MedicarePart.us

Medicare: A Snapshot View

admin — Sat, 09 Jan 2010 23:52:04 +0000

Health care has been a hot topic in the United States for several years now. As health care costs climb, many people are faced with the dilemma of choosing between taking care of their health or putting food on the table. Seniors are particularly vulnerable. President Lyndon B. Johnson signed the Medicare bill into law in 1965, in an effort to provide the nation’s elderly with affordable, low cost health care and hospitalization.

Medicare is a very complex program with many different facets. It is important to understand the various parts so that you can better choose which program works best for you.

Medicare is a federally funded health insurance program. Administered by the Centers for Medicare and Medicaid Services (CMS) the nearly 40 million Americans who participate must meet at least one of the basic qualifying criteria:

65 years of age or older
Under 65 years of age, but have certain disabilities
Any age, but have end stage renal disease (kidney failure requiring dialysis or transplant)

Participants must also be a citizen of the United States in order to be eligible, although there some instances where this is not true. Those who are not U.S. citizens can contact their local Social Security Administration office to see if they qualify for Medicare despite their non-citizen status. It is the largest health insurance program in the U.S.

Original Medicare is usually the first Medicare program the people get on when they begin coverage. This fee-for-service plan allows the insured to go to any doctor or provider that accepts Medicare and is accepting new Medicare patients. They may also go to any hospital or other health facility.

Recipients pay a deductible before Medicare begins to pay its share. When Medicare begins to pay, the recipients pay a copayment for services and supplies that are covered. Some Medicare recipients have supplemental coverage or a Medigap policy. This coverage will pay the deductibles, copayments and costs that Medicare does not cover.

Medigap policies are sold by private insurance companies. They are insurance policies that are designed to handle gaps that may be left in the Medicare coverage. They may pay some health care costs that are not covered by Medicare. Monthly premiums are paid to the insurance company that manages the policy.

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Medicare has four parts; each provides a particular type of coverage, or combination of services.

Medicare Part A Coverage

Medicare Part A covers various forms of hospital stays. Its focus is inpatient care in hospitals, skilled nursing facilities, hospice and critical access hospitals. Home health care is also covered under this plan.

Medicare Part B Coverage

Medical services and supplies are covered by Medicare Part B. There is a premium that most Medicare recipients are required to pay in order to utilize the coverage. Doctor’s visits and other services are covered by the plan, as are occupational and physical therapists, outpatient care and additional home health care.

Medicare Part C Coverage (Medicare Advantage)

The Medicare Advantage Plan, or Medicare Part C combines both Part A and Part B. Part C differs from the other plans, though, because it is supplied through private insurance companies. These companies have been approved by Medicare and the often offer additional benefits and lower costs.

Medicare Part D Coverage

Prescription drug coverage falls under Part D. It is a stand alone insurance and covers all drugs that are medically necessary. It does have different plans and each plan has its own differences and covers different medications. Coverage for this plan does, for most people, require that a premium is paid, however, the insured can select the plan that best meets their needs.

When a person first becomes eligible for Medicare, he or she has the ability to assess their medical, prescription and health needs, then, in the fall, change their Medicare plan accordingly. When assessing their needs, it is suggested that recipients use a 7 point system to adequately address all area of medical and personal requirements and needs.

1. Provider, doctor and hospital. Does the recipient have the ability to see the doctor of their choice? Are they able to go to the hospital that they want to go to? When seeing a specialist, do they need a referral?

2. Cost. Recipients should review the out of pocket costs associated with supplemental insurances, Medigaps and Medicare itself to determine what plans are best for them.

3. Prescriptions. The important thing here is to ensure that the recipient’s medication is covered under the plan that they have chosen. From there they should examine the costs associated with premiums, copays and deductibles associated with the prescription plan.

4. Benefits. Some plans offer additional benefits like dental, vision and hearing aids. Recipients should find plans that address their individual needs. Additionally, they should thoroughly review the entire Medicare benefits package to see if it contains the parts (A, B and prescription drug coverage) that they need.

5. Pharmacies. The choice of pharmacies can have an impact on which plan a recipient uses. Location, convenience and cost are all factors that play into where a person gets their prescriptions filled, so the plan that they select should be accepted at their chosen pharmacy.

6. Quality of Care. It is vital that recipients find a plan that offers a high quality of care. This means that their individual needs are addressed. The assessment should include whether the services provided are of good quality, timely and appropriate and that the results are the best that they can be.

7. Convenience. Providers for the plan, location of doctor’s offices and hours of operation as well as if they are accepting new patients are considerations that go into selecting a good plan. Also, if the recipient spends any part of the year in another state, it is beneficial if the plan covers them in that state as well.

