What are Medicare and Medicaid?

Medicaid and Medicare are two governmental programs that provide medical and health-related services to specific groups of people in the United States.

The two programs are very different, but they both come under the management of the Centers for Medicare and Medicaid Services. This is a division of the U.S. Department of Health and Human Services.

President Lyndon B. Johnson created both Medicaid and Medicare when he signed amendments to the Social Security Act on July 30, 1965.

Medicaid is a social welfare, or social protection, program. Data from August 2018 show that it serves about 66.6 million people.

Medicare is a social insurance program that served more than 56 million enrollees in 2016.

Medicaid, Medicare, the Children’s Health Insurance Program, and other health insurance subsidies represented 26 percent of the 2016 federal budget, according to the Center on Budget and Policy Priorities.

The Centers for Medicare and Medicaid Services (CMS) report that 91.1 percent of the U.S. population had medical insurance in that year.

According to the 2017 U.S. census, 67.2 percent of people have private insurance while 37.7 percent have government health coverage.

What is Medicaid?

Man accessing healthcare

Medicaid makes it possible for many people with a low income to access healthcare.

Medicaid is a means-tested health and medical services program for certain individuals and low-income households with few resources.

Primary oversight of the program happens at the federal level, but each state is responsible for:

  • establishing its eligibility standards
  • determining the type, amount, duration, and scope of its services
  • setting the rate of payment for services
  • administering its own Medicaid program

What services does Medicaid provide?

Each state makes the final decisions regarding what their Medicaid plans provide, but they must meet some federal requirements to receive federal matching funds.

Medicaid does not directly provide people with health services. Instead, it reimburses healthcare providers for the care that they deliver to enrolled patients.

Not all providers need to accept Medicaid, so it is essential that users check their coverage before receiving care.

People who do not have private health insurance can seek help at a federally qualified health center (FQHC). These provide coverage on a sliding scale, depending on the person’s income.

Centers must provide specific services, including:

  • inpatient hospital services
  • outpatient hospital services
  • prenatal care
  • vaccines for children
  • physician services
  • nursing facility services for people aged 21 years or older
  • family planning services and supplies
  • rural health clinic services
  • home healthcare for people who are eligible for skilled nursing services
  • laboratory and X-ray services
  • pediatric and family nurse practitioner services
  • nurse-midwife services
  • FQHC services and ambulatory services
  • early and periodic screening, diagnostic, and treatment (EPSDT) services for both children and adults under the age of 21 years

States may also choose to provide optional additional services and still receive federal matching funds. The most common of the 34 approved optional Medicaid services are:

  • diagnostic services
  • prescribed drugs and prosthetic devices
  • optometrist services and eyeglasses
  • nursing facility services for children and adults under the age of 21 years
  • transportation services
  • rehabilitation and physical therapy services
  • dental care

Who is eligible for Medicaid?

Each state sets its own Medicaid eligibility guidelines.

During pregnancy, Medicaid

During pregnancy, Medicaid can help people to access necessary services.

The program aims to help people in low-income households, but there are other eligibility requirements too. These relate to age, pregnancy status, disability status, other assets, and citizenship.

For a state to receive federal matching funds, it must provide Medicaid services to individuals who fall under certain categories of need.

For example, the state must provide coverage for some individuals who receive federally assisted income-maintenance payments and similar groups who do not receive cash payments.

The federal government also considers some other groups to be “categorically needy.” People in these groups must also be eligible for Medicaid.

They include:

  • children under the age of 18 years whose household income is at or below 138 percent of the federal poverty level (FPL)
  • pregnant women with a household income below 138 percent of the FPL
  • people who receive Supplemental Security Income (SSI)
  • parents who earn an income that falls under the state’s eligibility for cash assistance

States may also choose to provide Medicaid coverage to other, less well-defined groups who share some characteristics with those above.

These may include:

  • pregnant women, children, and parents who earn an income above the mandatory coverage limits
  • some adults and seniors with low income and limited resources
  • people who live in an institution and have low income
  • certain adults who are older, have vision loss or another disability, and have an income below the FPL
  • individuals without children who have a disability and are near the FPL
  • “medically needy” people whose resources are above the eligibility level that their state has set

Medicaid does not provide medical assistance to all people with low income and resources.

The Affordable Care Act of 2012 gave states the option to expand their Medicaid coverage.

In the states that did not expand their programs, several at-risk groups are not eligible for Medicaid.

These include:

  • adults over the age of 21 years who do not have children and are pregnant or have a disability
  • working parents with incomes below 44 percent of the FPL
  • legal immigrants during their first 5 years of living in the U.S.

Who pays for Medicaid?

Medicaid does not pay money to individuals but sends payments to healthcare providers instead.

States make these payments according to a fee-for-service agreement or through prepayment arrangements, such as health maintenance organizations (HMOs).

The federal government then reimburses each state for a percentage share of their Medicaid expenditures.

This Federal Medical Assistance Percentage (FMAP) changes each year, and it depends on the state’s average per capita income level.

The average reimbursement rate varies between 57 and 60 percent. Wealthier states receive a smaller share than poorer states, which can receive up to 73 percent of the money back from the federal government.

In the states that chose to expand their coverage once the Affordable Care Act became effective, more adults and families on low incomes became eligible because the new provision allowed enrolment at up to 138 percent of the FPL. In return, the federal government covers all of the expansion costs for the first 3 years and over 90 percent of the costs moving forward.

What is Medicare?

Medicare is a federal health insurance program that pays for hospital and medical care both for people in the U.S. who are older and for some people with disabilities.

