7 Steps to Make Medicare Work Better for You
Medicare is a federal health insurance program that pays for a number of covered health services.
First things first…What is Medicare?
Medicare is a federal health insurance program that pays for a number of covered health services. Generally, you’re eligible for Medicare if you or your spouse worked for at least 10 years and contributed to the associated taxes to fund Medicare benefits, are 65 years or older, and a citizen or permanent resident of the United States.
Those younger than 65 may also qualify for coverage if they have a disability or have End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or transplant.
Step 1: Know Your ABCs…and Ds
To be in the know, you have to get in the know. Choosing the right plan is not only important, it’s personal. To sort things out, it is best to know all of your options. So, what are the differences between Medicare Parts A, B, C, and D? Medicare has many options but there are four key parts.
Here is a summary:
- Part A is for Attention, I need a HOSPITAL. It covers inpatient hospital or facility stays.
- Part B is for feeling Blah, I need MEDICAL care. It covers certain doctor and preventive services and outpatient care.
- Part C is for COMPREHENSIVE
A + B + D = C aka: Medicare Advantage. This is a comprehensive plan offered by a private insurance company like SelectHealth. Part C provides hospital and medical, and some plans also include prescription drug coverage. Plus, these plans often offer supplemental coverage of other services, such as vision and dental.
- Part D is for DRUGS. It provides prescription drug coverage only.
Step 2: Be in Good Company
Choosing the right plan is hard, but wading through the hundreds of insurance companies can be downright exhausting. For starters, there are several categories to consider:
- NOT-FOR-PROFIT VS. FOR-PROFIT
Who is the priority—you or shareholders? For-profit companies must return profits to investors while not-for-profits often reinvest their profits back into the plan to benefit members.
- LOCAL VS. NATIONAL
Local insurance companies know your facilities, doctors, and resources, and they work with them to provide the highest quality services at the most affordable prices. Local companies often employ local representatives to make sure you get the service you need. They can also offer local discounts, classes, and programs throughout the community. National companies do not have that local know-how, but they may have broader coverage with a national footprint.
- SIZE AND FINANCIAL STABILITY
Larger companies, while big and robust, often lack what makes an insurance company great—customer service and coverage levels that match the community it serves. While smaller, well-established local companies have that local touch and, if big enough, can be just as stable as the larger companies.
- UM, HELLO? IS ANYONE THERE?
Customer service is a big deal! Can you talk to a local person on the phone? Do you have to wait on hold and jump through a thousand hoops just to be told a generic answer? When you need answers, you need a real person to make things happen for YOU.
- WHERE EVERYBODY KNOWS YOUR NAME
Well, maybe not everybody knows your name, but this goes back to the advantage of going local. When comparing companies, make sure to check the plan network. Are your current providers and facilities in the network? If not, are there better local providers to serve your healthcare needs?
- THE STARS ALIGNED FOR YOU
Star Quality Ratings can tell you a lot about a company’s customer service, member satisfaction, benefits, and overall quality. Pay attention to those stars! Based on real members’ answers to surveys and questionnaires, companies receive updated ratings annually. These rankings make it easy to weed out less than the best.
Step 3: It’s a Match!
…or not. Things change, people change, plans change, life changes. What may have been a great plan may not suit your needs anymore. Remember to review your plan and coverage every year.
Just as when you are shopping for your first plan, you should keep your eyes out for:
PROVIDER AND FACILITY NETWORKS: IN-NETWORK VERSUS OUT-OF-NETWORK
In-network or participating providers and facilities participate on your plan’s network. These providers must write off (in other words, can’t bill you for) charges—for covered services—that exceed the allowed amount (these are called excess charges).
If a provider is nonparticipating, he or she does not participate on your plan’s network and therefore does not accept our allowed amount as payment in full. Services may not be covered or payment to a nonparticipating provider may be reduced, depending on your plan.
This is the monthly bill you pay for insurance coverage (to be a member of an insurance plan).
This is an amount you must pay to doctors and facilities before your plan begins to pay for eligible charges. (But remember, you’re still only paying the allowed amount for covered services from participating providers!) Some categories of benefits may have a separate deductible.
This is the total amount you may pay for services covered by your plan each year. Amounts you pay toward your deductible, coinsurance, and copays apply to your out-of-pocket maximum. Some plans have separate medical and pharmacy deductibles, and some services may not apply to or may exceed the OOP maximum.
