The Medicare Journey™

For most of us, navigating the Medicare Maze is full of complexity and not having the right guide can end up costing you your time, money and health.

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The Medicare Journey

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Medicare coverage plays a significant role in the lives of 40 million Americans and growing at 10k per day! That is about 15% of the U.S. population enrolled in Medicare. Medicare is made up of both public and private sectors. Bridge Insurance has extensively researched and compiled all available Medicare information for you, so you don’t have to do the work. Hopefully, this article will help to answer some common Medicare questions, misconceptions and helpful tips to navigating the complex, Medicare Maze! If you are new to Medicare and want the education, you are in the right place.

Bridge is a licensed, insurance broker specializing in Medigap Plans, Fixed Annuities and Life Settlement insurance products.

*For the purposes of this article, we will be primarily focusing on Medicare, not Medicaid. For more information on Medicaid and how to apply, visit the official Medicaid site.

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What is Medicare?

According to CMS.gov, Medicare started in 1965 (over 50 years) when President Lyndon Johnson with U.S Congress enacted the Medicare bill (Title XVIII) of the Social Security Act providing health coverage for U.S. senior citizens (65 years and older). Medicare is a federal, “pay-as-you-go” program, which means; Social Security taxes today fund benefits today and any extra funds are held in a futures account. Part of the tax pays for OASDI (old age, survivor and disability) benefits and the other fund goes directly to Medicare. Medicare offers seniors two options Original Medicare (Part A and Part B) and Medicare Advantage (Part C).

What are the main differences between Medicare and Medicare Advantage?

The main differences between Medicare and Medicare Advantage go beyond just coverage, availability, and price. It comes down to trust. Since Original Medicare is funded by taxpayers, the idea of foregoing its management from the U.S government to for-profit, private insurance may have some more concerned than others. Another big difference is based on freedom. Original Medicare operates like a Preferred Provider Organization (PPO) whereas Advantage is similar to a Health Maintenance Organization (HMO). For example, PPO’s often give people freedom to choose doctors unlike HMO’s that can limit people to networks within states or even zip codes! For more information on Medicare, Medicare Advantage and Medicare Supplements follow us on the Medicare Journey and escape the Medicare Maze.

What does Medicare cover?

According to Medicare.gov, Medicare may cover many things depending on what path one takes. The question you should really be asking is, what does Medicare consist of?. The answer: Medicare is made up of Four (4) Letter ‘Parts’ NOT ‘Plans’. When dealing with Medicare, there is a big difference between the two terms ‘Parts’ and ‘Plans’ because they represent entirely different insurances as you will see. Plans represent Medigap Plans which are private insurance plans that help cover the costs that Medicare doesn’t pay for. By keeping these terms separate in your mind, you will understand Medicare more easily as this can be a major source of confusion for many. Medicare consists of of the following parts;

  1. Part A – Hospital Coverage (Gov’t Insurance).
  2. Part B – Physician Coverage (Gov’t Insurance).
  3. Part C – Medicare Advantage (Private Insurance).
  4. Part D – Prescription Drug Coverage (Private Insurance).

Medigap Plans also cover;

  • Hospital Insurance (Part A).
  • Medical Insurance (Part B).
  • Medicare Part A Coinsurance.
  • Medicare Part B Coinsurance.
  • First Three (3) Pints of Blood.
  • Part A Hospice Coinsurance.
  • Skilled Nursing Facility Care Coinsurance.
  • Part A Deductible.
  • Part B Deductible.
  • Part B Excess Charges.
  • Part B Co-payments
  • Foreign Travel Emergency Insurance.
  • Gym memberships and other perks.

What doesn’t Medicare cover?

Medicare may not cover the following items;

Always check your health plan carefully or have a licensed Agent help assist you.

How does Medicare enrollment work?

