The New Medicare Prescription Drug Plan Pitfalls

Coverage for the New Medicare Prescription Drug Plan begins on January 1, 2006. Many seniors are feeling confused and concerned about this plan. Here are some of the pitfalls associated with this plan that Medicare eligible individuals will want to be aware of.

1. To join the Medicare Prescription Drug Plan (Medicare Part D) you must choose one Prescription Drug Plan from dozens of plans that are available (there are up to 50 plans in some states). Once you have chosen a plan you are "locked-in" until the enrollment period the following year.

2. Prescription Drug Plan (PDP) providers can change the particulars of their plans at any time with a short warning period for plan enrollees. These changes can include changes to which drugs are covered under the plan, which pharmacies are in the plans network, the charges associated with being a part of the plan and any other detail of the plan. These changes are at the discretion of the plan administrator and can be implemented at any time.

3. For 2006, once you have used $2250 worth of medications, you are 100% responsible for paying for the full amount of the drug until you reach the $5100 Catastrophic coverage limit. This range between $2250 and $5100 where you have to pay for 100% of your drug expenditures is known as the "donut hole".

4. At its greatest level of savings Medicare provides a 49% savings. This is only 7% better than the average savings experienced with a licensed Canadian pharmacy. This greatest savings occurs when people spend exactly $2250 on medication in one year (if you spend more or less than that the savings go down). That means that the greatest savings anyone on Medicare can experience above a Canadian pharmacy's average savings is $157.50 annually (7% of $2250) or $13.13 a month. Is $13 a month worth the risk of being "locked-in" to paying monthly premiums for a plan that can be switched on you at any time. (Note: Some people can save more than 49% if they spend well over $7100 per year. This is in the catastrophic coverage range).

5. If you do not sign up with at Medicare Prescription Drug Plan before May 15th, 2006 then you will be penalized with a cumulative 1% increase to your premiums for every month that you do not enroll in a plan after that date. This penalty is the governments way of forcing people, who do not really need a drug plan, into joining a plan and thus "subsidizing" the Medicare program. 1% of the average plan is 32 cents. So for every month after March 15th, 2006 that people are not in a plan, 32 cents will be added to your monthly premium or basically $1 for every 3 months you do not join. This penalty is however applied to your premium for all future monthly premiums. What many seniors groups are advocating is for people to wait until the May 15th, 2006 deadline and then join the cheapest possible plan (approx. $10 monthly premium) and still order medicines from a licensed Canadian pharmacy like Universal Drugstore.

6. Average monthly premiums, the annual deductible and the Out-Of-Pocket expenditure limits are expected to increase substantially every year. This means you will be required to spend more and more money every year that you are part of the Medicare prescription plan.

7. Unless you are spending more than $800 on medications in 2006 there is no real savings with the Medicare Prescription Drug Plan. This required minimum amount of expenditure to experience savings will increase every year as the annual deductible, the monthly premiums and the Out-Of-Pocket expenditure limits are also increased every year.

8. It will be extremely time consuming and difficult to decipher myriad plans available in each state (all providing different coverage) and to try and figure out which plan is best for you personally. This will be twice as hard for a couple as the prescription drugs used by each person in the couple will be different and therefore they may require different plans. Even once a plan is chosen, there is still the risk of having the plan changed once you have made your decision and you are "locked-in".

9. Drug companies stand to make a ton of money off of the Medicare program. That is why they spent millions of dollars lobbying to get the legislation passed to make Medicare Part D a reality. It is also why Senator Bill Tauzin, a major advocate and motivating force behind getting the Medicare Prescription Drug Plan passed, is now a $2 million a year executive in Big Pharma's trade organization. On Sept. 5, 2003, Sen. John R. McCain (R-Ariz.) told the New York Times, "There's no doubt in my mind that the drug industry got everything it wanted and more," he said. "It perhaps should be called the 'Leave-No-Lobbyist-Behind Bill.' "

10. Plan providers have the ability to negotiate better drug pricing with the drug companies but they do not have to pass the savings on to the consumer or the government.

11. If you join a Medicare Prescription Drug Plan (PDP) at any time after Dec 31, 2005 your coverage is not available to you until the first day of the following month.

12. Action is required to enroll in Medicare Part D (the Prescription Drug Plan part) unlike Medicare parts A and B which are automatic. You are not simply enrolled in the best plan for you. You have to wade through piles of information to decide what is best for you.

13. It is very difficult for persons who qualify for Medicare Part D to be sure if their drugs will be covered under their plans formulary (which can change at any time anyways.) A formulary is a list of drugs covered under particular drug plan.

