.

Many people find MediCARE bewildering. It can be, but we propose entering this thicket of information with a sense of adventure. We hope that you are reading this from a place of health, comfort and ease. That makes it easier to absorb the subtleties of what follows. In the heat of an emergency is not the ideal time to try to decode and interpret your MediCARE policy. Here are some insights into your Frequently Asked Questions!

FIRST, A QUICK RUN-DOWN:

MediCARE is a fee-for-service program with three parts: part A which is free, and B and D with premiums. With B there is a premium normally deducted from your Social Security check. The premium increases annually, based on your income. MediCARE D is drug coverage, offering discounted drugs in exchange for paying a low monthly premium, typically deducted from your SS check. You need to be aware that  D Plans change often, so evaluate the policy closely every year to make sure that your needs are met. Open enrollment is in the fall, so now’s the time to begin checking.

Annual open enrollment for basic MediCARE coverage is in the fall as well, at which point you can change your coverage from traditional MediCARE to a MediCARE Advantage Plan (or vice-versa) with no penalty or lapse in coverage, with that change in coverage starting January 1. Beware: if a disqualifying event has occurred, this may prevent you from being eligible for two years. Talk to your carrier for details.

The decision about whether or not to purchase supplemental insurance depends upon how you perceive potential risk, in the context of potential out-of-pocket costs incurred with the 20 per cent copay.  It’s a fact that there is no cap on that 20 per cent, and so a significant medical expense could cost you many thousands of dollars. Bear in mind: supplemental insurance may be purchased with a pre-existing condition with no penalty in the first six months of eligibility for MediCARE. This is called a “guaranteed issue.” After the first six months, insurance companies can deny supplemental coverage.  Talk to your broker about supplemental plans that DO cap your out-of-pocket expenses at $2000.

The MediCARE Advantage Plan is aggressively pitched to seniors. Why? Insurance agents are paid more commission when they sell you a MediCARE Advantage Plan. There are indeed predatory insurance agents out there who will call you, visit you, email you and attempt to persuade you to switch. It’s to their advantage, but may NOT be to yours.  No doubt you’ve been invited to any number of free MediCARE seminars at your local restaurant! Beware. 

Advantage plans are initially appealing because they offer you a “one-stop shop”: these plans combine MediCARE A, B and D and may also be called Plan C, HMO, or a MediCARE PPO. These plans often offer additional benefits like hearing, dental and vision care; be forewarned that the cost, available, covered benefits, and eligible providers may change often, so part of the challenge of making the most of these plans is staying on top of these change in policy and networks. What you need to know: many nursing homes, rehab centers and medical providers in assisted living facilities will NOT accept patients who have chosen an Advantage Plan. These Advantage plans are rather limited in their flexibility and are not universally accepted.

You also need to know MediCARE Advantage HMOs offer you less health care flexibility than other arrangements, especially regarding access to specialists. If you discover that you’re trapped in an HMO you don’t want, find out about disenrolling and returning to traditional MediCARE. This is always an option during open enrollment each fall, and may also be possible at other points in the year. 

The supposed promise of an HMO is that it is less expensive insurance, but this may be false. Even more worrisome: The HMO business model is most profitable when fewer tests and procedures are done for a client. This is contrary to the capital-based, volume-based approach of hospitals using traditional MediCARE with a supplemental plan, that profits on having you agree to as many tests and treatments as possible. This is why an HMO seems “cheap” by comparison. But beware: there will be costs for co-insurance in a rehab facility, for example. Also, the Advantage Plan may not cover the standard 20 days of rehab in a skilled nursing facility offered by traditional MediCARE. And, the Advantage Plan requires higher co-pays for hospitalizations and many treatments, including chemotherapy.  

There are many nuances which become critical as we become more fragile. Take some time to closely read your policy regarding rehab coverage. For instance, your policy probably says you have “up to 100 days of coverage.” That does NOT mean you’ll get the hundred days, which is the maximum. If you break your hip, have it replaced and go into rehab, you might happily believe that you’re safely covered for the next 100 days. But not so: after 4 to 6 weeks. If you’re not showing steady improvement by the facility’s standards, a discharge notice will be filed, and you’ll have a mere three (3!) days to make other arrangements.

