Simplifying Medicare Health Coverage Options

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Health Insurance Coverage Questions are Answered

The past three columns have been on Medicare and your options as consumers. With all of the health insurance issues today, this writer sees people with more questions concerning their Medicare options than any other issue as of this time. One aspect these people share is confusion over what their health care options are with Medicare and how, EXACTLY, these options work.

As people turn age 65 or go onto Medicare as a result of disability they have options and choices. The first choice is to determine if they wish to stay with Original Medicare (like Medicare that your parents have/had) or choose a Medicare Advantage type of plan.

When someone has Original Medicare they usually need to purchase a Medicare Supplement (gap filler) and a Medicare Prescription Drug Plan. Gap fillers are designed to pay part or all of Medicare’s deductibles and co-insurance; and are standardized from company to company. They range from Plan A – Plan L. In short, most of the gapfillers pay expenses left after Medicare’s coverage. In the case of Plan F or Plan J you will have very little money for medical expenses payable out of pocket. Most gapfillers cover you for covered expenses you incur from any Medicare provider that you choose. Medicare Prescription Plans vary with their coverage and premiums. In simple terms, under these plans you have the most flexibility and usually the least amount of out of pocket costs for medical expenses.

Medicare Advantage (MA) plans are different from Medicare gap filler plans. An insurance company administers a person’s Medicare in the MA plans. So your claims go to that insurance company rather than to Medicare. The insurance company establishes benefits (which must be at least as good as Original Medicare), pay claims, and handle appeals. MA plans may have co-insurance payments (i.e. $150 a day for hospital stays and/or $15 doc office co-pay) and may or may not include prescription coverage. Advantages of MA plans include having one plan handle prescription and medical expense, optioning some other covered value added services (i.e. dental) and probable lower premium costs. Remember, people with MAs usually have coinsurance payments, but lower premium costs may more than make up these expenses.

Different types of MAs may be available. They include: Private Fee for Service (PFFS) plans where the insured person can use any provider that agrees to the terms and conditions for payment of that company. PPOs where you can go to any Medicare provider, but have better benefits in their provider network. And HMOs where you must go to a provider in a provider network. Of these MA plans, PFFS are the most flexible regarding seeing providers, PPOs next, and then HMOS are the most restrictive.

When gathering information for these plans, be sure to speak to qualified professionals that will also be there to help with your questions in the future. They should NOT “be actively selling” or use any sort of pressure, but providing the service of answering your questions. Research your personal situation on www.medicare.gov (Medicare’s official website) and read carefully any information on plans you are considering. Be sure to see the benefits, limitations, and exclusions. This is a very specialized area. If you talk with an insurance agent, be sure he/she specializes in this area. Be sure they have a track record of helping seniors. In addition, know that the plan your neighbor has may not be best plan for you.

While all of this may be confusing, it is important to know that you have options. Perhaps one of these options may work very well for you. In addition, you can change plans yearly. This column just touched on some of the basics of MAs, be sure to gather more information before making any decisions. If you would like to attend a seminar call the office below. As always, if we can provide further information, feel free to call our office.

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Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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