The program consists of:

  • two main parts for hospital and medical insurance (Part A and Part B)
  • two additional parts that provide flexibility and prescription drugs (Part C and Part D)

Medicare Part A

Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays and other services.

Medicare services

Medicare can help people to access facilities such as walkers and wheelchairs.

In the hospital, this includes:

  • meals
  • supplies
  • testing
  • a semi-private room

It also pays for home healthcare, such as:

  • physical therapy
  • occupational therapy
  • speech therapy

However, these therapies must be on a part-time basis, and a doctor must consider them medically necessary.

Part A also covers:

  • care in a skilled nursing facility
  • walkers, wheelchairs, and some other medical equipment for older people and those with disabilities

Payroll taxes cover the costs of Part A, so a person does not usually have to pay a monthly premium. However, anyone who has not paid Medicare taxes for at least 40 quarters will need to pay it.

Medicare Part B

Medicare Part B, or Supplementary Medical Insurance (SMI), helps pay for specific services.

These include:

  • medically necessary physician visits
  • outpatient hospital visits
  • home healthcare costs
  • other services for older people and those with a disability
  • preventive care services

For example, Part B covers:

  • durable medical equipment, such as canes, walkers, scooters, and wheelchairs
  • physician and nursing services
  • certain vaccinations
  • blood transfusions
  • some ambulance transportation
  • immunosuppressive drugs after organ transplants
  • chemotherapy
  • certain hormonal treatments
  • prosthetic devices
  • eyeglasses

For Part B, people must:

  • pay a monthly premium, which was $134 per month in 2018
  • meet an annual deductible of $183 a year, before coverage begins

Premiums might be higher or lower depending on the person’s income and Social Security benefits.

Enrollment in Part B is voluntary.

Medicare Part C

Medicare Part C, also known as Medicare Advantage Plans or Medicare+ Choice, allows users to design a custom plan to suit their medical needs more closely.

Part C plans provide everything in Part A and Part B, but may also offer additional services, such as dental, vision, or hearing.

These plans enlist private insurance companies to provide some of the coverage. However, the details will depend on the program and the eligibility of the individual.

Some Advantage Plans team up with HMOs or preferred provider organizations (PPOs) to deliver preventive healthcare or specialist services. Others focus on people with specific needs, such as individuals living with diabetes.

Medicare Part D

This prescription drug plan was a later addition in 2006. Several private insurance companies administer Part D.

These companies offer plans that vary in cost and cover different lists of drugs.

To participate in Part D, a person must pay an additional fee called the Part D income-related monthly adjustment amount. The fee will depend on the person’s income.

In many cases, the amount will come out of the person’s Social Security check. However, others will get a bill from Medicare instead.

Services that Medicare does not provide

If Medicare does not cover a medical expense or service, Medigap plans can provide supplemental coverage for it.

Private companies also offer Medigap plans.

Depending on the individual plan, Medigap may cover:

  • copayments
  • coinsurances
  • deductibles
  • care outside of the country

If a person has a Medigap policy, Medicare will first pay the portion that it will cover, and then Medigap will pay the rest.

To have a Medigap policy, a person must have both Medicare Part A and Part B and pay a monthly premium.

Medigap policies do not cover prescription drugs. A person must have a Part D plan for that coverage.

Who is eligible for Medicare?

To be eligible for Medicare, an individual must meet one of the following requirements:

  • being at least 65 years old
  • being under 65 years old and living with a disability
  • being any age with end-stage renal disease or permanent kidney failure that needs dialysis or a transplant

They must also be:

  • a U.S. citizen or permanent legal resident for 5 continuous years
  • eligible for Social Security benefits with at least 10 years of contributing payment into the system

Dual eligibility

Some people are eligible for both Medicaid and Medicare. Currently, 8.3 million people have both types of cover, including over 17 percent of Medicaid enrollees. Seniors with a low income and people with disabilities may be eligible for both.

Provisions vary depending on the U.S. state in which a person lives.

Who pays for Medicare?

Most of the funding for Medicare comes from:

  • payroll taxes that the Federal Insurance Contributions Act (FICA) collects
  • the Self-Employment Contributions Act (SECA)

Usually, the employee pays half of this tax, and the employer pays the other half.

This money goes into a trust fund, which the government uses to reimburse doctors, hospitals, and private insurance companies.

Additional funding for Medicare services comes from premiums, deductibles, coinsurance, and copays.

If health spending continues as it is, national health spending is likely to rise by 5.5 percent each year from 2017 to 2026. In 2016, government health spending represented 17.9 percent of Gross Domestic Product (GDP). In 2026, experts expect that it will account for 19.7 percent of GDP.

Original Source: https://www.medicalnewstoday.com/articles/323858.php

Original Date: Nov 30 2018

Written By:

Does Medicare Cover That?

Medicare covers the majority of your medical expenses after you turn 65 (and covers some people who are younger than 65 and disabled). But it still requires you to pay deductibles and co-payments, and it doesn’t cover some services at all. Take the following quiz to test your knowledge of what Medicare does and doesn’t cover–and to learn smart ways to fill the gaps. You can look up Medicare’s coverage rules for other items at Medicare.gov.

1: Outpatient prescription drugs?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is B. B. NOT covered by Medicare

Medicare doesn’t cover outpatient prescription drugs. If you have traditional Medicare, you can buy a Part D prescription-drug policy to cover drug costs, or you can get a Medicare Advantage plan, which provides medical and drug coverage, from a private insurer. See 8 Steps to Picking the Right Medicare Plans During Open Enrollment for more information about choosing a Part D or Medicare Advantage plan each year.