Also, MediCARE is NOT generous when it comes to home health care. The home health care provided by MediCARE is always short-term. And is usually in the form of a bath aide, if you are receiving therapy at home. When the therapy ends, the bath aide says goodbye. MediCARE doesn’t pay for live-in or part-time aides on a routine basis, as custodial or maintenance coverage. 

MedicAID may cover custodial care in a nursing home if your income is sufficiently low (usually less than $2000 in assets), and you need assistance with what’s known as ADL in the trade– short for “activities of daily living,” meaning going to the toilet, bathing and dressing. MedicAID is a separate, complex system which varies from state to state. There often is a long waiting list to receive benefits. If your income is low and you are confronting the potential of needing assisted care, look into qualifying for MedicAID in your state before you’re in crisis mode.

PRE-EXISTING CONDITIONS

Let’s review one of the scariest questions: will a pre-existing condition affect your basic premium for traditional MediCARE?  Short answer: no.  This point may become a political football in the 2024 Presidential race, but as it stands as we go to press, the answer is N-O spells “No.” One of MediCARE’s rules is that health status cannot affect premiums. If you are of moderate income, let’s say, you’ll pay the standard Part B monthly premium. The same holds true for MediCARE Advantage (MA) and Part D prescription drug plans: they cannot charge you more due to pre-existing conditions and lifestyle choices. Yes, this DOES include diabetes and smoking.

But MediCARE DOES have a few tricks up its sleeve relative to pre-existing conditions, regarding supplemental “MediGAP” policies. If you buy a policy during your six-month MediGAP open enrollment period, you cannot be denied coverage or charged more because of your pre-existing conditions. But if you miss that window, depending on what state you live in, an insurance company can charge you more, or refuse to sell you a policy because of your health status. The six-month sign-up window for MediGAP policies generally starts the month you turn 65. But if you are insured through your own or your spouses’s employer, the enrollment period begins when you leave your company’s coverage and sign up for MediCARE Part B.

MEDICAL SUPPLIES AND EQUIPMENT

MediCARE will pay for many supplies, like a walker, hospital bed, and oxygen gear.  But beware: some MediCARE Advantage plans do NOT cover certain home-improvement items, like wheelchair ramps, incontinence pads, catheters, unless these items  are needed as part of MediCARE-covered home healthcare. 

What it really gets down to is whether MediCARE assesses your request medically essential (as in, life-or-death) or just a nice-to-have convenience. For example, MediCARE may pay for an electric scooter if you literally need one to get around your house as the result of illness, injury or disability. But if you want the scooter to go road-trippin’…not so much.

These judgments are sometimes tricky, so to find out if an item is covered call the MediCARE hotline at 800-633-4227, or go to Medicare.gov.

And last but not least, if you are a veteran and/or are married to a veteran, you may be eligible for an array of benefits. In fairness, the Veteran’s Administration is a bit of a maze, with many strict regulations. Start by going to va.gov.

People who devote their professional lives to caring for others in need are admirable, and we are grateful for them. These individuals are entirely separate, however, from the insurance carriers which create the framework in which they must administer care. Insurance programs are very much like your bank. They are there to take your money and profit from you. This is not cynicism. It’s the fact of the matter. 

Talk to your peers, and find out who in your group is especially well-read and vocal in these areas. Hold your own private potluck with someone who can advocate for you (NOT your average carrier agent!), and get your concerns out on the table. And be prepared to do a thorough audit of your needs and policy changes as we approach open enrollment season.

For a comprehensive look at the latest updates to Medicare coverage, including plan options and benefits for the 2025 year, be sure to check out the official Medicare 2025 Brochure. This brochure is an invaluable resource for understanding your health care options, including any changes to premiums, deductibles, and available services. Whether you’re already enrolled or considering your options, the brochure provides clear guidance on how to navigate Medicare and make the best choice for your healthcare needs.