14. You may not qualify for Medicare Prescription Drug Benefits if your annual income is too high or if you own too many assets.

15. Different plans will have different monthly premiums. The plan you need may have a really high monthly premium. $32.20 is simply the "predicted" average monthly premium.

16. Will your plan cover temporary-use medications (such as antibiotics or heartburn medications) or only chronic medications (such as drugs used for diabetes or heart conditions)?

17. Plans with lower monthly premiums may have higher deductibles and co-pays.

18. Payments for drugs which are not on your plans formulary are not counted towards your Out-Of-Pocket expenditure limit.

19. Payments made by insurance plans do not count towards your Out-Of-Pocket expenditure limit

20. Is your regular pharmacy included in your plans network of pharmacies? Like many people you have most likely come to rely on a pharmacist that knows you and your medical conditions well. However, you may be forced to go to another pharmacy if your pharmacy is not included in your plans network of pharmacies.

21. How many days of medicine can you get at one time? Do you need to keep going back to the pharmacy every month or can you get 90 days?

22. Will your drug be covered by your plan the next time you go into your pharmacy?

23. Does your plan require step-up therapy or prior authorization? Step-up therapy means using drugs in a series of stages or steps in order to treat your condition. For example if you have GERD your plan may not cover Nexium unless you have previously tried ranitidine (Zantac) and/or omeprazole (Prilosec) first. Prior Authorization means that for certain drugs, your plan will not cover the drug without first reviewing your medical and drug history to determine if your treatment steps have been appropriate.

24. The Prescription Drug Plan providers stand to make a ton of money from the Medicare program (drug companies stand to make the biggest windfall).

25. Net cost to the government for Medicare Prescription Drug Benefits is estimated to go from $37.4 Billion in 2006 to $109.2 Billion in 2015 (estimate by Health and Human Services department). However, much higher estimates of the costs of Medicare Part D can also be found from non-government resources. Two years ago Congress reluctantly approved for the plan at a cost of no more than $395 billion dollars over 10 years. A few months later the cost ballooned to $534 billion and earlier this year it shot to $795 billion. Big Pharma is the biggest recipients of the increased dollars added to the costs of this program.

26. Plan may force you to use generics when you are used brand name medications and may not be able to tolerate generic versions.

27. The appeals process for some plans is very confusing and convoluted. (You can appeal to your plan if your drug is not covered.)

28. Many of the big pharmaceutical companies are now making anyone eligible for Medicare Part D, ineligible for their assistance programs. These companies are effectively forcing seniors into a "voluntary" program that may not be right for them. The AstraZeneca Foundation was the first to take such steps.

29. Many people are finding it difficult to obtain accurate, updated lists of what medications each plan will cover.

30. Medicare's own hotline can only answer general questions. For more specific questions you must contact each individual insurance provider.

31. Many people have waited 30 minutes or more when calling the Medicare hotline to get information that they need.

32. Rep. Dan Burton (R-Ind.) in a 60 Minutes segment televised March 14, 2004 said, "Seniors, when they find out what's in that bill, are going to be very angry. The problem is, they're not going to find out about it until after this next election."

Jeremy Cockerill is a licensed Canadian pharmacist who owns and operates htttp://www.UniversalDrugstore.com/ , one of the top Canadian mail-order pharmacies. Mr. Cockerill graduated from the Faculty of Pharmacy at the University of Manitoba with Honors in 1998. Mr. Cockerill recently won the 2005 Manager of the Year award from the Manitoba Customer Contact Association. Mr. Cockerill has been studying the new Medicare Prescription Drug plan since early 2005.

Coverage Options For Medicare Eligible Individuals

People with Medicare can obtain their medical care through original Medicare or the Medicare Advantage Program (Part C). Medicare Advantage Plans consist of HMO, PPO, Private Fee for Service Plans and Special Needs Plans. Of the more than 10 million individuals enrolled in Medicare Advantage Plans, the majority are enrolled in HMO's (Health Maintenance Organizations) which have been available since the 1980's.

To help your parents (or you) make an informed decision, they need to understand how these plans work, and then decide which plan is right for them. The following is a brief description of each of the plan types.

Original Medicare

If an individual elects to go with traditional fee for service Medicare, they can generally use any doctor or hospital that accepts Medicare assignment anywhere within the United States. However, Medicare does have deductibles, copays and cost sharing requirements that can play havoc with budgets. To help pay these additional out of pocket expenses, many individuals purchase Medigap or Medicare supplement policies.

Medicare Advantage Plans (Part C)

If you opt to go with a Medicare Advantage Plan, you actually trade your traditional Medicare benefits for these plans. Many of the Medicare Advantage Plans are offered to eligible individuals at little or no cost other than continued payment of their Part B monthly premiums.

