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So you are confused about Medicare Insurance – Here are some facts.

So you are confused about Medicare Insurance - Here are some facts.
By Mark Fine
Your Senior Insurance

Medicare is a health Insurance program that provides benefits for people 65 and older as well as certain people affected by disabilities.  It consists of the following choices:

Part A: In order to qualify for Part A, a person must have worked 40 quarters (or 10 years).  Part A helps cover hospital in-patient care, skilled nursing care, home health care and Hospice.  A deductible of $1,216.00 for days 1-60 in hospital was in place for 2014.  Cost sharing costs (days 61-90) is $304.00 per day. Part A covers the first 20 days in a Skilled Nursing Facility (SNF).  For days 21 – 100 there is cost sharing by the individual of $152.00 per day.  There is also cost sharing for certain home health and hospice care.

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Part B: Part B is a Voluntary benefit costing $104.90 per month.  This premium is subsidized by 75%, however the subsidy is phased out for those people with higher incomes.  Part B deductible is $147.00 per year with cost sharing of 20% for most services, exception being 40% co-insurance for outpatient mental health.  Part B can be deferred due to active employment of self or spouse (no penalty and no wait to enroll using special enrollment).  There is a 10% penalty charged per year that you do not have Part B and should have had it. Part B covers Doctor’s services, outpatient medical/surgical services & supplies, tests and outpatient therapy, preventive health and mental health services.  

Medigap plans: Medigap plans (most commonly referred to as Medicare Supplement or Alphabet plans A-N) cover some costs which are not covered under Original Medicare Parts A & B.  These plans are sold by private insurance companies, fill in the gaps in Original Medicare and are regulated by the Federal & State governments. Most importantly, they limit your out of pocket costs and as long as you pay your monthly premiums your benefits can never be change.  People choose Medigap plans because they lower their out of pocket costs and provide additional coverage!  Moreover, you have the opportunity to select your choice of Doctors and Hospitals. When traveling, out of network fees will not apply.  There are 12 Medigap policies available, and it is important to evaluate the risks with each plan that is offered – especially concerning excess charges.

Part C: Consists of Medicare Advan-tage plans.  These plans provide a combination of hospital, doctor, and various outpatient treatments as well as drug costs and other ancillary services. These plans have all been approved by the Federal Government. An individual must have BOTH Part A & Part B to qualify.  It is important to remember that the benefits in a Medicare Advantage plan can change from year to year.

Part D: This is known as PDP (Prescription Drug Plans).  It is required that all individuals 65 and over have a drug plan – whether separate or in conjunction with a Medicare Advantage plan (where it is included). The decision regarding the PDP plan is made during initial enrollment (age 65) or during the AEP (Annual Enrollment Period) which is Oct 15 – Dec 7 each year. Special enrollment periods (SEP) may apply for people who move out of an area, who are dual eligible, confined to a LTC facility or have a chronic condition.  The standard deductible for 2014 is $310.00.  The coverage gap (or donut hole) for 2014 is between $2,850.00 and $4,550.00 – all of the costs within this area is the responsibility of the individual.  When you exit the donut hole after $4,550.00 you enter catastrophic coverage.  Each company has their own prescription drug plan.  Gwinnett County alone has over 40 different plans. These formularies must meet certain requirements as set forth by the Federal Government.  If an individual cannot afford to pay for certain drugs, they can request extra help.  This would be a subsidy from the SSA (Social Security Area) or the State.  This subsidy could entail the waiver of the premium, coverage for various deductibles and reduced cost sharing.  An individual must contact both the Federal and State agencies to determine eligibility.  

In evaluating your Medicare options, it is important to consider risk management.  What is the maximum out of pocket cost (OPP) that one can incur?  Also, is having a choice of Doctor or Hospital important?  Do you travel and need the peace of mind knowing you will not have to pay out of Network fees?  This is why it is so very important that you contact your agent before the initial enrollment period (IEP) when turning 65 as well as during the annual enrollment period (Oct 15 – Dec 7) each year.  Let them do the hard work and show you all your available options to ensure you get the plan that best fits your needs!

For help from a Senior who actually uses these plans, Contact Mark Fine at (770) 831-8851 or email him at: