Medicare Enrollment Periods – Do You Know the Difference?

More than 58 million people in the United States are enrolled in Medicare. But there is still medicare
a significant amount of confusion about how and when to make Medicare coverage choices. For information about the basics of Medicare and its different parts of coverage, read our Quick Guide to Medicare.

There are 4 separate enrollment periods that are important to getting access to Medicare coverage.

  1. The initial enrollment period happens once – when you are first eligible for
    Medicare. And, generally, it lasts 7 months (the 3 months before your 65th birthday, the month of your 65th birthday, and 3 months after your 65th birthday). If you are eligible for Medicare because you have received SSDI benefits for 24 months, your Medicare will begin in your 25th month of receiving SSDI benefits.
  1. And, each year, from October 15 to December 7, you can make changes to your Medicare coverage, which will begin on January 1. This is called the open enrollment period.
  1. If you are over the age of 65, but are still working, you have a special enrollment period of 8 months after your employer-sponsor group health plan or your retirement plan coverage ends.
  1. And finally, if you do not sign up for Medicare when you are first eligible during your initial enrollment period or your special enrollment period, then you can still enroll in Medicare, but you have to wait until the general enrollment period. The general enrollment period occurs each year from January 1 to March 31. Individuals can sign up for Part A and B during this time frame. Once enrolled in Part A and Part B, between April 1 and June 30, individuals can add a Part D plan or move to a Part C plan. However, even if you sign up for coverage on the first day of the general enrollment period, you still have to wait until July 1, for your coverage to begin.

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And, because you didn’t sign up for Medicare when you were first eligible, you will likely have to pay a late enrollment penalty:

  • Part A: you must pay a 10% penalty for twice the number of years you were eligible, but didn’t sign up.
  • Part B: you must pay a 10% penalty for each full 12-month period you were eligible, but didn’t sign up. You must pay this penalty on your Part B premium for life!
  • Part D: you must pay a penalty of 1% of the national base monthly premium, times the number of full months you were eligible, but didn’t sign up. You must pay this penalty on your Part D premium for life!

Part B Penalty Example:

David’s initial enrollment period ended August 31, 2015, but waited to sign up for Part B until the general enrollment period in February 2018. David waited 30 months to sign up, but this only included 2 full 12-month periods. (2 full 12-month periods x 10% = 20% penalty). David will pay a 20% penalty, in addition to his monthly Part B premium, for life!

Waiting to enroll in Medicare coverage can cost you a lot over time, so it is important to understand your options. For more information about Medicare enrollment and penalties, visit www.medicare.gov

Changes Coming to Medicare

There are a number of changes coming to Medicare. Individuals who are already enrolled and new enrollees should both be aware of these Medicare changes.

A New Medicare Card

Sometime between April 2018 and April 2019, you will be receiving a new Medicare card that will not have your Social Security number on it. The cards will have Medicare Changesa new Medicare Number on them, which will be unique to you. This change will keep your Social Security number more secure, and help protect your identity.

The Social Security Administration is asking you to make sure that your mailing address is up to date.  If you do need to update your address, you can do so by calling 1-800-772-1213 or at http://www.ssa.gov/myaccount. They are also warning you to be aware of anyone contacting you about your new card.  The Social Security Administration will never call you and ask you for private information to get your card.  And finally, don’t worry if your neighbor gets their card before you do.  It will take some time to mail our cards to every Medicare member.

2018 Medicare Costs

For 2018, the Medicare Part B Deductible will be $183.  The Part B Standard Premium will be $134 or higher, depending on your income (see chart).  However, most people who get Social Security benefits pay less than this amount ($130 on average). You pay the standard premium amount of $134 (or higher based on the chart below) if:

  • You enroll in Part B for the first time in 2018.
  • You don’t get Social Security benefits.
  • You’re directly billed for your Part B premiums.
  • You have Medicare and Medicaid, and Medicaid pays your premiums.
  • Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount.
If your yearly income in 2016 was You pay (in 2018)
File individual tax return File joint tax return File married & separate tax return
$85,000 or less $170,000 or less $85,000 or less Your plan premium
Above $85,000 up to $107,000 Above $170,00 up to $214,00 Not applicable $13 + your plan premium
Above $107,000 up to $133,500 Above $214,000 up to $267,000 Not applicable $33.60 + your plan premium
Above $133,500 up to $160,000 Above $267,000 up to $320,000 Not applicable $54.20 + your plan premium
Above $160,000 Above $320,000 Not applicable $74.00 + your plan premium

