EASY - YEAR 2016
is not medical insurance. It is not a
complete health coverage plan, and
it was never meant to be. Medicare covers a limited portion of an
health care costs - and a portion of other medically-related services.
does basic Medicare cover? Under Parts A and B, if you go into
hospital, you pay the first $1288 for
the first 60 days; this
is your per benefit period deductible
(a new benefit period starts every 60 days). After day 60, if you’re
hospitalized, you are responsible for
the first $322 per day for the next
30 days. If you are still
hospitalized after that, you are
responsible for the first $644 per day
of the next 60 days. If you are hospitalized beyond that,
you are on your own; Medicare pays nothing. This $1288 deductible
recurs every 60 days if you are
hospitalized more than once.
you go into a skilled nursing facility and are considered in "recovery
mode" (too well to remain in the hospital but too ill to return home),
Medicare picks up 100% of an approved amount for the first 20 days.
From day 21
through day 100, you are responsible
for the first $161 per day. Beyond
day 100, Medicare pays nothing - you
are on your own. If you are looking for long
term care (an insurance plan geared toward nursing home, adult day
assisted living facilities, home health care, etc..... ), that is not part of Medicare nor is it covered
by Medicare; you need to talk to your insurance agent about a "long
care plan." Like many forms of insurance, long term care coverage is
as inexpensive as it is the day you apply for it, and rates usually
lock in for
the duration. Underwriting is substantially more liberal than it is for
medical expenses, doctor's fees and outpatient hospital services,
80% of the "approved" amount, after a $166 per calendar year
deductible. You are responsible for the
other 20%. If the doctor you see does not
take Medicare assignment, you may also be responsible for an additional
the Medicare allowed charges – called
above describes Medicare Parts A and B, the basic plan which all
Medicare-qualified applicants receive. Medicare itself is not always
many cases you must apply for it. And to be eligible for Medicare
all, you must have paid into Social Security a specific number of
during your working years. However, if you are 62 and already receiving
Security benefits, you are automatically enrolled in Medicare Parts A
starting with the first day of the month in which you turn 65. Note that enrollment simply means you don't have
to make formal application when you turn 65; Medicare benefits cannot
until the month in which you turn 65. If you are working and are
covered by a
group insurance plan, you can postpone enrolling in Part B; then, your
enrollment for a Medicare supplement will start the month in which you
enroll in Part B. Supplements are not
automatic; they must be applied for.
basic Medicare Parts A and B (not to
be confused with Plan A and B) cover
a portion of actual medical costs you are likely to incur.
picks up that $161 per day of skilled
nursing facility care which Medicare Part A does not
cover (beyond the first 20 days), as well as your $1288 per
benefit period hospital deductible and
$166 per calendar year medical expenses deductible. It will also
limited coverage if you travel outside the United States.
Medicare Plan F
covers the same things as Plan C and also picks up the 20% coinsurance
Medicare Part B's medical expenses.
"high option" Plan F, is as described above but has a $2180
deductible and is lower in price, due to the fact that you take
responsibility for the first $2180 of allowable medical expenses before
Medicare or the supplement kick in (medications do not count toward the
deductible on this or any other Medigap plan). Mathematically,
this option makes good sense, as the amount of premium
you would save on High Option F over regular F is about $800-1500 per
Only a few carriers offer High Option F and fewer people ask for it.
does not cover the doctor deductible but is otherwise identical to Plan
Plans K through M
….. There is a lot of cost-sharing with these plans, which are
described on the
inside cover of the rate book. They do not
pick up the Part B deductible, pick up only 50% of the coinsurance for
and skilled nursing facility, provide no foreign travel or preventative
benefits. The out-of-pocket limit on these plans is $2000-$4000.
is comparable to plan G but you also have a $50 co-pay for Emergency
co-pay for doctors (after the deductible, not
in addition to it) and the potential 15% excess.
can be declined supplemental coverage
based on health history if you wait until after you are 65-1/2 to apply
your supplement (exception: HMOs will always take an applicant, where
offered, so long as the applicant does not have End Stage Renal
of a supplemental plan will depend on whom you choose to provide
Coverage can be purchased through HMO/PPO's in the more populated areas
(primarily Maricopa, Pinal and Pima counties) or some of the regular
insurance carriers. It is easy to get an HMO after you have had a
it is almost impossible to get a Medigap plan if you are coming from an
Advantage plan. The “Annual Enrollment Period” does not apply to people
to go from Advantage Plans to Medigap plans or even from Medigap to
most frequently-asked question we hear is why basic
Medicare doesn't cover prescription drugs (which the new Part
D does as of January 1, 2006 or a small monthly premium) and how come
home isn't covered except in a "recovery mode" and long term care
isn't covered at all? Statistically, less
than 4% of all nursing home or extended care facility charges
Medicare. Most of those costs are paid for by private long term care
term care plans cover not only nursing home but other charges, such as
health care, assisted living and adult day care, and other long term
care-related medical expenses - services that Medicare won't provide.
