My first stop in the older adult Continuum of Care is Health Insurance; probably the first and one of the most important decisions you will make when become eligible for Medicare at age 65.
Medicare Part A
Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters in which they paid Medicare taxes while working. Medicare part A covers inpatient care in hospitals, skilled nursing facility, home health and hospice care
Medicare Part B
Most people pay a standard monthly premium for Medicare Part B. However, some people may pay a higher premium based upon their modified adjusted income. Most elect to have this premium taken directly from their social security check. For most items and services covered under Part B, you must also pay a COPAY, COINSURANCE, and a DEDUCTIBLE. Part B covers those services not covered under Part A such as outpatient services, doctor services, emergency room services, and office visits.
Medigap Policy
Medigap policies are designed to "fill in the gap" to pay for COPAY, COINSURANCE, and the DEDUCTIBLE and with some policies, services not covered by Part A & B. Medigap policies typically do NOT cover prescription drugs. The positive implication of purchasing a medigap plan is you have total freedom of choice, you can receive care anywhere you want as long as the provider accepts Medicare. You also do not have a "Managed Care Agency" monitoring your usage of coverage from hospital length of stay, to durable medical equipment. The most common medigap policy in Pittsburgh is offered by Western PA BC/BS. You do not need to purchase a medigap policy if you have a Medicare Advantage Plan. RECOMMENDATIONS: I believe the negative of extremely high cost for the medigap policy, less coverage for Skilled Care, along with with the need to purchase a part D supplement far out-weights the benefit of freedom of choice in the Pittsburgh area where we have excellent Medicare Advantage Networks with two large providers.
Medicare Advantage Plans (Part C)
Medicare Advantage Plans are private insurance companies approved by Medicare to provide this coverage. When you join one of these, you are still in Medicare. Medicare Advantage Plans provide all the coverage of Part A & Part B and generally offer extra benefits that may include Part D drug coverage. These plans have networks, which means you need to see doctors in the plan and go to hospitals in the network for care. In many cases, the cost for these plans can be lower than the original Medicare Part B premium. Recommendations: Make sure you live in a service area of the plan you join and that the plan has a large established network. You can't go wrong if you live in Allegheny County and choose one of the two largest providers in Pittsburgh - UPMC Health Plan (UPMC for Life)or Highmark (Security Blue HMO or Freedom Blue PPO)...more about these plans below:
HMO - Health Maintenance Organization - a type of health plan where you you can only go to doctors and hospitals in the plans network to receive coverage, with the exception of an emergency. If you choose the UPMC for Life coverage you can only receive care with UPMC providers or facilities. (you cannot receive care in the West Penn/Allegheny Health System) Security Blue's Network also includes the West Penn/Allegheny Health System along with UPMC facilities.
PPO -Preferred Provider Organizations - with this type of plan you have the choice of using hospitals and providers in the network or can choose to go outside of the network for additional costs. freedom Blue is an example of this type of PPO in Pittsburgh.
Final words: I have worked for both major and some minor providers of health care in Pittsburgh. As a previous insider, my recommendation is the Medicare Advantage plans. If a decision regarding care is ever made that you disagree with, you have the ability to appeal this decision immediately in most cases.
If you need assistance in determining the best Medicare plan to meet your individual needs, Options For Elder Care would be glad to assist. 412-443-1365 web: www.optionsforeldercare.com or e-mail: info@optionsforeldercare.com
Lets tackle Medicare Part D next time!
my Best,
Bobbi
