What You Need to Understand About Medicare

This guest post comes to us from Anne Tumlinson, author of Daughterhood.org, a blog she founded to support and build confidence in women who are managing their parents’ care.

“My dad doesn’t have Medicare!” a friend said to me on the phone a few months ago. “What?” I responded. Pretty much everyone over age 65 has some form of Medicare and my friend’s dad is at least 90 years old, so this seemed unlikely.

“Dad has something called ‘Blue Cross advantage,” he said. “Ah ha,” I thought. My friend’s father had “Medicare Advantage,” a plan offered by private insurers that seniors can choose in place of traditional Medicare.

Medicare Advantage plans often fill in the gaps of Medicare coverage, like vision or prescription drug coverage, and often at a lower price than the supplemental “Medigap” policies older adults typically buy to get these benefits and cover Medicare co-pays.

It’s no wonder my friend was confused, given that traditional Medicare is a complicated alphabet soup of different parts that Congress keeps tacking onto the program.

  • First, there’s “Part A” coverage, which pays for hospital and post-acute care, such as inpatient rehabilitation services.
  • Part B covers physician services and requires a monthly premium to the government that is deducted from the beneficiary’s Social Security payment.
  • Part D covers prescription drugs and requires signing up with a private insurer. It is commonly called a PDP, for part D plan.
  • Then there is the private Medigap policy that Medicare beneficiaries can purchase, which covers the stuff that is, amazingly, not included in Parts A, B, and D.

What happened to Part C you ask? That brings us back to Medicare Advantage, where you can turn all your coverage over to one plan, purchased from a private insurer. You pay your Part B premium and one other premium to the plan and you’re done.

Sign Dad up, you say? Not so fast.

As with everything in the world of health insurance, this is complex. There are trade-offs and challenges in choosing Medicare Advantage.

I’m going to boil it down here. Whether or not your mom or dad is in a plan now, or if you are considering one for them, you do have power and you do have choices. Here are four things you can do to get what you need for your parents.

Dealing with Plan Coverage Limitations

Medicare Advantage plans are not usually super flexible organizations.

Some of their rules for covering services can work in your favor; for example, most plans do not require a 3-day prior hospitalization for skilled nursing care.

However, they also limit your parent’s network of providers, and impose rules that may reduce access to needed services. One friend thought his dad should have been discharged from the hospital to a special rehabilitation center, but this center isn’t part of the plan’s network. His dad ended up going home without any post-acute care.

You have the right to ask your parent’s plan to provide or pay for services you think should be covered or continued. If the plan won’t cover what you ask for, there’s a four-step appeals process, you can pursue.

Get Expert Assistance in Choosing Your Plan

Your parent will get a lot of lovely marketing materials from some of the plans. These plans can be so different in what they cost and cover, and marketing materials aren’t the best way to pick the plan that will work best for your individual circumstances.

Get expert help from the government plan finder. It’s at www.medicare.gov.  Click on “Find health & drug plans” on the home page.

But, before you do this, invest in the excellent AARP’s Medicare for Dummies, and consult Chapter 11 as you go through the plan finder. The author guides you through the process.

But there’s no substitute for sitting down with a live person. And the good news is that the government funds a resource in every state called the state health insurance program (SHIP). SHIP is a free, confidential and unbiased insurance counseling service.

Go to this website and call to make an appointment with your expert and free SHIP counselor. This can be especially helpful if your parent is also eligible for Medicaid, which is available to individuals whose income and assets are below certain levels.

When your parent is eligible for both Medicare and Medicaid, the SHIP can help you find special programs for “dual eligibles” that may be available in your state, such as the Program for All-Inclusive Care for the Elderly (PACE).

Navigating Coverage Change Regulations Rules

You can make changes if you don’t like your parent’s plan or situation but know the rules because there are restrictions.

For example, if you want to sign up for Medicare Advantage, change plans, or change back from Medicare Advantage to traditional Medicare, the general time to do that is during the annual open season, which runs from mid-October to early December.

As Patricia Barry, author of Medicare for Dummies explains, in addition to the open season, there’s also a special season devoted exclusively to dis-enrolling or switching out of Medicare Advantage and into traditional Medicare. During this season that starts January 1st and runs through mid-February, you can even drop Medicare Advantage if you just enrolled.

In addition, there are special enrollment periods that provide opportunities for changing your situation if you move permanently outside a plan’s service area, you move in or out of a nursing home, you are new to Medicare, your plan withdraws from the program or somehow misleads you – and other situations, all of which are explained in Barry’s book.

With health care reform, coverage and payment rules are undergoing change.

Avoid Being Too Hard on Yourself

I have worked for 25 years on various aspects of Medicare (and Medicaid), and this was a hard blog to write. A good friend of mine who has even more experience with these programs described figuring out her Medicare coverage as a nightmare.

What that means is that you should not feel frustrated with yourself if you have to struggle to understand all the options. You could go to Medicare school and still not understand it perfectly.

If you have recently become your parent or spouse’s care manager, handling insurance issues is guaranteed to cause frustration at times. Reach out for help.

Your efforts matter greatly and, more importantly, just being there for your loved one, all of the paperwork aside, is what matters most.

I’d love to know your experiences figuring out your parents’ insurance options. Please go to the comments section of my blog daughterhood.org and share what has helped you.

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