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Medicare

May 14
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What is MEDICAID?

By Uncategorized

Medicaid: What it is and What you need to know

The Issue

Medicaid is a joint federal and state program that provides payment for medical care for persons unable to afford to pay. Medicaid covers physicians’ services, hospital care, supplies and other necessary services once a person has been made eligible for the program. It also pays for the expenses of long-term care in a nursing home.

The Medicaid program is administered independently in each state. While the basic eligibility standards are the same throughout the United States, there are significant differences between the state Medicaid programs. Despite these differences, eligibility is generally based upon the amount of assets a person has along with the income that the person receives. Eligibility is determined at state Medicaid offices and, in the case of married individuals; the assets and income of both spouses are considered in the determination process.

It is important to distinguish between Medicare and Medicaid. Medicare is an insurance program providing payment for medical needs for persons 65 and over and for certain people with disabilities. All persons 65 and over, regardless of financial resources or income, are eligible for Medicare. Medicare and Medicare supplemental insurance, however, provide very limited coverage with regard to the cost of long-term care in nursing homes. These non-covered services must be paid privately by the individual, unless the individual has coverage under a long-term care insurance policy. Medicaid, on the other hand, pays for medical needs for those of any age that have been determined to be eligible. In fact, a person with limited income and resources who has Medicare coverage may also qualify for Medicaid benefits.

What You Need to Know

Medicaid is considered to be one of the most complex laws of the United States and, further complicating matters, each state has a different version of Medicaid. Many Elder Law attorneys have carefully studied the Medicaid statutes and regulations and are able to assist clients.

Medicaid is often of importance to middle-income Americans because Medicare does not cover the costs of long-term care for illnesses such as Alzheimer’s disease or paralysis caused by a stroke. Most people who need such care for extended periods will eventually deplete their assets and become unable to pay the costs of their care.

At such a time Medicaid is available to pay the difference between their income and the actual costs of care provided in a nursing home, including room and board, as well as physicians’ care, hospital care and all other reasonable necessary medical expenses. Medicaid covers the costs of such care in nursing homes, adult care homes, hospices, and, in appropriate cases, in the individual’s own home.

If faced with the possibility of such long-term care expenses, there are certain rules that you should be aware of:

• In determining eligibility for Medicaid payment for long-term care expenses, the eligibility team will review the individual’s actual need for care, the person’s available resources (including life insurance and retirement plans) and income received from any source. In some states, if monthly income exceeds a certain amount, then the individual is ineligible for Medicaid, even though the individual’s long–term care expenses exceed his or her income.

• In determining eligibility, a person will be disqualified from Medicaid for gifts made within the previous few years.

• In determining eligibility for one spouse, the assets and income for both spouses are considered, regardless of premarital agreements, community property laws or the nature of the ownership of the asset.

• Assets of married couples, however, receive special treatment so that the spouse who remains living at home will not be unduly impoverished. Such a community spouse is permitted to keep one-half of all of the available assets (up to a federally-established maximum) and is allowed to keep a minimal amount of income of the couple in order to provide for support expenses at home.

• In addition, there are certain resources that are considered non-countable for eligibility purposes; these include the family residence, household contents, a vehicle, a prepaid burial fund and other necessary items.

• It is important to be aware of the state specific eligibility provisions and exemptions so that assets will not be unnecessarily spent down before applying for Medicaid.

• Finally, it is important to know that there are appeals processes built into the Medicaid system. If you are unhappy with eligibility determinations, care decisions or placements made under Medicaid, there is a process for an administrative hearing and even court proceedings to enforce your rights.

Where to Go For Help

WE ARE HERE TO HELP! We are attorneys who are versed in the rules of Medicaid eligibility. However, there are books published concerning the Medicaid program and its rules and you should check your library or bookstore for current titles. The Internet can be another source of Medicaid information. Keep in mind that the Medicaid laws and rules vary between states and are constantly changing so make certain that whatever you read is state specific and up to date. There have been major changes in the Medicaid program during the last few years.

Family support groups and organizations such as the Alzheimer’s Association and AARP provide assistance and often have literature available. Local Area Agencies on Aging (pursuant to the Older Americans Act) also have comprehensive advice and literature available concerning Medicaid. The state Medicaid Eligibility Office may be a good source of basic information about the program, its services and the requirements for eligibility.

