Help me help my mom figure out Medicare?
December 29, 2014 3:08 PM Subscribe
My mother is turning 65. She has no clue about health insurance. I, after diligent research, have a small clue, but not enough of a clue about practical information like distribution of doctors who take the insurance to help figure things out. Help? Snowflake details and questions inside. (Anon because I'm not going to share my mother's personal information on the Internet!)
Ok, my mom's in the LA area, has no chronic health conditions, no prescriptions, etc. She's actually ridiculously healthy. But works as an independent contractor, and doesn't have much money. Currently self-pays for an Obamacare-created EPO plan that is actually pretty good. She's turning 65 in a few months. So her main concern is not paying too much for basic care, checkups and stuff, plus being protected in case something bad happens.
As I understand it, the main difference between "Medicare advantage"/part c plans vs "original Medicare" is that original lets you go to any doctor that takes it, whereas the private plans have their own restricted networks like regular insurance, but generally have lower out of pocket costs (especially coinsurance), and cover more stuff. Is that right?
BUT: I also understand it to be the case that a lot of doctors don't participate in Medicare.
So the first question is, if a doctor "doesn't participate in Medicare," does that mean the doctor doesn't participate in original Medicare, or doesn't participate in the whole thing? Put differently, if she gets a part C plan from, say, Blue Cross, could there be doctors that would accept her Blue Cross Medicare that would not accept government Medicare? Or do all doctors who accept part c plans also accept original plans?
If doctors can (and do) accept the part C plans but not the original, then that seems to take away the one advantage of original ("go anywhere,") is that right? And then there wouldn't be any reason to go original at all? I must be missing something...?
Also, what's the deal with "medigap"/supplemental insurance? Is that a viable alternative? Or do part c providers provide much the same stuff as medigap, but without paying extra?
This is all terribly Byzantine...
Ok, my mom's in the LA area, has no chronic health conditions, no prescriptions, etc. She's actually ridiculously healthy. But works as an independent contractor, and doesn't have much money. Currently self-pays for an Obamacare-created EPO plan that is actually pretty good. She's turning 65 in a few months. So her main concern is not paying too much for basic care, checkups and stuff, plus being protected in case something bad happens.
As I understand it, the main difference between "Medicare advantage"/part c plans vs "original Medicare" is that original lets you go to any doctor that takes it, whereas the private plans have their own restricted networks like regular insurance, but generally have lower out of pocket costs (especially coinsurance), and cover more stuff. Is that right?
BUT: I also understand it to be the case that a lot of doctors don't participate in Medicare.
So the first question is, if a doctor "doesn't participate in Medicare," does that mean the doctor doesn't participate in original Medicare, or doesn't participate in the whole thing? Put differently, if she gets a part C plan from, say, Blue Cross, could there be doctors that would accept her Blue Cross Medicare that would not accept government Medicare? Or do all doctors who accept part c plans also accept original plans?
If doctors can (and do) accept the part C plans but not the original, then that seems to take away the one advantage of original ("go anywhere,") is that right? And then there wouldn't be any reason to go original at all? I must be missing something...?
Also, what's the deal with "medigap"/supplemental insurance? Is that a viable alternative? Or do part c providers provide much the same stuff as medigap, but without paying extra?
This is all terribly Byzantine...
Seeking state-specific information is very sound advice.
Keep in mind that there are multiple parts of Medicare. Part A comes automatically upon reaching age 65 and has no premiums. It is the equivalent of catastrophic coverage; it covers hospitalizations and the like.
Part B covers the more routine items like doctor visits, has a monthly premium (which is around $100), and has a 20% copay as well as a small initial deductible. If a doctor "doesn't participate in Medicare", it means s/he doesn't deal directly with Medicare Part B. That means they won't accept whatever Medicare decides a particular procedure should cost; rather, you pay them directly and get reimbursed from Medicare for whatever they compensate for that procedure and you, when all is said and done, pay the difference between the doctor's charge and Medicare's reimbursement.
"Medigap"/supplemental insurance is Part C, which is essentially a private alternative to Part B. Hopefully someone else can explain how it works; I have no experience with it.
posted by DrGail at 5:15 PM on December 29, 2014 [1 favorite]
Keep in mind that there are multiple parts of Medicare. Part A comes automatically upon reaching age 65 and has no premiums. It is the equivalent of catastrophic coverage; it covers hospitalizations and the like.
Part B covers the more routine items like doctor visits, has a monthly premium (which is around $100), and has a 20% copay as well as a small initial deductible. If a doctor "doesn't participate in Medicare", it means s/he doesn't deal directly with Medicare Part B. That means they won't accept whatever Medicare decides a particular procedure should cost; rather, you pay them directly and get reimbursed from Medicare for whatever they compensate for that procedure and you, when all is said and done, pay the difference between the doctor's charge and Medicare's reimbursement.
