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Medicare Myths

Medicare Myths

In retirement, the wild card is health care. Nothing can wreck the best of plans like an expensive illness. While those 65 and over can take advantage of Medicare, there are a myriad of myths and misunderstandings about Medicare that can prove costly.

Here’s a look at the myths and the truth.

Don’t expect a freebie. In a survey last year by PlanPrescriber.com, 20 percent of Baby Boomers who responded thought Medicare is free and 14 percent didn’t know. Medicare is not free. There are costs. Most people pay a premium for Part B; prescription drug coverage costs extra, and if you want dental or vision coverage, you’ll need a Medicare Advantage plan that offers enhanced coverage for these needs, says Ross Blair, president of PlanPrescriber.com. Original Medicare does not cover all out of pocket costs for services and medical expenses. For example, once the $162 Part B deductible for 2012 is met, beneficiaries must pay coinsurance ranging from 20-45 percent for certain medical services. To cover additional out of pocket costs not covered by original Medicare, seniors should look at Medicare Advantage plan or a Medicare Supplement plan.

There are rules. Don’t assume you can enroll in a Medicare Supplement plan at any time. Rules vary by state, but as a general matter, someone is guaranteed access to Medicare Supplement (Medi-gap) insurance when they are first eligible for Medicare Part B and for six months after that. Following that time horizon, carriers are usually allowed to ask health questions and to turn down someone’s request for Medigap coverage. So don’t assume that because you are applying for a Medicare Supplement plan that you are guaranteed to receive it. Make sure you apply for coverage during the Medicare Supplement eligibility period.

Know the rules. You can’t get an endless supply of drugs. There are “cost utilization measures,” which means there are drug limitations. In some cases, a health plan that offers prescription drug coverage may place limits on the cases in which certain medications are covered. Therefore, while you may assume your drug is covered, it may only be covered after prior authorization, step therapy (where your doctor must first try other, alternative medications to see if they work), or in certain doses and quantities (for example, only 10 milligrams per month of Lipitor, but not 100). Look for comparison tools that allow you to view drug limitations for Medicare Part D plans by specific region, such as that found on PlanPrescriber.com.

Things change. Check your Medicare Part D Prescription Drug Plan and Medicare Advantage plan each year, because insurers may change drug formularies each year, warns Blair. “Not only do you want to make sure you enroll in a Part D plan that covers your medications, but you may find that new Part D plans are available with lower cost sharing, premiums and or deductions,” he says. Stay abreast of changes. Go to the source, www.medicare.gov for the best information.

Switch to generics. When available, generic equivalents can save money. Through the end of 2011 into 2012, a number of brand name drugs, such as Lipitor and Plavix are expected to come off patent. Check for each brand name drug you use to see if there is a generic equivalent. If so, speak to your doctor about switching to the generic and see if you can save money in the process.

Pick the right plan. One size does not fit all. Selecting the Medicare Advantage plan that best matches your prescription drug utilization is huge. However, there are other factors that you should count too. For example, pay attention to deductibles, co-pays, co-insurance out-of-pocket limits and physician networks, when comparing networks side-by-side. Most Medicare prescription drug plans have sizeable pharmacy networks available, but there are others that leave much to be desired. Before you select a plan, make sure the plan has a participating pharmacy that meets your needs, whether that is: convenience of location, preference of pharmacist or the best prices.

Medicare is not a magic pill, but if you know how to play the game, it can be a lifesaver for controlling costs in your retirement years.