 

The 2018 standard Medicare Part D (the prescription drug benefit) Deductible is $405. Once that deductible is met, your costs break out as follows:

Deductible: $0-$405 100% paid by Participant until the deductible is met
Initial Coverage Limit $3,750 in total drug costs 75% Paid by Medicare 25% paid by Participant
 

 

Between $3,750 and $7,508.75 in total drug costs

Brand Name Drugs:

50% Manufacturer Discount

15% Paid by Medicare

 

Generic Drugs:

56% Paid by Medicare

 

35% Paid by Participant

 

 

 

44% Paid by Participant

 

Above $7,508.75 in total drug costs 95% Paid by Medicare 5% Paid by Participant

 

Medigap Plans C and F

One useful way to reduce your out-of-pocket Medicare expenses is to buy a Medigap Plan. These are supplemental Medicare plans that cover some of the costs that Medicare Parts A & B don’t cover, deductibles, and co-insurance amounts.  There are 10 different Medigap plans, each labeled with a different letter, each having a different level of coverage.  One of the most comprehensive plans is Medigap Plan F, which includes coverage of:

  • Part A hospital and coinsurance costs up to an additional 356 days after Medicare benefits are exhausted
  • Medicare Part A hospice care copayment or coinsurance
  • Medicare Part B coinsurance
  • Medicare Part B excess charges
  • Medicare Part A deductible
  • Medicare Part B deductible
  • First three pints of blood used in an approved medical procedure (annually)
  • Skilled nursing facility coinsurance
  • Foreign travel emergency coverage (80%, up to plan limits)

Another popular plan is Medigap Plan C.  Plan C covers almost everything Plan F covers.  The one difference is that Part C doesn’t cover something called “Part B excess charge”.  The www.medicare.gov definition of that is “If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.”

You can see why these 2 plans are so popular.  In 2015, Congress voted to close these plans to new people in 2020.  Meaning, if you are new to Medicare in 2020, you won’t have the option of choosing these plans or if you are a current Medicare recipient looking to change Medigap plans, these plans won’t be available.

Between now and 2020, seniors and people with disabilities need to think about this carefully.  Right now, people turning 65 or just switching to Medicare from an employer plan can be accepted into any Medigap plan they choose, regardless of their health.  If they want to switch Medigap plans later on, insurance companies can look at their health, and either turn them down for that reason, or charge them a hefty premium for a pre-existing health condition. So, your first choice is important.

That said, should you just jump and buy Plan F while you can?  Maybe not.  Experts expect the premiums on Plan F to rise after they close the plans because there won’t be any new, relatively healthy 65 years olds to offset the costs of the aging people already in Plan F.  So choosing a Medigap Plan F now could lock you into a very expensive plan in the future.

Experts are recommending people look at Plan G.  This is a plan that is almost as comprehensive as Plans F and C, but it does require you to pay the Medicare Part B annual deductible.

Will Medicare Plan F premiums go up too much?  Will you develop a medical condition that makes moving from Plan F to another Medigap plan too expensive? These are things to consider.  Medicare offers a really helpful grid comparison of the different Medigap plans at https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html#1319. Without a crystal ball, these choices are really hard, but know this, the clock is ticking.

How Medicare Covers Chemotherapy

Throughout our lifetimes, we enroll in health insurance for a variety of reasons. Medicare-ChemotherapyIt gives us access to doctors and provides preventive care and screenings for early detection of medical conditions. There’s no question, however, that the main reason we buy health insurance is to help us pay for major treatment if we are diagnosed with a serious illness such as cancer.

Many people who are new to Medicare or have been recently diagnosed wonder how Medicare covers various cancer treatments, such as chemotherapy. The good news is that Medicare provides extensive coverage of cancer treatment and cancer-related services.