2: Care while traveling in another country?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is B. B. NOT covered by Medicare

Medicare usually doesn’t cover care you receive while traveling outside of the U.S., except in very limited circumstances (such as on a cruise ship within six hours of a U.S. port). But Medicare supplement (medigap) plans C through G, M and N cover 80% of the cost of emergency care abroad, with a lifetime limit of $50,000. Some Medicare Advantage plans cover emergency care abroad. Or you could buy a travel insurance policy that pays some medical expenses while you’re outside of the U.S. and may even cover emergency medical evacuation, which can otherwise cost tens of thousands of dollars to transport you aboard a medical plane or helicopter. For more information, see Going Abroad? Check Your Health Coverage.

3: Preventive care?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is A. A. Covered by Medicare

Certain preventive care is covered by Medicare without any co-payments, including a “Welcome to Medicare” preventive visit within the first 12 months after you sign up for Part B. This visit provides certain screenings, a flu shot, blood pressure measurement, a simple vision test and a written plan that lets you know what other preventive services you may need. Many screenings are covered by Medicare without a co-payment based on your age, gender and certain risk factors. These include an annual mammogram for women age 40 or older and a yearly PSA test, which screens for prostate cancer, for men age 50 or older. See Preventive & screening services for more information about coverage for screenings.

4: Hospital stay?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is A. A. Covered by Medicare

Medicare Part A covers hospital stays, but you’ll have to pay a $1,340 deductible in 2018 before coverage kicks in. You’ll also have to pay a portion of the cost of long hospital stays. The co-payment is $0 for the first 60 days in the hospital during each benefit period (a benefit period ends when you go 60 days without receiving any care in a hospital or skilled nursing facility). But if you stay longer than 60 days during a single benefit period, the co-payment jumps to $335 per day for days 61 to 90 and to $670 per day after that. What’s more, over your lifetime Medicare will only help pay for a total of 60 days beyond the 90-day limit; those 60 days are your “lifetime reserve days.” After that, you will have to pay the full hospital cost. But a medigap policy, a Medicare Advantage plan or retiree health insurance coverage can fill the gap. See How to Fill Medicare Coverage gaps for more information. See the Medicare Rights Center’s chart to find out which types of medigap plans cover the Part A hospital deductible (all medigap plans cover the $335 daily hospital co-payment for days 61 to 90 in a hospital and the $670 daily co-payment for days 91 to 150, as well as payment in full for 365 additional days).

5: Any Medicare doctor you choose?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is A. A. Covered by Medicare

Traditional Medicare covers all doctors who accept Medicare, but with a caveat: Not all doctors are accepting new Medicare patients. Medigap policies also cover all doctors who accept Medicare. Medicare Advantage plans, on the other hand, usually have a limited provider network. Some Medicare Advantage plans don’t cover visits to out-of-network providers (except in an emergency), while others cover out-of-network doctors and hospitals but charge higher co-payments than if you went in-network for care. If you do get a Medicare Advantage plan, make sure that the doctors and hospitals you plan to use are covered. See What Retirees Must Know About Medicare Advantage Plans for more information.

6: Long-term care?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is B. B. NOT covered by Medicare

Medicare provides some skilled nursing services, but it doesn’t cover custodial care, such as help with bathing, dressing and other activities of daily living. But you can buy long-term-care insurance to help cover these costs. See The Long-Term-Care Insurance Dilemma for more information about long-term-care insurance and other ways to cover these expenses. See Medicare Rules for Home Health Care for information about Medicare’s strict rules for covering home health care.

7: Dental care?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is B. B. NOT covered by Medicare

Medicare doesn’t cover routine dental visits, teeth cleanings, fillings, dentures or most tooth extractions. Some Medicare Advantage plans cover basic cleanings and x-rays, but they generally have an annual coverage limit (a cap of about $1,500 is common). You could also get coverage from a separate dental insurance policy or a dental discount plan. See Retirees Create a Plan to Pay for Dental Care for more information.

8: Wheelchairs?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is A. A. Covered by Medicare

Medicare Part B covers manual wheelchairs as durable medical equipment that your doctor prescribes for use in your home. For a powered wheelchair to be covered, however, you must have a face-to-face examination and get a written prescription from your doctor after he or she determines that it is medically necessary for you to have that type of wheelchair. You also must use suppliers that are approved either by original Medicare or by your Medicare Advantage plan. See the wheelchair coverage page at Medicare.gov for more information about the rules. Medicare requires a 20% co-payment for durable medical equipment. That co-payment can be covered by a medigap or Medicare Advantage plan; the amount of coverage depends on the plan.

9: Hearing aids?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is B. B. NOT covered by Medicare

Medicare doesn’t cover routine hearing exams or hearing aids, which can cost as much as $3,000 per ear. But some Medicare Advantage plans cover hearing aids and fitting exams, and some discount programs provide lower-cost hearing aids. For more information, see Medicare Doesn’t Cover Hearing Aids but Retirees Have Options.

10: Routine vision care?

  1. A. Covered by Medicare
  2. B. NOT covered by Medicare

The correct answer is B. B. NOT covered by Medicare

Medicare generally doesn’t cover routine eye exams or glasses. (It does cover an annual eye exam if you have diabetes, and it covers eyeglasses after certain kinds of cataract surgery.) However, some Medicare Advantage plans provide vision coverage, or you may be able to buy a separate vision care supplemental policy or a supplemental policy that covers both vision and dental care. One way to cover these costs is to set aside money in a health savings account (if you have an HSA-eligible high-deductible policy) before you sign up for Medicare. You can use money in an HSA tax-free for out-of-pocket medical expenses at any age.

