Top 10 Medicare Terms to Know

Having trouble understanding Medicare terms? Medicare is the national health insurance program for seniors and some people with disabilities. The program can be complex and hard to understand. Use our glossary of commonly used Medicare definitions and terms to help you understand your Medicare coverage.     

  1. Annual Enrollment Period  – The period from October 15 to December 7 when you can enroll in a Medicare Advantage plan with Part D, a stand-alone Prescription Drug Plan, or switch Medicare plans.
  2. Appeal – A process to request your Medicare health plan to reconsider or perhaps change the decision of denying your request for coverage or payment.
  3. Coverage Gap – A stage in the Part D drug benefit during which you pay a certain percent of prescription drug costs set by Medicare. Also known as the “doughnut hole,” the gap begins after your costs reach an initial coverage limit and ends after you have paid enough to become eligible for catastrophic coverage. 
  4. Catastrophic Coverage – The part of the prescription drug benefit that kicks in after you have paid a certain amount in a calendar year. For 2020, that’s $6,350.
  5. Durable Medical Equipment (DME) – Certain medical equipment that is ordered by your doctor for use in your home. Some examples are walkers, wheelchairs, and hospital beds.
  6. Extra Help – Financial assistance from Medicare to help cover Part D drug plan costs. Also known as the low-income subsidy (LIS). To determine if you are eligible for Extra Help or other government assistance, click here.
  7. Formulary – A plan’s list of covered prescription drugs.
  8. Initial Enrollment Period (IEP) – The 7-month period when you first can enroll in Medicare (3 months before you turn 65, the month of your birthday, and the 3 months afterward).
  9. Medigap – Plans sold by private companies to supplement Original Medicare coverage by helping you cover some of the out-of-pocket costs of Medicare. Not to be confused with Medicare Advantage (Part C) or Cost plans.
  10. Special Enrollment Period (SEP) – A time other than the annual enrollment period or initial enrollment period when you may join, change, or drop a Medicare plan. An SEP can be triggered by certain events such as a change in residence.

What is SilverSneakers?

SilverSneakers is a nationwide program dedicated to helping seniors get fit and stay healthy through routine exercise. It was created by Mary Swanson in 1992 after her father survived a heart attack at 51 and pledged to improve his health with regular physical activity. Now offered at more than 14,000 fitness locations across the country, you can choose between Zumba classes at one gym, free weights at another, and swim laps at yet another.

SilverSneakers offers more than 70 types of classes to choose from, including boot camp, circuit training, strength and balance, tai chi, yoga, and water aerobics. With SilverSneakers, you truly have everything you could ever want out of a fitness program at your fingertips. You’ll never run out of choices or get bored of your exercise routine again.

Who covers it?

Although it’s not offered through Original Medicare (Part A and Part B), over 60 Medicare Advantage (Part C) and Medigap plans offer coverage of the program. Find out if your Medicare plan covers SilverSneakers here.

What do they offer?

SilverSneakers provides options beyond the gym, offering classes at community centers, churches, parks, and other local venues. And if you prefer a traditional gym experience, many gyms offer a free tour and equipment training in case you step into the gym and feel overwhelmed by the options and confusing equipment.

SilverSneakers also offers something most traditional gyms don’t: social support. Many SilverSneakers members report building strong relationships with other members and participating in potlucks and other community outings with people they’ve met through the program.

SilverSneakers reports that 94% of members rate their health as excellent, very good, or good, and 91% of members say the program has improved their quality of life. With SilverSneakers, you can strengthen your physique and social nature at the same time to assure you stay happy and healthy longer.

Where can you find SilverSneakers programs?

SilverSneakers can be found at over 14,000 fitness locations nationwide at no cost to you. That means if you go on vacation within the U.S., you don’t have to settle for sub-par hotel gym equipment.

Why settle for a membership at one gym when you can have access to thousands across the country? Over 67% of members have a SilverSneakers location within 5 miles of their home, so physical fitness and health is never far out of reach.

For more information about SilverSneakers, visit their website here

10 Things to Know about Medicare Advantage

Medicare Advantage, or Medicare Part C, is an alternative to Original Medicare that offers Part A, Part B, and sometimes Part D coverage through private insurance companies approved by Medicare. Plans vary by state and by county, so do your research and know what’s offered in your area.

Nearly one-third of Medicare beneficiaries (over 19 million people) use Medicare Advantage. The types of plans offered by Medicare Advantage include HMOs, PPOs, SNPs, and PFFSs, so you have plenty of options available to you.

