As a caregiver advocate for your parent, there are a myriad of things you’ll need to figure out in order to navigate your caregiving journey with the least amount of mistakes possible. So, if you’re not yet enrolled in Medicare or you’re not familiar with the benefits and options within the program, this article will give you a better understanding of them. We’ll also explore the pros and cons of choosing one program over the other.
I’m not personally enrolled in Medicare, but can share my perspective as my mother’s caregiver. As a caregiver advocate, I’ve done my best to gather information and synthesize it into a helpful reference for others. I encourage you to review your parent’s personal needs and thoroughly research the resources provided in this article to make the best decision for your loved one’s situation.
You’re eligible for Original Medicare Parts A and B if you’re at least 65 years old or if you’re under 65 and qualify for Social Security disability benefits, end state renal disease or ALS. If you or your spouse have worked for at least ten years (40 quarters) and paid Medicare taxes, you will be eligible for premium-free Part A benefits. Otherwise, you may be able to purchase Part A benefits. Everyone must pay a monthly premium for Medicare Part B. However, if you have limited income, you may qualify for assistance with paying for Medicare premiums.
What is Original Medicare?
Original Medicare is a government program designed to provide continued health coverage, similar to what your parents received in health care benefits while they were working. Original Medicare provides a pay-per-service model that reimburses health care costs, generally at 80%. When a senior enrolls into Original Medicare, they receive both Part A and Part B (which will be further explained).
To receive Social Security benefits, you’ll need to sign up in-person or via phone at your Social Security Office or online at https://www.ssa.gov/benefits/medicare/.
If at age 65, your parent will receive Social Security benefits, they’ll be automatically enrolled into Medicare and will receive a card in the mail.
Medicare Part A
Medicare.gov breaks Medicare into different parts offering support for specific areas of coverage.
In general, Part A covers
· Inpatient care in a hospital
· Skilled nursing facility care
· Nursing home care (not long term)
· Hospice care
· Home health care
Your parent’s physician or health care provider will explain your parent’s specific needs and you can contact Medicare at 1-800-633-4227 with questions regarding coverage. You can also reach out to your supplemental insurance company for prior authorization. You can work directly with Medicare to cover part of the cost and your supplemental insurance may cover the difference. If not, the balance must be paid out of pocket.
Medicare Part B Service Coverage
There are two different types of services, medically necessary and preventative services.
Medically necessary services or supplies are needed to diagnose or treat your medical condition and meet accepted standards of medical practice.
Examples of preventative services are health care that prevents illness (like the flu) or detects it at an early stage when treatment is mostly likely to work best. Generally, you pay nothing for these services.
Other examples of what might be covered includes:
➢ Routine services from doctors and other health care providers
➢ Outpatient care
➢ Home health care
➢ Durable medical equipment, like hospital beds, wheelchairs, walkers, and other equipment
➢ Many preventative service visits such as vaccines, screenings, and annual wellness visits
Original Medicare allows for a patient to choose a doctor or hospital of their choice that accepts Medicare.
Additional Coverage Options
After you enroll in Original Medicare, there are two options for additional coverage. You can choose to keep your Original Medicare coverage and enroll in a Medicare Supplement Insurance Plan.
Medigap Plans/Medicare Supplement Plan
Medigap is a supplemental coverage provided by private insurance companies that pays the gaps that exist after Original Medicare payouts. This insurance helps pay some of the out-of-pocket costs that come with Original Medicare like copays and deductibles. You can shop for and buy Medicare Supplement insurance. Generally, the best time to sign up for Medigap is when you turn 65 and enroll into Original Medicare or when you lose employer coverage. You pay the private insurance company a monthly premium in addition to the monthly Part B premium. It is important to compare Medigap policies since the prices vary between policies. Programs under Medigap are standardized by services provided. The premium prices will vary, based on the recipient’s provider and geographical location.
There’s a monthly premium for Part B and once it’s paid, Medigap coverage can be used to pay for all out-of-pocket expenses. Eligibility requires the patient to have turned 65 and enrolled in the program after January 1, 2020.