Medigap supplemental coverage is also available to round out that coverage, help pay for your deductibles, and protect you from catastrophic out-of-pocket medical spending. Let’s look at how Medicare’s coverage of chemotherapy and other cancer treatments works:

The Parts of Medicare

Original Medicare has two parts. Part A is your inpatient hospital coverage, and this provides for your hospital room and some skilled nursing care. Part B is your outpatient coverage, which includes physician services, lab work, diagnostic imaging, preventive care, durable medical equipment, and much more. Part D provides prescription drug coverage. Click here for an explanation of Part C.

Although chemotherapy is often administered in a hospital or clinic setting, it generally falls under Part B, since chemotherapy is a treatment administered by a physician. Radiation treatment and some anti-nausea medications are covered under Part B as well, if the doctor prescribes them to you within 48 hours of a chemotherapy session. Otherwise, these would be covered under a Part D drug plan. Click here for a complete chart comparing drugs covered by Parts B vs. Part D.  In terms of chemotherapy coverage, this is how it breaks out:

  Covered by Part B Covered by Part D
Infusion drugs Drugs administered by an implantable infusion pump

 

or

 

Drugs administered by an external infusion pump that you use at home and your local DME contractor covers them under Part B.

Drugs administered by an external infusion pump outside of the home (i.e., in a skilled nursing facility or hospital) and your stay is not being covered by Part A or you do not have Part A.

 

Drugs administered by an external infusion pump that you use in the home, but your Durable Medical Equipment contractor does not cover them under Part B for use in the home.

 

Infusion drugs administered at home without an infusion pump at home. One example of this is an IV push.

Injectable Drugs The drug generally cannot usually be self-administered and your doctor provides and administers the drug to you. You can buy the drug at the pharmacy and it is either administered by your doctor or you administer the drug yourself.
Oral Anti- Cancer Drugs It is an oral anti-cancer drug that was once available only in an injectable form that was covered by Medicare. You or your doctor can administer the drug. It must be used to treat cancer. You use the drug to treat a condition other than cancer.
Oral Anti-Nausea Drugs (antiemetics) Must be related to cancer, used as a full replacement for intravenous treatment, and administered within 48 hours of cancer treatment. It can be administered by yourself or by a doctor. The drug is used for conditions other than cancer.

 

It is used more than 48 hours after cancer treatment or is not a full replacement for intravenous treatment.

Part B has a small annual deductible that you must pay. That deductible is $183 in 2018. Then, Part B pays for 80% of covered services that you receive. You are responsible for the other 20%. This is called your Part B co-insurance. There is no out-of-pocket maximum for Part B, so your expenses could be high.

That is why a Medigap plan can be helpful to pay for that co-insurance and other Medicare-related out-of-pocket costs, such as deductibles and copays. You can find out more information about Medigap plans here.  You may also find a Medicare Advantage plan helpful to lower your out-of-pocket costs.  For more about Medicare Advantage, click here.

Creating A Sanctuary At Home For Your Loved Ones

By Jane Jenkins, a freelance writer

More than 1.6 million new cases of cancer are diagnosed every year. When cancer Home-Sanctuarypatients hear their diagnosis, they know that a potential struggle lies ahead of them including surgery, treatment, and a change in lifestyle habits. If you’re living with a loved one who’s going through cancer, you can ensure that your home is a sanctuary for them. Research has found that one’s environment can have a large impact on mood, but a happy home environment is about more than having bright colors on the walls. Your loved one who’s been diagnosed with cancer will need privacy when they want to be left alone with their thoughts and a stress-free space where they can rest between treatments, for instance. Here are other things you can do to make them comfortable and happy.

Keep It Clean

Cleanliness is important for cancer patients, whose treatments can lower their immune systems. Clean floors, counters, and pay special attention to the bedroom. If your loved one spends lots of time in there, it should be spotless to prevent infection. Bedding should be washed in hot water once a week to kill dust mites. Mop the floor and make sure you use antibacterial household cleaners to kill germs.

It could also be a good idea for your loved one to get into the habit of kicking off shoes before entering the bedroom as any germs or pollen collected from the garden could end up in this room, where they can cause allergies. Allergic reactions are commonly reported with most chemotherapy medicines, so you want to avoid any triggers, such as dust and pollen.

