Patricia Barry - Medicare For Dummies

Will my health issues and pre-existing medical conditions work against me? Current and past health problems don’t bar anybody from Medicare coverage or cause anybody to pay higher premiums or co-pays than somebody who is in perfect health. That kind of discrimination, which has been common in the past in private health insurance, has never existed in Medicare. The one exception is that people with advanced kidney failure can’t enroll in a Medicare Advantage health plan; however, they still receive coverage for the appropriate care — regular dialysis or a kidney transplant — under the traditional Medicare program. (For the record: A history of smoking, alcohol use, or obesity doesn’t increase rates either.)

Will Medicare be less expensive than the insurance I have now? Medicare isn’t free. Just like other insurance, it requires monthly premiums, deductibles, and co-pays that you’re responsible for paying unless you qualify for a low-income program or have extra insurance that covers these costs (see Chapter 4for details). However, you need to consider the alternatives. Without Medicare, most older and disabled people wouldn’t be able to find affordable insurance on the open market.Compared to most employer insurance (which as a whole covers younger and healthier people), Medicare is reasonably priced. In 2020, Medicare Part B premiums cost $144.60 per month per person, whereas, according to the Kaiser Family Foundation’s 2019 survey of employer health benefits, workers’ monthly contributions to employer insurance averaged $99 for a single person and $462 for a family of two or more. Still, this isn’t an apples-to-apples comparison; many employees pay more than these averages for health benefits, and Medicare beneficiaries usually pay extra for drug coverage, while those with higher incomes pay higher Part B premiums than the standard premiums.

Will I pay a large deductible before getting Medicare coverage? Medicare does have some deductibles, but they’re relatively small compared with the ones many people pay in high-deductible health plans that are sponsored by employers or bought through the 2010 Patient Protection and Affordable Care Act (commonly known as the Affordable Care Act or Obamacare) or on the open insurance market. (I examine deductibles, along with co-pays and other Medicare costs, in detail in Chapter 3.)

Will my out-of-pocket expenses be capped in Medicare? Not necessarily. Traditional Medicare sets no limit on the costs you pay out-of-pocket during a year, although you may buy Medigap insurance to cover those costs (see Chapter 4). But all Medicare Advantage plans are required by law to set caps on these expenses (up to $6,700 per year for in-network services and $10,000 per year for out-of-network services, but some plans have lower limits). And in the Part D program, after you’ve spent a certain amount out-of-pocket on your prescription drugs in a year, you qualify for catastrophic coverage that greatly lowers your costs for the remainder of the calendar year.

Do I have to sign up for Medicare again every year? No; your coverage just rolls over from year to year unless you decide to change it. But you do have the opportunity to change your coverage if you want to during the open enrollment period that runs from October 15 to December 7 each year. During this time, you can switch from traditional Medicare to a Medicare Advantage plan (or vice versa), from one Medicare Advantage plan to another, or from one Part D prescription drug plan to another, as explained in Chapter 15.

Will Medicare cover my younger spouse or other dependents? No. Family coverage doesn’t exist in Medicare — not for spouses, dependent children, or other family members. Each person must wait until age 65 to join the program unless he qualifies through disability at a younger age, as explained in Chapter 5. Also, if you and your spouse are both in Medicare, each of you must pay premiums separately and in full unless you receive government assistance to help pay for them. Medicare doesn’t give price breaks for married couples, even in its private Medicare Advantage health plans and Part D drug plans.

Will Medicare coverage be cut off when I grow old? No! Medicare coverage is based on medical necessity, not age. So if you need a hip replacement when you’re in your 90s or even over 100, Medicare picks up most of the cost in the usual way. The idea of Medicare rationing care and denying coverage for people over a certain age has been spread through mass emails designed to discredit the Affordable Care Act. In fact, the act doesn’t cut Medicare benefits or allow rationing, and no Medicare regulation limits care for people based on their age.

Do you really need to know the details of what Parts A, B, C, and D stand for? Doesn’t Medicare just pay its share of your bills and that’s it? Well, not entirely. Medicare’s architecture is more than a tad weird, but each of its building blocks determines the coverage you get and what you pay.

Besides that, however, is the simple fact that making sense of the information in the rest of this book is difficult unless you understand what Parts A, B, C, and D actually mean. The following sections break down the basics.

Medicare Part A is usually described as hospital insurance — a term originally coined to distinguish it from medical insurance (Part B). But the phrase is misleading. “Hospital insurance” sounds as though Part A covers your entire bill if you’re admitted to a hospital, but it doesn’t work that way. The services you receive from doctors, surgeons, or anesthetists while you’re in the hospital are billed separately and are covered under Part B. And you don’t even have to be hospitalized to get services under Part A, because some are provided in settings outside the hospital or even in your own home.

A more accurate way to think of Part A is as coverage primarily for nursing care. It helps pay for the following:

The services of professional nurses when you’re admitted to a hospital or a skilled nursing facility (such as a nursing home or rehab center) for short-term stays or when you qualify for home health services or hospice care in your own home

A semiprivate room in the hospital or nursing facility

All meals provided directly by the hospital or nursing facility

Other services provided directly by the hospital or nursing facility, including lab tests, prescription drugs, medical appliances and supplies, and rehabilitation therapy

All services provided by a home health agency if you qualify for continuing care at home, as explained in Chapter 2

All services provided by a hospice program if you choose to stop treatment for a terminal illness, as explained in Chapter 2

The vast majority of people in Medicare are eligible for Part A services without paying any premiums for it. That’s because Part A is essentially paid for in advance by the Medicare payroll taxes that you or your spouse contributed from every paycheck while working. I explain the details of how that setup works — and your options if you don’t qualify for premium-free Part A — in Chapter 5.

But of course Part A services themselves aren’t free. You still pay deductibles and co-payments for specific services. I itemize these costs in Chapter 3and explain how you may be able to lower them in Chapter 4. I also provide more-detailed information on certain Part A coverage issues in Chapters 2and 14.

Many people in Medicare never need to go into the hospital, but almost everybody sees a doctor or needs diagnostic screenings and lab tests sooner or later. That’s where Part B — known as medical insurance — comes in. The wide range of services it covers includes the following: