The Medicare Factor in Long Term Care Planning

Medicare and Health Insurance History in the United States With a vision to provide a universal health plan, such as Medicare, the United States does not truly have a national health care plan. Even though universal health care, another name for national health care plans, has its conception in the 20th century, the United States has shied away from its inception. In fact, the United States is one of the few industrialized countries that do not offer true, government provided universal health care.

The first private health insurance programs created nation wide was the Blue Cross plans. Originally paid by individuals on prepaid bases for certain hospitals, this was later changed to include any sponsored hospital. The individual would provide a monthly payment that ensured he was cared for a specified number of days.

The Blue Shield plan was another plan created during the 1940s. It allowed the prepayment for doctor services. The plan’s creation provided an alternative to a national health care plan. The Blue Shield and Blue Cross plans eventually merged, forming what we call today Blue Cross Blue Shield.

There are varying reasons that a national health care insurance plan has not taken hold in the United States. As the American Medical Association has opposed the establishment of a national plan, the employer sponsored insurance plan has added the catalyst to not create a national plan. Since the employers can write off the plans provided to their employees, Congress has not received any push to change the concept of employer-sponsored plans.

The closest conception of universal health care the United States institutionalized is Medicare. Medicare was created in 1965.

Then Came Medicare

So how did Medicare take hold? Though it is not a true national health care plan for everyone, only for those over 65, it is because of President Lyndon B. Johnson and a majority of Democrats in both houses of Congress that the plan came into existence.

Attempting to provide a plan comparable to the private sector, the creation of Medicare part A came about. By mimicking the current plans, Medicare part A provided a determined amount of hospital care. Any more care beyond what the plan stated was to be paid by the patient.

The disadvantage to a plan such as this is the increasing expense of hospital care. The costs paid by the insured are now at a level to completely destroy financially that individual. In other words, as expenses have increased with hospital care, Medicare Part A has not kept pace. Therefore, any difference in cost is paid for by the patient.

This realization gave way to catastrophic plans. These plans allow the insured to pay for some of the upfront costs up to a predetermined out-of-pocket limit. Once that is reached, the insurance pays 100% of the cost. Unfortunately, Medicare has not evolved into this type of arrangement.

As such, we are beginning to see the bankruptcy of the plan, as well as the bankruptcy of the insured attempting to cover their part of the insurance plan.

Medicare part B evolved into a plan to encourage doctors to be paid by the federal government with the attempt to not institute price controls by the same. Under the original intent, Medicare part B paid for 80% of a doctor’s services while the patient paid the other 20%, and any fees above the reasonable costs.

However, the plan has degenerated into a government price control plan, where the government dictates to doctors what they will be paid for services the doctors provide.

Medicare Eligibility

Medicare enrollment takes place only one time during the year. The time frame usually is between October and December of the year prior to its activation for an individual. To learn more of the enrollment process for Medicare, read this publication: http://www.medicare.gov/Default.asp .

Most individuals understand that to enroll one must be age 65 years or older. However, most may not know that they also must be eligible for receiving Social Security or Railroad retirement. Furthermore, the individual does not need to be receiving either one of the retirement payouts, but one must be eligible to receive them.

In short, you can receive Medicare without receiving Social Security or Railroad Retirement income. You probably know someone who has decided to continue working. As such, they have delayed their receipt of government retirement payouts. However, to ensure a medical benefits plan, they have signed up for Medicare.

When you sign up for Social Security or Railroad retirement at age 65, or decide to receive payments at 65, you are automatically enrolled in Medicare Part A and Part B.

If an individual under 65 is disabled, and has applied for and receives Social Security disability for two years will receive Medicare. Furthermore, if a person of any age with end-stage renal disease may also receive Medicare.

Anyone born after 1938 will not receive their full retirement benefits from Social Security until the age of 67. Due to this, most individuals may decide to continue working. As such they will not apply for Social Security at the age of 65, thus not automatically receiving Medicare Part A.