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depacctsfan   |     |   Comment #1
Medicare and the states have created a State Health Insurance Program (Medicare SHIP) for each state. In California, for example, it is HICAP (Health Insurance Counseling and Advocacy Program). Statewide number is 800-434-0222. The number is on the back of Medicare and You. People can have free counseling sessions with registered volunteer counselors who will help them go over all their options and weigh the pros and cons. In our county we also offer Welcome to Medicare Seminars in adult schools and other sites. SHIPs also help people and represent them at no cost if there are claims issues.  Medicare has  contracted with companies in every state to insure quality of care. In California, for example, it is HSAG. A call to HSAG stops a hospital discharge while an expedited appeal is conducted at no charge. There must be written advanced notice of discharge with the HSAG information included on it. There is no reason to be confused about Medicare.  Ample help is available at no charge. In California for example there are more than 600 HICAP volunteers and a small paid staff. See calmedicare.org.   In Contra Costa County, see cchicap.org  To find the SHIP for your state, call 800 Medicare, go to medicare.gov, or shiptalk.org.  To search for the most cost effective drug plan for your specific meds, use the planfinder on medicare.gov   SHIP counselors cannot be affiliated with any insurance company or even reveal their own insurance choice to clients.
Apache   |     |   Comment #2
Doctors also seem to take a "quota" of Medicare patients and when they reach their quota, you are out of luck.  I had a problem not too long ago trying to find a gyn after we moved to a new city and there was only "one" of the many I called listed in network with my Advantage Plan who was still accepting Medicare patients.  It didn't matter that I paid extra for the Advantage Plan.  It is still affiliated with Medicare and under the quota.  So select your doctors as soon as you can when you get on Medicare.
depacctsfan   |     |   Comment #3
Re Apache's comment: when you are in a Medicare Advantage plan you have signed your Medicare over to that plan. All benefits go through the plan.  Medicare pays that plan to assume all the risk of taking care of you.  You are limited to that plan's network.  When you keep Original Medicare, or Fee for Service Medicare, you have access to all doctors who accept Medicare. That is most doctors and hospitals. You can buy a Medigap that pays your share of costs with Original Medicare. So Apache limited her available doctors when she got a Medicare Advantage plan, but she got the additional benefits that a Medicare Advantage plan can offer, like worldwide emergency coverage and optional vision and dental. There are lots of pros and cons to consider before making your choice of whether to go with Medicare Advantage or keeping Original Fee for Service Medicare.
Apache   |     |   Comment #4
#3:  I specifically asked them if they would accept me if I just used Medicare without the Advantage Plan to find what was the real reason for refusing me.  I was told the quota was for Medicare with or without being involved with any Advantage Plan.  The quota was against Medicare.  If I was not involved with Medicare in any way, let's say I had a Blue Cross or Cigna Plan they would have accepted me.  Doctors have this quota because they don't get paid as much for Medicare patients even if they are connected with Advantage Plans.
lof   |     |   Comment #5
There's also a  surge charge if your AGI (income) is in a higher range (single, it starts at about 160K, with brackets up to 212K), it's reviewed each year.
rosie43   |     |   Comment #6
To lof #5-- The Medicare Part B premium goes up to $139.90 with an income of $170,001-$214,000---$199.80 for income $214,001 to $320,000---  $259.70 for income $320,001 ti $428,000 and to $319.70 with income above $428,000. This is for joint filers

For single filers the premiums are the same for each bracket and the brackets are $85,001 to 107,000---$107,001 to $160,000, $160,001 to $214,000 and the last bracket  is for income above $214,000.

If I remember correctly these figures are not indexed to inflation until 2018. This was part of the Part D legislation when it was passed in 2003.  

Incomes below $85,000 for single filers and below $170,000 for joint filers pay $99.90

rosie43   |     |   Comment #7
Table 2: Part B Monthly Premium
Beneficiaries who are married, but file a separate tax return from their spouse and lived with his or her spouse at some time during the taxable year

Your 2012 Monthly Premium is Beneficiaries who are married but file a separate tax return from his or her spouse

 $85,000 or less




Above $129,000

If you are having trouble paying your premiums, you should call your State Medical Assistance (Medicaid) office to see if you qualify for some help. Some states refer to the Medicaid office as the Public Aid office, the Public Assistance office, or the State Medical Assistance office.