Keep It Quiet

Many people who undergo cancer treatment experience sleep problems such as insomnia. It’s important to ensure quietness in the home as noise can create further stress by increasing one’s heart rate and blood pressure. Make sure your loved one’s bedroom is in an area of the house where there’s not a lot of noise from the road or neighbors as this will help them to relax. Cancer patients require lots of rest between radiation or chemotherapy treatments to regain their strength.

Make It Safe

You will need some important features to make your home safe and user-friendly for your loved one. Toilet grab bars that are mounted to the wall can make it easier for your loved one to lower and lift themselves up when they’re feeling weak or fatigued. Chairs in the shower can also prevent falls. Weakness and fatigue are common during cancer treatments, so you want to be sure that your loved one will be safe when walking around the house. Make sure that there aren’t any snags in the carpet that can trip them up. Place some chairs in risky spots, such as on the staircase landing or in the middle of a long passage, so that they can rest if they need to.

If your loved one is struggling with treatment side effects such as fatigue, having a resting place on or moving their bedroom to the ground floor of your home can help them avoid having to use staircases multiple times a day, which can be exhausting.

Boost Their Interaction With Nature

A lot of research has shown that just a few minutes of being in nature can decrease stress, anger and fear, while boosting one’s mood. If you don’t have a garden in which your loved one can walk and sit, make sure you bring more pictures of nature into the home. Even these have been shown to alleviate stress and boost feelings of wellness.

Pictures of nature can be good replacements for real plants if you don’t have a garden, or your loved one is receiving chemotherapy. Research has found that patients undergoing chemotherapy shouldn’t be around plants in the house. This is because indoor plants and flowers release mold into the air, which can cause infection.

Fill The Space With Love

It’s important that people feel that they can do the things they love in a space that allows them to enjoy this activity. For instance, if your loved one enjoys reading, a room with good lighting and a comfortable sofa can be a relaxing retreat for them. On the other hand, if they love to fix things, a workspace can be invaluable. Time to do what they love can provide a good distraction while providing a sense of normalcy.

Turning your home into a safe and comfortable sanctuary is important way to support your loved ones and allow them feel that they can relax, do things they love, and regain their energy in a healing place.

Medicare vs. Medicare Advantage: Know the Difference?

There are two ways to access Medicare coverage: Original Medicare and Medicare Medicare advantageAdvantage Plans.

Currently, 58 million people in the United States are enrolled in Medicare — of which 19 million are enrolled in Medicare Advantage Plans.

Obviously there is a great confusion about all things Medicare.  With the end of Medicare open-enrollment coming up on December 7th, we wanted to take this time to explain your Medicare options.

For more information about Medicare basics, read our Quick Guide to Medicare or watch our Medicare webinar.

If you aren’t familiar with Medicare Advantage plans, you are not alone.

  • 65% of seniors on Medicare are unfamiliar with Medicare Advantage
  • 49% percent of those enrolled in Medigap plans say the option of Medicare Advantage was not made clear to them when researching Medicare coverage options
  • 55% of those enrolled in Original Medicare say they either do not understand or do not know the difference between being enrolled in Original Medicare and Medicare Advantage only
  • 20% of those enrolled in Medicare Advantage report not knowing the difference between Original Medicare and Medicare Advantage.
  • 59% across plan type do not understand or do not know the differences between Advantage and Medigap plans

In Original Medicare, the government pays for your health care benefits.  In a Medicare Advantage plan, your health care benefits are paid through a private insurance company that has been approved by Medicare.  Medicare Advantage plans come in many plan types, but the two common types are HMOs and PPOs. And, they work just like private insurance HMOs and PPOs. There is a network of doctors that accept the plan, and your costs are lower if you go to an in-network doctor. In Original Medicare, you can see any providers that accept Medicare.

