Greater Harrisburg's Community Magazine

When You’re 64: The ABC(D)s of Medicare coverage.

If you or a family member is turning 64 this year, there’s actually some homework to do for Medicare, which is available when you turn 65*.

Not sure where to start? No problem. Let’s start with the basics. Original Medicare is only provided by the federal government and consists of two parts:

• Part A—Covers in-patient hospital care, skilled nursing care, home health care and hospice care. This is typically available at no cost.
• Part B—Covers doctor’s visits, blood tests, ambulatory and emergency services, medical supplies, some drugs, X-rays and outpatient care. Part B typically has a monthly premium.
• Both Parts A and B also have annual deductibles that must be met before they pay on any services, which will be paid at 80 percent of the allowed amount.

Other parts are called Part C (Medicare Advantage), Part D (prescription drug coverage), and Medigap, which is also called Medicare Supplement:

• Part C / Medicare Advantage—These plans must cover everything that Parts A and B cover. However, they may include extra services such as prescription drug coverage, vision, dental and gym memberships. These plans are offered privately through health insurance companies and can be purchased directly from the company or with the assistance of a broker. Medicare Advantage plans typically have a low or possibly no premium. These plans often come in multiple options, the most popular of which are:

• Health Maintenance Organization (HMO). You must select a primary care physician (PCP) within network and, depending on the plan, may be required to obtain all your referrals through them. Because you use one PCP to fulfill all your needs, this type of plan could come at a reduced price.
• Preferred Provider Organization (PPO). You do not need referrals with a PPO. You also do not need to stay in the network. However, it may cost more to get care from out-of-network providers except for emergency and urgent care.

• Part D/ prescription drug coverage—Part D is simply a program that offers insurance for your prescription medication needs. Part D benefits, and the premium, could be included in a Part C plan, but not always. Depending on the type of plan, you may have an annual deductible to meet before coverage begins, and then you may have copayments or coinsurance amounts due each time you have a prescription filled at an in-network pharmacy. Prescription coverage is offered separately for those who have Parts A and B, but it’s typically included with Part C.

• Medigap, or Medicare Supplement—This is extra coverage to take care of services that Original Medicare does not cover—i.e., the remaining 20 percent. You cannot have a Medicare Supplement policy if you have Medicare Advantage.

Okay, you know the different parts and the different options, now how do you choose? Start by knowing what is included. Original Medicare (Parts A and B) covers a lot, but not everything. Things like dental care, routine eye exams and eyeglasses, and routine hearing tests are not included in Parts A and B, but are available through a Medicare Advantage plan. Other things that could be included are over-the-counter allowances, transportation services, healthy meal deliveries, companionship programs, discounted gym memberships, weight management programs, chiropractic services or acupuncture.

Overwhelmed yet? Don’t be. Here is a suggestion to help you cut through the noise and make an informed decision.

Make a chart. In the first column, write down the things that you want from your policy and the questions you want answered. Things like:

• What type of policy do I want?
• Is my doctor in the network?
• How large is the network?
• What is my budget?
• What other benefits do I want/need? Be specific and list everything—like hearing aids, certain dental services, and eyeglasses to name a few.
• Are my prescription drugs covered?

Next, make a column for each plan you are considering, and answer the questions from the first column. Doing this gives you a broad view as to what each plan offers and the cost. A word of caution: carefully consider the bottom line. A plan that has a zero or low monthly premium and higher out-of-pocket costs (like office visit copays and deductibles) may end up costing you more over time than a plan that has a slightly higher monthly premium but lower out-of-pocket costs.

Be sure to enroll in Medicare Parts A and B three months before your 65th birthday. This will ensure your benefits begin on your birthday. You can sign up through the Social Security Administration at ssa.gov.

Still have questions? You can always speak directly to an insurance company or broker, and you can find answers at your local Area Agency on Aging or at Medicare.gov.

 

For more information, visit www.capbluecross.com.

* Medicare is also available to people under the age of 65 with certain qualifying situations and health conditions; however, this article is strictly for those age 65 and older.

Continue Reading