Medicare HMO's (Health Maintenance Organizations)

These plans cover the same physician and hospital costs as traditional Medicare, but usually with lower out of pocket costs. HMO's are attractive to Medicare eligible individuals because they often provide extra benefits like eyeglasses, hearing aids, and dental benefits which are not covered by traditional Medicare.

Individuals considering a Medicare HMO should be aware that they can only receive medical services from providers who are part of the HMO's network of contracted providers. The HMO usually requires that an individual joining their plan select a primary care physician from those who participate in their network. This primary care physician would then be responsible for all medical care including referrals to a specialist and admittance to a hospital. The HMO will not pay for unauthorized visits to specialists nor non-emergency care received outside the HMO's service area or visits to non-network physicians.

Medicare PPO's (Preferred Provider Organizations)

These plans are private healthcare plans like HMO's. However, PPO's and HMO's do differ into two very important areas. First, Medicare PPO's do cover eligible medical care services obtained from doctors and hospitals outside the PPO network. And, second, Medicare PPO's do not usually require that you obtain an authorization before seeking care from a specialist.

Regional PPO's are available in many areas of the country. These plans serve large geographic areas and must offer the same premium costs and plan benefits to all individuals residing in these areas. Medicare PPO's cover the same types of medical expenses that traditional Medicare does. In addition, Medicare PPO's commonly include a prescription drug benefit. Unlike traditional Medicare, Medicare PPO's have an annual out of pocket limit for benefits covered under Parts A and B of Medicare. The out of pocket limit caps the amount an individual can spend on covered medical expenses in a calendar year. As with any PPO program, when an individual uses a non-contracted provider for covered services, they will pay more out of their pocket.

Private Fee for Service (PFFS) plans

These plans are available to Medicare beneficiaries in exchange for their traditional Medicare Benefits. PFFS don't have a formal network of doctors and hospitals to choose from and not all doctors or hospitals are willing to provide medical services to participants in these types of plans. If an individual is considering enrollment, it is wise to check with their doctor and local hospitals to make sure that they will accept the plan's payment for services before enrolling. Also, the enrollee should thoroughly understand the benefits of a fee for service plan because the fee for service plans decide how much they will pay for Medicare covered services and may charge a higher cost sharing percentage than traditional Medicare. Private fee for service plans may include a prescription drug benefit. If they do not, the enrollee is free to join a Medicare stand alone prescription drug plan.

Special Needs Plans (SNP)

These plans are private plans that provide benefits to Medicare beneficiaries, including prescription drug coverage, who need additional help paying for their medical benefits. These would include individuals who qualify for both Medicare and Medicaid (MediCal in California), those residing in long term care facilities, and those with chronic or disabling medical conditions.

Medicare Prescription Drug Plans (Part D)

Prescription drug plans are available to all Medicare eligible persons regardless of medical history or income levels. When a person first qualifies for Medicare, their initial enrollment period begins three months before their 65th birthday, includes their birth month, and ends three months after their birth month. Otherwise, the annual open enrollment period for prescription drug plans runs from November 15th thru December 31st, with the coverage commencing on the following January 1st.

Medicare drug plans are designed to reduce drug costs for enrollees and protect against catastrophic drug costs. However, there is a monthly cost for these plans. In addition to a monthly premium, the covered individual is required to pay a percentage of the cost of the medications (or a copay) and Medicare pays part of the cost. Costs for a plan will vary depending on the medications taken and the type of plan selected. At a minimum, the plans available must provide a "standard" level of coverage.

For 2010, a standard prescription drug plan will have the following costs:

A monthly premium which varies from approximately $24 per month to in excess of $100 depending upon the plan selected and medications taken.

An annual deductible equal to the first $310 worth of prescription drugs.

After the annual deductible has been satisfied, the insured will pay the following amounts for the remainder of 2010:

25% of the cost for covered medications from $310 up to $2830 in charges, (the plan pays the other 75% of these costs); then

100% of the next $3842.50 in total drug charges (often called the donut hole or coverage gap); then

After exceeding the annual of pocket limit of $4550, 5% of your drug costs or a copay of $2.50 or $6.30, whichever is greater for the rest of the current calendar year.

This describes a "Standard Plan." Many of the prescription drug vendors do offer better benefit plans which forego the plan deductible and substitute copays instead of the 25% coinsurance. Generic medications are available for substantially less than brand names with these plans.

There is a penalty of 1% per month, using the average national premium, for non-enrollment/late enrollment, which is assessed for as long as they remain enrolled in the plan.