Medicare Part A

admin — Sat, 09 Jan 2010 23:50:11 +0000

Medicare Part A Coverage is the basic element of the federal health insurance program that was enacted as an amendment to the existing Social Security legislation in 1965. It was enacted to create an insurance program for people age 65 or older and people with certain disabilities.

Originally, the program was created in two parts -A for hospital coverage, and B for medical coverage. Activity involved with Medicare Part A Coverage includes both copayments and coinsurance applicable in any kind of Medicare-covered situation.

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What is the Coverage?

Medicare Part A coverage is hospital insurance. It will provide inpatient healthcare for people in hospitals, nursing homes, or other skilled nursing facilities. It does not include any long-term custodial care. People who meet certain types of requirements may also be eligible for both home health care and hospice care. An important aspect to understand about Medicare coverage is that it does not cover everything. Medicare Part A Coverage helps to pay for the necessary medical services up to your copayment amount. These include:

Blood – Transfusions are covered for necessary services needed in a hospital, or skilled nursing facility, after receiving the first three pints. Insureds pay the total cost for the first three pints and 20 percent for every pint thereafter.
Hospital confinement – Medicaid Part A Coverage includes hospital admissions to a semi-private room, general nursing charges, miscellaneous services and supplies as well as meals. Copayment includes none for the first 20 days. Out-of-pocket expenses include $128 a day when confined from 21 to 100 days, plus all of costs for every day past 100.
Stay in a Nursing Home or Skilled Nursing Facility – Medicare Part A Coverage for people admitted to a nursing home or skilled nursing facility will cover charges if the diagnosis warrants such a stay, for example, if a person had a stroke. A stay in these facilities for rehabilitation purposes would be covered including charges for a semi-private room, the actual rehabilitative and nursing services, as well as meals. Out-of-pocket expenses for a stay in a nursing home or skilled nursing facility are the same as they are for admission to a hospital.
Medicare Part A Coverage for Hospice Care will partially pay for program services for patients with a terminal illness expecting to live for six months or less. The plan will cover medical care, drugs and support services from certified providers. Copayment for this part of the program is up to you five dollars for prescription drugs and five percent copayment for inpatient care. Room and board fees may not be covered.

Applying for Medicare

People already receiving Social Security or disability benefits should apply for Medicare as well. Typically, people will have been determined eligible for Social Security or disability will receive information about and rolling in the Medicare program several months before that eligibility takes place. If you live within the United States, or the District of Columbia, enrollment is automatic for both parts A and B. Residents of U.S. territories or Puerto Rico must request Medicare coverage beyond Part A. However, participation in Part B requires premium payments and this is optional. People are not yet receiving retirement benefits should contact the Medicare office three months prior to reaching the age of 65 to request information about program coverage. Special enrollment situations include:

A disabled widow or widower between the ages of 50 and 65 who have not applied for any disability benefits due to receiving other Social Security coverage.
Government employee who has become disabled before the age of 65.
Have a spouse or dependent child with permanent kidney failure.
You once had Medicare coverage but have since dropped it.

Costs Skyrocketing

The annual cost to administer the Medicare program is expected to hit $480 billion. This is more than one fifth of the total national spending on personal healthcare. It also represents 13 percent of the federal budget and is close to 3.5 percent of the nation’s gross domestic product. The program is financed through a combination of payroll taxes and general tax revenues plus interest earned on an investment trust fund set up to help pay for the program.

Participants in the Medicare federal insurance program will receive a red, white, and blue card that will designate the participant and either Medicare Part A Coverage, Part B or both.

Medicare Part B

admin — Sat, 09 Jan 2010 23:48:34 +0000

Medicare Part B Coverage is that part of the program that deals with doctor fees and other outpatient charges are. Almost everybody who is age 65 or over can be eligible for the Medicare Part B Coverage. Although it does help to pay great amount of program participants’ doctor bills as well as other outpatient costs, it pays for only a portion of some services and does not cover others.

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Who can be Eligible for the Medicare Part B Coverage?

Anybody who is a US citizen or legal resident having lived in the country for 5 consecutive years can be eligible for Medicare part D. coverage even if not subscribing to Medicare part a. A monthly premium is paid to participate in Medicare Part B Coverage except for people who are participating in Medicaid, which will pay the premium for part B. The premium rises each year on January 1st. Anyone collecting Social Security pays about $96.40 per month. People not collecting Social Security pay $110.50 per month. Individuals with adjusted gross incomes more than $85,000 a year will pay higher premiums as well as married couples with an adjusted gross income exceeding hundred and $170,000. The following schedule dictates premium payments for eligible participants:

* A monthly premium of $150.70 per person for either single or couple who have a yearly income of $107,000 (single) to $214,000 (couple).
* A monthly premium of $221 per person for people exceeding this amount up to $160,000 (single) or $320,000 (couple).
* A monthly premium of $287.30 per person for people exceeding this amount up to $214,000 (single) or four and $428,000 (couple)
* A monthly premium of $353.60 is paid by people who exceed this last amount.

