Consider Plan Costs And Your Budget
Once you know what you could spend on health insurance each month, comparing the costs of different MA plans is a good idea. For example, some plans offer zero premium as a selling point. Under these Medicare Advantage plans, you do not pay a monthly premium for your Part A coverage. But zero premium does not mean free: You may still have to pay your Part B deductible and any out-of-pocket costs associated with care.
What Does Medicare Part A Cover
It helps to think of Medicare Part A as your hospital, or inpatient, benefit. In general, if you have a covered inpatient stay in a hospital or skilled nursing facility, Medicare Part A covers your costs.
Your inpatient benefits under Part A typically include the cost of a semi-private room, meals, prescription medications, and medical supplies and services. Medicare Part A typically does not cover personal items such as shampoo or telephone.
Medicare Part A also covers some home health services if your doctor certifies you as homebound. Covered home health services may include:
- Short-term, intermittent skilled nursing care
- Physical, occupations, and speech-language therapy
- Medical social worker services
- Intermittent hands-on home health aide services
Note that Medicare Part A does not cover long-term care or custodial care in a nursing home or other care facility.
Part A also generally pays 100% of your hospice care services if you sign a statement choosing hospice instead of treatments to cure your disease, your hospice doctor and your regular doctor certify that youâre terminally ill, and you accept palliative care instead of care to cure your illness. Your only costs under Medicare Part A hospice care include a $5 copayment for certain prescription drugs and a 5% coinsurance amount for inpatient respite care.
Do I Need To Enroll In Part D
You do not need Medicare Part D with PEBB medical plans. PEBB medical plans include prescription drug coverage that is as good as or better than Medicare Part D. If you or your dependent enrolls in a stand-alone Part D plan, your PEBB medical plan may not coordinate prescription drug benefits with that plan. However, you may want to explore a Part D plan if you waive PEBB medical in favor of Medicare.
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Financial Assistance If You Cant Afford Medicare
If you are having trouble affording your Medicare premiums, copays and other out-of-pocket costs, the federal government has four Medicare Savings Programs that provide help for people with limited incomes. There is also a program called Extra Help that assists beneficiaries with their out-of-pocket costs for prescription drugs. Even if you havent qualified for these programs before, the open enrollment period is a good time to check to see if your financial circumstances now allow you to qualify.
The Inflation Reduction Act also may soon come into play. Beginning in 2024, Medicare beneficiaries with annual incomes of up to 150 percent of the federal poverty limit who also meet the programs resources limit can qualify for full benefits under the Extra Help program. The income threshold for full benefits currently is 135 percent of the federal poverty guidelines .
How to get help picking a Medicare plan
Beneficiaries can compare plans and change their enrollment by going to www.medicare.gov. During the open enrollment period, there is also live chat assistance on the website.
In addition, Medicare has a 24-hour, seven-day-a-week hotline where representatives can answer your open enrollment questions. That toll-free number is 800-633-4227. Also, every state has a State Health Insurance Assistance Program with counselors who can help answer your questions.
More on Medicare
Medicare Advantage Vs Original Medicare
The Medicare program covers 62 million disabled individuals and seniors 65 and older, nearly 42% of whom are enrolled in Medicare Advantage plans, policies provided by private insurance companies that contract with the Medicare program.
Medicare Advantage plans are becoming more popular, and some experts predict that most Medicare beneficiaries will be enrolled in a Medicare Advantage plan by 2030.
Original Medicare is a fee-for-service plan, meaning providers are paid for each service they provide. Original Medicare pays for about 80% of medical costs, which is why nearly 15 million beneficiaries carry supplemental policies to fill in coverage gaps and mitigate out-of-pocket expenses.
With Original Medicare and a supplemental plan, most of your costs result from predetermined, monthly premiums. As a result, the costs with Original Medicare are front-loaded, making it much easier to budget for health costs with Original Medicare than Medicare Advantage, where the costs occur on the back end of care.
How plan administration could affect your health care
With Medicare Advantage, health plans and providers are usually paid based on a global-risk or full-risk model, meaning they are paid a sum of money up front to manage patient care, giving them incentives to keep patients healthy and out of the hospital.
Characteristics Of People On Medicare
Many people on Medicare live with health problems, including multiple chronic conditions and limitations in their activities of daily living, and many beneficiaries live on modest incomes. In 2016, nearly one third had a functional impairment one quarter reported being in fair or poor health and more than one in five had five or more chronic conditions, . More than one in seven beneficiaries were under age 65 and living with a long-term disability, and 12 percent were ages 85 and over. Nearly two million beneficiaries lived in a long-term care facility. In 2016, half of all people on Medicare had incomes below $26,200 per person and savings below $74,450.
Figure 1: Characteristics of the Medicare Population
Medicare Advantage Plans Often Provide More Benefits Than You Would Receive Under Original Medicare
Medicare Advantage plans must offer at least the same level of coverage as Medicare Part A and Part B and many plans offer added benefits. These may include coverage for routine vision care, hearing aids, routine dental care, prescription drug coverage, and fitness center membership.
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All Medicare Advantage Plans Feature Out
With Original Medicare, there is no annual limit to how much out-of-pocket health care spending you may have to pay. That means you could potentially face an infinite amount of medical expenses in any given year.
Medicare Advantage plans, however, are required to include an annual out-of-pocket spending limit that caps the amount of money you will be forced to spend in a calendar year. Once you reach that limit, the plan will pay 100% of your expenses for the remainder of the year.
What Is Medicare Part A Hospital Insurance
Medicare Part A covers the following services:
- Inpatient hospital care: This is care received after you are formally admitted into a hospital by a physician. You are covered for up to 90 days each benefit period in a general hospital, plus 60 lifetime reserve days. Medicare also covers up to 190 lifetime days in a Medicare-certified psychiatric hospital.
- Skilled nursing facility care: Medicare covers room, board, and a range of services provided in a SNF, including administration of medications, tube feedings, and wound care. You are covered for up to 100 days each benefit period if you qualify for coverage. To qualify, you must have spent at least three consecutive days as a hospital inpatient within 30 days of admission to the SNF, and need skilled nursing or therapy services.
- Home health care: Medicare covers services in your home if you are homebound and need skilled care. You are covered for up to 100 days of daily care or an unlimited amount of intermittent care. To qualify for Part A coverage, you must have spent at least three consecutive days as a hospital inpatient within 14 days of receiving home health care.
- Hospice care: This is care you may elect to receive if a provider determines you are terminally ill. You are covered for as long as your provider certifies you need care.
Keep in mind that Medicare does not usually pay the full cost of your care, and you will likely be responsible for some portion of the cost-sharing for Medicare-covered services.
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Original Medicare Vs Medicare Advantage: Providers
A final key difference to consider when choosing between Original Medicare and a Medicare Advantage plan is what health care providers you can see.
With Original Medicare you can go to any hospital and see any doctor or provider within the U.S. who accept Medicare. You do have limited coverage in foreign countries, though.
With Medicare Advantage, most plans have a network of doctors and providers you can see. If you go outside the plans network, its likely youll have to pay more to do so. However, emergency and urgent care are covered nationwide. You also have limited coverage in foreign countries, though some plans may offer special foreign coverage or travel benefits.
What Does Every Senior Need To Know About Medicare
The Benefits of Medicare. Most Americans, adults in particular, are familiar with the basic premise of the Medicare program operating in this country. However, those who are not taking advantage of the coverage Medicare offers may not be familiar with all the Medicare benefits that can be provided. The overall goal of Medicare is to provide senior citizens and other individuals
Does Medicare Cover Vision
Medicare Part B, for example, typically covers 80% of your medical costs, but you may be responsible for covering the remaining 20%. No vision, dental or hearing benefits. If you receive a routine hearing test, or if you visit an eye doctor or a dentist, Original Medicare generally will not cover the cost.
Note The Plans Overall Reputation And Star Rating
The Centers for Medicare and Medicaid Services provide Star Ratings for Medicare Advantage plans. These ratings are designed to help consumers compare plans before their open enrollment periods. Star ratings use a 1-5 scale, with 1-star ratings representing poor performance and 5-star ratings representing excellent performance. These ratings are released annually based on survey data from individuals enrolled in these plans.
Along with Star Ratings, online reputation plays a role in selecting your MA plan. A quick search of your potential insurer will offer insight into customer service, coverage, and complaints, which can help you make your decision.
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Can I Keep My Pebb Medical Plan When I Turn Age 65
Yes, unless you have a consumer-directed health plan. Employees and dependents becoming eligible for Medicare can choose to keep PEBB medical as primary coverage, with Medicare coverage as secondary, if they enroll in Medicare.
I have a consumer-directed health plan. What should I do?
Enrolling in Medicare creates a special open enrollment that allows you to change medical plans. If you are enrolled in a consumer-directed health plan with a health savings account , you should consider a plan change when you, the employee, enroll in Medicare. Employees cannot contribute to an HSA while enrolled in Medicare. If you do, you will face tax consequences.
If you are eligible for premium-free Medicare Part A but don’t enroll when first eligible, your Part A will be enrolled retroactively six months before the month you apply for Medicare, but no earlier than the month you turn age 65. If you keep your CDHP past your Initial Enrollment for Medicare, plan carefully when to stop contributing to the HSA to avoid a tax penalty.
If your dependent enrolls in Medicare, however, you can still contribute to an HSA. Contact HealthEquity, Inc. UMP members call 1-844-351-6853 Kaiser Permanente members call 1-877-873-8823 for more information about how Medicare enrollment affects your HSA.
The Pros And Cons Of Medicare Advantage
These popular plans may carry hidden risks. Heres what to know.
If youre one of the 63 million Americans enrolled in Medicare, youre probably being deluged by marketing pitches for Medicare Advantage plans, which offer managed care with low or zero premiums.
Medicares fall open enrollment season starts Oct. 15 and runs through Dec. 7, when you can switch your coverage between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or make changes to your prescription drug plan.
All that marketing seems to be working. Recently, 42 percent of Medicare beneficiaries were enrolled in Advantage plans, up from 31 percent in 2016, according to data from the Kaiser Family Foundation. Those numbers include 50 percent of Black and 54 percent of Hispanic enrollees vs. 36 percent of whites in 2018. By 2025, half of Americans are expected to be in Advantage plans.