Or, if the person is under a group plan, he or she may be forced into enrollment in Medicare at the age of 65. The person will not lose their group coverage, but it will be shared with Medicare.

I Have A Group Plan

Returning to the previous situation where an individual continues to work, or not retire, and not having a group plan, he or she may not receive a reminder to sign up for Medicare Part A. Fortunately, there will not be any penalties. However, he or she will only be allowed to sign up during a specified period during the year.

As for Medicare Part B, there is a penalty. You must sign up for Medicare Part B either three months before or after your 65th birthday. Otherwise, a penalty will be assessed against the premiums. However, if a person is covered under equivalent group coverage or is on Medicaid, the penalty is waived.

Though Medicare Part A is paid via payroll deductions and there is not cost when implemented, this is not the case with Medicare Part B. Medicare Part B is a cost-sharing plan.

The premiums for Medicare Part B are $88.50 (for year 2006). However, these premiums increase every year as the cost of medical services increase. Beginning in 2007, for those individuals in high-income brackets, they will pay a higher premium as a percentage for Medicare Part B.

The increases are phased in over a five-year period. The increases are scheduled as such:

income of: $80,000 -$100,000: 65% subsidy
income of: $100,000-$150,000: 50% subsidy
income of: $150,000-$200,000: 35% subsidy
income above: $200,000: 20% subsidy
If you are married, the incomes are twice what are depicted. However, for both individuals and married couples, the income ranges increase annually based on the Consumer Price Index (CPI).

I’m Not Eligible for Social Security

What about those individuals who are not eligible for Social Security and their spouse is not eligible either? That person can still get Medicare but will pay a premium, which may be equivalent to the Medicare Part A premium.

Eligibility for Social Security requires at least 10 years, or 40 quarters, under the system or paying into the system.

You do not have to participate in the Medicare program. However, if a person does not participate in Part A, they are not allowed to participate in Part B. If the person, though, must pay premiums for Part A, they can elect not to, and instead purchase Part B. It also works the other way. If you do not desire to participate in Part B, you do not have to.

To sign up for Part B, it must be done so during the first three months before the month of an individual’s 65th birthday, or three months after. This equates to seven months to sign up (3 months before and after, and the individual’s birthday month).

If an individual does not sign up for Medicare Part B during the initial period, they are penalized. The penalty is 10% for each full 12-month period the individual does not sign up. A person can sign up for Part B between January 1 and March 31 if they do not sign up during their initial enrollment period – the seven months mentioned earlier.

Can I Afford Not To Have Medicare Part B?

But what of the individual who cannot afford the premiums for Medicare Part B? Most individuals who are affected in this manner may be able to receive assistance through Medicaid or a state’s Medicare Savings Program. Normally, someone must meet the state’s requirement of limited income and resources. The plan will pay for Medicare premiums and possibly Medicare deductibles and coinsurance.

A situation which may help with understanding may include a person who receives Medicare Part A (which the Medicare Savings Program might pay the premium) and

He or she has resources equal to or less than $4,000; a couple would be $6,000. The resources may include monies in checking or savings account, stocks or bonds.

He or she has a monthly income of less than $1,068; a couple would be $1,426 (as of 2005; Alaska and Hawaii have higher limits).

If you are an individual that is 65 or older and still working with a group insurance plan, there are solutions to Medicare Part B. Most individuals under this scenario will continue with their group plan and use Medicare Part A as their secondary, or supplemental, insurance. However, they may not need the Part B.

But what if they do need Part B? As mentioned earlier, would they not be penalized if they signed up later? There are special rules for someone under a group insurance plan that allows them to sign up for Part B without a penalty.

If an individual is retired but has continued with a group plan under an agreement with the company, there are waivers to allow for coverage of Part B. However, the waiver only takes effect if the person loses their group coverage in the future.

If you are one of the aforementioned individuals who need to take advantage of these waivers for Medicare Part B, then you will need to apply during the Special Enrollment Period.