The Role of the Elder Law Attorney

Many Elder Law attorneys have extensive training and experience concerning Medicaid and have been advising clients and their families for many years. Much of the planning done by older persons concerning Medicaid has been done with the help of such experienced attorneys. It is important to see such an advisor as soon as possible to enable the greatest benefit from such planning.

Long-term care insurance is one way of preparing for the expenses of long-term care and should be considered. Such insurance is not available for everyone and will not be available once a disabling long-term illness has struck.

Because the law is so complex, Elder Law attorneys are a particularly appropriate source of advice. We can assist you in planning for the expenses of long-term care as well as planning for the protection of assets for the rest of the family.

Jan 20
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The Long Term Care Crisis

By Uncategorized

The Silver Tsunami is Coming

America faces a looming long-term care crisis that threatens both family finances and state budgets.  As the Baby Boomer generation enters its 80s and 90s, demand for assistance with basic daily activities is surging.  Yet most Americans lack adequate savings or insurance to cover care costs that routinely exceed $168,000 annually.

The problem is amplified by widespread misconceptions.

How Is Long Term Care Paid For?

Fifty-six percent of Americans mistakenly believe Medicare covers long-term care, and many also assume their health insurance or disability-income insurance will pay for these services.  They do not.

In reality, Medicare covers only up to 100 days of short-term skilled nursing following a hospitalization, not ongoing long-term care.  As a result, families are left exposed to catastrophic costs that can quickly drain retirement savings and ultimately force reliance on Medicaid after assets are exhausted.

State Resources and Medicaid

This reality places enormous fiscal pressure on states.  Driven by basic supply-and-demand dynamics, the share of annual state Medicaid budgets allocated to Long-Term Services and Supports continues to rise year over year.

Medicaid now pays for roughly half of all long-term care in the United States, placing growing strain on state budgets as middle-class families are forced to “spend down” into poverty just to qualify.  To prevent abuse, Medicaid imposes an intrusive five-year look-back audit, scrutinizing financial transactions to ensure assets were not transferred below market value to appear “poor on paper.”

In Facility Placement versus Home Based Waiver Care

Rhode Island does offer resources to provide assistance in home for families that are doing their best to care for their loved ones at home. The Home Based Waiver is a program where once you establish a medical need, countable assets in accordance with the regulations, you can apply for help to come into the house. Representatives from DHS will meet with the family, determine need, and help coordinate resources to come into the home. This can often act as a lifeline for families and allow them to have some respite or time to get out of the house, for employment or errands.

In facility placement is having your family member reside at the skilled nursing facility. Current Medicaid Long Term Supports and Services rules require individuals to satisfy 4 prongs before they are eligible for LTSS Medicaid benefits:

  1. Medical Need  – applicants must demonstrate that they have a medical need for skilled nursing care.
  2. Countable Resources – applicants must demonstrate that they have countable resources as defined by the Medicaid regulations below $4,000
  3. Monthly Income – must be below $10,190 per month in Rhode Island to be eligible for LTSS Medicaid benefits
  4. No Disqualifying Transactions – applicants must be prepared to demonstrate that they have not engaged in any transfers of assets in the 5 years prior to applying for benefits where they would be deemed to have made a transfer of assets for less than full consideration in return (i.e.: did you make a gift of assets?)

The Importance of Planning

Planning for long term skilled nursing is more critical than ever. The fiscal pressures placed on spouses and families to provide for the level of care needed for our aging family is not a matter of if the services will be need by rather when.

With the ever present 5 year look-back rule the sooner you discuss and execute a plan that establishes a path to Medicaid eligibility the better.

Dec 03
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2026 Medicare Premiums

By Uncategorized

On November 14, 2025, the Centers for Medicare & Medicaid Services (CMS) released notices detailing the Medicare Part A and Part B premiums and deductibles for calendar year 2026:

  • The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,736 in 2026, an increase of $60 from $1,676 in 2025.
  • The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2026, beneficiaries must pay a coinsurance amount of $434 per day for the 61st through 90th day of a hospitalization in a benefit period and $868 per day for lifetime reserve days.
  • For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $217 in 2026.
  • Individuals who had at least 30 quarters of coverage, or were married to someone with at least 30 quarters of coverage, may buy into Part A at a reduced monthly premium rate, which will be $311 in 2026, a $26 increase from 2025. Certain uninsured older individuals who have fewer than 30 quarters of coverage, and certain individuals with disabilities who have exhausted other entitlements, will pay the full premium, which will be $565 a month in 2026, a $47 increase from 2025.