10 things to know about Part C

Here are 10 important things to know when considering a Medicare Advantage plan:

  1. Under Medicare Advantage, you pay a monthly premium in addition to your Part B premium.
  2. You can’t have Medicare Advantage and Medigap (Medicare supplement) at the same time.
  3. You cannot have Medicare Advantage with prescription drug coverage and a stand-alone Medicare Part D plan at the same time.
  4. If you have End-Stage Renal Disease (ESRD), you are not eligible for Medicare Advantage.
  5. Some plans offer vision, hearing, dental, and prescription drug coverage.
  6. Fitness memberships are included in some Medicare Advantage plans.
  7. Under a Medicare Advantage plan, you must use the doctors and hospitals that are in-network. (With PPOs, you can use out-of-network doctors, but you will usually pay more.)
  8. Unlike Original Medicare, Medicare Advantage plans have annual out-of-pocket limits.
  9. With Medicare Advantage, you still have Medicare and all the rights and protections that come with it.
  10. Plans and coverage can change. Be sure to do your research annually to assure your plan is still the best one for you. Also check the deductibles, star rating, and travel coverage to make sure your plan meets all of your needs.

If you are thinking of switching to Medicare Advantage, you can do so during the fall Open Enrollment Period from October 15 to December 7. If you are enrolling for the first time, you may do so during your Initial Enrollment Period: the three months before your 65th birthday, your birthday month, and the following three months. If you need to disenroll from a Medicare Advantage plan, you may do so during the Medicare Advantage Disenrollment Period, January 1 to February 14.

Top 5 Medicare Mistakes to Avoid

Medicare mistakes are common due to the complex nature of Medicare, the national healthcare system for people over 65 and some disabled people. Here are five costly Medicare mistakes to avoid.

1.      Not enrolling when you first become eligible

Most people will automatically be enrolled in Medicare Part A when they turn 65. If you are not already receiving Social Security benefits, you will need to enroll in Medicare Part B during your Initial Enrollment Period. This is the three months before your 65th birthday, your birthday month, and the following three months. If you don’t enroll when you first become eligible, you could face late enrollment penalties later on.

2.      Failing to read your Annual Notice of Change

This document arrives in the mail each September and notifies you of any changes to your current Medicare Advantage or Medicare Part D plans, like increasing premiums, deductibles, or changes in covered services. It’s important to read this document in case you need to change plans during the Open Enrollment Period. Failing to do so could mean you’re stuck with an expensive plan that doesn’t give you the coverage you need in the following year.

3.      Assuming Medicare will cover everything

While Medicare will probably cover most of your healthcare expenses once you turn 65, it doesn’t cover everything. For example, Medicare doesn’t cover deductibles, premiums, copays, or coinsurance. If you have a chronic illness or expect recurring doctor visits, this could mean you’re paying a lot out-of-pocket. Thankfully, Medigap exists to help you cover some of the out-of-pocket costs of Medicare.

4.      Not picking the right Medigap plan

Medigap currently offers 10 plans (standard in most states) to help you save on out-of-pocket Medicare costs, so knowing which one is right for you can be tricky. Do you choose the one with the most coverage with higher premiums? Or one with fewer coverage options and lower premiums? Consider consulting your local State Health Insurance Assistance Program (SHIP) to help you decide.

5.      Not doing your research for Medicare Advantage

Original Medicare is made up of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), which most Medicare beneficiaries have. Original Medicare doesn’t cover services like dental, vision, and hearing care. However, many Medicare Advantage (Medicare Part C) plans do cover these services. If you know you’ll want coverage of these services, it would be wise to research your Medicare Advantage options before enrolling in Medicare coverage.

Additional Medicare resources:

·         Visit www.Medicare.gov

·         Call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day, 7 days a week

·         Call your local State Health Insurance Assistance Program (SHIP) to see if you qualify for any financial assistance.

Everything You Need to Know about Medicare Part A

Original Medicare consists of two parts, Medicare Part A and Medicare Part B. Part A (Hospital insurance) covers inpatient care, care at a skilled nursing facility, and at-home care (in limited circumstances).

To be eligible for premium-free Part A, you must be entitled to receive Medicare based on your earnings or those of a spouse, parent, or child. You must also have 40 of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. Most people will be automatically enrolled in Part A once they turn 65. You may also be automatically enrolled in Part B if you are already enrolled in Part A and receiving Social Security benefits.  

In general, Medicare Part A covers inpatient hospital care, limited home health services, hospice care, and skilled nursing facility care. These benefits are covered based on your specific situation and only if certain conditions are met.