Medicare Advantage plans combine your Part A (hospital benefit), Part B (health insurance benefit) and sometimes Part D (prescription drug benefit) all in one convenient plan.  In addition to those benefits, Advantage Plans often offer coverage that goes beyond Original Medicare, such as:

  • Routine eye exams, prescription eyewear, and/or contact lenses
  • Hearing exams; some may include an annual benefit toward hearing aids
  • Routine dental exams and non-surgical restorations
  • Wellness and fitness programs (some even include discounted gym memberships)

The cost of a Medicare Advantage plan will vary based on the plan you choose, the insurance company that is offering the plan, and where you live.  You may pay your monthly Part B premium plus a possible additional premium charged by the Medicare Advantage plan.  Keep in mind that premiums, co-payments, and benefits can change from year to year, and vary greatly from plan to plan, and company to company.  Read the fine print carefully, especially concerning prescription drug coverage. One benefit to Medicare Advantage is that some plans offer an out-of-pocket maximum, capping the medical expenses that you pay out-of-pocket during the year.  Original Medicare does not have an out-of-pocket maximum.

If you choose to go with a Medicare Advantage plan, you need to understand that this plan replaces Original Medicare, it does not supplement it.  You can also not use Medigap plans (supplemental Medicare) with a Medicare Advantage plan. That said, having a Medicare Advantage means you are in the Medicare Program and under the same protections that all Medicare recipients receive.  Your plan will last an entire year, at which point you can change plans or revert back to Original Medicare.

For more information about Medicare Advantage Plans, visit:

Six Key Things You Need to Know During Open Enrollment

Open enrollment for plans sold in the Marketplaces started yesterday and we have Six Key Things to Know Open Enrollmentbeen hearing that there is still a lot of confusion. As a reminder, open enrollment is the time of year consumers can shop for a new plan or make changes to existing plans. For Marketplace and Medicare plans the plan won’t start until January 1, 2018. Employer plans may have different start dates, so check with your employer. Here are six key things you need to know during open enrollment:

  1. Health insurance can be confusing.
    1. Make sure you understand the key terms used in your health insurance policy. Watch our new video – Triage Cancer Presents: Health Insurance Basics to learn more. This information is useful regardless of where you get your health insurance coverage.
  2. Financial assistance still exists for most people who purchase plans in the marketplace.
    1. For 2018, 8 in 10 people have Marketplace health insurance options for $75 or less, a month. This is mostly due to the premium tax credits available to people based on their income level.
    2. Even though the Administration has said that they will no longer pay the insurance companies back for providing cost-sharing subsidies (aka cost-sharing reductions), the insurance companies still have to provide those discounts to consumers.
  3. Individuals shopping for insurance (regardless of where they get it – Medicare, employers, private companies), should be sure to do the math when comparing options!
    1. Often times we only look at the monthly premium of a plan. However, to accurately determine what a plan with cost you for the year, you have to do the math! Assuming that a consumer will reach their out-of-pocket maximum during the year, the way to do the math is to multiply the monthly premium by 12, then add that amount to the plan’s out-of-pocket maximum. You may be surprised to find that the bronze plan may not be your most affordable option.
    2. Consumers should also look at the network of doctors and hospitals, the other costs (e.g., co-payments, deductibles, etc.), and prescription drug coverage.
    3. For more information on how to pick a plan watch our webinar, Choosing Wisely: How to Pick an Insurance Plan or visit CancerFinances.org.
  4. Individuals who are eligible for Medicare are not eligible to purchase plans in the Marketplace. Visit http://medicare.gov for more information about plan options.
  5. Be wary of short-term health insurance plans.
    1. These plans may look attractive based on their low cost, but they are not considered creditable coverage and when they end, consumers typically aren’t eligible for a special enrollment period to buy a plan in the Marketplaces, which could leave them with a gap in coverage. Additionally, they do not have to include the consumer protections in the ACA and may be able to charge people with cancer more, or exclude covering cancer treatments.
  6. Open enrollment dates may vary depending on where you live.
    1. The federally run Marketplace will be open from November 1 – December 15; however, some states have extended their open enrollment periods.
    2. There are also some extensions available for people who were affected by the recent hurricanes. (see the link above)

Clarifying Open Enrollment

There has been a lot of confusion about open enrollment for health insurance coverage in the news and on social media and we want to clarify some things and share some news:

