Understanding your benefits: Medicare

In the world of senior care there are hundreds of options and avenues you can take to meet your goals, however some of the benefits out there are tricky and confusing.  In this article I’ll break down the four components of Medicare.  I will also answer two frequently asked Medicare questions: what is the difference between traditional Medicare and a Medicare Advantage plan, and what are the advantages of each one?

Medicare is the federally funded health insurance for individuals over 65 or with certain disabilities.  Within Medicare lies four components A,B,C, and D.  Part A, is your hospital coverage, this pays for a hospital stay, home health care, hospice, and skilled nursing care.  In order for Medicare to pay for a period of time in a skilled nursing facility a "three midnight inpatient stay" (the patient has been in the hospital, as an inpatient status, for at least three consecutive midnights in the prior 30 days) must have been completed.  Part B, pays for your therapy, doctor visits, lab work, x-rays, and ambulance service. It is important to note that Medicare does not always cover the entire bill and a co-payment usually is required.  Part C, this is your private insurance option.  These are private companies that are approved by Medicare, but take the place of Part A and B.  Frequently used Medicare advantage plans are the UPMC, Highmark, Aetna, Humana, and United Health Care.  Medicare Part D is your prescription drug plan.  This pays a portion towards your medication. 

The advantage of traditional Medicare is that it covers more,  your list of providers is wide open and a lower co-payment.  A Medicare Advantage plan requires the service you desire to be in network with the provider (insurance company).   Many of the Medicare Advantage plans only have select providers in your area that they have contracts with.  Traditional Medicare is widely accepted by all providers, however the down side of traditional Medicare is that if a skilled nursing stay is needed a three midnight stay at an inpatient facility is required.  This is not necessary with a Medicare Advantage plan if an individual would require a skill nursing stay and has a skilled need, an authorization can be obtained by the insurance company for that individual to be placed into a skilled nursing facility.

Once in a skilled nursing facility there are also differences in the way the two pay.  Traditional Medicare will pay 100% of the skilled nursing stay from day 1 through day 20.  After day 20 through 100, there will be a copay.  With a Medicare Advantage plan copays vary and small increments of days are authorized.  This authorization is based on the progression of the patient which allows the insurance company to continue to pay for the stay at a skilled nursing facility.  It is important to note, that with both Medicare and Medicare Advantage plans when the plan says you are granted 100 days in a skilled nursing facility, this is based on the individuals steady progression in therapy.   If an individual is not meeting goals or not participating in therapy both Medicare and Medicare Advantage can cut the service to the individual and the family would have to either privately pay or leave the facility.

When choosing the coverage to meet your needs it is important to weigh the pros and cons between the two and review what plan can provide the services you require.   For Insurance counseling you can check with your local Active Aging to see if they have an Apprise program.  The Apprise program is a free insurance counseling service that can look at your individual needs and help you make the right choice.  For any other questions feel free to contact me Tom Erickson at 814 806-4556 or send me an email at tome@h-v-a.org.