Its easy to see the appeal of Advantage. Original Medicare doesnt cover all your medical expenses, while Advantage plans have cost-sharing requirements but then cap your out-of-pocket costs. Plus, you have low premiums and the simplicity of all-in-one coverage.
But there can be hidden risks to Advantage plans, especially for those with major health issues.
Some people in Medicare Advantage end up paying unexpectedly high costs when they become ill or find their network lacks the providers they need, says Tricia Neuman, senior vice president at Kaiser.
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Types Of Medicare Advantage Plans
There are different types of Medicare Advantage plans to choose from, including:
- Health Maintenance Organization .HMO plans utilize in-network doctors and require referrals for specialists.
- Preferred Provider Organization .PPO plans charge different rates based on in-network or out-of-network services.
- Private Fee-for-Service .PFFS plans are special payment plans that offer provider flexibility.
- Special Needs Plans .SNPs help with long-term medical costs for chronic conditions.
- Medical Savings Account .MSA plans are medical savings accounts paired with high deductible health plans.
Compared to original Medicare, there may be advantages if you choose a Medicare Advantage plan.
Medicare Advantage Plans Coverage For Some Services And Procedures May Require Doctors Referral And Plan Authorizations
Medicare Advantage plans try to prevent the misuse or overuse of health care through various means. This might include prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedures. Medicare Advantage plans may also require your primary care doctorâs referral to see specialists before they will pay for services.
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Medicare Advantage Plans May Cost You Less
If you enroll in a Medicare Advantage plan, you must continue to pay your Medicare Part B premiums and you may pay an additional premium. The insurer determines the Medicare Advantage planâs premium, which can vary from one Medicare Advantage plan to another. Some Medicare Advantage plans may offer enrollees monthly premiums as low as $0.
Your cost sharing may also be less under Medicare Advantage. For, example, if an enrollee visits a primary care physician under Medicare Advantage, they may have a copayment of $10. However, if the enrollee visits a primary care physician under Original Medicare, they may have a coinsurance of 20%, which could be more than $10.
Also, a Medicare Advantage plan limits your maximum out-of-pocket expense. Once you have spent that maximum, you typically pay nothing for covered medical services for the remainder of the year. Original Medicare does not provide a maximum out-of-pocket cap, so potential expenses are limitless.
Often a Medicare Advantage plan can be less expensive than comparable coverage with Original Medicare. To get the most out of a Medicare Advantage plan with Original Medicare, you may also need to enroll in a stand-alone Medicare Part D Prescription Drug Plan as well as a Medicare Supplement Insurance plan.
Mistake #: You Can’t Rely On A One
While 62 is the earliest age you can start collecting Social Security, conventional wisdom says you should delay filing for as long as possible so you get a bigger check. Many advise at least waiting until your full retirement age because that’s when you can start receiving your full retirement amount. The Social Security Administration puts that number between 66 and 67 years old, depending on the year you were born.
However, it’s not always that simple. For some people, it makes sense to retire later and wait to collect the maximum Social Security benefit. But others could lose money by delaying retirement.
The strategy that could help you get the most from Social Security will be totally unique to you. Don’t rely on a one-size-fits-all strategy or traditional rule of thumb.
Are There Different Types Of Medicare Advantage Plans
There are a total of six Medicare Advantage plans to choose from. The four most commonly used are:
The first type of Medicare Advantage plan is a Health Maintenance Organization , you will receive your necessary coverage in-network, with the exceptions of: Emergency care Out-of-area urgent care Out-of-area dialysis. In some HMO cases, you will need a referral for specialist visits.
The next kind of Medicare Advantage plan is Preferred Provider Organization plan, you are medically covered through a private Medicare-approved insurance company. One of the advantages of PPO is that you can save money by seeing the plans in-network providers.
The third Medicare Advantage plan is Private Fee-for-Service Plan. These plans are also offered by private Medicare-approved insurance companies, and the plan determines how much enrollees will pay health care providers and other coverage. This information is provided in âAnnual Notices of Changeâ and âEvidence of Coverageâ documents that are sent to enrollees each year.
The last type of Medicare Advantage plan is the Special Needs Plan which is ideal for enrollees who have specific medical diseases or characteristics. With these plans, Medicare tailors coverage and benefits to meet the specific needs of the groups served.
Option : Original Medicare
- Medicare is primary and Medi-Cal is secondary. In Original Medicare, also known as fee-for-service, it is important to present providers with both Medicare and Medi-Cal cards. With Original Medicare you can choose any medical provider that accepts Medicare and Medi-Cal, no referrals to a specialist is needed.
- In addition to the Medicare and Medi-Cal card, beneficiaries also have a CalOptima Member Identification card and a Part D Prescription Drug Plan card.
- Medi-Medi beneficiaries that do not enroll in a Part D Plan or a Medicare Advantage Plan will automatically be enrolled in a Part D benchmark plan. Medi-Medi beneficiaries are automatically eligible for , the program that helps pay for prescription drug plan co-payments.
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