The standard monthly premium for Medicare Part B enrollees will be $202.90 for 2026, an increase of $17.90 from $185 in 2025. The annual deductible for all Medicare Part B beneficiaries will be $283 in 2026, an increase of $26 from the annual deductible of $257 in 2025.

Sep 13
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Public Health Emergency Continued

By Uncategorized

Emergency Policies Remain In Place

On July 15, 2022, Xavier Becerra, Secretary of the Department of Health and Human Services, announced that the public health emergency related to COVID-19 still exists and therefore the public health emergency determination originally announced on January 31, 2020, continues. The determination continues in 90-day increments.

States must maintain Medicaid eligibility standards and cannot make procedures more restrictive than they were on January 31, 2020. In addition, if a Medicaid recipient is validly enrolled in any Medicaid program, then continuous enrollment applies. If a recipient is validly enrolled and reports a change in circumstance, then the change is processed as a redetermination but the individual is still deemed as being validly enrolled.

Apr 18
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Will I Ever Live In A Nursing Home?

By Uncategorized

How Much Care Will You Need?

The duration and level of long-term care will vary from person to person and often change over time. Here are some statistics (all are “on average”) you should consider:

  • Someone turning age 65 today has almost a 70% chance of needing some type of long-term care services and supports in their remaining years
  • Women need care longer (3.7 years) than men (2.2 years)
  • One-third of today’s 65 year-olds may never need long-term care support, but 20 percent will need it for longer than 5 years

Distribution and duration of long-term care services

Type of care Average number of years people use this type of care Percent of people who use this type of care (%)
Any Services 3 years 69
 

At Home
Unpaid care only 1 year 59
Paid care Less than 1 year 42
Any care at home 2 years 65
 

In Facilities
Nursing facilities 1 year 35
Assisted living Less than 1 year 13
Any care in facilities 1 year 37

Who Pays for Long-Term Care?

The facts may surprise you.

Consumer surveys reveal common misunderstandings about which public programs pay for long-term care services. It is important to clearly understand what is and isn’t covered.

Medicare:

  • Only pays for long-term care if you require skilled services or rehabilitative care:
    • In a nursing home for a maximum of 100 days, however, the average Medicare covered stay is much shorter (22 days).
    • At home if you are also receiving skilled home health or other skilled in-home services. Generally, long-term care services are provided only for a short period of time.
  • Does not pay for non-skilled assistance with Activities of Daily Living (ADL), which make up the majority of long-term care services
  • You will have to pay for long-term care services that are not covered by a public or private insurance program

Medicaid:

  • Does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level and you must meet minimum state eligibility requirements
  • Such requirements are based on the amount of assistance you need with ADL
  • Other federal programs such as the Older Americans Act and the Department of Veterans Affairs pay for long-term care services, but only for specific populations and in certain circumstances

GOOD TO KNOW

Like public programs, private sources of payment have their own rules, eligibility requirements, copayments, and premiums for the services they cover.

Health Insurance:

  • Most employer-sponsored or private health insurance, including health insurance plans, cover only the same kinds of limited services as Medicare
  • If they do cover long-term care, it is typically only for skilled, short-term, medically necessary care

There are an increasing number of private payment options including:

PLAN BEFORE YOU HAVE A NEED

Planning for the eventuality of needing long term care is critical in reducing stress and uncertainty. Meeting with an Elder Law attorney familiar with the rules of Medicaid qualification is a step in the right direction. Contact our office for a no-obligation consultation to see if developing an estate plan with the goal of Medicaid qualification is a right fit for you.

Mar 23
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Estate Planning and the Coronavirus Pandemic

By Uncategorized

Estate Planning Amidst the Coronavirus Pandemic

The Coronavirus (COVID-19) Pandemic has impacted every corner of the world at this point. As medical experts, financial advisors, and our colleagues that specialize in healthcare law, employment law, and other related areas are busy advising clients on the best course of action for the weeks and months ahead, we – as estate planners – also want to remind our clients and friends of some important considerations during these uncertain times.

At this point, we would simply promote the following actions to ensure that your estate planning affairs are in order:

(1) Review your existing documents. Make sure that you have copies (either paper or electronic) of your existing estate planning documents, and review them to confirm that they still reflect your wishes. If you cannot locate your documents, consider calling or emailing your estate planning attorney to obtain copies.