This has been just a brief overview of the benefits available to Medicare eligible individuals. For more detailed information, please consult the Medicare handbook, Medicare & You. The handbook is available by contacting Medicare at 1-800-MEDICARE or visiting the Medicare website at http://www.medicare.gov.

In addition, a copy is available at our website- http://www.waldenbrokers.com. Should you or your parents need assistance in selecting a Medicare plan, please feel free to contact us at 818-597-2890.

Edward Walden, CLU, RHU, REBC

A Guide to Medicare Coverage

Signed into law by then-President Lyndon B. Johnson on July 30, 1965, Medicare coverage began as a social insurance program for American citizens age 65 or older. Today Medicare also covers citizens who may not be 65 years old but demonstrate need. Those suffering with Lou Gehrig's Disease, in need of a kidney transplant or have been receiving Social Security benefits for at least 24 months are all examples of people who qualify for Medicare.

Originally, Medicare coverage applied only to Hospital Insurance (known as Part A) and Medical Insurance (Part B). Former President Harry S. Truman was the first recipient of an official Medicare card, which then rarely entitled the holder to prescription drug coverage. As of early 2006, more comprehensive drug coverage was provided.

Medicare Part A

Part A of Medicare is Hospital Insurance, which will cover hospital stays, nursing home or assisted-living home care for a period of time. To receive the benefits of Medicare Part A, there are four main criteria that must be met, the first of which addresses only hospital visits:

The hospital stay must be a minimum of three days and three midnights, not including the day you are discharged
A nursing-home stay is covered only if the problem is diagnosed during the hospital visit outlined above. For example, if a respiratory issue sent you to the hospital, Medicare would cover a nursing home stay to help rehabilitate your lungs.
If you don't need rehabilitation at a nursing home but have an ailment that requires constant medical assistance or supervision, the stay would be covered.
Those caring for you at the nursing home have to be skilled. Part A of Medicare does not cover long-term, unskilled or custodial care.
Regarding nursing-home stays, Medicare will only cover 100 days per ailment. The first 20 days are paid for by Medicare in full; the next 80 days require a copayment of $128 per day (as of 2008). Whenever you go 60 days without using Medicare to help pay for a nursing home stay, the 100-day clock is reset and you qualify for a new 100 day period.

Medicare Part B

Part B of Medicare deals with Medical Insurance. This section covers most outpatient services and medically necessary products that Part A leaves untouched. Everything from doctor's visits to immnuosuppressive drugs for organ-transplant recipients are covered by Part B, including limited ambulance transportation.

In addition to outpatient doctor's services and treatments like chemotherapy, Part B helps you to pay for durable medical equipment (DME). Examples of DME include mobility scooters, prosthetic limbs, canes and oxygen.

Medicare Part C

Part C of Medicare deals with Medicare Advantage plans. After the Balanced Budget Act of 1997 passed, Medicare recipients were given the choice to either keep their original Medicare plan (Parts A and B) or receive their benefits through a private health insurance plan. After the Medicare Prescription Drug, Improvement and Modernization Act was enacted in 2003, those using private health insurance through Part C became known as Medicare Advantage (MA) recipients.

If you choose Medicare Advantage, Medicare will pay a set amount each month toward private health insurance. You're required to pay any additional premiums, and in many cases you'll have to pay a fixed copayment amount (usually around $10 or $20) each time you see a doctor. By law, the private insurance company you choose must offer a benefit package that is at least as good as the one provided by Medicare Parts A and B.

Medicare Part D

Medicare Part D provides coverage for prescription drug plans and went into effect at the beginning of 2006. If you use Medicare Part A or B, you are eligible for Part D. If you're using an MA Plan, you can adjust your benefits to take advantage of Part D, in which case the overall plan becomes an MA-PD.

To get Medicare Part D, you need to enroll in a Prescription Drug Plan (PDP) or change your MA coverage to MA-PD. Costs and benefits vary between the different plans, and medications that you need may not be covered by all plans. Some drugs, such as cough suppressants, benzodiazepines and barbiturates, aren't covered at all.

To get the best Medicare Part D coverage at the best price, you should compile a list of your prescriptions and talk to your pharmacist, MA provider or a Medicare representative. You can get a head start by visiting http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp, which provides a list of Medicare Part D options by state when you provide your prescriptions.

Costs

Each year that you work, 2.9% of your wages are taxed under the Federal Insurance Contributions Act (FICA) and applied to your future Medicaid coverage. This 2.9% is split between employers and employees. Those who are self-employed have to pay the full 2.9% on their own. There is no limit to the amount of your wages that must be paid to FICA tax.

