5 Medicare secrets you should know
Filed under: Retirement, Healthcare
Medicare may help some 45 million seniorsNavigating Medicare can be a nightmare for anyone, let alone seniors whose survival depends on the coverage they receive from this critical program.
Here are 5 secrets that will help you squeeze the most out of your Medicare coverage and avoid some all-too-common pitfalls.
Coverage restrictions could bankrupt you
If you suffer a stroke, it's likely that you'll need prolonged care at a skilled nursing facility. By "prolonged", I mean a year or longer. That type of care can cost as much as $10,000 a month, according to Medicare consultant Jim Plonsey, President of Medicare Training and Consulting.
Think Medicare is going to cover that astronomical bill? Think again.
In order to get any reimbursement, you need to meet all of the following conditions:
- You have Medicare Part A, with unused days remaining in your hospital benefit period;
- You were in a hospital for at least 3 consecutive days and entered the nursing facility shortly thereafter;
- You need skilled nursing care for the condition for which you entered the hospital;
- Your doctor has ordered the skilled nursing care;
- The skilled nursing facility is Medicare certified.
Incur those costs on your own and your retirement nest egg could be wiped out. To help protect your assets, consider consulting with an attorney who specializes in elder law. A good place to start is the web site
"Advantage" plans aren't as advantageous as they may seem
The pitch is enticing: Buy a "Medicare Advantage" policy (known also as Medicare Part C) and you'll get all of the benefits of Medicare Parts A and B (hospital and medical coverage), as well as prescription drug coverage that is better than what you get from Medicare Part D.
Lower costs and better coverage all packaged into one policy? The choice should be a no-brainer, right?
Almost twenty percent of Medicare participants think so and have purchased these plans, which are offered by private insurers including Wellcare and Humana.
Advantage plans clearly offer some benefits: They cost less than if you have to enroll in Medicare and buy private insurance to fill the gaps in coverage ("known as "Medigap" plans) and you can get extra benefits like hearing and vision screening and even dental care.
But these policies can also be a trap for the unwary. Most Advantage plans require you to use designated doctors and hospitals or to pay an additional fee if you obtain care from providers outside their network. For those living in rural areas this can prove to be a costly restriction. "Many hospitals and doctors in rural areas are not in the network," says Medicare consultant Jim Plonsey.
Even if you are happy with the plan, the insurer may not be. Without justification, they can boost your premiums, change your benefits or drop your policy altogether. Even worse, if your plan is discontinued (either by you or the insurer) you may not qualify for Medigap insurance due to pre-existing conditions.
Look before you leap into an Advantage plan. The Medicare web page
Climbing out of the "doughnut hole" will cost you
Medicare Part D is supposed to help seniors deal with the high cost of prescription drugs. And, at first, it does a great job of that. After a $295 deductible, it covers 75% of drug costs. But then something strange happens. After your drug costs hit $2,700, all of a sudden you are 100% responsible for the next $3,453. Once you accrue more than that amount, Medicare coverage kicks in again.
This gap in coverage is known as the "doughnut hole."
Medicare offers suggestions
- Use generic drugs
- Check out national and community-based charity programs
- See if the drug company has an assistance program
- See if your state has an assistance program
- Contact Social Security to see if you qualify for extra help.
Health care reform legislation pending in Congress would lessen the burden. It provides that seniors in the doughnut hole would pay only 50% of the cost of their brand name medications, instead of the 100% they now incur.
Medicare covers a kidney transplant, but not all of the drugs needed for recovery
Generally, Medicare recipients must be 65 years of age or older. But there are a couple of exceptions.
Younger people who have permanent kidney failure, requiring dialysis or a kidney transplant, may also qualify for Medicare coverage. The bad news is, for those under 65, Medicare coverage for the critical immunosuppressive drugs they require are only covered for 36 months after the transplant. (If you are a 65 or older Medicare recipient, there is no time limit on coverage for immunosuppressive drugs.)