(2) Pinpoint any items that require attention sooner rather than later. As you review, take note of any major changes that may have occurred in your family since you last updated your estate plan. These might include child births, deaths, marriages, divorces, etc. And also consider whether the individuals that you previously appointed to serve as your agents are still appropriate.

(3) Follow up with your loved ones and advisors.

  • Make sure that your loved ones know to contact your estate planning attorney in the event anything should happen to you. This includes your named executor (i.e. personal representative under your will, or trustee of your trust), guardian for your minor children, attorney-in-fact under your financial durable power of attorney, and patient advocate under your health care power of attorney.
  • Consider reaching out to your financial advisor, insurance advisor, etc. to ensure that your beneficiary designations are up to date and discuss any new planning opportunities relative to your current financial status.
  • If you require any medical attention in the near future, confirm that your medical provider has a copy of your patient advocate designation and is informed as to who you wish to have access to your confidential health information.

NOTE – If you do not already have an estate plan, now is as good of a time as any to consider the opportunity before you. Having a will/trust, a durable general power of attorney, and a healthcare power of attorney can certainly contribute to a healthy state of mind.

Apr 05
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Medicare Update 2019

By Estate Planning

Medicare 2019 – Everything You Need To Know

Medicare is an important piece of the American insurance landscape, not only for people age 65 and older, but for all Americans. That said, this benefit is not easy to navigate. Eligible individuals must be thoughtful about the coverage they need, the timing of enrollment, and coordination with other healthcare benefits, if they want to make the most of the Medicare program.

Attached is a report recently published by Northern Trust that recaps the Medicare program and is a good resource for people wanting to learn more.

It addresses the following questions:

  1. What does Medicare cover? Do I still need Private Insurance?
  2. How much does it cost?
  3. I am thinking about early retirement but I am concerned about health insurance coverage and eligibility. What are my options?
  4. I am turning 65 next year and still working, should I transition from private insurance to Medicare and if so, how do I do that?

CLICK HERE TO READ THE FULL REPORT wpi-medicare 2019

Medicare is a critical component of every persons health insurance portfolio but it does not cover long-term skilled nursing. The Medicaid program covers eligible individuals cost for long term skilled nursing, however, there asset and income limits before someone becomes eligible. Generally, a person must have countable assets below $4,000 and monthly income below $10,000 to be eligible. A person who is on Medicare and then transitions over to Medicaid will be required to maintain their Medicare coverage. Medicaid being a welfare program, is an insurer of last resort, whereas Medicare is a primary insurance for people.

Still have questions about planning for your future healthcare needs including long term care planning? Contact us for a no cost consultation.

Matt Leonard

Jan 25
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Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill

By News

Federal law requires Medicare to pay indefinitely for home care

Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,” he said. He has Medicare.

Colin Campbell at his home in Covina, Calif., on Dec. 18, 2017. Campbell was diagnosed with ALS eight years ago. He has Medicare due to his disability but can’t use it for home care and instead is paying $4,000 a month for that service. His adjustable wheelchair allows him to recline, which makes breathing easier. (Heidi de Marco/KHN)

Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or “Lou Gehrig’s disease,” which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.

The former computer systems manager has Medicare coverage because of his disability, but no fewer than 14 home health care providers have told him he can’t use it to pay for their services.

That’s an incorrect but common belief. Medicare does cover home care services for patients who qualify, but incentives intended to combat fraud and reward high quality care are driving some home health agencies to avoid taking on long-term patients such as Campbell, who have debilitating conditions that won’t get better, according to advocates for seniors and the home care industry. Rule changes that took effect this month could make the problem worse.

“We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes,” said Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm. The group is considering legal action against the government.

Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement. Those who qualify can also receive an aide’s help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.

Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home —to maintain a patient’s abilities or to prevent or slow decline. It also agreed to inform providers, bill auditors and others that a patient’s improvement is not a condition for coverage.

Campbell said some home health care agencies told him Medicare would pay only for rehabilitation, “with the idea of getting you better and then leaving,” he said. They told him that Medicare would not pay them if he didn’t improve, he said. Other agencies told him Medicare simply did not cover home health care.

Medicaid, the federal-state program for low-income adults and families, also covers home health care and other home services, but Campbell doesn’t qualify for it.