Original Source: https://finance.yahoo.com/news/does-medicare-cover-195709366.html

Original Author: Kimberly Lankford

Published Date: Dec 3 2018

Getting to Know Your Way Around Medicare – Part 2

In our first installment we answered some basic questions to give enrollees some basic knowledge on how things worked and what they should know about Medicare even before talking with a Medicare Agent.  In this installment we will continue covering the basics to further help bring a better understanding to the topic of Medicare, Medicare Advantage, and Medigap Supplemental Insurance.

Original Medigap vs Medicare Advantage

As previously mentioned, there are two options to choose from when initially enrolling in Medicare, Original Medicare Part A and Part B with Medigap and Medicare Advantage.  A basic understanding to this is that Original Medicare offers basic coverage and Medigap plans are used to supplement the basics.  Medicare Advantage however takes the place of Medicare and is run privately.

Most often Medicare Advantage plans offer lower premiums for more restrictions such as networks, annual plan changes, and having to receive pre-approvals for services.  It is important of participants are going to choose Original Medicare with Medigap Supplementing their choice that they enroll right away.  Waiting can lead to higher premiums and having to qualify for a Medigap plan. Guaranteed enrollment in a Medigap plan only occurs during the initial enrollment period.

Medigap Plan D, Prescription Drug Coverage

Although you do not need to enroll in Medigap Plan D when you enroll in Original Medicare, it is the only Medigap plan that offers prescription drug coverage. If you change your mind after the open enrollment period, you will be subjected to a late enrollment penalty.  Coverage in most markets starts around $15 to $25 a month.  It makes sense to enroll when you first can because the late enrollment penalty adds up quickly and can have you quickly paying 60% more for the same coverage as someone else.

Medigap Decisions

When is comes to choosing a Medigap plan it is important to talk with a Medicare Agent to compare coverage and costs of each plan.  Available coverage is the same no matter where you live.  Medigap Plan F in Michigan offers the same coverage as it does in Texas.  The difference from state to state and even county to county is the price you will pay.  The price is set by the private insurance company that is offering you the coverage thus the changes in costs from company to company.  The best company will be the company that offers you the coverage that you need at a price that is acceptable for your budget with unparalleled customer service.


The experts at eMedicare Supplemental Insurance, powered by Omega, have all the answers you are looking for when it comes to your Medicare Supplemental Insurance needs.  More information can be found at http://emedicare-supplemental-insurance.com/.

Getting to Know Your Way Around Medicare – Part 1

It is so important that Medicare enrollees are educated before it comes time for them to enroll.  Although there are several companies where you can speak one on one to Medicare agents it is important for participants to have some basic knowledge to avoid confusion when talking to a specialist.  It is important to have a basic understanding of generic terms, time frames, and available options in order to hit the ground running when you speak to an agent.

Signing Up for Medicare

Signing up for Medicare is simple and complex, as much of a conundrum as that is.  The actual process of being enrolled in Medicare is simple, the first day of the month in which you turn 65 is when you must act to enroll in Medicare.  There are a few options that need to be considered: are you going to opt in to Medicare Part A and Part B, known as Original Medicare so that you can also enroll in supplemental plans such as prescription drug coverage and Medigap or are you planning on choosing from one of the many Medicare Advantage Plans, HMO or PPO?

It is also a crucial point to note that beneficiaries of social security will automatically be enrolled in to Medicare Part A, however if you have not participated in SS and want to participate in Medicare you are still allowed to but will need to enroll.  You can do this online, in person at a Social Security office, over the phone by calling 800.772.1213 or online at https://www.ssa.gov.

Costs Associated with Medicare

As many of the answers do when it comes to Medicare, the cost will vary depending on your unique situation.  Medicare Part A is free of charge if you have worked 10 years and paid into the system through your payroll taxes.  Medicare Part B has a premium which can be deducted from your Social Security check.  For 2017 the monthly premium was $134.00.  Certain situations will allow you to pay less of a premium for Medicare, mainly your income.  If an Income-Related Monthly Adjustment Amount applies to you your premium will be decreased.

Medicare and Preventative Care

There is a myth circulating that states Medicare doesn’t cover preventive services however, this is not the case.  Medicare covers a complete physical upon enrolling in Medicare and then a once a year annual exam as well as screening and tests on a schedule that Medicare determines along with the assistance of physicians.  Some of the screens included are: mammograms, colorectal cancer, glaucoma, flu shots, prostate exams, and more.

We will continue this discussion and answering important Medicare questions and concerns in our next installment of, Getting to Know Your Way Around Medicare.

The experts at eMedicare Supplemental Insurance, powered by Omega, have all the answers you are looking for when it comes to your Medicare Supplemental Insurance needs.  More information can be found at http://emedicare-supplemental-insurance.com/.

3 health care questions to ask yourself this Annual Election Period

During the Annual Enrollment Period, it’s always a good idea to evaluate your Medicare options and make sure your current health plan is still the best fit.

The Medicare Annual Enrollment Period (AEP) runs from Oct. 15 to Dec. 7 each year and it’s generally the one time a year when you can make changes to your supplemental Medicare coverage. AEP is a great time to reevaluate your current and future health care needs and make sure your plan is a good fit for the upcoming year. Taking the time to explore your Medicare options can potentially save you money and help you find a plan that better aligns with the coverage and benefit features that are most important to you for the upcoming year. You may find your current plan is still the perfect fit, but it’s always a good idea to reaffirm your decision. During this AEP, Priority Health encourages you to ask yourself these questions to help you decide if your current Medicare plan is still meeting your needs:

1. Have my health care needs changed?

Health care needs are constantly changing, and there is a chance that what worked for you in previous years may not be the best fit for you moving forward. It’s a helpful exercise to estimate your expected costs for the upcoming year by using your benefit usage from the past 12 months as a guide. This should include common expenses such as monthly premiums, deductibles, copays and prescription costs. Also, if you’ve been diagnosed with a new health condition or your medications have changed, you may need different Medicare plan benefits next year. Anticipating your health care needs will help you choose the best plan from a cost and coverage perspective.

