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Loading... Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs (The Get What's Yours Series) (2016)47 | 3 | 545,039 |
(4.19) | 1 | "A coauthor of the New York Times bestselling guide to Social Security Get What's Yours authors an essential companion to explain Medicare, the nation's other major benefit for older Americans. Learn how to maximize your health coverage and save money. Social Security provides the bulk of most retirees' income and Medicare guarantees them affordable health insurance. But few people know what Medicare covers and what it doesn't, what it costs, and when to sign up. Nor do they understand which parts of Medicare are provided by the government and how these work with private insurance plans--Medicare Advantage, drug insurance, and Medicare supplement insurance. Do you understand Medicare's parts A, B, C, D? Which Part D drug plan is right and how do you decide? Which is better, Medigap or Medicare Advantage? What do you do if Medicare denies payment for a procedure that your doctor says you need? How do you navigate the appeals process for denied claims? If you're still working or have a retiree health plan, how do those benefits work with Medicare? Do you know about the annual enrollment period for Medicare, or about lifetime penalties for late enrollment, or any number of other key Medicare rules? Health costs are the biggest unknown expense for older Americans, who are turning sixty-five at the rate of 10,000 a day. Understanding and navigating Medicare is the best way to save health care dollars and use them wisely. In Get What's Yours for Medicare, retirement expert Philip Moeller explains how to understand all these important choices and make the right decisions for your health and wealth now--and for the future"--
"GET WHAT'S YOURS FOR MEDICARE explains for those 65 and older how to make the best choice in the annual Medicare enrollment period to maximize your health coverage without overpaying -- just as GET WHAT'S YOURS advised older Americans about the right Social Security decisions"--… (more) |
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To the day when good health care is a birthright —PHILIP MOELLER | |
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Glen didn't retire until he turned 70 in 2010. | |
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Ruinous health expenses are a major if not the major cause of personal bankruptcies in the United States. At 65, if you're a U.S. citizen, or if not, you have been a permanent resident of the United States for at least five consecutive years, you are eligible to begin Medicare. Being eligible does not mean you must sign up right then. There is one simple rule to keep in mind if you are fortunate enough to have a private retiree health plan: such plans always pay secondary to Medicare. If you are 65 or older and file for Social Security, the government will require you to take Part A, which triggers your official filing for Medicare. And if you have an HSA and are on Medicare, you will no longer be able to make pretax contributions to it. In fact, the rules say you need to stop contributions six months before Social Security benefits begin! Part A covers certain inpatient care at hospitals, skilled nursing facilities, home health agencies, and hospice. Part B deals with covered services involving doctors, durable medical equipment, and other outpatient expenses. Everybody usually needs to have Part A and B, before they can buy any additional Medicare coverage, including a Medicare Advantage (MA) plan, Part D prescription drug insurance (often included in Medicare Advantage), or a Medigap policy that supplements Original Medicare. Medigap and Medicare Advantage plans don't play well with one another, meaning that you can't get both of them at the same time. Your best bet is to verify, verify, verify that something is covered before committing yourself to a health care spending decision. Part B charges a monthly premium that in 2016 is $104.90 for most beneficiaries. However, about 5 percent of Part B subscribers earned enough money to push them into higher premium brackets. This set of surcharges is known as the income-related monthly adjustment amount, or IRMAA. Social Security makes this call and bases premiums on federal tax returns two years prior to the program year in question. So, the agency used 2014 returns to determine any 2016 Part B premium surcharges. For the detail-minded, the agency uses a measure of taxable income called "modified adjusted gross income." There also is a free "welcome to Medicare" appointment with your doctor to make sure you get off on the right foot when you begin Medicare. Remember, you are entitled to these services. Many of them are woefully underused. Even though most are free, you may face coinsurance should the visits and screenings lead to additional tests and medical services. —on the subject of preventive services Several Medigap "letter" plans, also called Medicare supplement insurance, offer emergency coverage for foreign travel, as do some MA plans. Check with insurers if you plan to travel abroad. Beyond this, you may need to seek non-Medicare insurance. If you spend lots of time in a single foreign