What Part A covers

  • Hospital Care
    • Acute care 
    • Critical access
    • Inpatient rehabilitation facilities
    • Long-term care
    • Mental health care
    • Qualifying clinical research study
  • Home Health Care
    • Part-time or intermittent skilled nursing care
    • Part-time or intermittent home health aide care
    • Physical therapy
    • Occupational therapy
    • Speech-language pathology services
    • Medical social services
  • Nursing Home Coverage
    • Semi-private room
    • Meals
    • Skilled nursing services
    • Rehabilitation services
    • Medical social services
    • Medications received while in SNF care
    • Medical supplies and equipment used in SNF
    • Ambulance transportation
    • Dietary counseling
  • Hospice
    • Doctor services
    • Nursing care
    • Pain relief medications
    • Social services
    • Durable medical equipment
    • Medical supplies
    • Hospice aide
    • Homemaker services
    • Physical and occupational therapy
    • Dietary counseling
    • Short-term inpatient care
    • Short-term respite care

What is not covered?

Medicare doesn’t cover everything, so you may have to pay out of pocket for certain services. Even if Medicare covers the costs of a service or piece of equipment, you will most likely still have to pay your copayment, coinsurance, and the Part A deductible, which is $1,408. Talk to your doctor to find out specifics about what Medicare won’t cover.

Some examples of services that Part A does not cover are:

  • A private room (unless medically necessary)
  • Private-duty nursing
  • Personal care items, like razors or slipper socks
  • Extra charges, like a telephone or TV in your room
  • Non-donated blood
  • Meals delivered to your home
  • 24-hour-a-day care at home
  • Homemaker services
  • Personal care
  • Custodial (long-term) care

2020 Part A premium, deductible, and coinsurance

Premium. Most enrollees will not have a Part A premium, but those who don’t have 40 quarters of work history or a spouse with 40 quarters of work history will need to pay a premium. For 2020, the premium for people who have between 30 and 39 quarters of work history is $252 per month. For people with fewer than 30 quarters, it’s $458 per month. 

Deductible. The Part A deductible for 2020 is $1,408 (up from $1,364 in 2019) and applies to each benefit period rather than calendar year, but many beneficiaries have supplemental coverage, such as Medigap, that pays for this deductible. 

Coinsurance. If you need inpatient care, the deductible will cover your first 60 days. After that, you will be charged a daily coinsurance charge of $352 per day for days 61-90. After 90 days, the coinsurance rate is $704 per day.

Understanding Medicare Part A

Medicare Part A covers inpatient care like a skilled nursing facility, care received in a hospital, and some limited in-home care. You will probably be automatically enrolled in Part A whenever you turn 65. If you are not already enrolled in Part B and need to enroll manually, you can do so during your initial enrollment period, which is a six-month window that begins three months before you turn 65. 

If you still have questions about your coverage or health care pertaining specifically to you, call 1-800-MEDICARE.

Everything You Need to Know about Medicare Part B

What is Medicare Part B coverage?

Original Medicare is made up of two parts: Part A and Part B. While Part A covers hospital stays, Part B focuses on medical insurance.

Medicare Part B helps cover medically necessary services and supplies needed for the diagnosis or treatment of your health condition. This includes outpatient services received at a hospital, doctor’s office, clinic, or other health facility. Medicare Part B also helps cover many preventive services to thwart illnesses or detect them at an early stage.

Medicare Part B benefits

Medical services and supplies covered by Medicare Part B include (but may not be limited to):

  • Doctor visits
  • Clinical research
  • Laboratory tests and X-rays
  • Emergency ambulance services
  • Mental health services
  • Durable medical equipment (DME)
  • Preventive services, such as pap tests, flu shots, and screenings
  • Getting a second opinion before surgery
  • Rehabilitative services, including physical therapy, occupational therapy, and speech-language pathology services
  • Some outpatient prescription drugs

If in doubt, check to find out if Medicare covers a service or item.

Medicare Part B costs

Medicare Part B involves costs. You’ll pay both a monthly premium and a yearly deductible for Medicare Part B. The monthly premium amount may vary depending on your specific situation:

  • The standard Part B premium for 2020 is $144.60.

You may have to pay a higher premium if your yearly income is above a certain amount, as reported on your tax return from two years ago. In addition, if you didn’t enroll in Medicare Part B when you were first eligible, you may have to pay a late-enrollment penalty in the form of a higher premium, unless you’re eligible for a Special Enrollment Period.

  • In addition to your monthly premium, you’ll pay $198 for the yearly Part B deductible in 2020.

For individual services and supplies, your Medicare Part B costs may vary. Some preventive services are completely covered if your provider accepts Medicare assignment. If the Medicare Part B deductible applies, you must pay all costs until you meet the yearly deductible amount before Medicare begins paying its share.