Worried about cost? Priority Health’s Medicare Advantage plans start at just $0 per month.

2. Has my current plan changed at all?

If you’re currently enrolled in a Medicare Advantage plan, you should have received a package of information from your insurance company explaining any changes to your plan for the upcoming year. You’ll receive a lot of communication about insurance during this time, so it’s important to review these documents carefully. Pay special attention to premium changes and adjustments to your plan’s network or benefits. Double check to make sure your coverage still includes your prescriptions and that your primary care provider (PCP) is still under your plan’s network. You should also look to see what other providers have been added to your network in case you ever want to change your PCP.

Did you know: Priority Health’s network includes 98% of providers in Michigan.

3. Are there other options that might be a better fit?

AEP is your chance to do some health insurance exploring. If you want to evaluate your plan but aren’t sure where to get started, there are many resources available to you. A great place to start is medicare.gov, which offers information, explanations and other free resources on everything you need to know about Medicare. Another option is speaking with a certified insurance agent who can help you compare plans. You can also check with your health insurance company to see if they have specific tools or additional resources to help you get to know your current plan better. Priority Health offers several tools such as a cost calculator to estimate your annual costs and a Medicare Guide that can help you choose the right plan.

Priority Health lets you compare plans so you can find the best fit for your health and budget.

Medicare may seem overwhelming, but don’t let that get in the way of making sure you have the right plan. Do your research, think about your needs, ask the right questions and take advantage of this year’s AEP to choose a plan you can feel good about.

Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in Priority Health Medicare depends on contract renewal. Contact Priority Health today for questions and to learn more about our Medicare options.

Original Source: https://www.detroitnews.com/story/sponsor-story/medicare-special-section-2018/2018/11/13/3-health-care-questions-ask-yourself-annual-election-period/1988854002/

Original Date: Nov 13 2018

Written By: Priority Health

Medicare For All: Sounds Good, But What Does It Mean?

Medicare is a popular program that enjoys broad political support. Perhaps seeking to borrow a popular brand name, some have proposed “Medicare for All,” “Medicare Extra for All,” and “Medicare buy-in” as a means of expanding and improving health insurance coverage in the United States for individuals younger than age 65.

The newly formed Medicare for All Caucus has more than 70 founding members from the US House of Representatives, including several potential 2020 presidential candidates. Yet, there is substantial variation in proposed plans, and public support for such proposals varies greatly depending on the language used.

For policy analysts, such high-level proposals quickly draw a question: “What do they really mean by Medicare?” Medicare has multiple components: traditional Medicare (Part A and Part B, also called original Medicare or fee-for-service Medicare), Medicare Advantage (Part C), and Medicare prescription drug plans (Part D). Each of these components requires a separate premium, and Parts C and D plans are offered by private insurers. Individuals (or their spouses) who have paid Medicare taxes for at least 40 quarters do not pay premiums for Part A (hospital insurance). Beneficiaries pay Part B (medical insurance) premiums, starting at $134 per month in 2018 and increasing with beneficiary income.

Traditional Medicare also has deductibles and coinsurance and—surprisingly to some—does not have an out-of-pocket maximum. More than 80 percent of Medicare beneficiaries have a source of supplemental coverage beyond traditional Medicare, whether through Medicare Advantage, employer-sponsored plans, Medigap, Medicaid, or other coverage combinations. Part C premiums vary by plan and cover hospital and medical services. Premiums for Part D plans vary by plan and beneficiary income.

If “Medicare for All” evokes an expansion of traditional Medicare, its proponents should make this explicit and explain whether and how they propose to address the coverage limitations of traditional Medicare.

Medicare Design From The Beneficiary Perspective

From the beneficiary perspective, traditional Medicare has two key shortcomings in terms of benefit design:

No Cap On Out-Of-Pocket Spending

Like other health insurance products, each part of traditional Medicare features cost sharing (that is, consumer out-of-pocket expenses) via deductibles, copayments, coinsurance, and other gaps in coverage.

The main limitation of traditional Medicare is its lack of an out-of-pocket maximum—an annual beneficiary spending limit (the sum of deductibles, copays, and coinsurance across all service categories) beyond which insurance covers all additional costs. In contrast, qualified health plans—those offered through the Marketplaces under the Affordable Care Act—can charge an individual member no more than $7,350 in 2018.

Having an out-of-pocket maximum matters. An out-of-pocket maximum is the main mechanism used in health insurance to guard against catastrophic financial loss. For example, an individual in Iowa in 2017 generated $12 million in paid claims due to a complex genetic disorder. These claims were covered by a qualified health plan, which placed a fixed ceiling of no more than $7,350 on the patient’s out-of-pocket costs. Had this individual been on Medicare, the patient could have faced $268,000 (Part B drugs) in out-of-pocket costs (assuming 200 infusion visits with a co-insurance amount no greater than the Medicare Part A deductible per visit).

