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Subject:  Re: Medicare Question... Date:  6/8/2020  4:20 PM
Author:  BruceCM Number:  22107 of 22193

SD
Strongly suggest you go online and download the booklet "Medicare and You". User friendly and comprehensive in explaining the fundamentals of Medicare and its various parts and choices...and you have LOTs of choices.

Brief overview:

Part A, hospitalization, is provided without a premium but with a $1,408 Deductible (2020) per admission diagnosis (not per year)

Part B, outpatient and Dr. Bills. Premium (for most except very low and very high household income) of $144.60/month, taken automatically from your Social Security or you pay if not receiving SS. A $198 deductible per calendar year and then a 20% copay on Medicare allowable charges

Medicare Supplement (or Medigap) is private insurance with standard coverages for plans A through N, that cover some-to-all of what Medicare allows but does not cover. Premiums run from $20 or so for A plans up through $150 - $250 for the F plan (the most comprehensive), although this will vary by your location and how the premium is determined by age. All these private plans are 'guraranteed issue' meaning they have to take you on initial enrollment, but may deny coverage if you delay enrollment. These rules vary by state.

Part D plans for drug coverage. Like part B, you can elect not to enroll, but later enrollment will carry a penalty. Plans vary from basic coverage for around $20/month up to expensive for plans that cover most or all drug costs. Varies widely by state.

Medicare Advantage (MA) Plans are the alternative to Medicare + Supplement + Part D. VERY IMPORTANT: when you choose an MA plan, Medicare is no longer the insurer...the plan is. You must follow the plan's rules for coverage. MA plans can be divided into 4 types: Group HMO, Point of Service (sometimes called Community) HMO, PPO and Fee For Service.

Group HMO: Kaiser Permanente is the standard here, although there are others. It owns the hospitals, clinics and most oupatient services. Monthly enrollment premium includes Part A, Part B and Part D coverages that are part of the plan and usually much less expensive than standard Medicare + coverages would be. But you must choose a primary care provider (physician) within the plan and almost all referrals must go through them, you must live in the plan's catchment area and cannot elect coverage outside the plan, unless you pay for it. (except emergency coverage which the plan covers)

Point of Service (POS) HMO. This HMO model requires a primary care provider for each enrollee but allows enrollees to go out of the plan to seek specialty care, although the plan may place restrictions on this. Typically, the out of plan deductible is higher than in-service visit deductibles

Preferred Provider Organizations or PPO. This is a group of contracted medical offices, hospitals and outpatient services in a broad network. The primary difference with the PPO is it does not require the enrollee have a primary care provider through which all specialist referrals must be made. There is a potential major problem with this, as any treatment or surgery involving a provider not enrolled in the PPO will bill directly for their services to you as the PPO will not pay for it. So its up to you to make sure all providers who see/treat you are part of the plan.

Private Fee-For-Service. These I understand are declining in number, The attraction is most do not charge a monthly premium and you can go to any Dr. you wish who accepts their payment. The bad news is you don't know how much the insurer will pay and anything they don't, you will pay. My advice: stay away if these are offered in your area.

A great resource is your states Senior Health Insurance Program (SHIP) or Senior (or Statewide) Health Insurance Benefits Advisors program. This is a consumer-driven program offered to you for free, funded by Medicare. I'd say this should be a mandatory visit for all those first comming into Medicare.

BruceM
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