Once you're eligible for Medicare, it works like private health insurance. Your care provider bills Medicare for expenses, and you make up any differences that aren't covered.

Medicare coverage is limited, and while it can provide some protection for routine expenses or a minor injury, such as a broken leg, it's not a solution for long-term care needs. For this reason, it's a good idea to look into supplemental coverage, known as Medigap, to cover additional costs. While the monthly premiums for Medigap insurance can be high, they're still far lower than the medical bills that pile up in the event of a catastrophic illness or if you need long-term care.

For more information on medicare, visit the career and money section of Life123.com.

Discover the 8 Critical Questions to Ask When Selecting a Medicare Supplement Plan

Once you qualify for Medicare, there are many options for a Medigap, or supplemental coverage plan. All the information out there can make the process confusing, however use this guide to help help ask the right questions so you can understand the differences.

The 8 Critical Questions YOU MUST Ask When Picking a Medicare Plan

1.  Do I retain my rights to Medicare Part A & B?

The reason you want to ask this question  is because even though you have your rights to Medicare Part A and B, your choices on where you use your benefits may be limited.  For example, Most Medicare Advantage plans have a network which you must use to get your benefits, if you go out of the network you may pay a much higher portion of the bill or not even covered at all unless it is an emergency situation.


2.  Will I be able to see the same doctor or visit the same hospital?

Just as in the question above, if your favorite doctor or hospital is not in the Medicare Advantage network, then you will have to make a choice on whether the plan is worth it.  On the other hand a Medicare Supplement plan along with Original Medicare will not restrict you to a network, as long as the doctor or facility accepts Medicare then they will accept your Medicare Supplement as well.


3.  Is there a co pay-and if so, how much?

Currently the Medicare Supplement plans do not have a copay option, however some of the plans to require you to take care of your Part B deductible.  Depending on the plan, this might still be a good option depending on what your monthly premium is.  There are some supplement plans that take care of both your Part A & B deductible for you.
Medicare Advantage programs typically have a co-pay, deductible and an out of pocket maximum that you are responsible for each year.  Be careful, these plans also change each year as well, so your co-pays and deductibles could increase from year to year.


4.  Is there an out of pocket maximum?

Medicare Advantage plans do have an out of pocket maximum, which is the portion you are required to pay above and beyond your deductibles and co-insurance.  Medicare Supplement plans typically have a deductible you have to meet if there is one and that is it, once you meet your deductible the plan takes care of the rest.


5.  What happens if I travel to Florida or outside of my normal area -am I still covered?

With Medicare Supplement plans, the only requirement is that the provider accepts medicare, then your benefits will take care of the rest up to your plan limits.  With a Medicare Advantage plan, you may only be covered in emergency situations or if there happens to be coverage you are typically exposed for much much more of the expenses incurred.  Make sure you look at your plan benefits summary to see what your true financial exposure is.


6.  Does it cover prescriptions? Glasses? Dental?

Medicare Supplement plans do not cover prescriptions glasses or dental, you will have to obtain a separate policy for these coverages.  Medicare advantage programs are not required to offer all of these benefits but you may find some plans that incorporate some of these benefits within your plan. 
There are some Medicare Advantage plans that do have prescription coverage included, however the included prescription plan may not be the best option for you.  Make sure you look at all options before you choose a plan.


7.  What does the coverage cost, and will my rates go up?

Typically the Medicare Advantage have a lower monthly premium when compared to a Medicare Supplement program, however your potential total expenses each year may be 2x, 3x, maybe even 5 times the amount you would spend on a Medicare Supplement plan.  Don't just look at the monthly, also factor in your doctors co-pays, deductibles, and out of pocket expenses you would be responsible for during the year.
As for rates going up, just as with any other type of insurance program, rates do change from time to time because they have to compensate for their actual expenses. How much do Medicare Supplement policies cost? More information on premiums can be found here.
Medicare Advantage programs on the other hand also have one other factor you may want to consider, the current administration has made many statements and started to take action towards reducing the funding for the Medicare Advantage programs, because of the fact that it costs Medicare more than Original Medicare benefits.  Which as an agent concerns me as to what will happen to the benefits of those programs over the long haul.


8.  As my agent, how much commission will you make?

Each company sets a commission amount that they are willing to pay an agent or advisor to recommend their product.  The companies pay the agents directly so you should never have to pay an agent for their services.  The other thought process is that you are paying that agent for their services by being their client, so are they thinking about more than what they are going to make for each sale.  Medicare Advantage commissions are approved by Medicare and released by the private companies,  depending on the situation there may be more of a financial incentive for an agent to place you in on product instead of the product that is best for you.   Do not be afraid to ask your potential agent how they will be compensated for that product they recommend, compared to other potential products.

