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The Medicare Maze

Posted by on 13 Jan, 2016

BASICS OF THE MEDICARE MAZE

Are you approaching the magic number that qualifies you, or depending on your viewpoint, requires you to enter the Medicare maze? The complexity of the program may seem daunting to those who are unfamiliar and deciphering the details is usually not a priority until the need for the benefit is impending. To help you understand what Medicare is and how it works, here are a few of the basics of the social insurance program.

HOW IS IT FUNDED?

Medicare is a benefit from the U.S. government that is funded by two U.S. Treasury trust funds; the Hospital Insurance Trust Fund and the Supplementary Medical Insurance Trust Fund. The Hospital Insurance Trust Fund is underwritten with monies from payroll taxes, which employees, employers, or self-employed business owners pay. Additional funding comes from the premiums paid to Medicare Part A, interest earned from the trust fund investments, and income taxes paid on Social Security Benefits. The Supplementary Medical Insurance Fund is financed by monies authorized by Congress, interest on investments, and premiums from Medicare Part B and Part D. Basically, taxpayers fund Medicare with a little help from Congress and interest earned on investments in the funds.

SIGN-UP TIMING

If you're approaching the age of 65 and not already on Medicare Parts A and/or B, you will need to apply during the 10-month window that is seven months before you turn 65 and three months after you turn 65. It's important to note that there is an open enrollment period from January 1 to March 31 each year when you may sign up. There may be a penalty for late enrollment and a higher premium, so it's important to pay attention when you are approaching the eligible age. There are special enrollment periods related to employer covered group health care conditions. Additionally, if you are in End Stage Renal Disease (ESRD), the enrollment periods do not apply. There are also special circumstances for those who are volunteering in a foreign country.

WHAT IF I HAVE SECONDARY OR SUPPLEMENTAL INSURANCE?

If you are privileged to have additional insurance, you will need to advise your healthcare provider that you have a secondary or supplemental insurance plan. You should know which insurance is primary and which is secondary. In other words, you should know which insurance pays first. You may be required to apply for Medicare Part B if your secondary insurance is your employer. However, the “coordination of benefits” rules determine which pays first.

WHAT ABOUT RETIREES WITH EMPLOYER COVERAGE?

Some retirees have coverage through a group plan from their employers. While planning retirement, it's important to determine if extended coverage is available. Sometimes the group plan costs more, or ends upon retirement. If you do have retiree coverage through your group plan, you will need to figure out the costs and exceptions such as limits and out-of-pocket costs. You need to understand what will happen when you reach the Medicare age. Some plans will cease at this point and others may have restrictions. You will need to find out if there is a gap in coverage between Medicare and your retiree coverage. Ultimately what this means is, there may be a gap in coverage which might prompt you to purchase a supplemental or Medigap plan.

WHAT ARE CHOICES FOR COVERAGE?

Medicare offers a variety of options including original Medicare, which encompasses Part A (Hospital) and Part B (Medical), or Part C, which is a Medicare Advantage Plan similar to a PPO or HMO.

Additionally, Medicare Part D provides supplemental coverage for prescriptions. Like traditional insurance, Medicare does not cover all of your expenses carte blanche. If you want to cover more of your expenses, a supplemental plan may be a good option for you. There are many choices and options and it is wise to read all information on the website https://www.medicare.gov.  You should also talk with a representative if you have questions. Medicare has many options and choices which you will want to explore and make yourself aware of in order to make an informed decision related to coverage.

If Part A is selected, Part B is usually chosen as well unless you meet one of the following exceptions: You have Tricare, CHAMPVA, receive Veterans benefits, or have union or employer coverage. If you have union or employer coverage, you will need to check the details of how that insurance and Medicare work together. If you don't have any of the above-mentioned exceptions, you will need to sign up for Part B at the same time you sign up for Part A. Additionally, if you want Part D, you must sign up at the same time you sign up for Parts A and B to avoid the penalty of late fees.

Medicare is a complex program but there is plenty of valuable information and resources available to help you navigate through the maze. Urgent Clinics Medical Care accepts Medicare Part B at all of our conveniently located facilities in Pearland, Champions, The Woodlands and 3 locations in League City: Creekside, Marina Bay and Tuscan Lakes.

 

 
 

 

 
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