According to the National Kidney Foundation
What happens if your Medicare coverage runs out and you can't afford the continuing costs of these drugs? You can get another kidney transplant, of course!
Medicare will pay the cost of the second transplant (around $125,000). Then the 36-month clock starts all over again.
Some members of Congress agree this makes no sense. Bills have been introduced in the House and the Senate to end the 36-month limitation on coverage for immunosuppressive drugs.
Medicare may cover weight loss surgery
In February 2006, the Centers for Medicare & Medicaid Services
There are a number of requirements you must meet to qualify for coverage, however:
- You need to have a Body Mass Index (BMI) of 35 or higher;
- In addition to morbid obesity, beneficiaries must have serious health conditions, like hypertension, coronary artery disease or osteoarthritis;
- The surgery must be performed in approved surgery centers.
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Reader Comments (Page 1 of 1)
10-09-2009 @ 7:22AM
Chad said...
medicare is socialist and should be stopped immediately. it is bankrupting this country and our taxes will sky rocket over the next40 years because of this socialism.
Reply
10-10-2009 @ 10:29PM
joann said...
You're an idiot They take money out of your social security check every month for medicare so it is not free!
10-09-2009 @ 8:35AM
Richard said...
Chad wrote: > medicare is socialist <
Yes it is. And so is Social Security, the Fire Dept, EMS, Police, Highway Dept., etc. Why are Americans so afraid of the word? Before Social Security was passed in 1936, many of the elderly population lived in extreme poverty. Before Medicare, they were in poor health and the death rate was much higher.
Do you have grandparents or elderly parents? I bet they don't agree with you. The debate about Health Care reform could be ended by extending Medicare to the entire population, not just those over 65. Then we could be on an equal footing with every other industrialized country in the world. And the economy would improve because business and industry would no longer have to pay the outrageously high costs of health care for their employees.
Stop falling for the Conservative's fearmongering with code words like "Socialism".
Reply
10-11-2009 @ 12:28PM
Tom said...
Allowing everyone who chooses to sign up for medicare
makes a lot of sense. That could be be simplists because most
citizens have a social security number.
Medicare is not a new beauracy. Those under 65 could pay a higher premium.
Never happen though. Too Simple
10-09-2009 @ 7:55AM
Jenniferh021 said...
PLEASE stop using the words "Seniors" and "Elderly" for Medicare, specifically this article. I am 34 years old and disabled, therefore, I am on Medicare. Remember the rest of us? Yeah, well you should.
In fact, I am in my coverage gap now, which is a bunch of B.S. Please allow me to tell you WHY:
*I started using Medicare for my prescriptions in 2004. Here it is, 2009, and one day they wouldn't cover a MONTHLY drug I am on that costs $493.95 without coverage. When I called, they explained the exact same thing as your article but here is where it really has been driving me crazy and I just don't "get it"...since 2004, my drug costs that were covered exceeded well over $15,500.00 - YES, that number is correct. Which would mean that I would've reached this so called coverage gap YEARS ago and never did. Now suddenly, in the midst of a DEPRESSION...I got "cut off" until I pay my out of pocket share.
THE LAW MUST CHANGE.
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10-11-2009 @ 4:56PM
LaCrosse said...
I agree. I have been on disability for 4 yrs., and also on Medicare. Retireing after working for 34 1/2 total yrs., 32yrs.at one place i received insurance for life from my place of employment for free, then for a small price. The insurance paid well until I got on disability and Medicare. Now they won't pay anything Medicare won't pay for (thats crazy because I have had no big surgeries). I do take alot of Medication and some do cost a bit. The only reason I keep my secondary Insurance (BCBS) is because they do pay well on presciptions, no deductable. But their medical is worthless and now I am up to a $500.00 deductable. But I consider my self half way lucky, because some people don't have what I have. One more thing, why are Medicare premiums so HIGH?????
10-09-2009 @ 8:35AM
Johnny said...
As an insurance agent dealing in Medicare Advantage Plans. I noticed an misleading statement in the article. If an insurer discontinues your plan you are guaranteed another open enrollment period. You can get a medicare supplement policy with no underwriting.
Reply
10-09-2009 @ 8:46AM
Bonbon said...
I'm in that boat now. My advantage plan has been canceled. I can't get a Medigap policy because I had surgery this year. The advantage plans that are worth any value at all have an extra premium and less coverage than I had. While I was very happy with my plan before, now I'm screwed. I either have to pay a huge monthly premium or huge co-pays. What's a poor ol' senior to do?
Reply
10-09-2009 @ 8:49AM
msw said...
Insurance? Socialism? Government-paid medical care? Doesn't ANYONE get it? I am in my 60's and recall when a doctor would come to my house to treat me. The cost was not exhorbitant. Then Medicare arrived. Then employer-paid medical plans, HMOs, etc. What is the result? Medical costs have SKYROCKETED compared to general inflation. Why? Because now, the cost can be spread over a large population, the majority of whom don't need medical care in any one year. Does the government care? No, they just increase taxes. Do the insurers care? No, they just increase premiums (and as a result, their profits since their profits are held at a % of their costs). Who benefits? Well, the doctors, hospitals, administrators, pharmaceutical firms, etc who are able to continually increase the price of their "services" because the increase is passed on to everyone, not just those in need of the services. Until this is controlled, all talk of "reform" is just that - talk. The result will always be the same - higher costs for the same services.
Reply
10-09-2009 @ 6:54PM
Delicious said...
Socialism is a bad word only to those who watch FAUX NEWS and the Tea Baggers who represent backwards government.
Reply
10-10-2009 @ 9:50AM
Dan said...
"Socialism is a bad word only to those who watch FAUX NEWS and the Tea Baggers who represent backwards government. " Yes, and Socialism is a good word who want other people to pay for everything they need, and never actually work themselves. Oh, and nice homophobic slur there. I though the left was supposed to be tolerant. Yet, you insult gays so easily.
10-09-2009 @ 7:01PM
delicious said...
Insurance companies made a 1000% (yes that is 3 zeros) profit over the last 5 years...I no longer go for yearly physicals as I cannot afford the out of pocket for the first $1000 on Medicare. Everyone is afraid that the people who work for the insurance companies will lose their jobs...too bad they don't give a rat's butt about the millions who have lost their homes because of huge medical debts after losing their jobs due to ill health.
Reply
10-10-2009 @ 9:10PM
JIm King said...
The Congressmen and Senators take a government plan and it works for them and pay less than medicare. Why can't the public have their plan.
Reply
10-11-2009 @ 12:41AM
shar said...
Does Congress have a choice of several insurance companies or only one in their coverage? ... perhaps United Health Care (AARP's INSURANCE)?
Many of us are looking for that answer.
Reply
10-16-2009 @ 2:16PM
Bob said...
Members of goverment are given each year an open enrollment period in November. during that time period they are allowed to change plans, or keep the same plan they now have. They are supplied with a list of different plans (Public Option) depending on the area they live in (State etc;) There are also times (death, divorce, birth ) when they can make changes to their plan other then the open enrollment period. Same for Federal employees, and federal retirees. Retirees pay more then the employees share of cost.
10-11-2009 @ 1:06PM
Margaret said...
Medicare is not the retired persons friend!!!!!! You think so until you get into the Medicine trap. Doughnuts are for eating not robbing senior citizens for the wealth of Medical companies. President Obama, push that new law through asap before we all end up bankrupt. Between long care health care and the doughnut hole, seniors will all die broke.
PLEASE HELP US,,,,,,,,Margaret
Reply
10-13-2009 @ 7:39PM
Jackie said...
People who qualify for Medicare have many choices. For my situation, I found a Medicare Advantage plan that meets my needs and budget. I recommend using the helpful tool at PlanPrescriber.com. You simply enter your zip code and all the Medicare plans available in your area appear. You can then do a plan comparison. I found the search tool extremely helpful in selecting my Medicare plan.
Reply