Study Up So You Don’t Have To Pay Up

Make sure you go to the Medicare link (http://www.medicare.gov/Default.asp) and read what you are entitled to. I don’t like that word, entitlement, but you have paid for Medicare so use it. Just don’t abuse it. Make it part of your Long Term Care Planning so you can make it through your golden years.

T. Sydney Shinn Home Health Care Solutions [http://www.home-health-care-solutions.com]

A developer of technical health care solutions, a Crown Ministries budget counselor, and a family man, Mr. Shinn understands the challenges of today's families. After taking care of his own father for five years, he created Home Health Care Solutions to to provide the material that families need to make informed decisions on home care options.

Wonder if a loved one will be able to continue to live in their home as they mature? Discover information for families and seniors about in home care giving, in home care services, mental and hospice care, legal and financial planning to ensure that the elder family member is able to live in their home forever. The site provides guidance in preparing the retiree, family, caregiver and senior family member.

How to Select the Right Medicare Plan

Just deciding which way to go when choosing from the combination of different types of healthcare coverage is confusing for many people eligible for Medicare. For most people, having choices is a very good thing. But what about when you have thousands of plans to choose from?

When it comes to Medicare, you have nothing but choices. Depending upon your circumstances, you may want to stay with traditional Medicare, or Medicare Parts A and B. If you choose this path, you'll probably want to get a Medicare Part D (prescription drug) plan, too, to ensure your medications are covered. Or, you might be more interested in a Medicare Advantage plan, which can combine traditional Medicare with drug coverage and other benefits. You also may be interested in even more coverage, such as that offered through a Medigap (supplemental) plan.

Fortunately, help is available. A Medicare advisor offers education on available Medicare programs, answers questions, and offers detailed plans of action to get the most out of your insurance choices. You also should know the basics beforehand.

Traditional Medicare

Medicare Parts A and B, also known as traditional or original Medicare, have been around since 1965. Medicare Part A is free to most people who've worked and paid Medicare taxes for at least 10 years and provides people with inpatient hospital coverage. Medicare Part B, which costs most people $96.40 in 2009, covers outpatient medical expenses.

People who have traditional Medicare can see any doctor they want in any facility they want without a referral, as long as that doctor or facility accepts Medicare patients. But traditional Medicare's benefits are limited.

Not only does traditional Medicare not cover most outpatient prescription drugs, if a beneficiary uses their coverage frequently enough, it can get very costly. That's why we also have Medicare Advantage and Medicare Part D plans available.

Medicare Advantage Plans

Medicare Advantage, also known as Medicare Part C, combines Medicare Parts A and B in one plan so you can get your Medicare Part A and Part B coverage in the same place. Medicare Advantage plans also often include prescription drug coverage and other benefits not commonly found under traditional Medicare, such as vision and dental services.

This program works just like private insurance - you have different types of plans to choose from depending upon what type of provider access you want (for example, health management organizations (HMO), preferred provider organizations (PPO) and more) and what health conditions or prescription drugs you take. You also can choose from a number of different levels of coverage. All Medicare Advantage plans must offer at least as much coverage as that offered under traditional Medicare. If they offer prescription drug coverage, that coverage must meet minimum Medicare Part D standards as well.

Medicare Part D

Medicare Part D is prescription drug coverage. Like Medicare Advantage, Part D is offered by private companies who are reimbursed for providing healthcare coverage. Also like Medicare Advantage, a minimum amount of coverage is required for a plan to qualify as a Part D plan and many different plans, some with different levels of coverage, are offered throughout the United States. Part D plans are best for people who use prescriptions, but don't need to see their doctors often.

Medigap Medigap, or Medicare supplemental plans, is sold by private companies to fill the "gaps" in traditional Medicare. This includes the cost of deductibles, co-payments and coinsurance. It also may cover other services that Medicare does not insure. In 2009, there are 12 Medigap plans - A through L.