"Medigap"/supplemental insurance is Part C, which is essentially a private alternative to Part B. Hopefully someone else can explain how it works; I have no experience with it.
posted by DrGail at 5:15 PM on December 29, 2014 [1 favorite]
Yes, find the HICAP program and go with your mother to get informed. It is Byzantine. Medicare Advantage seems simpler, since it includes drug coverage in a single payment. But many of those policies are quite limited geographically, require you to be in an HMO where you must visit doctors who participate, and the insurer can drop you if you become too expensive to cover. (Medicare is required to take you, but Medigap insurers in some states don't have to take you at all or at the regulated rate if you missed the six-month window to buy a regulated Medigap policy when you first sign up for Medicare.) You can switch from regular Medicare+Medigap+drug plan into Medicare Advantage, but it can be much harder to go the other way since you can get shut out of an affordable, regulated Medigap plan after that first six months of the initial sign-up.
As for doctors, my husband and I had no trouble finding good doctors who take good old regular Medicare, which we switched into after we had a heap of trouble with one of our Medicare Advantage plans while travelling in another part of the U.S.
Here's a very good NY Times article about the pros and cons of each. The cons of Medicare Advantage outweigh the advantanges when push comes to shove. In particular, read the comments section.
posted by Elsie at 5:41 PM on December 29, 2014 [2 favorites]
As for doctors, my husband and I had no trouble finding good doctors who take good old regular Medicare, which we switched into after we had a heap of trouble with one of our Medicare Advantage plans while travelling in another part of the U.S.
Here's a very good NY Times article about the pros and cons of each. The cons of Medicare Advantage outweigh the advantanges when push comes to shove. In particular, read the comments section.
posted by Elsie at 5:41 PM on December 29, 2014 [2 favorites]
3rding HICAP. Medicare is very confusing in the beginning. I recently moved from an area where there were almost no choices, to a town with at least 50 different options. I considered myself pretty savvy about this stuff but I needed help figuring out the best plan. The HICAP counselors met with me and we went over all my needs (meds) and they helped me pick the most cost effective plan. I was on original medicare and paying a lot of money on copays (chronic health and regular aging issues) and have signed up with Kaiser and I am loving the price difference.
Everybody has different needs and the HICAP counselors are trained to help seniors sort all of this out.
posted by cairnoflore at 5:54 PM on December 29, 2014
Everybody has different needs and the HICAP counselors are trained to help seniors sort all of this out.
posted by cairnoflore at 5:54 PM on December 29, 2014
Call 1-800-MEDICARE and request a copy of "Medicare & You 2015" specifically for your area. The first parts of the book will explain original medicare, Medicare supplement (medigap) insurance, Medicare Advantage Plans (Part C) and prescription drug coverage (Part D). Section 12 will contain information about plans specific to your area. It's written in an easy-to-understand style and will give you a good idea of your mother's options before you meet with a HICAP counselor.
posted by Joleta at 7:19 PM on December 29, 2014
posted by Joleta at 7:19 PM on December 29, 2014
Very good suggestions in these comments. I'd add: if the nearest public library is a convenient distance away, maybe try calling to see if there are any resources on this sort of thing. I worked in a public library that provided several information sources for seniors specifically, and stocked a ton of tax forms every year (before online became The Thing) and other kinds of literature that are relevant to the community. All libraries are different of course, but between LA County and LA City library systems alone there are so, so many branches and a lot of opportunities for them to do outreach. At the very least, you might get a helpful staffer who knows how to find more resources.
posted by artful at 8:44 PM on December 29, 2014
posted by artful at 8:44 PM on December 29, 2014
Lots of good information is available at Medicare.gov.
posted by yclipse at 3:58 AM on December 30, 2014
posted by yclipse at 3:58 AM on December 30, 2014
Excellent information above, and a personal testimonial about Kaiser.
The good thing about Kaiser is that it's affordable and it's very easy to use. They have a big, self-contained building. You see your doctor, get your labs and fill your prescriptions all in the same place. They have an ER, urgent care, etc. So you never have to make decisions about who, what or where. Go to the big building and they'll sort you out.
If your doctor is on vacation, you don't have to wait, there's always someone who can see you. It's as close to socialized medicine as you can get, without having to move to the UK.
They were the first HMO in the country and IMHO, they do a really good job.
posted by Ruthless Bunny at 6:12 AM on December 30, 2014 [1 favorite]
The good thing about Kaiser is that it's affordable and it's very easy to use. They have a big, self-contained building. You see your doctor, get your labs and fill your prescriptions all in the same place. They have an ER, urgent care, etc. So you never have to make decisions about who, what or where. Go to the big building and they'll sort you out.
If your doctor is on vacation, you don't have to wait, there's always someone who can see you. It's as close to socialized medicine as you can get, without having to move to the UK.
They were the first HMO in the country and IMHO, they do a really good job.
posted by Ruthless Bunny at 6:12 AM on December 30, 2014 [1 favorite]
Whatever you do, don't buy any Medigap insurance right now - or any other Medicare supplements, either - not yet. The odds are that regular-old Medicare will be all she'll want, but it all depends on her income and there may be particular requirements for the state of California. But insurance salesmen will try their very best to convince old people that they have to buy all sorts of supplements because so many doctors don't take Medicare (baloney) and Medicare supplements will pay whatever Medicare doesn't pay for a hospitalization, etc. The truth is that the supplements are required to pay the same amount that Medicare would pay and if they want to they can pay more - but most don't. IOW, you're usually paying the Medicare premium plus the supplement premium and when you have a hospitalization or a significant bill, your "insurance" will pay only the same thing that Medicare would pay anyway. My doctors all (3, and I've had more) take Medicare-only patients and Medicare supplement patients under several different HMO groups and so do all the hospitals and Urgent Care places here.