In addition, traditional Medicare has annual and lifetime limits on hospital coverage. Qualified health plans are not allowed to place such limits on any services. For example, an individual who needs to be hospitalized for 180 days in a benefit year would have the entire hospital stay covered if the beneficiary is enrolled in a qualified health plan. However, if the individual is insured by Medicare, coverage stops after the 150th day of hospitalization.

Although million-dollar claims in a single year are infrequent, insurance is supposed to protect individuals from rare and catastrophically expensive shocks. Traditional Medicare does not do this. For this reason, many Medicare beneficiaries buy additional supplemental (Medigap) insurance, which provides catastrophic protection as well as additional assistance with cost sharing.

Holes In Traditional Medicare Coverage

Qualified health plans are required to offer 10 categories of “essential health benefits.” These benefits include limited dental and vision services (for children), prescription drug coverage, hospital care, and professional services. In contrast, Medicare offers neither vision nor dental service coverage, and other essential health benefits are offered “a la carte,” depending on which parts of Medicare beneficiaries enroll in.

Individuals covered by Medicare can have most of the essential health benefits required of qualified health plans if they enroll in Medicare Parts A, B, and D. Or they can build their own benefits by choosing inpatient and outpatient coverage (Parts A and B) while declining prescription drug coverage.

Beneficiaries can elect to fill in some of the coverage gaps in traditional Medicare’s complex benefit design by purchasing a Medigap policy, or they can integrate their benefits by enrolling in privately run Part C (Medicare Advantage) insurance plans. Some individuals may have additional coverage that is integrated with their Medicare coverage and functions like a Medicare supplemental plan but is paid for and integrated with employer- or union-provided coverage. 

The Meaning Of “Medicare For All”

Traditional Medicare is popular (and therefore can lend a good “brand name” to coverage expansion proposals), but its limits can be significant for some patients. Those proposing and evaluating “Medicare for All” proposals should consider whether and how these limits are addressed. The details of policy proposals that either extend the Medicare scope of coverage and cost sharing or establish a new benefit package have ramifications for enrollees’ finances and access to care.

Original Source: https://www.healthaffairs.org/do/10.1377/hblog20181116.137123/full/

Original Date: Nov 19 2018

Written By: David Anderson

Welcome To Medicare’s Open Season: Your Head Is About To Explode


It is Medicare open season. And, let’s face it, nobody has any idea what to do.

The other night, I got a call from a friend who works in the long-term care advocacy world. She will soon turn 65 and is confronting the reality of enrolling in Medicare. She has been doing diligent research and creating detailed spreadsheets. And she is baffled.

Some choice is good. So is competition. But needless complexity is something else entirely. And we know from behavioral science that, faced with too many choices, humans often make poor decisions or …do nothing.

Hence, Medicare—the poster child for choice overload:

The rules

If you have just turned 65, you need to enroll in Part A, even if you still are working and have insurance through your job. If you don’t have employer-sponsored health coverage, you need to decide whether to go with Medicare Advantage managed care (Part C) or with traditional Medicare (Part B), also called original Medicare. If you pick traditional fee-for-service Medicare, you also should choose a Part D drug plan (basic Medicare doesn’t pay for most drugs) and decide whether to buy a Medicare Supplemental   (Medigap) policy to cover costs basic Medicare doesn’t.

If you decide to buy a Medigap policy, you have to choose between 10 different plan designs (lettered A-N). Each letter represents a different benefit package.  And, of course, you need to remember that Medicare Supplemental plans A,B,C, and D are different from Medicare Parts A,B, C, and D.


You could simplify your life and enroll in a Medicare Advantage plan. Because these generally provide comprehensive benefits, including drugs, you won’t need a Part D plan or a Medigap policy. But once you get into MA world, it is hard to get out. You can go back to traditional Medicare, but you may not be able to buy an affordable Medigap policy if you have pre-existing medical conditions.

More rules

Deciding which version of Medicare you want is just the first step. You still need to pick specific insurers.  Where I live, there are 25 Part D plans, 10 managed care plans, and 29 plans that offer, for instance, Medigap F policies. Different carriers offer other policies for other letter plans.

And which plan you choose matters—a lot. The benefits for each letter plan are identical, no matter whose insurance you buy. But provider networks may be very different and so are the premiums. In Maryland, premiums for those Part F plans vary from $151-$344 a month—for identical benefits.

And there is more.

If you are already getting Social Security benefits, you will automatically get Part A and B coverage starting in the month you turn 65. But if you are not yet taking Social Security, you need to sign up for Part A. If you don’t have other insurance, you also need to sign up for Part B during your initial enrollment period, which starts three months before your turn 65 and lasts for three months after. If you don’t sign up in that window, you will owe penalties when you finally do enroll. Congress has been trying to fix this mess but has yet to act.

More rules

The rules are similar for Part D. If you don’t sign up when you are first eligible, you may owe a penalty.

As long as you are still getting insurance through work or another group policy, you won’t owe a penalty if you wait to enroll in Medicare Part D. But once you lose coverage, you must sign up for Medicare during a special enrollment period or you will have to pay a penalty.

The rules are different still if you are getting individual insurance through the Affordable Care Act health exchanges. In that case you may want to drop your individual coverage and switch to Medicare.

There’s more. What if you have Medicare but want to switch plans?

I won’t even try to describe those rules. Here is how Medicare explains it:

When you first become eligible for Medicare, you can join during your Initial Enrollment Period.

  • If you get Part B for the first time during the General Enrollment Period, you can also join a Medicare drug plan from April 1–June 30. Your coverage will start on July 1.

  • You can join, switch, or drop between October 15–December 7 each year. Your changes will take effect on January 1 of the following year.