  1. Open enrollment to buy coverage for 2018 through the State Health Insurance Marketplaces has been cut from 12 weeks to just 6 weeks, running from November 1 to December 31. However, there are some additional things you need to know:
    1. If you live in one of the states below, your state may have decided to keep open enrollment open longer:
      • California – November 1 to January 31
      • Colorado – November 1 to January 12
      • D.C. – November 1 to January 31
      • Massachusetts – November 1 to January 31
      • Minnesota – November 1 to January 14
      • Washington – November 1 to January 1
    2. If you were affected by Hurricanes Harvey, Irma, or Maria, you also have access special enrollment periods, which extends the time you have to get coverage in 2017 or enroll in coverage for 2018.
      • Group A:
        • Timing: The date of the SEP qualifying event through December 31, 2017.
        • Eligibility: Individuals who experienced an SEP qualifying event between 60 days prior to the start date of the incident period and December 31, 2017 and reside, or resided at the time of the hurricane, in any of the counties declared as meeting the level of “individual assistance” or “public assistance” by FEMA.
        • What to do: Contact the Marketplace Call Center at 1-800-318-2596.
      • Group B:
        • Timing: December 16, 2017 through December 31, 2017.
        • Eligibility: Individuals who reside in or move from areas affected by a hurricane in 2017, who are applying for 2018 coverage.
        • What to do: Contact the Marketplace Call Center at 1-800-318-2596 to request an enrollment after December 15, 2017.
  1. Medicare open enrollment occurs each year for people to enroll or switch Medicare plans and prescription drug plans. Medicare open enrollment runs from October 15 to December 7, but the Centers for Medicare & Medicaid Services have announced a special enrollment period to give people more time to enroll due to the recent hurricanes.
    1. Timing: From the start of the incident period through December 31, 2017.
    2. Eligibility: Individuals who reside, or resided at the start of the incident period, in an area for which the Federal Emergency Management Agency (FEMA) has declared an emergency or a major disaster; individuals who do not live in the affected areas but rely on friends or family members who live in the affected areas for help making health care decisions.
    3. What to do: Contact 1-800-MEDICARE to access the special enrollment period. Click here for more information.

Remember, with both Medicare and Marketplace plans, when you sign up for coverage in open enrollment, you coverage won’t actually start before January 1, 2018.

If you need coverage now, visit CancerFinances.org or watch our webinar recording on how to pick a health insurance plan, to see if you have other options.

Medicare and Hospice Care

Hospice is a program of care and support for people who are terminally ill. The focus ofHospice Care hospice care is on ensuring patient comfort, and not on curing an illness. In hospice, a specially trained team of professionals and caregivers provide care for the “whole person,” including physical, emotional, social, and spiritual needs. There are hospice facilities, but hospice care is generally provided in the home. Medicare can help cover some of the hospice care costs.

Hospice care can be a blessing for those suffering from a terminal medical condition and can even include specialized care, such as reading to a patient, playing music, and companionship. Hospice care providers can also provide respite for caregivers.

Medicare recognizes the importance of hospice and covers it fully. Meaning even if you only get Medicare Part A (hospital coverage), which is the minimum Medicare coverage, you will be fully covered for hospice care. Once you start getting hospice care, your Medicare hospice benefit should cover everything you need related to your terminal illness if your care comes from a Medicare-approved hospice provider. If, while in hospice, you need care that is not associated with your terminal illness (for instance, you fall and break your arm), you would be covered by your regular Medicare or Medicare Advantage plan benefits.

If you have determined that you no longer want to pursue curative treatment for your medical condition, you should discuss your decision with your health care team. Your health care team can help you coordinate hospice care. You always have the right to stop hospice care, and seek a curative treatment, at any time.

However, while in care of a Medicare-approved hospice provider, Medicare will not cover any of the following:

  • Prescription drugs (except for symptom control or pain relief).
  • Care from any provider that wasn’t set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness and related conditions must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.
  • Room and board. Medicare doesn’t cover room and board. However, if the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
  • Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness and related conditions.

For more information on hospice care, please review: Hospice FAQs from the National Hospice and Palliative Care Organization.

For more information about Medicare’s coverage of hospice benefits, you can read: Medicare Hospice Benefits.

Did You Know? Medicare Covers Home Health Care

If you’ve ever been admitted to a hospital, you know it’s not the best place to rest up Home Health Careand recuperate from an illness. Medicare understands that, too. That is why Medicare covers home health care services for eligible individuals. Home health care can be less expensive, more convenient, and provide better quality of life for many patients.

