with that plan. A PPO allows nonparticipating physician visits with a higher copayment. Original Medicare allows you to choose your own physicians, hospitals, and other providers, and covers eligible services anywhere in the U.S.
Check with your doctors, specialist(s), and hospital to find out whether they are already members of the HMO or PPO or accept the PFFS you are considering. You may have to change your current doctor or specialist if he or she is not affiliated with the plan. If your doctor leaves the plan, you will need to find a new physician who participates.
- In an HMO, you may be required to have prior approval from your primary-care physician (usually a general practice physician, family care physician, or internist) to see a specialist, have surgery, or obtain medical equipment if you expect the plan to pay for it; in some instances, you must also have prior approval from the managed care company. In Original Medicare and PFFS you have more freedom in choosing medical providers.
- Medicare Advantage plans often have modest premiums and low copayments and coinsurance.
- Medical expenses are more predictable under Medigap and Medicare Advantage plans because the monthly premiums and any deductibles are known in advance.
- Inpatient hospitalization may require a daily copay. It may be very expensive, depending on your plan. Evaluate carefully the inpatient deductible for each type of plan you are considering.
- Some Medicare Advantage plans include transportation as one of the services they provide to their enrollees.
- PPOs allow members to see specialists without a referral and may also offer out-of-network benefits.
- You must continue to pay Part B premiums in all types of Medicare Advantage Plans.
- You should understand clearly what is required by your plan if you need emergency or urgent medical care when you are not in the geographic area served by your plan.
- Benefits, premiums, copays, and medical providers included in the plans may change from year to year, as may the plans available in our area.
- When comparing Medicare Advantage plans, compare copayments, premiums, and added benefits and their costs and limits. For example, what medicines will it pay for? What is the copay for hospital or nursing home stays?
If you join a Medicare Advantage plan and drop your Medigap policy, you may have special Medigap protections that give you a right to get your old Medigap policy back (possibly at a higher cost) or buy a new one if you choose to leave your Medicare Advantage plan or other Medicare plan within the first year.
You can compare the Medicare Health Plan Choices available in Knox County at www.medicare.gov.
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