  • If you’re enrolled in a Medicare Advantage Plan, you can join, switch, or drop a plan during the Medicare Advantage Open Enrollment Period, between January 1–March 31 each year.

  • If you qualify for a Special Enrollment Period. See the next page.

Medicare tries to explain all this in its Medicare & You handbook. This year’s version is 122 pages long.

Or you can try to sort it out through the Medicare.gov website. Or you can contact a counsellor from your local State Health Insurance Assistance Program (SHIP) program.  Or, you can just pour yourself a stiff drink.

Medicare is insanely and needlessly complicated. Different enrollment rules and periods for different plans, complex and restrictive rules for switching plans, and penalties for poor choices all discourage older adults from buying the most appropriate coverage.  They make people like my advocate friend pull out their hair in frustration. And that’s no way to celebrate your 65th birthday.

Medigap vs Medicare Supplemental Insurance Plans

What’s the difference between Medigap and Medicare Supplemental Insurance?

Is Medigap Plan F the same as Medicare Supplemental Insurance Plan F?

What does each of these plans offer me in terms of coverage?

These are just a few of the many questions that enrollees ask when first becoming eligible for Medicare.  Thankfully, we have all the answers you will need!  There are absolutely NO differences between Medigap and Medicare Supplemental Insurance Plans, they are in fact synonymous for the exact same type of health insurance.  Each of these ten standardized plans are offered by private insurance carriers and were put in place to help cover some of the out of pocket expenses that are not covered under Medicare Part A and B.

Medicare Part A – Hospital Insurance

Medicare Part B – Medical Insurance

Medigap insurance plans work in conjunction with Medicare Part A and B to help with out-of-pocket expenses such as deductibles, copayments, and co-insurance amounts.  Medicare Part A and Part B pay its share of Medicare approved expenses that patients receive.  In order to enroll in Medigap you must be enrolled in both Medicare Part A and Part B.

Standard Benefits

One of the benefits that come along with Medigap is knowing that no matter where you purchase your insurance plan from it provides the same coverage.  Medigap Plans are regulated under both federal and state laws in order to protect enrollees.  Each policy must be identified as a Medicare Supplemental Insurance Plan which is identified by a letter.

Cost and Availability

No matter what insurance company sells you Medigap each standard plan of the same letter offers the same basic benefits.  Plan premiums can and often do vary between providers.  The best option for enrollees is to first decide what plan works best for your health care needs.  After this has been decided, with he help of a Medigap agent, they can help you find the best rate where you reside.  When you are deciding this, you should consider:

  • Not every insurance company allowed to provide Medigap will offer each of the ten standard plans. You will want to make sure the plan that you want is available through the carrier.
  • The amount you will pay, the cost or premium, will vary amongst insurers even though they are all offering the exact same coverage.


Open enrollment for both Medicare Part A, Part B, Part D, and Medigap (Medicare Supplemental Insurance Plans) begins on the first day of the month in which they turn 65.  This period will last for 6 months.  This allows you to apply for coverage without worry that you will be turned down during medical underwriting.

The experts at eMedicare Supplemental Insurance, powered by Omega, have all the answers you are looking for when it comes to your Medicare Supplemental Insurance needs.  More information can be found at http://emedicare-supplemental-insurance.com/.

Which letter? Find the right Medicare package

It’s open enrollment season; here’s a primer in finding the right Medicare answers for you

If picking a Medicare plan makes you panic, you’re not alone.

Most people avoid the whole thing as long as possible, but “it’s not as scary as it seems,” said Jim Murphy, a Statewide Health Insurance Benefits Advisors volunteer in Moscow who offers free advice about health insurance to senior adults.

With enrollment currently open for Medicare parts C and D, now is the time for many seniors to take some decisive action. And thanks to volunteer advisers, it’s not something you have to figure out on your own.

Murphy offered this basic information about Medicare, the current open enrollment season and help that is available for those seeking to enroll:

Q: What are the different parts of Medicare?

A: Medicare is broken into four main parts:

Medicare Part A is hospital insurance that covers inpatient stays and is free or very low cost.

Medicare Part B is medical insurance that covers doctors’ services, diagnostic and preventive care. This low-cost insurance generally covers 80 percent of the fees.

Medicare Part C, also called Medicare Advantage Plans, are offered by private companies that contract with Medicare to provide coverage. This can include dental and vision coverage.

Medicare Part D is prescription drug insurance provided through private companies.

Additionally, Medicare supplemental insurance, also called Medigap, is offered by private insurers and helps to cover costs not covered by other parts of Medicare, for example, the 20 percent not covered by Medicare Part B. For more information visit www.medicare.gov.

Q: When do I enroll for Medicare?

A: It depends. People younger than 65 who are already receiving Social Security or railroad retirement benefits will be automatically enrolled in Medicare parts A and B when they turn 65.

Anyone using Medicaid will get Medicare for free (Medicaid pays the Medicare premium), plus extra help to assist with Part D.

Most people enroll in Medicare around age 65, during a seven-month window called the Initial Enrollment Period that begins three months prior to the month of their birthday and continues through their birthday month and the three months following. Some people are automatically enrolled for Medicare parts A and/or B, and some must enroll manually. Advisers can help individuals determine if they need to enroll.

A person can also enroll during the General Enrollment Period from Jan. 1 to March 31, but there can be late-enrollment penalties for not signing up for Medicare when you are first eligible. If a person has health coverage through their employer or spouse’s employer, however, they can delay Medicare Part B enrollment without penalty by enrolling during the General Enrollment Period or an eight-month Special Enrollment Period that begins the month the employment or health coverage ends.