Although Medigap may offer some additional coverage if an individual chooses to keep traditional Medicare, you can't buy a Medigap plan if you have Medicare Advantage. Because most Medicare Advantage plans offer better coverage and frequently more benefits than Medigap, having both is usually unnecessary. You can have both Medigap and Medicare Part D, but it may be more expensive to do this than simply purchasing a Medicare Advantage plan instead.

Comparing And Contrasting

It's no wonder that people are confused. There are thousands of plans available throughout the United States, and an average of 40 Medicare Advantage and Medicare Part D plans in any given area.

This is where a Medicare advisor can come in handy. With so many options in just one area, choosing a plan might feel like throwing darts at a board. Using a Medicare advisor can help you narrow down your choices so you know which combination of Medicare coverage will work best for you and which plans will give you the best and most affordable coverage for your needs.

Jim Allsup writes for Allsup, a provider of Social Security disability, Medicare and workers' compensation services, including Allsup Medicare Advisor, Medicare assistance services for people with disabilities and seniors.

Medicare and Medicare Advantage Update 2010

Q. What are the changes to Medicare in 2010?

A. Medicare is made up of three parts: Hospital Insurance (Part A), Medical Insurance (Part B), and Drug (RX) Insurance (Part D). Part A Deductible for 2010 is $1,100 for a hospital stay of 1 - 60 days, $275 per day for 61-90 days, and $550 day for 91-150 days of a hospital stay (lifetime reserve days). After 150 days, you pay all costs for the hospital. Part A also includes Skilled nursing facility and some home health care but not long term care. Skilled nursing facilities is subject to a $137.50 per day co-insurance for days 21-100. Part B covers Medicare eligible physician services, outpatient hospital services and certain home health services and durable medical equipment. You pay 20% of the Medicare-approved amount after you meet the $155 deductible.

Part D coverage is for both short and long-term prescription needs not given in the hospital, coverage for both brand name and generic drugs and can differ dramatically from one company to the other. Part D is not deducted from your Social Security check.

Q. Can you explain the difference between a Deductible, co-pay(ment) and out of pocket.

A. The deductible is the amount you must pay for health care before Medicare begins to pay. These amounts can change every year. A co-payment is a partial cost you will spend to see the doctor. These can be zero or more. These are out of pocket which are costs that you must pay on your own because they are not covered by Medicare.

Q. What are the differences in HMO, PPO, PFFS, SNP and MSA plans?

A. Health Maintenance Organizations (HMO)- Just like the private sector, HMO is a group of doctors, hospitals and other care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You get your care from the provider in the plan.

Preferred Provider Organization (PPO)- Doctors, hospitals and providers that belong to the network and with most PPO plans, you can use doctors, hospitals and providers outside the network for an additional cost.

Private Fee for Service (PFFS)- These are sometimes referred to as regional PFFS since the doctor or hospital accepts payments from the insurance plan rather than Medicare. The Insurance plan decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare covered benefits.

Special Needs Plan (SNP) - A type of plan for people with chronic illnesses or conditions with special needs.

Medical Savings Plans (MSA) - A type of savings plan for those people who do not go to the doctor often but need a savings plan to pay some of the costs of the deductibles and co-payments.

Q. My Doctor takes Blue Cross but he does not take Medicare Advantage Blue Cross. What does that mean?

A. Medicare Advantage plans are a hybrid of coverage offered from an insurance company. When you are eligible for Medicare at age 65, you select Part C--Medical Insurance offered by a company. You still pay your premiums out of your social security check for Part B but the government pays the insurance company to administrate the benefits. These Medicare Advantage Plans appear to have many benefits and include Drug coverage (Part D). Medicare Advantage plans are the best of both worlds but they have some drawbacks. If your doctor is not a Medicare Advantage plan doctor, you will pay additional costs to see him/her but with most plans you can see another doctor (usually not available with HMO plan). You will be subject to separate deductibles and separate co-payments and often need a referral for approval before you can get care from the specialist. If you do not get a referral, the plan may not pay for your care.