Note: Remember—the premium you pay for your plan does not apply to your out-of-pocket maximum or other amounts you must pay for covered services (see Premium).
This is a fixed amount you must pay the doctor for services. Most plans have lower copays for primary care providers and higher copays for secondary care providers.
What if you need to see a specialist? With many plans, a referral from your primary care provider is required before you can seek any specialized care or you may be responsible for footing the bill. That is a cost you will want to avoid.
Step 4: What’s Your Medication Situation?
Okay, so you know which facilities and doctors are in-network. But what about prescription drug coverage?
Many of us take one or more medications on a regular basis. It is important to review the annual drug formulary to ensure there haven’t been any coverage changes. When reviewing your drug formulary, make sure to check:
- Drug brand names and generics
- Quantity limits (how much you can get in a specific time period)
- Prior authorization requirements (additional hoops to jump through)
- Limited pharmacy access (some drugs are only available at specific pharmacies)
- Prescription tiers and the associated cost
So, whether you have Medicare Advantage or Part D, learn about what your medication situation will look like.
Step 5: Out-of-Sight Prices
Out-of-pocket limits are often overlooked when estimating annual healthcare costs. Depending on the plan you choose, you could end up with a “sky’s the limit” out-of-pocket cost! Original Medicare typically pays 80 percent and you pay 20 percent, right? But there is NO out-of-pocket limit. With Medicare Advantage, your out-of-pocket costs are limited a to specific amount each year. Don’t forget to check your plan for those out-of-pocket costs every year when it comes time for renewal.
What about coinsurance? Some plans offer a fixed copay rate in which you pay very little, whereas other plans may charge you a coinsurance. Keep an eye out for those costs, too.
Step 6: Bonus Points for Perks
What options, tools, and services are included on your plan? Find out about gym memberships, wellness discounts, vision and dental, and other extras. Some of these perks do cost more. Consider things like glasses, eye exams, dental cleanings, and other dental services. Many plans will cover the basics for vision and dental, but if you need special bifocals or a dental procedure, you may end up paying through the teeth.
Other perks may be gym memberships or discounts. Take a look to see how they fit your budget, lifestyle, and needs.
Step 7: Don’t Miss the Boat!
Like birthdays, enrollment only comes around once a year. You do not want to miss enrollment; otherwise, you will end up waiting another year for coverage. So, as they say, carpe diem! There is no time than the present to review your plan and make changes if needed. After you have compared plans and prices, it’s a good idea to call the insurance company representative or talk with a licensed insurance agent. Make sure you do all of this with ample time because you won’t want to miss out on your enrollment period.
Take a look at these important dates:
FIRST-TIME MEDICARE ENROLLMENT
Turning 65? You have a seven-month window around your birthday month.
That is: Three months before your birthday month, three months after your birthday month, and of course, your birthday month. (P.S. Happy Birthday!)
ANNUAL ENROLLMENT PERIOD
Mark your calendars. Every year from October 15 to December 7 you are allowed to make changes and switch plans. This is a great opportunity to review your coverage to make sure it still works for you.
MEDICARE ADVANTAGE DISENROLLMENT PERIOD
Is Medicare Advantage just a tad too much? January 1 to February 14 you may cancel your Medicare Advantage plan to return to your Original Medicare plan. You may also add Part D during this period for prescription drug coverage (if it isn’t included on your Advantage plan).
SPECIAL ENROLLMENT PERIODS
Special is the key word here. These periods are reserved for specific situations. Here is a sample list of those Special Enrollment Periods:
- Have Medicare and Medicaid
- Move out of your geographical service area
- Qualify for low-income prescription drug assistance
- Move to a Medicare-certified nursing facility or other institutional facility
- Lost other creditable employer or retiree insurance coverage benefits
* If you have Medicare due to a disability but are not yet 65 years old, you may also have a special enrollment period when you turn 65.
Ready, Set, Go. What’s next?
You’ve done your homework and you’re ready! If you’ve decided to enroll in a SelectHealth Medicare Advantage plan, let’s get to know each other! We would like to chat with you to make sure you understand everything about your soon-to-be plan, network, benefits, and contacts. Call us today to get started.
For more information about Medicare Plans or SelectHealth Advantage (HMO), call us toll-free (855) 442-9940. TTY users please call 711.
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The content presented here is for your information only. It is not a substitute for professional medical advice, and it should not be used to diagnose or treat a health problem or disease. Please consult your healthcare provider if you have any questions or concerns.
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