Paying For Home Health Care - What Do Medicare and Medigap Cover?

Prescribed only by a physician, home health care is skilled nursing care that aids in the recovery from illness, injury, or surgery in the patient's home. And fortunately for many seniors who are now opting for care at home, Medicare insurance covers most costs related to home health care.

The government, however, has set some limitations on payouts - you are only eligible if you need intermittent care (usually defined as seven days a week or less than eight hours a day over 21 days or less) (1), physical/occupational therapy or speech language pathology; you are homebound; and the home health care agency providing care is approved by your Medicare insurance program.

In addition to medication administration, general supervision, and therapy services, the Medicare home health benefit covers a number of other necessities, including medical aids and supplies to aid in recuperation. On the occasion, though, you may be required to cover some of the costs associated with home health care. But what can you expect to pay out-of-pocket that's not covered by Medicare dollars?

Medicare Insurance: Part A and Part B

Hospital Insurance (Medicare Part A) helps cover the costs of your inpatient care at hospitals, skilled nursing facilities, or religious non-medical health care establishments. Part A can also help cover hospice and home health care services. Individuals aged 65 and older are usually automatically enrolled in Medicare Part A and do not have to pay a monthly premium if Medicare taxes were paid while working. If you did not pay taxes, you are still eligible, but you will be required to pay a monthly premium.

Medical Insurance (Medicare Part B) helps cover services such as those offered by your physician and outpatient care. Many seniors maintain their enrollment in Part A, but elect not to use Part B, which requires a monthly premium that is dependent upon income, the requirements of which change yearly. Unfortunately, if you didn't sign up for Part B when you were first eligible for insurance, your premium may be slightly higher (2).

For questions on your Medicare insurance benefits, you should contact 1-800-MEDICARE or read the handbook mailed to you each year entitled "Medicare and You."

What's Covered and What's Not

Medicare insurance pays for physical and occupational therapy and speech language pathology services, counseling, some medical supplies, durable medical equipment (which must meet coverage criteria), as well as general assistance with daily activities which include dressing, bathing, eating, and toileting. For most other medical equipment, Medicare insurance will cover 80% of its cost (3).

However, Medicare will not cover twenty-four hour care at home, meals delivered to your home, and services unrelated to your care such as housekeeping. Of course, as mentioned above, you will be required to pay 20% for medical equipment not fully covered by Medicare insurance such as wheelchairs, walkers, and oxygen tanks (4).

In some cases, your home health care agency may present you with a Home Health Advance Beneficiary Notice (HHABN), which, simply put, means if your agency is ceasing your care services, you will be presented with a written statement outlining the supplies and services the agency believes your Medicare insurance benefits will not cover as well as a detailed explanation of why. Should this situation arise, you do have recourse - the HHABN lists directions on acquiring the final decision on payment issues or filing an appeal if Medicare refuses to cover costs for home health care. In the meantime, you should continue receiving home health care services, but keep in mind that you will be paying for these services out-of-pocket until Medicare accepts your claims and remits past expenses.

Medigap and Other Out-of-Pocket Expenses

Medigap, a supplemental insurance policy, is sold privately and covers the services and supplies not paid for by Medicare insurance. When used in conjunction, Medigap and Medicare can often cover a large majority of the costs of your home health care. Insurance companies offer a variety of different Medigap policies (A through L), but since each one comes with specific benefits, you'll need to compare the highlights closely. Medigap policies vary by cost, and many insurance companies require you to have both Medicare Parts A and B in order to purchase a supplemental plan (5).

For seniors with both Part A and Part B Medicare, your home health care situation is usually covered, save for the 20% out-of-pocket expenses for medical equipment. Just remember to keep track of your Medicare insurance benefits (and Medigap if applicable) by verifying with your physician, home health care agency, and insurance representative. Paying for home health care does not have to cost you an arm and a leg, but do be prepared for the occasional (but necessary) out-of-pocket medical expenses.

Sources

1. Centers for Medicare and Medicaid Services, Medicare and Home Health Care, page 6

2. Medicare website: "Your Medicare Benefits."

3. Ibid.

4. Ibid.

5. Medicare website: "Medigap (Supplemental Insurance) Policies."

Jill Gilbert is the President and CEO of Gilbert Guide, a comprehensive website helping seniors and their loved ones find a senior care provider along with extensive tools and resources to solve the challenges of aging. She is the author of "Leading by Example," a monthly column in McKnight's Long-Term Care News, the chief industry publication for long-term care providers. Jill has been interviewed for a CBS News special, was a key presenter at the Pennsylvania Assisted Living Association's annual conference, and was recently interviewed on San Francisco TalkBack.