If you have Medicare, you can use your home health benefits if you meet all of the following criteria:

  1. You are in the care of a doctor and being regularly seen by a doctor.
  2. A doctor certifies that you need any of the following:
  • Intermittent skilled nursing care (“intermittent” is defined as skilled nursing care that’s needed or given on fewer than 7 days each week or less than 8 hours each day over 21 days (or less) with some exceptions in special circumstances)
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational therapy
  1. The home health agency caring for you is approved by Medicare (Medicare-certified).
  2. A doctor certifies that you are homebound.
  3. A doctor or nurse practitioner documents that they’ve seen you in person within the required timeframe and that the findings of that encounter support that you’re homebound and need skilled care.

If you think you or your loved one may be eligible for these benefits, you can learn more by reading this booklet: Medicare & Home Health Care, which includes information about choosing a home health care agency, how the payment for services works, guarding against fraud, and your rights as a recipient of home health care.

Do You Need a Medigap Policy? Your Ability to Get One May Depend on Where You Live.

Americans who receive their health insurance through Medicare may want to purchase Medigapextra coverage through a Medigap Policy.  However, one’s ability to purchase a Medigap policy may depend on where they live.

Medicare is a government funded and run health insurance program for eligible individuals. To be eligible for Medicare, you must be:

  • 65+ years old;
  • have collected SSDI more than 24 months; or
  • have been diagnosed with end stage renal disease (ESRD) or ALS.

Medicare coverage is divided into four parts:

  • Part A: Hospital Insurance. Includes hospital care, skilled nursing facilities, nursing homes, hospice, and home health services.
  • Part B: Medical Insurance. Includes services from doctors, preventive care, outpatient care, lab tests, mental health care, ambulance services, and durable medical equipment.
  • Part C: Advantage Plans. Part C is an alternative to Parts A & B and it includes the benefits and services covered under Parts A & B, and usually Part D. You can select a PPO or HMO plan that is run by a Medicare-approved private insurance company. Make sure to select a plan that covers your health care providers.
  • Part D: Prescription Drug Coverage. You have different plans to choose from depending on where you live, with different premiums and formularies. Make sure to select a plan that covers the drugs you take.

For more information about Medicare, you can read our Quick Guide on Medicare, or watch this webinar.

Parts A and B of Medicare are often called “original Medicare,” because that is the coverage that originally existed. Part B of Medicare has an 80/20 cost share, meaning that Medicare covers 80% and you are responsible for 20% of your medical expenses covered under Part B.  In order to help people pay for the 20% and for other things that Medicare does not cover, Medicare created an option to buy supplemental health insurance coverage, called Medigap. There are different Medigap plans, which are named by letters, which are offered by private health insurance companies. You must have Medicare Parts A and B to buy a Medigap plan.

Medicare’s website allows you to type in your zip code and whether or not you already own a Medigap policy, and it shows you the different Medigap policies available to you. . Medicare also provides a chart comparing Medigap plans A-N and their benefits. For example, Medigap plan A does not cover skilled nursing facility care coinsurance, while Medigap plan F does. Medigap plans K and L have an out-of-pocket limit, while the other 12 plans do not. It is important to note that three states – Massachusetts, Minnesota, and Wisconsin – offer different Medigap plans not available in other states. There are separate pages for the Medigap plans on Medicare’s website for these exceptions.

Medigap policies, however, are only available in certain states. According to Medicare, “each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer.”

While Medigap policies seem like they would be welcomed and encouraged in each state, there are 22 states that are allowed to not sell Medigap policies to those under 65 years of age who qualify for Medicare because of a disability. Those states are: Alabama, Alaska, Arizona, Arkansas, Idaho, Indiana, Iowa, Kansas, Kentucky, Montana, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Rhode Island, South Carolina, Utah, Virginia, Washington, West Virginia, and Wyoming. Simply put, if you live in one of these and are on Medicare but under 65, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65.

The remaining 28 states require insurance companies to offer people under 65 at least one Medigap plan: California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, and Wisconsin.

Click here for more information about Medigap plans and coverage.