Additional information about the Medicare premiums, deductibles, and coinsurance rates for 2012 is available in the October 27, 2011 Fact Sheet titled, "Medicare Premiums and Deductibles for 2012" on the www.cms.gov website.
niniss   |     |   Comment #8
Just reading these posts is making my head spinning.  I don't understand why americans put up with this kind of health care system.  It's just so **** complicated.  Sometimes i think there are certain "parties" or organizations with "speical interests" purposly made the system like a spide web to fatten their wallets and feed their greed.  Personally i'm still young and healthy enough to stay away from docs but am having to deal with this stupid and moronic system because of my mom.  So when i'm old and sick i'll just get treatment from foreign countries, or there's always the Euthanasia option in Switzerland.
Bozo   |     |   Comment #9
Further to Apache's comment, I had the same concerns, as I turn 65 in late May. I found Kaiser's Advantage plan to be the best. It's not the cheapest (they charge an additional $85/month above and beyond your normal Medicare Part B premium), but they guarantee access to a local primary care MD (all are on their staff) and the aggregate annual deductibles are transparent. Here in Northern California, fewer and fewer MDs are accepting "new" Medicare patients and that's a big issue. As Apache found out, it doesn't do you any good if you sign up for a plan and have to drive (or be driven) a very long distance to see "your" primary care physician. Once you lose mobility, you'd better hope you (a) have a doctor close-by and (b) can arrange for transportation. Medicare doesn't cover taxis to the doctor.
rosie43   |     |   Comment #10
niniss I hope you never have a kidney stone, a car accident etc. I know this has happened to  2 of my son's friends and they had a high deductable health plan and will never get out of debt. Hope you reconsider your plans.

To Bozo I hope you will look into a Medicare supplement which would let you see any specialist any internist, etc. You do not have to have a referral. Like Medicare it will pay any doctor in ANY STATE.  Look into this please. Go to a senior center and have them explain this to you and the charges. Do not speak to any salesperson. Their commissions are very high and they are interested in their pocketbook not you. I believe it is plan F that will pay for any doctor that does not accept Medicare. What happens if you are in the hospital and that doctor does not accept Medicare. Many physicians do not follow their patients to the hospital after admission.
niniss   |     |   Comment #11
Poster #10 - Not sure why you have to say such mean things to me, and where did i say I have a high deductible plan?  For over decade i've been paying sizable monthly premiums (well, the majority by my employer) and i never really used any of the benefits because i'm proudly say that I never had a need and also because I hate to see docs or sick people.  I have gone as far as seeing the doc once in 7 yrs.  The insurance company reminds me every year about annual physical, but i believe more in healthy diet, active and healthy life style (good genes too!).  If you don't understand what i said in my earlier post, let me make it a bit clearer for you:  I'm fine for as long as i don't have a need for their service (they can just continue to make money off my premium every year), but when i get old and need the service I will choose to get the service from overseas and not to deal with this stupid system.  To me, it's just a simple matter of taking a better option if you have one.
Inforay   |     |   Comment #12
Thank you for posting this article and also the helpful comments by depacctsfan (#1). Although not yet eligible for Medicare I will copy all this information for future use.
lou   |     |   Comment #13
I am not old enough to qualify for Medicare, but like Bozo and Apache, I have heard that many doctors will not accept Medicare patients anymore. Apparently, the reimbursements are low and no doctor is obligated to see Medicare patients. I think plan f that Rosie refers to is a supplemental plan that will pay charges in excess of what Medicare will cover, but it does not permit doctors to charge more than the Medicare rates. Unfortunately, doctors are dropping out of the Medicare program in alarming numbers and with further cuts contemplated for Medicare, it doesn't look like this trend will be reversed any time soon.
DOA   |     |   Comment #15
For those soon turning 65 and are considering a medicare supplemental plan, be aware that the plan F supplemental plan is being eliminated and will no longer be offered starting in year 2020.
Apache   |     |   Comment #14
Lou:  What I was told was that, at this time, the doctors have to accept a certain "quota" of Medicare patients and if we are not lucky enough to get in for the quota, they don't have to accept us.  The ones I called refused to budge to even take one extra patient once they reached the quota!  I'm sticking with this gyn I really can't stand until another gyn has an opening.  If you are not Medicare age and like the doctors you have, you should check if they will keep you once you get on Medicare.  If you are already with them, they will usually keep you, from what I have found out.  So if you are any wheres close to 65, it would be prudent to check up on your docs before you really have to.