Flashcards in Medicare and Medicare Advantage Deck (7)
Part A is hospital only coverage.
There will be a co-pay and a deductible.
Covers stays at hospitals or short term nursing care.
Covers doctor services
Durable medical equipment (DME)
Inpatient and Outpatient and prevention care
Limited outpatient prescription drugs
Some medical supplies
Premiums increase 10% every 12 months you are overdue in enrollment
Helps pay for prescription drugs
Average monthly premium is $30.83 for 2019
Note: once you are in Medicare, make a note of the enrollment period October 15 through December 7th. That is when you may switch coverage for the coming year.
There s a deductible for hospital in Medicare of $1,364. With Medicare advantage most if not all should be covered, because the advantage option takes the place of Medigap supplemental insurance.
Choose doctors carefully!
These are the main categories of doctors:
A. PARTICIPATING. These providers accept what is on original Medicare’s fee schedule as their full payment.
(You or your supplemental insurer will still be responsible for the deductible and coinsurance amount.)
B. NONPARTICIPATING. Doctors in this category take Medicare’s approved payment, but are allowed to charge you up to 15% more.
C. OPTING OUT. These providers can charge patients whatever they want.
AVOID SURPRISE BILLS
To prevent this check in advance if your doctor accepts Medicare and if Medicare covers the treatment or procedure you are having, particularly if it is an elective or optional surgery.
Note: There is a list of covered services at Medicare.gov.
Dealing with unexpected bills.
Do not pay the bill right away. Check with your provider to see if it sent the bill to the insurance company and if it was coded with the correct billing code.
Call your medigap supplementary insurance to see why it was not paid.
If Medicare or supplement insurer has rejected a claim, file an appeal.
If all else fails, negotiate for a lower amount.
Note: Go to aarp.org/Medicare for comprehensive advice, news and explanations.
Know your rights.
Call the medicare RIGHTS CENTER, 800.333.4114.
Ask your doctor to put in writing why you need or needed the services, medication or equipment.
You can appeal a discharge from a hospital or skilled nursing facility; often, you may be able to stay in the hospital at no additional charge.
If you or your doctor are worried your health could be seriously harmed by waiting for an appeals decision, you can ask for a quick answer within 72 hours.
Take what is offered
Medicare masters do not leave free care on the table.
WELLNESS VISITS— mini checkup
EYEGLASSES— corrective lenses for cataract surgery
NUTRITION COUNSELING— if you have diabetes or kidney diseases
KEEP GOOD RECORDS
Any conditions you have and when diagnosed
Hospital stays, dates and procedures
Your prescription drug list, including doses
Any medical equipment you are using
Contact info for your preferred pharmacy
Insurance info for all policies including supplements
Emergency contact and whether you have durable power of attorney or healthcare directive.
All health care providers, including specialists, eye doctors and dentist, with phone numbers.
Be open to change.
You can switch plans during enrollment periods. Info on choices at shipacenter.org and click on SHIP located to find neutral help from expert.
If you have part D, drugs and prices change.
Medicare Advantage plan
This is a bundled plan that covers all the bases. It covers more things like vision, hearing, dental and even sometimes wellness activities like gymnasium memberships.
It cost more up front but takes the place of medigap supplemental insurance.
Also you don’t need any Medicare supplemental insurance because this takes the place of Medigap.
To find out if something is covered you can ask for a decision upfront and sometimes it’s an absolute requirement. This is called “organization determination.”
This type of insurance is an HMO so you must stay within the network of hospitals and doctors. It also has a nice system of limits once you reach the limit, you pay nothing more for part A and part B covered services.
Before choosing this option make sure that you live in the covered area with your doctors and hospitals.
To learn more about the cost in specific Medicare advantage plans, visit Medicare.gov/plan – compare.
Rules for Medicare advantage plans.
Medicare pays a fixed amount for your care each month to companies offering Medicare advantage plans. These companies must follow rules set by Medicare. Each Medicare advantage plan can charge different out-of-pocket cost. They can also have different rules for how you get services like:
1. Whether you need a referral to see a specialist.
2. If you have to go to the doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care.
These rules may change every year.
The cost for Medicare advantage plans.
Your out of pocket cost in a Medicare advantage plan depend on whether the plan charges a monthly premium some plans have no premium.
Whether the plan pays any of your monthly Medicare part B insurance premium. Some plans pay all or pay part of your part B premium.
Whether the plan has a yearly deductible or any additional deductibles.
How much you pay for each visit or service co-pay or coinsurance. For example, the plan may charge a co-pay like 10 or $20 every time you see a doctor. These amounts can be different then those under original Medicare.
The type of health care services you need and how often you get them.
Whether you go to a doctor or supplier who excepts assignments. If you’re in a PPO, PFFS, or MSA plan.
You go out of network.
Whether you follow the plans rules, like using network providers.
Whether you need extra benefits and if the plan charges for it.
The plan’s yearly limit on your Out of pocket cost for all medical services.
Whether you have Medicaid or get help from your state.
Note: Each year, plans set the amount they charge for premiums, Deductibles and services. The plan, rather than Medicare, decides how much you pay for the covered services you get. What do you pay the plan may change only once a year on January 1.