Medicare Part D
If you have Original Medicare or a Medical Supplement insurance plan, you must elect a Medicare Part D plan for prescription drug coverage. This drug coverage is provided by private insurance companies that follow the Medicare guidelines.
Each September, Part D prescription plans will send out a list of changes to drug coverage. This allows Medicare members to shop plans, request to be switched to a new prescription, or ask their physician to write a letter requesting medical coverage.
Medicare beneficiaries may qualify for Extra Help with prescription costs. The Extra Help program is a federal subsidy program that helps low-income Medicare-eligibility consumers save money on prescription costs and other Part D related costs. Information regarding this program is available on the Social Security Administration website. Your parent may also receive savings on prescription costs by accessing the website Good.RX, which provides you with free coupons that can result in a savings of up to 80% on prescription drugs.
Although you are not required to enroll in Part D, there is a penalty of 1% of the average monthly premium for each month you delay enrollment.
Medicare Part C (Also known as Medicare Advantage)
As medical care evolved, single provider and health care network providers (like an HMO or PPO) were permitted to offer more comprehensive medical offerings including wellness programs, hearing, vision, and more. This additional offering to the basic bundle of A and B led to a new Medicare program, Medicare Advantage, provided by private health care companies and in cooperation with Medicare. Medicare Advantage is a system signed into law in 1997 that allows private health care providers to offer an alternative to the original Medicare program. Medicare Advantage is paid a lump sum from the government for all the care provided to the recipient.
Part C is a separate health coverage option run by private insurance companies that are under contract with Medicare. This includes Part A, Part B, and usually other coverage like prescription drugs. Medicare Advantage Plans may offer extra coverage such as vision, hearing, dental, transportation, and/or health and wellness programs. In addition to a Part B Premium, there is usually one monthly premium for the services provided. Out-of-pocket costs may be higher, but the care options are comprehensive with broader coverage. Another benefit of Medicare Advantage is that the co-pays are often lower than the Original Medicare program.
You will have to use in-network providers. If choosing an out-of-network doctor is important you may choose a Medicare Advantage PPO plan which will allow you to see doctors outside the network for a higher cost. A downside of moving back to Original Medicare after having been in Medicare Advantage for longer than a year is that you may be charged a higher premium for Medicare supplement coverage or be denied gap coverage altogether.
Medicare Advantage/Prescription Drug Annual Enrollment Period
During annual enrollment period, between October 15 - December 7, adults 65 years or older should review their medical insurance through Medicare and choose the best option which fits their needs. If your loved one will be turning 65, you can enroll them three months prior to their 65th birthday to start receiving benefits. Additionally, if your parent has a disability, end-stage renal disease, or ALS (Lou Gehrig’s disease), they will be eligible for Medicare under special enrollment.
During the enrollment period, it’s important to reassess your care recipient’s needs and review the available options that meet their needs. While the enrollment process can often be overwhelming and confusing, taking time to review the plans extensively can mean annual cost savings and the opportunity to find the plan that best fits your loved one’s changing needs. A trusted agent or broker will be able to assist you in choosing the right plan for you. If you need assistance and are an Ohio resident, please contact Licensed Sales Representative, Gail Ellington at https://www.myuhcagent.com/gail.ellington
Resources for this Article:
Medicare Advantage Plans at 25 – More enrollees are choosing them, attracted by their extra benefits. But experts say the plans can deliver better on their promises. By Dena Bunis AARP Bulletin/October 2021 -
As the COVID-19 pandemic lingers, it’s important to review your coverage and make changes by Dec. 7 by Dena Bunis, AARP, October 12, 2021
Medicare Face-off: ORIGINAL vs. ADVANTAGE HOW DO THE TWO MAIN FORMS OF MEDICARE COVERAGE COMPARE ON COMMON HEALTH CARE NEEDS? HERE ARE SOME KEY DIFFERENCES BETWEEN ORIGINAL MEDICARE (OM) AND MEDICARE ADVANTAGE (MA) PLANS FOR SITUATION YOU MAY ENCOUNTER SOMEDAY. By Sari Harrar
Additional resources to help determine which plan is best for your senior:
Centers for Medicare and Medicaid services plan finder website.
AARP Medicare for Dummies