Navigating the Medicare Nightmare

What is Medicare?

This is one of the hardest blog topics thus far. This topic of Medicare is so complicated and this topic could go on forever. I have summarized the information that I feel will help others understand the in’s and out’s of Medicare, which is very difficult for those in need of health care.

Many folks think Medicare is for those 65 or older. When in fact it also includes those deemed disabled, and includes individuals under 65 with certain disabilities. Additionally those people of any age with End-Stage Renal Disease (ESRD). It is based on Federal and state laws, and national coverage decisions are made by Medicare as to if something is covered or not. For me personally, I qualified, even though I am 37, for SSDI, which automatically provides me with Medicare.

When I went to sign up for Medicare two years ago I thought it would be a simple process! I was wrong. I actually spent about a month researching and figuring out what would be the best advantage plan (I will discuss this definition); including the costs of all 17 of my medications! Discussion of the basic definitions and parts of Medicare is provided below.

So let us start with the basic aspects of Medicare and the coverage’s included. Medicare consists of four parts, Medicare A, B, C, and D.

Medicare Part A: Hospital Insurance helps to cover:

Inpatient care in hospitals; Skilled nursing facility care; Hospice care; and Home health care

Medicare Part B: Medical Insurance helps to cover:

Services considered medically necessary to treat and diagnosis disease or illness. This could include lab tests, doctor’s visits, surgeries, and durable medical supplies such as a wheelchair.

Under this section of Medicare, preventative services are included. I have found that Medicare and Medicare Advantage plans encourage the use of these services, and many plans include these services at no cost as long as you find a health care provider who accepts costs. Some of the preventative services include (this list is brief): flu shots; breast cancer screening; cervical and vaginal cancer screening; colorectal screening; depression screening; and diabetes screening. Under Part B, diabetes self-management, and diabetes supplies are included.

Additionally Part B pays for inpatient hospital care; including mental health inpatient; outpatient and partial hospitalization. Limited outpatient prescription drugs are included as well.

Medicare Part C: Medicare Advantage Plans

This is the part, for me found very confusing, and what I referenced above as taking me a month to research. This is where Medicare Advantage Plans come into play. Medicare approved private insurance companies run these plans. The benefits of these companies include Part A and B, with the option to pick up Part D, which is the prescription drug coverage. With these plans, there are many different policies so this is where the dreaded decision comes as to whether one wants a supplemental plan such as a HMO, PPO, PFFS, Medigap, and others. If you are in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare.

Some services may only be covered in certain settings or for patients with certain conditions, and on top of the regular cost of Part A and B Medicare premiums, there is an extra cost. Medicare Advantage Plans are from some of the same companies that group employee and private individual plans pay for. Some of these are Humana; Care First; Anthem; Blue Cross Blue Shield, these are just some examples. Additionally plan coverage is based on place of residency. Companies in each state that process claims for Medicare make local coverage decisions.

Medicare Part D: Prescription Drug Coverage

The Medicare approved private insurance companies that include Part D, the prescription drug coverage, run similar to Part C. You can pick this Medicare part up by itself or most Advantage Plans include it when you pay out of pocket. Under this part additional drug coverage is provided, and aids to help lower prescription costs. I would like to note, Original Medicare only provides standard Medicare Part A and B, with limited prescription coverage. For me I’m on a Medicare Advantage Plan, which includes Part D, the prescription plan as well, and helps enormously with out of pocket prescription costs, being that I’m on 17 medications.

I know I know your heads are probably spinning. I do not understand how this country’s biggest health plan, is so confusing to understand and difficult with all its twists and turns. Luckily, for me I am “with it” enough to go online and research the Advantage Plans for extra help with my enormous medical and prescription costs. For those who are elderly and severely disabled, I have found that there is not a lot of local help to help navigate this steep path.

Lastly, the most important thing I will mention, upon deciding on a Medicare plan make sure the Medicare plan covers what you need. Talk to your doctor or health care provider to make sure your coverage includes their services. Also, discuss with them what services or supplies they will not cover. You can also call Medicare directly to ask about specific procedures and services. Below are some resources to help you getting started on your quest to navigate through the Medicare system, or prepare you for future use.

Resources to help get some additional information and questions answered

Direct Medicare Help

1-800-633-4227

TTY 1-877-486-2048

www.medicare.gov

Social Security Administration

1-800-772-1213

TTY 1-800-325-0779

www.socialsecurity.gov