Enrolling in Medicare is automatic, upon turning age 65 years old or after applying for Social Security benefits. According to SSA, if a recipient earned their full, 40 Social Security credits, they are entitled to free, Medicare Part A not Part B. If they didn’t receive full credit, this coverage is paid for out of their Social Security income. Read more about Social Security Benefits and Medicare Enrollment Periods.

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How do I compare Medicare and Medicare Advantage?

When comparing between Original Medicare and Medicare Advantage Plans, one needs a Complete Health Plan Perspective before settling. Seniors are often bombarded with information and sales calls to make quick decisions which may impact their entire life. Still many make decisions in haste based on pushy sales agents, poor information or price alone. Switching between plans is not as easy as some expect. There are rules. The Complete Health Plan Perspective looks at Medicare as a whole and helps seniors evaluate their options.

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How is Medicare paid for?

Every employed or self-employed American pays for Medicare in the form of payroll taxes called the Federal Insurance Contributions Act (FICA). FICA Infographic.

How does Medicare billing, claims and appeals work?

According to CMS, Medicare billing is handled by Medicare and private insurance carriers. Every three (3) months, those enrolled into Medicare, will receive a Medical Summary Notice (MSN), also known as an Explanation of Medicare Benefits (EOMB) which denotes all the specific medical costs and supplies billed to Medicare on behalf of the beneficiary from the previous quarter. Any excess charges (ie: the 20% left over costs) are coordinated with private Medigap Insurance, Medicare Advantage or paid out-of-pocket.

If a recipient was under or over-charged, they can make a claim to the Medicare claims processor. In the case of Medicare claims, every enrollee has the right to appeal the following:

  • An application that was denied for a Medicare program.
  • If an enrollee received a service or line-item that is not covered by the plan and he or she believes it should be.
  • A service or item was denied and the enrollee believes it should be paid for.
  • The amount that Medicare actually paid for a service or item.
  • If Medicare or the enrollee’s plan provider (Carrier) stops providing or paying for all or part of a healthcare service, supply, item or prescription drug that the enrollee believes he or she still needs.

When appealing, an enrollee can self-file or appoint a representative to help with the process. A representative can be any of the following: family member, friend, attorney, doctor or anyone an enrollee chooses. After filing an appeal against a Medicare decision or expense, there are five levels of appeals an enrollee can go through (NIS, 2018);

  1. A redetermination by the company that manages claims for Medicare.
  2. A reconsideration from a Qualified Independent Contractor (QIC).
  3. A hearing before a Administrative Law Judge (ALJ).
  4. A review by Medicare Appeals Council (Appeals Council).
  5. A Judicial review by a federal district court.

Click Here to Make an Appeal. Here is an article we found that explains Medicare spending for stats.

Who manages Medicare?

Medicare eligibility and the processing of premiums go through the Social Security Administration (SSA) but Medicare laws and Medicare administration are not managed by the SSA. The Centers for Medicare and Medicaid Services (CMS) further administer the program by providing ‘enrollees’ with over 1.5 million healthcare providers and suppliers, that are contracted with the Federal Government.

What if I don’t accept Medicare?

Although seniors are not forced to accept Medicare, it would be unwise not to accept it because Medicare is the foundation for health care. Even if one is covered by a group plan, Medicare is still a secondary safety net. Any claims beyond the group coverage fall on Medicare to cover the costs. You could be putting yourself in a compromising situation without basic Medicare coverage and could pay a penalty for choosing not to enroll on-time.

In Conclusion

Medicare is a mix of both government and private health insurance for seniors (65yr+) who have two main paths to choose from 1) Original Medicare and 2) Medicare Advantage. Medicare consists of 4 Letter Parts NOT Plans that work together in a confusing way. Basic Medicare (Part A) is normally, freely given to Americans who have worked for at least 10 years and made (FICA) tax contributions. Medicare coverage varies depending on the path one takes with supplemental options available. Everyone should enroll in Medicare because it is the foundation of all health insurance even if you have guaranteed employer health coverage as your primary insurance.

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