Medicare will base its calculations on participants’ tax returns from the previous two years. Documentation of any income dropping significantly in the last couple of years can warrant a change in premium. However, participants must contact Medicare for a request to have any monthly premiums adjusted to a new income requirement level. There is also a penalty involved for people who do not enroll in Medicare Part B Coverage when they first reached the age of 65. Premiums will be charged with attempted cent higher rate for each year that the participant did not enroll in the program.

Doctor Bills Take the Largest Bite

An individual’s doctor bills will be that area where Medicare Part B Coverage will address the most. Payments include any doctor delivered service no matter where it is provided, in a private practice office, a clinic, hospital or other health care facility. It also covers fees and charges for any staff related services performed for you at the doctor’s request as well as the administration of drugs in the doctor’s office or other health-related facility.

Coverage Rules Applied

Medicare Part B Coverage rules include two basic approaches – care has to be medically necessary, It must be undertaken by a medical doctor or doctor-directed staff where Medicare payments are accepted. All Medicare participants should always check with a new doctor to see if this medical professional accepts Medicare payments before making an appointment for services. Additionally, chiropractic services may be covered for short-term purposes only when a need arises for the manipulation of vertebrae in the back or neck. However, the chiropractor has to be Medicare certified. Program participants must check with the chiropractor to ensure that Medicare will cover the prescribed services.

Other Coverage Areas

Medicare part B coverage also pays for other types of outpatient services such as emergency room , X-rays and other laboratory work. Ambulance services are also covered in both an emergency and non-emergency situation (hospital release) when no other transportation is available. Medicare Part B Coverage also includes equipment and supplies that would include such items as splints, bandages, braces, prosthetics, medically prescribed footwear, bandages, glucose monitors, ventilators, pacemakers, wheelchairs and hospital beds. All of these medically related equipment and supplies must be prescribed by a doctor administering the necessary services. Additionally, services such as physical and speech therapy can be covered if these are prescribed by a medical doctor and are regularly reviewed periodically. In this instance, the therapist must be Medicare approved.

Medicare Part B Coverage does not concern itself very well with any types of preventive medicine, for example, annual physical exams or other types of medical visits designed to produce preventive care.

Medicare Part C

admin — Sat, 09 Jan 2010 23:46:59 +0000

Medicare Part C Coverage, also known as the Medicare Advantage, is a private plan that people can purchase replacing both Medicare Part A and B. Participants essentially enroll in a separate Medicare Part C Coverage plan and that are no longer participating in either Medicare Part A Coverage or Medicare Part B Coverage.

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Government Regulated

Medicare Part C Coverage is government regulated. The simple requirement for a private Medicare Part C Coverage plan is that it makes the minimum coverage received under both parts A and B. while donating some of the Medicare co-payments and deductibles. It also provides coverage for some of the gaps found in Medicare part A and Part B Coverage. Participants then roll in a Medicare Part C Coverage do not need to find an additional insurance policy to cover items not addressed in Medicare part A or part B.

Why Use Medicare Part C Coverage?

Although one of the essential differences between Medicare Part C Coverage versus Medicare part A and B. is that part C. provides coverage for many of the items that the other two do not, the chief reason for looking at this plan is its low cost. The participants total out of pocket expenses utilizing a Medicare Part C Coverage plan are typically much lower than the combined expenses of both the traditional Medicare programs even combined with a supplemental insurance plan, normally called a Medigap policy.

Who is Eligible?

Anyone who has qualified for both Medicare part A and Part B can acquire Medicare Part C Coverage plan instead. In order to obtain a Medicare Part C Coverage plan has to be offered in the region where you live. Additionally the plan has to be in a enrollee accepting mode. There are two types of Medicare Part C Coverage plans.

A Managed Care Plan

Participants can choose from a number of different managed care plans. However, they all operate following a basic principle that full coverage is available only through services provided by a member of the plan’s network. The least expensive and most common plans are provided by health maintenance organizations, HMOs. But, these will be the most restrictive plans. Other managed care plans include preferred provider organizations, PPOs, as well as Part C Coverage HMOs that provide point of service options adding certain variations to the traditional HMO approach. There are certain restrictions on services provided through the Medicare Part C Coverage HMO plan that include:

Services obtained under a Medicare Part C Coverage HMO plan can only be provided by physicians, hospitals and other healthcare facilities that the law to that HMOs network of providers.
Specialist care will not be paid for under a Medicare Part C Coverage HMO plan unless the patient is referred by the HMO plan primary care physician.
There are limitations under Medicare Part C Coverage HMO plan for certain kinds of services that need to be approved in advance before rendered.
Patient appeal rights are quite limited under Medicare Part C Coverage plan with regards to services that the plan will not cover.