In addition, she needs to get Medicare Part D for her medications - she just has to sign up for it. She'll have a copay for her prescriptions, but it won't matter what pharmacy she uses, the copay will be the same, which is nice sometimes; my pharmacy is a locally-run pharmacy that will deliver my medications if I ask them to, which I do sometimes in bad weather when I can't get around in my scooter. But I don't have to use Walmart or Costco because that's all I can afford.
Here's all you need to do: Call 1-800-MEDICARE and talk to them. You can request the book, but then you have to read it and try to figure out which parts apply to your mother and which don't. If you call Medicare - or she does (she'll have to talk to them and give them permission to talk with you), you'll need her Social Security Number and that's about it. They'll tell you exactly what she'll have to pay and whether it would be in her best interest to get a supplement or not. And they're not selling anything, so they're not going to push you into buying anything. Depending on her financial status she may or may not be eligible for state help with her Medicare premium, with her copays, etc. If not she may indeed do well to purchase a supplement, but talk to them first.
As for the different types of supplement policies and companies, they all have some wondrous stuff to bait you with - 12 free cab rides a year to and from the doctor's office, etc - and they all claim to pay for "vision" and "dental" but that's a joke. My friend was supposed to get two free cleanings a year, so she went in and had one done; they only did one-fourth of her mouth, which she thought was weird. A few days later she got a bill for $250 from the dentist. When she called about it they told her that she had "needed a DEEP cleaning" and her insurance doesn't pay for that. She was supposed to go back for three more sessions at $250 each, even though she had "dental" coverage via her supplement.
The supplement I had a few years ago actually did buy me a pair of glasses - or, at least they paid $100 toward the glasses that cost me just under $300. That was the only thing they ever paid that was more than what Medicare itself pays, though. And one other thing about the supplement programs - they leave town. I've had Asuris and Essence and both just closed up shop and left (us hanging). The one I've heard the most complaints about here in this place where I live - a beehive of old people - is AARP. Oooh, the stories would curl your hair.
So beware - go to the source first - call 1-800-MEDICARE (dang if I can figure out what the numbers would be but Google would have the number). The people there are very nice and very helpful and they aren't selling anything. BUT be warned: It could take hours, though it may just seem like hours, to get in touch with someone there - it's worth the wait, though.
posted by aryma at 12:59 AM on December 31, 2014
In addition, she needs to get Medicare Part D for her medications - she just has to sign up for it. She'll have a copay for her prescriptions, but it won't matter what pharmacy she uses, the copay will be the same, which is nice sometimes; my pharmacy is a locally-run pharmacy that will deliver my medications if I ask them to, which I do sometimes in bad weather when I can't get around in my scooter. But I don't have to use Walmart or Costco because that's all I can afford.
Here's all you need to do: Call 1-800-MEDICARE and talk to them. You can request the book, but then you have to read it and try to figure out which parts apply to your mother and which don't. If you call Medicare - or she does (she'll have to talk to them and give them permission to talk with you), you'll need her Social Security Number and that's about it. They'll tell you exactly what she'll have to pay and whether it would be in her best interest to get a supplement or not. And they're not selling anything, so they're not going to push you into buying anything. Depending on her financial status she may or may not be eligible for state help with her Medicare premium, with her copays, etc. If not she may indeed do well to purchase a supplement, but talk to them first.
As for the different types of supplement policies and companies, they all have some wondrous stuff to bait you with - 12 free cab rides a year to and from the doctor's office, etc - and they all claim to pay for "vision" and "dental" but that's a joke. My friend was supposed to get two free cleanings a year, so she went in and had one done; they only did one-fourth of her mouth, which she thought was weird. A few days later she got a bill for $250 from the dentist. When she called about it they told her that she had "needed a DEEP cleaning" and her insurance doesn't pay for that. She was supposed to go back for three more sessions at $250 each, even though she had "dental" coverage via her supplement.
The supplement I had a few years ago actually did buy me a pair of glasses - or, at least they paid $100 toward the glasses that cost me just under $300. That was the only thing they ever paid that was more than what Medicare itself pays, though. And one other thing about the supplement programs - they leave town. I've had Asuris and Essence and both just closed up shop and left (us hanging). The one I've heard the most complaints about here in this place where I live - a beehive of old people - is AARP. Oooh, the stories would curl your hair.
So beware - go to the source first - call 1-800-MEDICARE (dang if I can figure out what the numbers would be but Google would have the number). The people there are very nice and very helpful and they aren't selling anything. BUT be warned: It could take hours, though it may just seem like hours, to get in touch with someone there - it's worth the wait, though.
posted by aryma at 12:59 AM on December 31, 2014
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The CA Health Advocates site also has a lot of helpful, readable information.
posted by insectosaurus at 3:44 PM on December 29, 2014 [1 favorite]