Understanding Medicare

Understanding Medicare.

If you are ill, your health care coverage is the most important financial piece and keeping you on your treatment plan. I want to take a moment to give a high level overview of Medicare.

Surprisingly, few people really understand this program and what it covers and what options you have and don't have. Additionally, people don't really take the time to review their options after enrolling.

Medicare is a health plan system funded by the government on behalf of Americans that are 65 years old or older.

You can sign up for this benefit up to three months before you turn 65. If you want the coverage to be effective on your 65th birthday,

You will then have the month of your birthday and an additional three months after your birthday to sign up.

If you do not sign up during this time, you will have to wait until the next enrollment period, which lasts from October 15th to December 7th. There are different parts to Medicare because Medicare is a government funded insurance.

Seniors have few options when signing up. You can either sign up for traditional Medicare, which is Medicare Part A and B, or you can sign up for Medicare Advantage or Medicare Part C, The prescription drug program is Medicare Part D, that you have the option for enrolling in. Medicare Part A is your traditional hospital and home health care insurance.

It covers services related to doctor's visits, ambulance services and mental health services, among others.

Many also believe it's for nursing home care. We will talk more on this a little later on. If you sign up for Medicare Part A and B, you can go to any hospital in the country that accepts Medicare patients.

Keep in mind there is no monthly premium for Medicare Part A, but there is a monthly premium for Medicare Part B.

Medicare Part B covers two types of services.

First, it covers medically necessary services.

These are services or supplies that are needed to diagnose or treat your medical condition. Second, it covers preventive services, meaning health care to prevent illness or detect it at an early stage. You pay nothing for most preventive services if you get the help from a health care provider who accepts assignments.

Part B covers things like getting a second opinion before a surgery, limited outpatient prescription drugs., clinical research Analyst service., durable medical equipment, mental health, inpatient care, outpatient care, a partial hospitalization.

Medicare Part C or Medicare Advantage are private insurance programs administered by health insurance companies.

These plans must offer the same coverage as traditional Medicare plans, except for the hospital coverage, which is covered under their traditional Medicare Part A program.

However, Medicare Part C must also offer additional services and coverages that are not covered in traditional Medicare. Unfortunately, this coverage is restrictive in that it does not allow you to visit any doctor you want. Does Medicare pay for a nursing home costs or long term care needs? Medicare does provide limited nursing home calls. Medicare Part A covers institutional care in hospitals and skilled nursing facilities, as well as certain care given by home health agencies and care provided in hospice.

Medicare Part A will cover up to 100 days of skilled nursing care per incident of illness. However, guidelines must be met and they are quite stringent. The recipient must have entered the nursing home no more than 30 days after a hospital stay for which they receive treatment and must have been in the hospital for at least three days, not including the day of discharge.

The care they receive at the nursing facility must be for the condition that cause the hospitalization or for the condition related to the hospital stay. The patient must receive skilled level care in the nursing facility that cannot be provided at home or on an outpatient basis. Skilled means a nursing home must be ordered by a physician and delivered by or under the supervision of a professional such as a physical therapist, registered or a licensed practical nurse.

The care must also be delivered daily.

First, many nursing homes assume that if a patient has stopped making progress toward a recovery, the Medicare coverage should end.

They should understand instead that if the patient needs the skilled care in order to maintain his or her status, or to slow or prevent deterioration. Then care should be provided and is covered by Medicare. Second, many nursing homes falsely believe that the care in the facility must be given directly by a skilled nurse and are therefore excluded from Medicare, a skilled nursing facility benefit. In fact, care could be given while being supervised by a nurse and still be covered by Medicare, a skilled nursing facility benefit.

Additionally, a patient may need a wide variety of treatments that do not require a nurse to directly provide. However, supervision by the nurse may be required to monitor the patient's care and status to prevent adverse interactions among the treatments.

Medicare, in this instance, will continue to provide coverage when a patient leaves a hospital and enters a nursing facility, the nursing home will provide Medicare coverage.

The nursing home must give the patient a written notice of whether the nursing home believes that the patient requires nursing home, at which point the Medicare is merited. Unfortunately, even though the skilled nursing facility may initially treat the patient for several weeks, often the skilled nursing facility will determine the patient no longer require skilled care, and will issue a notice of non coverage terminating the medical coverage.

Even if the non coverage determination is made prior to or even after treatment at the skilled nursing facility, the patient is offered a notice asking if they would like the bill to be submitted to Medicare despite the nursing home assessment of the patient's care needs.

The patient or the legal representative should always ask for the bill to be submitted. This requires the facility to submit the patient's medical records for review to the fiscal intermediary and insurance company hired by Medicare, which reviews the facility's determination. This review is free of charge to the patient and may result in more Medicare coverage. Also, while the case is in review, the patient is not responsible for the bill.