were diagnosed with Alzheimer's or Parkinson's, or any number of other
ailments, Medicare wouldn't cover any
of the medical costs - because these are not
conditions from which one recovers, they are progressive
will receive basic information related to Medicare months before you
which is when everyone starts being inundated with brochures, etc. The
you have information on Medicare, the better decision you will make
need it. You don’t need to be on Social Security to get Medicare;
you are not, then enrollment in Medicare is not automatic and you need
for Parts A and B of Medicare, and you can go online and do this at
WHAT IS THE DIFFERENCE
ADVANTAGE PLAN (HMO / PPO) AND A MEDIGAP PLAN?
the original true Medicare insurance supplement plans. Plan F, the most
and offered by all carriers who offer Medicare insurance
plans, picks up 100% of whatever Medicare doesn’t pay,
for services that Medicare otherwise approves. If you take Plan G, you
responsible for the Part B deductible ($166 per year) and Part B is
that occurs outside of a hospital, such as diagnostics or doctor
but the plan then still picks up 100% after that, and of everything
G is offered by only a few carriers.
Plan F costs between $135
and $185 per month, depending on
the carrier and zip code; Plan G normally runs about 10-12% less. Any
Medicare will take a Medigap plan, no matter who the carrier is.
are standardized - that means that the Plan F through BCBS is the same
Plan F through AARP which is the same as the Plan F through Mutual of
Equitable; the only difference in plans is price.
However, some carriers pay claims more quickly than others. When you
doctor who takes Medigap plans, he sends the claim to Medicare; the
name of your
carrier doesn’t matter to him - unless it is an Advantage plan, as a
number of doctors
do not take them. With a Medigap plan, you can go to any
doctor, anywhere, anytime, who takes Medicare.
You can move with it, you can travel with it; you don’t need
If you have an
Advantage plan, much of that changes.
Many doctors who take
Medicare do not take Advantage plans. When you have an
Advantage plan, you
are restricted to the doctors in that plan’s network (usually within
county, though some let you go to "any participating doctor" - but
their plan will spell that out). With an HMO, you
usually select a
primary care doctor from their list of participating providers and that
see whenever you need medical attention. If you need to see a
your primary care doctor will then write a referral so you can go see
the list). If you have an Advantage PPO (not as easy
to find) you can
go to any doctor on the list of
participating providers without a referral - just like a major
medical PPO. Again, carriers offering Advantage plans have a
With an Advantage Plan,
you technically disenroll from Medicare Parts A
and B as the Advantage plan becomes your primary plan. So “original”
no longer the deciding factor in how much is paid toward your eligible
nor can you file a claim directly to Medicare since - technically - you
longer have original Medicare. Generally, whatever Medicare approves,
Advantage plan does, also. However, you will still go out of pocket for
portion of the hospital, out-patient, labs, x-rays, doctor
Example: Medicare’s hospital
$1288 per hospitalization and re-sets every
60 days. Medicare picks up 100% after the first $1288 per
your Medigap plan pays that
time, with no out of pocket to you.
With an Advantage plan, you may pay anywhere from $250-500 per
to as much as $250 per day (up to six
days) depending on
the plan. With a Medigap plan, you
pay nothing, at any time.
In some cases, you may be
responsible for the 20% of diagnostic
and other out-patient services that Medicare itself would normally not
pay but that
a Medigap plan would usually
pick up at 100%.
Example: cancer treatment.
approves chemotherapy and picks up 80% of the approved cost. A Medigap
picks up the other 20%. Many Advantage plans cover only the 80% that
would have paid and leave you to pay the balance (an average round of
$3500 and treatment usually consists of four to eight rounds). However,
Medicare approves only about 40-50% of the cost of chemo and the
would relate to the Medicare allowed
amount, not the billed
Advantage plans cover you only in the US and, if
outside your local provider network, only
for life-threatening illness or injuries. A few plans do offer
coverage. Medigap plans
provide emergency foreign travel health
coverage, up to $50,000.
Relocation: if you
move outside your provider service area,
you cannot take an Advantage plan with you. You must apply for a new
wherever you move, and Advantage plans are not plentiful in a majority
of rural counties.
