Aging and Medicare: Navigating the Alphabet Soup of Health Care and Getting the Information Straight


Aging is not easy! If you have led a healthy lifestyle, chances are you will age gracefully and healthy. If you have more or less --sort-a-kind-a -- led a semi healthy lifestyle (like most of us!) then chances are you will be visiting the doctor’s office more often than not. As a matter of fact, the segment of the population that visits their doctors the most are those individuals 65 and older. It is typically common to think that once you hit retirement, you can survive on Social Security and Medicare. Think again!

Medicare is the insurance program provided by the federal government to people who are 65 or older, people with specific disabilities – whether they are younger than 65 or not, and people with permanent kidney failure. Medicare includes visits to your regular doctor and hospital stays. You typically pay a deductible or co-insurance, and Medicare covers the rest once the provider (doctors, hospitals, nursing facilities, home health agencies and medical equipment suppliers) files the corresponding claims.

The Alphabet Soup of Medicare

Many people get confused between the lettered ‘Parts’ of Medicare, and 'Plans' of Medicare. The more informed you are on your health coverage alternatives, the better! Making an informed decision will avoid stress, headaches, confusion and costs! You will often hear about Medicare Advantage (or Part C), and more commonly, Medicare Part D.

Originally, Medicare is divided into Part A and Part B. A brief summary of the differences include:

Part A: If you are 65 or older and receiving Social Security benefits, you will automatically be enrolled in Medicare Part A. It covers the cost of hospital services, including nursing facility or hospice, and supplies that are considered medically necessary to treat an illness.

Part B works very similar to medical insurance in that you will pay an annual deductible and coinsurance. You will have to apply for enrollment within 6 months of turning 65 or 30 days after applying for your Social Security benefits at a later age, even if it's at 66. There is a monthly premium for Part B. Most people pay a standard premium of about $122, and it is typically deducted from your Social Security benefit. Part B helps pay for visits to your doctor and preventive services such as cancer screening and vaccines. It also pays for some medical supplies and equipment once the fees and deductibles are covered.

Part C, hereinafter referred to as Medicare Advantage, is an additional, approved and private health insurance plan that you can purchase so long as you are enrolled in Medicare Parts A & B. When you choose an Advantage Plan (Part C) you are fore fitting your Part A, B & D benefits. Therefore this decision should not be taken lightly! Advantage Plans offer include hospital and physicians services as well as prescription benefits. Additional benefits may include vision, dental and hearing, and even a membership to health and wellness clubs. You may enroll in a Medicare Advantage Plan within a period of 6 months after you turn 65, or, if at a later age, 30 days after becoming eligible for Part A & Part B.

Part D is strictly prescription coverage. It MUST be purchased to compliment Parts A&B. Penalties apply if you do not purchase it concurrently. However, it is included in the Advantage Plans (Part C). Again, you have to be enrolled in Medicare Plans A & B in order to access Part D.

If there is something that you REALLY need to understand, it's the difference between Medicare Gap Insurance and Medicare Advantage Plans

This is where you really need to talk to your insurance professional to make sure you have the best understanding of your healthcare options.

Medicare Gap Insurance is a supplementary policy that is necessary only if you are receiving Parts A,B & D. These are known as the 'lettered plans' or 'classic Medicare'.

'Medigap' offers additional coverage in the areas of copayments and deductibles for hospital stays, and, in many circumstances, specific costs related to skilled nursing facilities and hospice, for example. ‘Medigap’ typically DOES NOT cover vision, dental or hearing care. It also utilizes letters, but not the whole alphabet! There are around 10 types of Medicare Gap Insurance; the most popular being Plan F. Plan F covers all deductible and coinsurance 'gaps' that Part A & B do not. In California, the average monthly premium for Plan F is $160.

Medicare Advantage Plans, as mentioned earlier, are designed to include all benefits provided by Parts A, B & D. Keep in mind that these are 'managed' plans with strict guidelines pertaining to doctor networks, facilities and services. Premiums vary from $0 premium to up to $75/month; not to be confused with the above mentioned Plan F.

A word of caution: although Medicare Advantage Plans have become very popular due to low or no premiums, navigating the healthcare system when ill can become extremely frustrating: if you feel you need immediate service, chances are you will have to wait for a referral that not only takes a long time and limits your access to specialists. You will probably also have to fore fit brand drugs for generic ones, for example.

Deadlines, Deadlines, Deadlines!

Please, please please! Keep in mind that many deadlines surround Medicare enrollments. The thing about these deadlines, is that there are a lot of variables depending on your personal circumstances. There are different deadlines for different situations, such as:

  • Initial enrollment into a Medigap or Advantage plan upon becoming eligible for Medicare, ensuring you get the best plan despite any pre-existing conditions.

  • Initial and annual enrollment in Part D prescription plan to avoid future penalties

  • Annual Open Enrollment to change Advantage Plans

  • Special enrollment that guarantees coverage with another company when your existing Advantage Plan or Medigap insurance carrier moves out of your service area.

Where it all comes together

“You don’t have to deal with Medicare by yourself”, comments Susana Leon Krieger, insurance professional for over 20 years. “Your insurance professional can help determine a strategy for health coverage in the latter years of your life.

When thinking about Medicare, there are exceptions, restrictions and variables that must be considered, and that might affect the quality of care you get and the cost you pay for it". When meeting with Susana, she goes back to the ABC's of Medicare:

  • Most people get Medicare Part A automatically when receiving Social Security benefits. You are eligible for Medicare at 65 if you or your spouse have worked in the US for at least 10 years. If you have worked less than 7 ½ years, you will have to pay for Medicare Part A. If you are not getting Social Security benefits you can opt to delay access to Parts A & Part B.

  • Part B is not required by law; however, it is in your best interest to get it because it covers comprehensive physician's services.

  • Parts A & B DO NOT COVER prescriptions. You NEED Part D.

  • Medicare Advantage plans (Part C) are comprehensive and cost effective. However you must forego access to Parts A,B and D and be 'fully managed' as a patient by your health insurance company. It is virtually impossible to go back to original Medicare if you have been on an Advantage Plan for over 12 months and have a pre-existing condition.

According to Susana, these are some of the important questions she addresses with her customers when discussing the best strategy for Medicare coverage:

  • When do you NEED to be enrolled in Medicare and the consequences of skipping an enrollment deadline? What specific group of plans work for YOUR needs and specific circumstances? Should you consider a Long Term Care policy to compliment your medicare coverage when facing illnesses such as Alzheimer’s?

  • How does Medicare work with other insurance plans you might have as far as costs and coverage are concerned? What are the costs of the insurance plans and how do they compare with what you paid prior to turning 65?

  • Does your current physician accept the Medicare coverage you are considering? What would the referral process be? How can you find another doctor if the one you are currently seeing is not in the coverage network?

  • Are you satisfied with the quality of your current care? If not, what alternatives do you have?

  • What are other resources can you refer to when dealing with Medicare?

When deciding on your Medicare options, don't 'go it' alone; Medicare's rules and regulations tend to be VERY complicated and confusing. Before you turn to the internet and try to figure things out, contact your insurance professional for clarification. Remember that the years of his or her experience in the field of insurance help best serve YOUR interests when discussing your life in the latter years!

Please make sure you contact me if you have any questions! I can gladly help!

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