country, you should explore health coverage issued by an insurer in that nation. You might investigate health care options in travel insurance policies for shorter trips. Medigap policies, also known as Medicare supplement plans, are private insurance plans that fill a lot of the gaps that expose Original Medicare beneficiaries to enormous medical expenses. Part B generally pays only 80 percent of the cost of covered services and medical equipment. You pay the other 20 percent—forever. Part A has fewer gaps, as explained in the last chapter, but you are still responsible for any deductibles. And the costs of long hospital stays not covered by Part A can bankrupt all but the wealthiest households. Once you have secured Part A and Part B coverage, the clock normally starts to tick on your Medigap enrollment period. The "cost" of missing this first enrollment window for Medigap is not a financial penalty but something that may be even greater. You might lose valuable health insurance guarantees. People aged 65 and older have guaranteed access rights to Medigap within the enrollment window—insurers must sell you the plan you want (assuming they offer it), can't refuse to insure you because of preexisting conditions, and can't nail you with higher premiums because of these conditions. Also, the policy is guaranteed to be renewable on these terms so long as you keep up with the premiums. These guarantees may go poof if you miss your enrollment window. There are 10 different types of Medigap policies that can be sold by insurers. They are designated by different letters and—surprise!—known as letter plans. Due to the creation of new letter plans and the retirement of old ones, the array of Medigap plans is not lettered A through J but currently consists of A, B, C, D, F, G, K, L, M, and N. There are two types of letter F plans, so if someone says there are 11, I'm fine with that, too. You must be formally admitted to a hospital for at least two midnights before you're eligible for certain key Medicare benefits. MA insurers get roughly $10,000 from Uncle Sam for each and every beneficiary who buys a policy. users of Original Medicare have great freedom in selecting their caregivers, and can travel freely within the United States and know they will still be covered. MA plans, by contrast—and it's a major contrast at that—usually require members to use only the care providers within a plan's network. the key takeaway is that you should not, repeat, not purchase an MA plan unless your doctor and other preferred health care providers are in its provider network. The 2003 law led to the federal government being the guaranteed payer of last resort for many drugs that Medicare beneficiaries cannot afford to buy. And it did so while tying the hands of Medicare by forbidding the agency from being able to use its enormous buying power to negotiate lower drug prices. 1 percent a month tacked on to the basic Part D premium for each month you're late in enrolling. Drugs may also be dispensed in the hospital, where they will be covered by Part A of Medicare if you're an inpatient or even Part B if you're an outpatient. Likewise, some drugs provided to you in your doctor's office or other outpatient settings may be covered by Part B of Medicare. There are separate annual deductibles for Parts A and B. And 20 percent coinsurance rules may apply for Part B drugs. So don't assume that all your drugs are covered by your Part D plan. Ask before a drug is administered. Part D plans usually charge a monthly premium. There is an annual deductible as well, meaning you must pay all of the cost of drugs covered by your plan until you've met the deductible. In 2016, the maximum annual deductible allowed by Medicare is $360. Many plans charge less, although more plans are using the maximum deductible in response to higher drug prices. After the deductible has been reached, your insurance kicks in and pays its share for covered drugs. You usually pay a share as well, which may be called a copay or coinsurance. Then, in a departure from sanity, your insurance coverage just stops after you've reached a certain level of spending. This level includes the total of your annual deductible and what you and your plan have paid. At this point, you have entered the infamous coverage gap. It's also called the donut hole—a phrase that makes less sense every time I encounter it. The spending level that triggers the coverage gap changes every year to reflect medical inflation. In 2016, it is $3,310. The coverage gap has an annual end point that also shifts every year. In 2016, it is $4,850. So, while in the donut hole, you must use drugs costing $1,540 before your insurance coverage resumes. While in this gap, you have to pay all of the costs for your covered medications. Only you really don't. You will pay less for both branded and generic drugs. The percent reductions are different for the two. In one of many Medicare quirks, your savings on branded drugs are credited back toward what you have spent in determining the end point of the gap, while discounts on generic drug spending do not trigger this favorable credit. Once you reach the end of the gap, you're reached the "catastrophic" phase of Part D coverage. Is this fun, or what? The insurers who run