You have limited rights to appeal a decision made by the Medicare Part C plan with regard to the care they won’t cover.

Through the two other plans – point of service (POS) and preferred provider organization (PPO) participants can see any provider outside the plan network. Participants can also see any specialist without first getting a referral from a primary care physician. However, these types of plans will pay smaller amounts for the total bill. They are are also less commonly available than a Medicare Part C HMO plan.

Fee-for-service plans

A Medicare Part C Coverage fee-for-service plan is operated completely differently than a managed care one. It does not possess the limitations of having to stay within a network, but allows for a fee to be paid for services rendered by any provider a participant visits. The restriction comes down to the selected provider accepting the plans requirements including the amount of fee willing to be paid for the particular service rendered. Unlike Medicare Part C Coverage HMO plans, a Medicare Part C Coverage fee-for-service plan does not restrict participant’s choice of doctors to a specific list like all the managed care plans require. With this type of plan, all you need to do is go to a doctor that participates in Medicare.

Medicare Part D

admin — Sat, 09 Jan 2010 23:45:02 +0000

Back in 2006, the federally funded national health insurance program called Medicare began covering many prescription drugs participants took at home. The program introduced the Part D drug plans that are actually administered by private insurance companies. The basic requirement for participating in a Medicare Part D Coverage plan is to be eligible to join Medicare part A or B and be enrolled in Medicare Part B in order to join a Medicare Part D Coverage prescription drug program. It can be a stand-alone plan that a participant purchases in order to supplement Medicare part A and Part B coverage or can enroll in coverage provided by Medicare Part C, the Medicare Advantage managed care program.

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Enrollment is Voluntary

Participation in a Medicare Part D Coverage plan is voluntary and about 55 percent of the population that is eligible has enrolled in such a program. There are penalties imposed for people who do not enroll when they become eligible, which is usually at age 65. Participants who enroll at a later date will pay a 1 percent per month increase in premium for every month that they did not enroll. This higher premium cost applies to any plan selected and becomes permanent. A participant in Medicaid is automatically enrolled in the low-cost Medicare Part D Coverage plan when they become age eligible.

Private Insurance Runs the Plan

The federal government will set rules and regulations for any Medicare Part D Coverage drug plan, but it will be private insurance companies that sell the plan to individuals and administer the plans on their own. There are many different plans available and they may vary from state to state. Some of these plans are considered stand alones. This means that the plan will cover prescription drugs only, complementing insurance held by participants in both Medicare Part A (hospital) and in Medicare Part B (doctor office). People who replace coverage available in Medicare Part A and B witha Medicare Part C Advantage managed care can receive drug payment coverage through this plan instead of taking out a Medicare Part D Coverage drug plan.

Monthly premiums are paid for coverage

The private insurance company will set the terms of coverage and payment for anyone receiving a Medicare Part D Coverage drug plan and these are only subject to the general rules provided by Medicare. Enrollment is done directly with the company and not through the federal government. Monthly premiums for participants and a Medicare Part D Coverage drug plan page typically from $10-$75 which will be dependent upon the type of plan one chooses as well as where one lives. The average plan cost is about $25 per month and some plans have no premiums at all. A good rule of thumb to remember is that the plans with the greatest amount of coverage possessing the lowest co-payments are going to demand higher monthly premiums.

What Drugs are Paid for Under a Medicare Part D Coverage Plan?

There is not any one plan that will cover every single drug. There are certain drugs that are restricted by law prohibiting any kind of payment through many insurance programs and are typically a list of prescribed sedatives, tranquilizers or sleeping pills. Prescription drugs for weight loss or over-the-counter medicines are not covered. They do require that each plan covers two types of drugs that are either brand-names or generic and must be in the therapeutic medication class. What this means is that the drug must be prescribed for treatment of a disease or condition. However, each Medicare Part D Coverage drug plan provides a list of medications that are covered in the plan. The plan will only pay for the drugs listed to a recognized pharmacy that agrees to participate in the plan. Unfortunately, these drug lists change from year to year. Participants may find one particular year that all of their drugs are covered, and in the next year many may not be. The Medicare Part D Coverage drug plan list, called a formulary, changes every fall with announcements about what specific drugs will be covered for the next calendar year. It is important for participants to make an annual review when the plan announces the participating drugs for the coming year in order to make a switch of plans if the medications needed and not on that list.

Additionally, individual Medicare Part D Coverage drug plans may require different co-payments for different drugs.