Gilbert Guide was founded on the concept that quality matters, and its primary goal is to educate consumers on a breadth of senior care issues. Visit http://www.GilbertGuide.com for a comprehensive provider database, expert advice, and quality assessment tools that help consumers conduct their own "expert" evaluations of providers.

Medicare Supplement Insurance Helps to Make Sense of Medicare

Many of those over 65 who saved for retirement have retained greater economic flexibility than those hit by layoffs while still trying to amass savings. That makes seniors a very desirable market for several industries. In fact, senior marketing is the fastest growing marketing segment today.

In sharp contrast, one of the biggest marketing failures that can have seriously harmful complications for those over 65 surrounds Medicare. With multiple parts, two deductibles, partial coverage (only 80 percent) for doctors' services, no coverage at times (such as when you travel outside of the U.S.) and no reconciliation when doctors charge above what Medicare will pay, Medicare is a maze of contradictions. How do seniors calculate and plan for their health care costs?

In truth, both people under and over age 65 find Medicare often to be obscure and some simply give up in confusion. It's a sad comment on the "information age" that we haven't explained Medicare's coverage in a way that allows many seniors to estimate their expected health care costs and plan accordingly.

Medicare Supplement Plans Help to Translate Medicare's Coverage

Private insurers marketing Medigap insurance must explain Medicare, at least in part, to show the need for their plans to protect seniors from all the health care charges that Medicare won't cover. For many, private insurance companies discuss Medicare in ways that are more direct and more comprehensible to give seniors a better overall understanding of where the holes in Medicare's coverage put them at risk. The risk is real because hefty doctor and hospital bills far too often devour retirement savings forcing seniors to reduce their standard of living. Health care costs may be the single biggest concern for many seniors because their need for health care grows as they age and because health care prices are spiraling out of control.

A Medicare Supplement Can Cut Seniors' Medical Bills down to Size

With existing Medicare benefits in jeopardy (Medicare was extended beyond it's predicted bust in just eight years), baby boomers and seniors are exploring alternatives, such as Medicare Advantage plans and Medicare Supplement plans.

In the face of the new health care laws, Advantage plans are beginning to lose their subsidies. It's expected that these plans will become increasingly expensive with the decline of government subsidies. Medigap insurance, often called Medicare supplement insurance, is a viable alternative. With 10 different plans, each one fills the gaps in Medicare in a slightly different way so seniors are free to choose only the benefits they need without paying for any extras. Medigap plans cover Medicare's Part A and Part B deductibles to make seeing the doctor and going to the hospital when you need more affordable. These plans can also cover Medicare's co-pays and co-insurance charges, and certain plans expand Medicare's coverage to services beyond Original Medicare, such as emergency medical care when you're out of the country.

Confusion over Medicare Has Left Seniors Unprepared for Health Care Debt

Although millions are now enrolled in Medicare in order to pay for their health care needs, many remain unprotected simply due to a lack of understanding about the intricacies of the Medicare system. One of the biggest misunderstandings involves the Medicare "pre-approved" amount. Medicare only pays for 80 percent of a standardized amount for procedures. That doesn't stop doctors from charging more; it just shifts the burden of payment onto the patient. Doctors can continue to charge their regular fee, Medicare can continue to pay its standard payment and it's up to you to make those ends meet. Getting the right information is crucial to getting the most out of Medicare, and Medicare supplement insurance is one key to bridging the gaps in Medicare coverage.

By Wiley Long - President, MedigapAdvisors.com - The nation's leading independent agency specializing in Medicare Supplemental Insurance. Our professional MediGap advisors look forward to the opportunity to help you get the best insurance for your Medicare needs.

The Medicare System and Senior Citizens

Medicare benefits are, inevitably, something we must all become familiar with as we get closer to retirement age. However, what exactly is medicare? When did it begin? And what is its purpose? Here is a brief outline of the federal government's medicare program, including its history and the rationale for its existence.

Medicare came into existence in 1965. It was created as one of the component parts of then-President Lyndon B. Johnson's "Great Society" initiative. The principal purpose of medicare was to provide a system of healthcare for elderly U.S. citizens, i.e. individuals who were sixty-five years of age or older.

However, medicare benefits are not simply for the elderly. Medicare is also availabe to individuals who are younger than sixty-five and who are disabled.

Qualifying for medicaid benefits on the basis of disability status, of course, requires that a person file an application, or initial claim, for title II benefits with the social security administration. Title II benefits are mandated under title 2 of the social security act and title II benefits are commonly referred to as social security disability benefits, or SSD.