After your deductible is met, you typically pay 20% of the Medicare-approved amount for the service. You may also owe a copayment for certain outpatient services.

Alternatives to Original Medicare Part B

If you feel you might need extra help paying your expenses, you can purchase a Medigap plan to help cover expenses for drugs for a chronic illness or other medical needs.

There are also Medicare Advantage plans (Medicare through a private insurer that covers Parts A and B and sometimes D) if you choose not to go with Original Medicare. You may not have Medicare Advantage and Medigap at the same time.

These alternatives incur the same Part B premium costs (plus the extra premiums of these programs). However, with Medigap you have the peace of mind of knowing your extra costs are covered, and with Medicare Advantage there is a maximum limit on what you can spend out of pocket per year on Part A and B expenses.

Top 10 Medicare FAQs

Medicare is a complicated topic. It makes sense that there are a lot of questions floating around. Some of the most common Medicare related questions are answered below.

Top 10 FAQs

  1. Will preexisting medical conditions work against me in Medicare? No. The one exception is that those with advanced kidney failure (End Stage Renal Disease or ESRD) can’t enroll in a Medicare Advantage plan. However, they can still receive coverage under Original Medicare.
  2. Are my out-of-pocket expenses capped in Medicare? No, not in Original Medicare. You can purchase a Medigap plan to help with those costs, however. Alternatively, under Medicare Advantage plans, there is an annual cap on how much you can spend out of pocket.
  3. Will Medicare cover my spouse or dependents? No. Medicare covers only you. A person must be age 65 to join or have a certain disability. If you are married, both you and your spouse need to join Medicare separately and must pay separate premiums.
  4. Will my Medicare benefits end? No. Your Medicare coverage will last as long as you need it, as long as you live.
  5. How can I get dental and vision coverage though Medicare? Original Medicare does not cover vision or dental, but some Medicare Advantage plans do cover these services.
  6. Do I have to sign up for Medicare again each year? No, your choices will stay the same. However, you might want to review and make changes during the annual Open Enrollment period from October 15 – December 7 to make sure your coverage fits your exact needs.
  7. Will I be automatically enrolled in Medicare at age 65? If you are already receiving Social Security benefits, then yes. You’ll be enrolled in Parts A and B, and your Part B premiums will be automatically deducted from your Social Security checks. If you’re not already receiving Social Security, then you will need to sign up through Social Security. You can do this during your intial enrollment period: the three months leading up to your 65th birthday, your birthday month, and the following three months.
  8. What is not covered by Medicare? Original Medicare does not cover long-term care, dental, vision, hearing, or acupuncture and other alternative medicine practices. See our more complete list of what Medicare does not cover. Some Medicare Advantage plans do cover vision and dental – research plans in your area to find out.
  9. How much does Medicare cost? Costs for Original (not Medicare Advantage) Medicare in 2018 are almost the same as 2017, with a few small changes. The standard monthly premium for Part B in 2018 is $134 per month.
  10. How can I get help paying for my prescriptions under Medicare Part D? Extra Help provides help paying for prescriptions for those with low income and assets. Other ways to save are using generic drugs, choosing a plan with extra “donut hole”coverage, and Pharmaceutical Assistance Programs.

Medicare and Mental Health: What are Your Options?

Did you know that more than 40 million American adults suffer from mental illnesses such as depression, bipolar disorder, anxiety disorder, and schizophrenia? Mental Health Awareness Month has been observed in May since 1949 in the United States. It was initially started by Mental Health America, which releases a toolkit of materials every year in March. The toolkit is useful as a guide for outreach activities.

According to Mental Health America, 56% of American adults with a mental illness do not receive the treatment they need. A large part of the problem remains the lack of access to the treatment that people need.

“In my work as a Clinical Psychologist, I have seen numerous improvements related to mental health and behavioral health over the years in a geriatric population,” said Dr. Kelly F. Trusheim, Clinical Director at Highland Rivers Health. “Namely, I have seen them benefit from regular screenings at annual ‘wellness’ visits, at which time early identification and treatment psychiatric symptoms and disorders was initiated.”

Mental Health Coverage Under Medicare

Here is what Medicare does and does not cover when it comes to mental health care.

What Part A Covers

Medicare Part A covers mental health services that you receive in a hospital that require you to be admitted as an inpatient. While this includes both general hospitals and psychiatric hospitals, Part A only covers 190 days of inpatient psychiatric hospital services during your lifetime. It does not cover a private nurse, a private room (unless medically necessary), a phone/television in your room, or personal items during your stay.

The deductible for each benefit period in Original Medicare is $1,408. There’s no limit on the number of benefit periods you can use when you get mental health care in a general hospital. You can have multiple benefit periods when you receive care from a psychiatric hospital as well, but there is still a lifetime limit of 190 days.