Part D plans don't like the high drug prices, either. Even though their cost exposure is only 15 percent—remember, you pay 5 percent at most and Uncle Sam pays 80 percent—they would like it to be 15 percent of the smallest number possible. —in reference to the catastrophic phase of Part D plans and the high price of drugs Indeed, its workload is so heavy that it takes OMHA 20 to 24 weeks even to enter new appeals onto its docket, prompting this sobering if not shocking website notice to claimants: "If 22 weeks have not lapsed since you submitted your Request for Hearing, do not resubmit your request." There is a dedicated mail stop within OMHA for consumer appeals. So, unless you see a rating for your specific health needs, don't assume that a hospital with high overall ratings will be the best one for you. Even if you can find your specific need covered in one or more health ratings, proceed with caution. Your use of ratings should be driven by your medical needs. Medicare's high-income surcharges for Part B and Part D premiums are based on your tax returns of two years ago. Original Medicare is administered by largely anonymous Medicare Administrative Contractors, or MACs. Here are the questions to ask a prospective surgeon: In general, how many of the surgeries I need have you done during the past 12 months, and what's your record in terms of deaths, complications, and how quickly patients return to their usual activities? Also ask the same questions as they apply to patients similar to you in terms of age, overall health, and other risk factors. You should also pose these questions to any hospital you're considering for your surgery, procedure, or care. They have this information and know that this is increasingly what patients want to know. Medicare insurers analyze your health records to produce a numerical risk score. Believe me here that mere mortals cannot figure out how this is done. The process begins with your health diagnosis codes provided by hospitals, doctors, and other caregivers. Doctors get paid by health plans for contributing to these profiles, according to Fred Schulte, who has done eye-opening journalism on this topic for the Center for Public Integrity. Then the information gets messaged by enough factors to impress even the most imaginative bureaucrat. About a third of all health care spending stems from hospital stays, of which there were a whooping 36.5 million in 2012, lasting an average of 4.5 days each at an average daily cost of nearly $10,500. If a hospital provides treatment under a DRG code (diagnosis-related groups) with an average inpatient stay of, say, four days, that's what it gets paid, regardless of how many days the patient (again, remember that this could be you) actually stays in the hospital. So, if your stay is shorter than this average, the hospital likely will make more money. And if you stay in the hospital longer than this average? Well, your doctors get paid more, but the hospital won't. — how Medicare pays hospitals for their services as of 2016 when this book was written Roughly 19 out of 20 doctors are what's called "participating providers" in Medicare. This means they have agreed to "accept assignment" with their Medicare patients and will accept Medicare's fees as payment in full. Further, they will collect these fees directly from Medicare or from an MA plan and not from patients. You owe only copayments and perhaps other charges based on the terms of your Medicare coverage. The other few percent, according to a 2014 Kaiser Family Foundation report, are what are called nonparticipating providers. They can charge you more than Medicare charges and your Medicare insurance may not cover these excess amounts. This practice is called "balance billing." Studies regularly tell us that the average 65-year-old couple faces future out-of-pocket health costs ranging between $250,000 and $300,000 in today's dollars. This excludes the cost of long-term care, which averages close to $80,000 a year in a nursing home, and can easily top six figures a year in some locales. These are averages, it should be noted. If you look at the distribution of such expenses over the entire population of older people, you will see lots of million-dollar-and-up health care bills. Genworth presented the median (Geek Alert: median is the midway point between the highest and lowest costs; it is not an arithmetic average) annual rates of six care services:
Homemaker services: $44,616 Home health aide services: $45,760 Adult day health care: $17,904 Assisted living facility (one bedroom, single occupancy): $43,200 Nursing home (semiprivate room): $80,300 Nursing home (private room): $91,250 Roughly half of those older than 65 admitted to a hospital are unable to make their own care decisions and need a friend or relative to be their health care decision maker, or proxy. Leaving your future health care planning needs to some undefined and distant manana is a bad idea on multiple fronts. Here, I'll only reinforce the notion that you need to make these plans while you still can. Amy Vandenbroucke, an advocate for strong patient tools to ensure that their end-of-life wishes are carried out by doctors and other health care workers, passes on one tech-appropriate tip in today's wireless