So at that time you would have a new but short enrollment period in
could then apply for a new Advantage plan or even a Medigap plan, as
that might be all that is
your new location. Losing an Advantage plan through no fault of your
own creates a "Guaranteed Issue" enrollment period, whereby you can
apply for a Plan F Medigap
plan with no underwriting. Plan G, in an Guaranteed issue
scenario, requires underwriting with most carriers.
plans are contractual.
If you have an Advantage plan and in July decide you don’t want it, you
cancel it until the annual enrollment period (every October 15 through
7). Exception: if you move outside your coverage area, per above. The
(annual enrollment period) applies to Advantage plans and drug plans, not
to Medigap plans. During the AEP you could cancel and change to a
Advantage plan or try to apply for a Medigap plan; for the latter, you
underwritten and can be declined coverage.
plans are cheaper than Medigap insurance plans -
of course they are: you have more out of pocket expense on an Advantage
that a Medigap plan would cover at 100%. You have a limited number of
and providers to choose from. You still have deductibles and co-pays.
words, you pay less premium because you pay more in medical costs.
Every Advantage plan will
indicate, in its literature, what
its maximum out-of-pocket expenses are. Usually, that maximum is $3200
per year (excluding prescription drugs). On a Medigap plan, that annual
averages $0 to $166 – a little bit
more on Plan N.
often include drug coverage; basically, Part
D is part of most Advantage plans. If you have a Medigap plan there is
coverage but you can get a stand-alone drug pan (if you even need one) for about $20-75 per month. It
works the same way that it does in the Advantage plan.
So, the basic
differences: flexibility, portability,
coverage, benefits and overall out of pocket costs.
HINTS AND HELPS
WHERE CAN I GET THE BEST
PRICES ON PRESCRIPTION DRUGS?
First of all, whether you
are 25, 45 or over 65,
prescription costs can be a bear. Some carriers won't cover certain
drugs haven't been in wide spread use long enough to be approved by
carriers, some are excluded due to sheer cost….. but there is
There are many avenues to
saving money if you don't have a
health plan that covers your particular medication needs - or if you
a plan at all.
First….. doctor's samples.
Almost every prescription that a
doctor can write has been given to him in sample form, by
If nothing else, a doctor should be able to give you a two week to two
supply of samples. Some doctors have kept patients going indefinitely
Second….. ask if the
prescription comes in a generic form. It is
surprising how many doctors just write out the prescription for the
even when there is a generic.
Third….. if you take a
medication that is in a breakable tablet
form, ask your doctor to write it for double your usual strength with
instructions to break it in half. The price difference between 20 and
a drug is often less than 20%. Sometimes, there is no difference.
Fourth….. shop around! Many of
the stores have those wonderful $4
generics. For the most part, the least expensive retail store I have
brand name is Costco. Go to www.costco.com
and check out any of your prescriptions - you may be surprised by some
Fifth….. I have never
horror story about prescriptions
filled in Mexico
those factories are simply independently contracted and Canada's are owned and operated by many
manufacturer's themselves, I would tend
to trust Canada
Sixth….. Canadian mail order.
For some reason, some folks think
this isn't around anymore. The only ones complaining about Canadian
are all the "middle men" involved in the distribution of prescription
drugs who won't get their "cut" if you buy your prescription outside
By the time a medication leaves the factory and gets to your drug
goes through about six distribution
points, each with their own fee tacked on. Try www.candrugstore.com.
This is a very easy-to-use website, they are on the west coast of
Canada and open on Saturdays. Or call them at 866-444-6376 to place
your order (you do need a copy of your prescription, which they will
verify with the physician). This group does not,
never has and never will
order from China
due to quality control issues.
brand name drugs is only good in the US.
Many of the
same companies who manufacture prescription drugs in the US make them
in Canada and other countries, also - in their own
facilities and in ageneric form. This is true - and the cost, ordering
through Canada, is anywhere from 35% to 75% less the cost of the brand
name equivalent. Even brand
names, pruchased through
Canada, can be a good
15-35% lower than in the US - and again, these are the brand nane.
Seventh….. if you are low income
or simply have some really costly
meds, you can contact the manufacturer directly and ask if they
any prescription assistance programs. Many do and none advertise this.
takes is for you and your doctor to fill out a form and send it in.
costing in the $75 to $300 range are dispensed at little or no charge
Medicare itself can assist those with a low income to get a Part D plan
with no premium; consult your Medicare & You booklet or go wo
www.medicare.gov for more information.
Bear in mind, too, that
many brand name and some generics,
are manufactured in China,
regardless of where you are buying them. There have been some recalls of prescription drugs
manufactured in China
that contain heparin. The Internet is a valuable tool is keeping up
type of information.
The above tips are for
everyone - not just the over-65, the
unemployed, the disabled…. everyone.