This appeal can take a year as well as a need to hire an attorney. This appeal should only be pursued if after reviewing the patient's medical records, the lawyer believes that the patient was receiving a skilled level of care that should have been covered by Medicare.

If you get to this point and are still turned down, there are subsequent appeals to the appeals court in Washington and then to federal court.

In order to make sure you have chosen the best coverage for your unique situation.

It is best to talk to an expert that can go over your unique health situation and other credible coverage options you may have and the costs associated with this plan. There are late fees or exclusions that some of their choices are not made in a timely manner. You can get additional information from www.medicare.gov.

You can also get in touch with a local expert on Medicare.

 

Medicare savings accounts.

This is a type of consumer directed Medicare Advantage plan or Part C that is similar to health savings accounts.

With a MSA account, you are not in a network of doctors or other health care providers or hospitals.

MSA is combining a high deductible insurance plan with a medical savings account to pay for your health care expenses.

You are responsible for handling your account, including deciding whether to pay for your health care services, using your account funds, or using other funds, you may have.

MSAs are composed of two parts. The high deductible health plan. This is a type of high deductible plan that only starts to cover your cost for health care after you have met a yearly high deductible.

These deductibles can vary by plan.

Medical savings accounts.

This is a type of savings account where Medicare will deposit money into your account each year for your health care expenses.

The amount is based on your plan is deposited into your account once a year, beginning of the year or calendar year, once a year, beginning of the year or calendar year,

or you're entitled to Medicare in the middle of the year based on your birth date and your joining and MSA at that time.

The plan will deposit money into your account the first month that your coverage starts.

You can use this money to pay for uncovered expenses until you meet the plan's deductible.

Again, you should check with your plan provider.

The yearly deposit and your yearly deductible are pro-rated based on when you're re-enrolled, it begins.

Contact the plan.

You're interested in joining for enrollment.

Go to this website, medicare.gov to see what plans are available in your area.

They will give you instructions as to how to set up the account and the think that that plan chooses.

You must set up the account before enrollment can be processed.

You will receive notification when coverage begins.

Are there other insurances that can work with your plan, such as dental and vision?

Are there any preventative services that need to be met prior to meeting the deductible?

You can't enroll in the MSA plan if you're on Medicaid.

You have health coverage that would cover the Medicare MSA deductible, including benefits under employer or union retiree plans.

You do on another Medicare Advantage plan or you get benefits from the US Department of Defense, which is TRICARE

or, the U.S. Department of Veterans Affairs.

If you're a retired federal employee and part of the Federal Employee Health Benefits Program,

and if you're currently getting hospice care, if you live outside the US 183 days of the year.

You can leave a MSA plan, if you change your mind.

You can cancel your enrollment by December 15th of the same year of your enrollment during the open enrollment.

If you would like to choose another health drug plan.

After December 7th and after December 15th,

you can only return to the original Medicare Part A and Part B.

If you leave the plan before the end of the year,

no more money will be deposited into your account because a yearly amount was deposited into the account at the beginning of the year.

You will need to reimburse Medicare part of the most recent yearly deposit.

Your MSA account can be canceled or disenrolled by Medicare if you get Medicaid, you enroll in a federal employee health benefits plan,

you get benefits from the U.S. Department of Defense,

you get benefits from the U.S. Department of Veterans Affairs,

you get benefits that cover the MSA plan deductible and you move outside the service area of the plans for more than six months.

Important point to remember about the MSAs.

These plans do not have a monthly premium.

However, you must continue to pay your part B premium.

you will need to determine if you need a prescription coverage plan,

at which point you will need to enroll in a separate Medicare prescription plan Part D, standalone.

You don't have to choose a primary doctor, nor will you have to get a referral to a specialist.

MSA plans to cover the Medicare services that all Medicare Advantage

plans must cover.

They may also provide additional benefits such as digital, dental and hearing services.

However, it's possible you may have to pay a premium for the extra coverage.

Here is important to note,

your plan cannot charge more than the original Medicare for certain services like chemotherapy, dialysis and skilled nursing facility care.

If your plan gets you prior approval for treatment,

the approval must last for as long as the treatment is medically necessary.

Additionally, your plan cannot require you to get additional approvals for that treatment.

If you are in the middle of getting treatment and you switch plans, you have 90 days before the plan

can require you to get a new prior approval for your ongoing treatment during the time you are paying out of pocket for services

before your deductible is met,

your medical providers cannot charge you for more than the

Medicare approved amount.

If you do not use all of the money in your account at the end of the year,

the remainder will remain in the account for future year costs.

As always, remember to review your plan

and speak to your health care providers about your current and ongoing treatment.

Make necessary changes accordingly.