age: bring along a smartphone and make a video recording of the meeting. This will create a needed record for you and, perhaps of greater importance, for family members who aren't present. "Seeing a video of Mom saying she never wants to be hooked up to a machine is very powerful," she notes. Doctors, as Gawande and other informed observers have noted, may not be particularly well-equipped or interested in having helpful end-of-life discussions. More to the point, doctors in general appear to be a shrinking breed. And geriatricians—doctors specifically trained to care for aged patients—are very, very hard to even find. Only about 7,000 now practice in the United States, serving a population of older Americans well north of 30 million. Do the math. As we age, finding the best possible physician with whom to grow older should be a priority. If you can't find a geriatrician, look for a doctor who is not only competent but listens to you—not one so pressed for time that they are checking their watches or smartphones after your appointment has exceeded a few minutes. Advance directives are not medical orders, so, for example, emergency medical technicians (EMTs) are not legally able to follow them. Instead, they are legally required to do everything possible to try to save your life. Likewise, if you have a life-threatening health situation, hospital personnel may feel morally and often legally obligated to keep you alive. Advance directives are reviewed at the hospital with your surrogate and used to make treatment decisions. advocates have been working to develop state-by-state acceptance of what are known collectively as Physician Orders for Life-Sustaining Treatment (POLST); they go by different names in some states. These orders are signed by a physician (or in some states, also nurse practitioners, advance practice registered nurses, or physician assistants) and the patient (or his or her representative). The POLST form is completed based on the specific medical issues involved in your end-of-life care situation and your goals for care. As a result, POLST documents often are not signed until a patient is ill or frail, and facing important care decisions. Unlike an advance directive, Vandebroucke explains, a POLST is a specific medical order that must be followed by health care professionals, including EMTs. Hospice care at home has become the preferred place that people want to spend their final days. To many people, the biggest problem with hospice is that the patient has to cease what's called "curative" medical care in order to use Medicare's hospice benefits. Palliative care is care given to improve the quality of life of patients who have a serious or life-threatening disease, such as cancer. The goal of palliative care is to prevent or treat, as early as possible, the symptoms and side effects of the disease and its treatment, in addition to the related psychological, social, and spiritual problems. The goal is not to cure. Palliative care is also called comfort care, supportive care, and symptom management. | |
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▾References References to this work on external resources. Wikipedia in EnglishNone ▾Book descriptions "A coauthor of the New York Times bestselling guide to Social Security Get What's Yours authors an essential companion to explain Medicare, the nation's other major benefit for older Americans. Learn how to maximize your health coverage and save money. Social Security provides the bulk of most retirees' income and Medicare guarantees them affordable health insurance. But few people know what Medicare covers and what it doesn't, what it costs, and when to sign up. Nor do they understand which parts of Medicare are provided by the government and how these work with private insurance plans--Medicare Advantage, drug insurance, and Medicare supplement insurance. Do you understand Medicare's parts A, B, C, D? Which Part D drug plan is right and how do you decide? Which is better, Medigap or Medicare Advantage? What do you do if Medicare denies payment for a procedure that your doctor says you need? How do you navigate the appeals process for denied claims? If you're still working or have a retiree health plan, how do those benefits work with Medicare? Do you know about the annual enrollment period for Medicare, or about lifetime penalties for late enrollment, or any number of other key Medicare rules? Health costs are the biggest unknown expense for older Americans, who are turning sixty-five at the rate of 10,000 a day. Understanding and navigating Medicare is the best way to save health care dollars and use them wisely. In Get What's Yours for Medicare, retirement expert Philip Moeller explains how to understand all these important choices and make the right decisions for your health and wealth now--and for the future"--
"GET WHAT'S YOURS FOR MEDICARE explains for those 65 and older how to make the best choice in the annual Medicare enrollment period to maximize your health coverage without overpaying -- just as GET WHAT'S YOURS advised older Americans about the right Social Security decisions"-- ▾Library descriptions No library descriptions found. ▾LibraryThing members' description
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