NOW IS THE TIME TO GET HELP WITH MEDICARE

          Tis the season! While you are contemplating your holiday purchases, please remember that it is time to be shopping for the best health insurance plan as well.  November 15th – December 31st each year is open enrollment for Medicare. Even if you already have a Medicare plan, now is a good time to review your coverage to be sure it remains the best plan for you. Sorting out Medicare can be daunting, especially the relatively new Part C Medicare Advantage Plans and the Part D Medicare Prescription Drug Plans. These programs are offered by a variety of private carriers each with different costs and features.

Part C

          Part C (Medicare Advantage) plans allow you to choose to receive all of your health care services through a provider organization.  These plans may help lower your costs of receiving medical services or you may get extra benefits for an additional monthly fee.  You must have both Parts A (inpatient) and Part B (outpatient) to enroll in Part C.  Some programs include vision and dental insurance. You will also be limited to doctors, hospitals or skilled nursing homes within the network.  You may pay a higher premium for this expanded coverage.

Part D

          Part D Prescription Plans cover the cost of certain drugs within each company’s “formulary” although you may be able to get drugs outside the formulary covered by special request from your doctor. You may pay a “co-pay” or “deductible” for the drug with the insurance company picking up the balance. In 2010, the first $2,830 of cost is covered by insurance, but then the consumer must pay $4,550 out of pocket (“OOP threshold”) before the insurance company would begin to pay for “catastrophic” coverage. The out of pocket period has been referred to as the “doughnut hole”.

Understanding and Comparing Programs

          The Federal Government provides an excellent website with explanations of the various Medicare programs available including comparative charts, frequently asked questions, tips and helpful links to related websites (visit Medicare.gov). It is an excellent place to gain a better understanding of the system, but may be inaccessible and/or overwhelming to most seniors.

The Ohio Department of Insurance established the Ohio Senior Health Insurance Information Program (OSHIIP) in 1992. Trained staff and a network of more than 1,300 volunteers throughout the state provide educational workshops and one-on-one assistance to consumers about the various Medicare Programs and other senior insurance topics such as long term care insurance. For specific questions, you can call to speak to a trained representative at 1-800-686-1578 or you can meet personally with a local OSHIIP volunteer. There is no charge for these services.

Getting Help

          OSHIIP Volunteer, Claudette M. Rogers, a Program Coordinator with  Family & Community Services Inc. shares a number of ways that OSHIIP volunteers can help:

• Compare and contrast Medicare C Advantage Programs
• Compare the multitude of Medicare D Programs available and narrow the senior’s search to three that are most suitable based on the particular prescriptions needed
• Counsel seniors as to enrollment periods for various programs
• Direct seniors as to how to apply for low income subsidy programs which may pay for premiums, deductibles or co-insurance
• Direct seniors to other sources of charitable or low cost prescriptions such as veteran benefits and pharmaceutical assistance programs provided by drug companies
• Investigate and report predatory practices of some insurance companies
• Advise clients as to the best way to dispose of unused drugs
• Spread the word by speaking to senior groups about Medicare and other insurance coverage

Make reviewing your Medicare an annual event. As complicated and varied as the C and D Programs are, they are also in a constant state of flux.  In 2009, Ohio offered more than forty Part D Prescription Plans. Next year, five companies will be pulling out of Medicare Part D. Virtually all companies will periodically change premiums, deductibles and even formularies.

So, do not wait! The season is upon us and help is available.

THE ABC’s (and D’s) OF MEDICARE

Medicare is a federally funded and managed health insurance program for people 65 or older, disabled individuals under the age of 65 and those with end stage renal disease.  It is an entitlement program.  To be entitled to participate one must have paid into the Social Security system a minimum number of quarters.  Those eligible for Medicare may choose the health insurance plan or plans most appropriate for them.

MEDICARE PART A  is hospital insurance.  It covers inpatient care in hospitals, limited, temporary care in a skilled nursing facility, hospice care and limited home health services.  Most people do not pay premiums for Part A because they paid Medicare taxes while working.

MEDICARE PART B is for outpatient care such as doctor’s services, durable medical equipment, emergency room services, diagnostic tests, treatment of medical conditions and preventative services.  Most people pay $96.40 per month for Medicare Part B.  Those with higher incomes may pay more.  The 2009 Medicare Part B premium will not change from the 2008 amount.

Certain services require the patient to pay co-insurance of 20% of the Medicare approved amount.  Other services may be subject to a deductible of $135 per year.  Many people purchase “Medigap” insurance to cover the co-pay and deductible amounts.

MEDICARE PART C is the Medicare Advantage Plan.  Private companies offer health plan options such as HMO’s and PPO’s that are approved by Medicare.  These plans provide all services otherwise covered by Part A and Part B and may cover extra benefits such as vision, hearing, dental, wellness programs and prescription drugs.

Monthly Medicare premiums go to the private company.  The plan may charge different premiums, co-payments and deductibles.  These plans usually restrict coverage to a network of providers.  Out of network costs are higher or not covered at all depending on the plan.

MEDICARE PART D is prescription drug insurance.  Medicare drug plans are run by insurance companies and other private companies approved by Medicare.  Each plan varies in cost and covered drugs.  Although everyone with Medicare is eligible for Part D coverage, Medicare charges a late enrollment penalty to those who do not enroll when first eligible.

Most Medicare D plans have a coverage gap each year (referred to as a “donut hole”).  During this gap, patients must pay all out of pocket costs for drugs.  Once the gap has passed, the plan will pay 100% of costs.  Beginning with each new calendar year, costs are again paid by the company subject to deductible and co-payment until the gap is again reached.

The Centers for Medicare and Medicaid Services provide an excellent annual handbook “Medicare & You”.  Additional information is also available at www.medicare.gov or 1-800-MEDICARE (1-800-633-4247).