Individuals who are approved for social security disability benefits are eligible to receive medicare benefits two years after their date of entitlement has been established and, no doubt, this provides for a healthcare safety net for disabled citizens who must subsist on a relatively small monthly disability benefit.

Who is eligible for medicare? Fortunately, unlike supplemental security income and medicaid benefits, medicare is not considered a needs-based program. In other words, younger individuals who are disabled and individuals who are of retirement-age may be eligible without regard to their income.

Until recently, medicare benefit coverage was thought of primarily in terms of hospital insurance and medical insurance. Medicare part A covers hospital visits and nursing home stays, while medicare part B pays for outpatient care and services, including doctor's visits, xrays, and lab reports. However, the medicare program was recently restructured to include a prescription drug benefit. This is known as medicare part D.

Medicare part D went into effect on January 1st, 2006, as part of the Medicare, Prescription Drug Improvement and Modernization Act. Medicare Part D is available to any individual who is eligible to receive medicare part A and medicare part B benefits. The intent of medicare part D is to guarantee prescription drug coverage for medicare beneficiaries. However, the federal government does not actually provide this coverage. Prescription drug coverage under medicare part D is provided by independent drug plans that are actually operated by private health insurers, though, legally, such plans are regulated by the federal government, i.e. the medicare program.

Are medicare benefits free? No, medicare part B requires the payment of a monthly premium which, for 2006, was $88.50. However, for those individuals who might have difficulty paying this premium, an assistance program is available to qualified individuals to pay part B premiums. This program is known as MQB, or medicaid for qualified (medicare) beneficiaries. Like other types of medicaid, this particular medicaid program is needs-based and serves no other purpose than to pay a medicare recipient's monthly medicare insurance premium.

The Medicare program may well be the most transformational program to arise as a result of Lyndon Johnson's Great Society initiative, and its effect, in many ways, may be as profound as the creation of the social security program under President Franklin D. Roosevelt. Recent estimates hold that medicare accounts for more than a tenth of all federal spending and approximately one-third of healthcare spending.

The author of this article is Tim Moore, who, in addition to being a former food stamp caseworker, medicaid caseworker and AFDC caseworker, is a former disability claims examiner. He publishes a blog on the disability process which is titled the Social Security Disability and SSI blog

Medicare Part D Insurance - An Insurance Plan That Covers Prescription Drugs

It is humanly impossible for anyone to know all there is to know, the same can be said about the world of insurance. There are various kinds of insurance; however, we are looking at Medicare part D insurance. If you are not armed with information regarding Medicare part D insurance read on to educate yourself on the same. When it comes to Medicare part D insurance one should be sober minded and not get carried away with all the various options. In reality Medicare part D insurance is related to the prescription drug part of the program. In order to be actively involved in any of these insurance plans a person needs to first establish the fact of eligibility. One should bear in mind that there is no stringency when it comes to sign up for any part of the program, it is human nature to experience agitation, and a person always tends to foresee medical expenses. Due to this foresight many are being lead to sign up for Medicare part D insurance. If you qualify for part A and B then automatically you will qualify for the Medicare part D insurance coverage as well.

Regardless of whether you are enjoying the best of health presently you should consider enrolling for the part D insurance as this will come handy if at all there are high medical expenditures in the future. It will be possible for you to get help through the co-payments and premiums. However, if you neglect to enroll in the initial stages you are liable to pay a penalty if you intend to enroll at a later stage. Remember that some of these Medicare options extend to future needs as well as current ones, if at all you have coverage in the present time you can keep that as well. The benefits of enrolling for the plan as early as possible lower the monthly premiums, co-pays are taken away and the waiving of deductibles. The downside of not qualifying for additional help where costs are concerned a person is held responsible for the yearly deductibles, respective co-insurance amounts for prescriptions and monthly premiums. It would be wise on your part if you opt for plans that have a low yearly cost. Co-payments, premiums and deductibles as well as any other cost that needs to be paid over the coverage gap, the gap that is being spoken about here is the amount of prescription expenditure that is shelled out by an individual after exceeding the benefit amount due per year has been exhausted.

When it comes to the Plan D insurance plan there are certain drugs that are covered by the same, other supplement plans are available and help a person pay for prescribed drugs. The supplement plans later help pay for generic drugs or brand names. It is clearly mentioned in every Medicare part D insurance plan as to how much a person is liable to pay for a particular drug or if they are restricted from the same. It is imperative that you scrutinize each Medicare part D insurance plan and find the one that covers a wide range of prescription drugs.

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