What Part B Covers

Medicare Part B covers mental health services and visits for outpatients with professionals such as psychiatrists, clinical social workers, clinical psychologists, clinical nurse specialists, nurse practitioners, and physician assistants. It also covers outpatient mental health services in settings like a healthcare provider’s office, hospital outpatient center, or community mental health center.

Along with these services, Part B covers:

  • one depression screening per year when done in a primary care doctor’s office or clinic
  • individual and group psychotherapy with doctors or licensed professionals allowed by the state
  • family counseling
  • medication management
  • testing to see if you’re getting the services you need
  • certain prescription drugs
  • diagnostic tests
  • psychiatric evaluation
  • partial hospitalization
  • yearly “wellness” visit and a one-time preventive visit.

The costs for Original Medicare are 20% of the Medicare-approved amount for visits to a doctor or health care provider.

While the stigma attached to mental health issues has improved, there are still steps to take when improving the quality of life and access to help for those who struggle with mental health issues.

Benefits of getting help

Dr. Trusheim notes she has seen people benefit from access to help. “While conducting individual psychotherapy, I have watched patients successfully cope with severe medical diagnoses and major transitions in life,” she said. “I have witnessed the benefits of psychiatric evaluation and medication management, including lessening depressive symptoms, reducing anxiety, promoting restful sleep, managing psychotic symptoms, and slowing the progression of dementia symptoms. I have conducted assessments/testing that have clarified if a patient’s presentation is considered part of the normal aging process or is indicative of a psychiatric or neurological condition. In my work with families, I have assisted them in better understanding their loved one’s illness, as well as what they can expect and how to help the patient. The benefits of behavioral health treatment are too many to list.”

Suicide

With respect to suicide, this is a rather important topic for patients of all ages. There are 25 attempts per every death by suicide per year, and the ratios are 4:1 for the elderly, according to the American Association of Suicidology. In addition, white males who are 65 years old or older are at a higher risk than the general population.

There are various misnomers about suicide. For example, talking about it does not increase the risk. In fact, asking about it earlier can assist in early intervention, treatment, and recovery. For more information on how you can learn how to ask your loved ones about suicide, visit the QPR Institute and the Suicide Prevention Resource Center.

If you or someone you know is in danger, call the National Suicide Prevention Lifeline at 1-800-273-8255. You can speak to a counselor 24 hours a day. You can also text 741741 to talk to a trained crisis counselor for free 24/7.

5 Tips for Picking a Medicare Advantage Plan

With all the choices out there, it’s important to find out the best ways to pick out a Medicare Advantage plan. Medicare Advantage plans are an alternative to Original Medicare in that sometimes include other benefits like prescription drugs, dental, vision, and fitness benefits.

With Medicare Advantage plans, you sometimes have lower premiums and there is an annual out of pocket limit on how much you can spend each year. This amount varies with each plan, but cannot be more than $6,700. Also with Medicare Advantage, there is a network of providers that you have to stick with, and you don’t have as much freedom to visit any doctor in the country like you do with Original Medicare.

5 Tips for Choosing a Medicare Advantage Plan

Here are 5 tips to follow when choosing a Medicare Advantage plan:

  1. Don’t choose based on what benefits the plan offers. The main things to look at are whether the plan covers the doctors and the prescription drugs that you need. You might really want a plan that gives you membership to a fitness club, but make sure to look at the medical essentials first so you’re not caught in a bind.
  2. If you already have a Medicare Advantage plan, check your Annual Notice of Change (ANOC). Your plan should send you this ANOC in the fall to let you know if anything is changing in your plan. Check it carefully (any major changes should be listed on the first few pages) so that you can make sure your needs are still covered. If anything major with drug or doctor coverage is changing, you should look at other plans that might be better for you.
  3. If you choose to go with Medicare Advantage, it is safe to have some other funds set aside for possible medical emergencies, since out of pocket costs can go up to $6,700 with these plans. If you don’t have extra medical savings, a Medigap plan with full coverage will be a good option for you. (Note: you can’t have a Medigap plan and a Medicare Advantage plan at the same time.)
  4. There’s no one-size-fits-all Medicare Advantage plan that’s going to be great for everyone. Look around and see what options are best for you and your situation, especially regarding the doctors in the plan’s network.
  5. Check the Medicare Advantage plan’s star rating. Medicare gives each plan a star rating from 1 to 5. It’s best to choose a plan with a 3.5 or higher star rating. Plans with a 4 or 5 star rating receive extra funding from the government for your medical benefits.