Q. Since Medicare Advantage provides all Medicare health care through that plan, what if I don't like it? I have heard Doctors payments will be cut and the company I sign up with may stop insuring them. What protection do I have?

A. Since Medicare is a government provided plan for those 65 and older, you have many options for coverage. Every November 15 through December 31 you can switch from one Medicare Option to another--you can enroll in any Medicare Advantage or Part D at this time. This is called the Annual Enrollment Period. (AEP) Your new coverage would begin on January 1. From January 1 to March 31 Medicare members can make ONE plan change to a like kind. For example, you can change to another MA plan. The member CANNOT change Part D coverage during this time unless they have it with the plan they are leaving. This is called Open Enrollment Period (OEP). During Special Enrollment Period (SEP), members must enroll within 63 days of a special event. This is if you move outside the service area, move into or out of a long term care facility, loose credible prescription drug coverage, return to the US from another country or get assistance from the state in which you live, loose coverage under an employer or union either voluntarily or involuntarily.

Q. What other benefits do I get with a Medicare Advantage Plan?

A. You may get extra benefits by selecting a Medicare Advantage Plan. These may include vision, hearing, dental and/or health and wellness program including membership to a specific gym. Because you do not need to buy a Medigap or Medicare Supplement policy, the premium are supplemented by the government and are less expensive than a traditional supplemental plan.

Q. I hear there are many gaps in the Part D (Drug) coverage and I take 5 prescriptions a day. How do I get most of my drugs covered?

A. Every insurance company that offers Part D coverage has a written list of drugs. These include generic and brand name drugs. (Check the web sites or ask your agent for a printed formulary drug book.) Your plan may have several tiers and your co-payment amount depends on which "TIER" your drug is listed. Not all brand names will be covered and these can be very expensive if you have a high copayment or it is not listed. Always ask your doctor whether the drugs prescribed are available as generic. Be sure to ask your doctor whether you can split a high-dose version of the prescribed drugs as

they are often the same price as low-dose version or go to http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C7%7CWinXP&language=English&defaultstatus=0&pagelist=Home&ViewType=Public&PDPYear=2010&MAPDYear=2010&MPDPF%5FMPPF%5FIntegrate=N to compare drug plans in California.

Q. I like what I see--a policy issued by a leading insurance company that does not cost me the same as a Medigap or Medicare Supplement. Why should I buy a Medicare Supplement instead of a Medicare Advantage Policy?

A. That is a good question. If you can afford the individual premiums for a Medicare Supplement with a separate part D, you should do that. You can choose you own doctor as long as that doctor takes Medicare patients. Today many plans are a hybrid and some cost ZERO monthly premium and include a RX plans are also a PPO so people have the freedom of a PPO. As Seniors age, options and benefits become very important and we are here to help you decide which plan is best for you. Be confident in your Medicare Choices.

For the past 30 years, Karen Adams has been an independent insurance agent working primarily in Southern California. She has help hundreds of clients find the right insurance program to meet their needs. Rapidly approaching age 65, she decided to become as knowledgeable as possible about Medicare solutions. "I have written articles about Medicare Supplements and have insured clients who have reached Medicare age. Most Medicare Supplements (MS) are about the same and as long as a doctor takes Medicare he/she must accept the supplement their patient uses (not an HMO plan). Therefore, the advantage from one company over another is how easy they make their payment process, how patient orientated the company is, how large their network of Doctors and the premium they charge for the plan," says Karen. "Then came highly government regulated Medicare Advantage (MA) plans and the ball game changed. Now there is ZERO premiums with Drug coverage. What cost from $200 to $300 a month in premium in a supplement with a prescription drug card now appears to be free. What's that all about? Karen can help you untangle the web of MEDICARE insurance. Call her today or go to http://adamsinsuranceagency.com/ for your personalized quote.