Q: How do I enroll for Medicare?

A: There are three ways to enroll for Medicare parts A and/or B. You can visit your local social security office, call (800) 772-1213 or go online to www.socialsecurity.gov.

Q: Am I required to enroll in Medicare?

A: No. However, if you do not enroll when you are first eligible, you may have to pay higher premiums as a penalty when you enroll later.

Q: What is the purpose of the current open enrollment season?

A: The current enrollment season allows those with Medicare to enroll in or make changes to Medicare parts C or D without penalty. The enrollment window runs from Oct. 15 to Dec. 7.

More information about enrolling in other parts of Medicare is available by talking to a SHIBA volunteer advisor or visiting www.medicare.gov.

Q: Why might I want to get help selecting a Medicare Plan D or Medicare Advantage Plan?

A: There are many Medicare Part D plans to choose from, and a person’s prescription drug needs are highly personalized.

The number of prescriptions people take and where they buy them will influence how much their Medicare Part D coverage will cost. For example, there are 25 Medicare Part D plans available for Latah County residents. Some may benefit from a more expensive plan that covers a larger percentage of drug costs, while another would not benefit from the same plan. Likewise, Medicare Advantage Plans vary significantly in cost and coverage, and many people benefit from personalized advice.

Q: How do I get help selecting a Medicare Plan D or Medicare Advantage Plan?

A: Each state provides advisors to help people select Medicare plans that are best for them.

In Idaho and Washington, this free service is offered by SHIBA.

The advisers are primarily volunteers who are certified after training each year to help people understand what their options are and the best way to get health care coverage. They don’t sell insurance or recommend one company or agent over another, but they provide unbiased and confidential help in determining options.

Q: How do I meet with a volunteer advisor?

A: You’ll want to meet with an adviser that specializes in the options available in your county. Someone in Whitman county, for example, is able to access a list of options in Asotin county, but will not be as familiar with them. To find a volunteer adviser in your area and make an appointment, see the accompanying information in “Free Medicare open enrollment help” or call the state office: (800) 562-6900 in Washington and (800) 247-4422 in Idaho.

Q: What should I bring to the appointment?

A: Bring your Medicare card, along with a list of your medications and dosages. If you aren’t currently enrolled in Medicare, do that first, as it will take a few weeks to receive your Medicare card.

Original Source: https://lmtribune.com/golden_times/which-letter-find-the-right-medicare-package/article_55dfcd3c-f3d3-5669-a1b0-83a06f0a6a66.html

Original Date:  Nov 5 2018

Written By:

Quick guide: Do you need Medicare supplemental insurance?


You’ve worked your entire life. All of that work has led up to you reaping the benefits of the Medicare program. Given the rich history of this program that’s been around since 1965, those benefits seem like a sure thing.

Now, quickly approaching the ripe old age of 65, you’re almost ready to claim your Medicare benefits. Have you ever asked yourself just how far those benefits will take you? More specifically, have you ever asked yourself:

Do I need Medicare supplemental insurance?

But why would you need supplemental insurance anyway? Isn’t Medicare good enough to support you in old age? Given the rich history of this program that’s been around since 1965, those benefits seem like a sure thing.

Perhaps not. Keep reading to find out why.

When Medicare Isn’t Enough

Medicare provides our elderly population with an important safety net. In fact, when Lyndon B. Johnson first established the program decades ago, he had one particular goal in mind:

To ensure that older Americans could enjoy the “healing miracle of modern medicine.”

Unfortunately, though, Medicare has its drawbacks.

One such drawback is the out-of-pocket expenses. Some plans, for instance, only cover a certain percentage of your costs (e.g. 70 or 80 percent). That means that you have to shoulder the rest of the costs of your treatment.

As it turns out, Medicare only covers the cost of certain medical treatments. Let’s say, for example, that you started losing your hearing at age 67. Well, Medicare typically won’t cover the cost of your treatment.

Furthermore, Medicare doesn’t usually cover the cost of visits to eye doctors or dentists. In other words, you’d rack up a lot of out-of-pocket costs if you didn’t have a supplemental plan and received these treatments.

Do I Need Medicare Supplemental Insurance?

So do you need Medicare supplemental insurance? If what we’ve said thus far is any indicator, it’s an absolute must.

That does leave you with one important question:

What’s the cost of a Medicare supplemental insurance (or Medigap) plan?

Let’s take a closer look:

The Cost of Medigap

Medigap plans aren’t free, but they’re well worth the cost. Fortunately, the costs aren’t exponential.

Typical insurance plans, for example, take your age into consideration. Medigap plans, however, don’t use your age to calculate costs–assuming, of course, you enroll during your Initial Enrollment Period.

The type of plan you choose will also affect the cost of your supplemental insurance. There are several plans to choose from, some more comprehensive than others. Needless to say, the more comprehensive plans come with higher premiums.

All in all, it’s up to you to select the plan which best suits your needs. You can view more information about the costs of Medicare supplemental insurance if you click the link we’ve provided for you.

Consider Getting Medical Supplemental Insurance

“Do I need Medicare supplemental insurance?” In truth, if you’re still asking yourself that question, we recommend that you invest in a Medigap plan.

Because here’s the truth:

Disaster can strike at any moment. And while Medicare is great, it’s just not as comprehensive as disaster calls for.

After you’ve selected a Medigap plan, don’t forget to check out our lifestyle section for other useful tips. You can also contact us if you have any questions about the content you find here.

Original Source: https://azbigmedia.com/quick-guide-do-you-need-medicare-supplemental-insurance/

Original Date: 10-29-2018

Written By: Darren Wilson