Securing Medicare coverage for home health services requires persistence, said John Gillespie, whose mother has gone through five home care agencies since she was diagnosed with ALS in 2014. He successfully appealed Medicare’s decision denying coverage, and afterward Medicare paid for his mother’s visiting nurse as well as speech and physical therapy.

“You have to have a good doctor and people who will help fight for you to get the right company,” said Gillespie, of Orlando, Fla. “Do not take no for an answer.”

Yet a Medicare official did not acknowledge any access problems. “A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit,” said spokesman Johnathan Monroe.

But a leading industry group contends that Medicare’s home health care policies are often misconstrued. “One of the myths in Medicare is that chronically ill individuals are not qualified for coverage,” said William Dombi, president of the National Association for Home Care and Hospice, which represents nearly half of the nation’s 12,000 home care providers.

Part of the problem is that some agencies fear they won’t be paid if they take on patients who need their services for a long time, Dombi said. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible or they suspect billing fraud. Rather than risk not getting paid, some home health agencies “stay under the radar” by taking on fewer Medicare patients who need long-term care, Dombi said.

And they may have a good reason to be concerned. Medicare officials have found that about a third of the agency’s payments to home health companies in the fiscal year ending last September were improper.

Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time, Dombi said.

Another factor that may have a negative effect on chronically ill patients is Medicare’s Home Health Compare ratings website. It includes grades on patient improvement, such as whether a client got better at walking with an agency’s help. That effectively tells agencies who want top ratings “to go to patients who are susceptible to improvement,” Dombi said.

This year, some home care agencies will earn more than just ratings. Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don’t will pay penalties. Some criteria used to measure performance depend on patient improvement, Holt said.

Another new rule, which took effect last Saturday, prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor’s order. But that, too, could backfire.

“This is good,” Holt said. “But our concern is that some agencies might hesitate to take patients if they don’t think they can easily discharge them.”

This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Silver Century

Foundation.https://khn.org/news/home-care-agencies-often-wrongly-deny-medicare-help-to-the-chronically-ill/

Nov 01
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Medicare and Late Sign Up Penalties

By News

Medicare Should Warn Enrollees on Steep Late Sign-up Penalties

For many Americans entering retirement, it comes as an unwelcome surprise: Medicare premiums become much more expensive if you do not sign up on time. The program tacks on a 10 percent penalty on monthly Part B premiums for each full 12-month period of late enrollment, and you keep on paying the penalties for the rest of your life.

The aim is to avoid “adverse selection,” which occurs when people sign up for coverage only when they think they will need it. That helps keep premiums lower for all Medicare enrollees.

Medicare Enrollment Form

But a heads-up would be nice. And that is the intent of the Beneficiary Enrollment Notification and Eligibility Simplification Act (BENES Act), a bill introduced with bipartisan support last week in the U.S. Senate (companion legislation was introduced in the House of Representatives earlier). It would require the government to send a notification letter in the year before your 65th birthday – the first date of Medicare eligibility.

The letter would explain the enrollment rules, and – importantly – how Medicare interacts with other insurance coverage you might have.

Roughly 750,000 Medicare beneficiaries paid late enrollment penalties in 2014, according to the Congressional Research Service (CRS). That is less than 2 percent of enrollees, but for those who do pay the penalties, the bite is painful. On average, total premiums for late enrollees were 29 percent higher, CRS reported. 

Medicare is the primary source of health insurance for seniors, and choosing the correct Medicare plan is important. However, it only provides for 100 days of skilled nursing care. Planning for those potential costs are a critical component for anybody, regardless of when you sign up for Medicare.

Want to discuss your plan for paying for your care needs today and in the future? Contact us to discuss how you can plan for future long term care needs that are not covered by Medicare.

Matt Leonard

Sep 13
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Tips for choosing the Medicare plan that’s right for you

By Uncategorized

Fall and winter don’t just bring cooler temperatures and the holidays — the final seasons of the year also mean open enrollment for Medicare. For most seniors in the United States, the period between Oct. 15 and Dec. 7 is the only time they can switch or make changes to their Medicare plan insurance.

“As people age, their health care needs evolve,” says Dawn Maroney, chief growth and strategy officer for Alignment Healthcare. “When that happens, they may find the Medicare plan they first chose when they became eligible no longer meets all their needs. This open enrollment period is their yearly opportunity to re-evaluate whether to continue with their plan or switch to another, with changes becoming effective the first of the new year.”

Medicare basics

Most Americans are aware that Medicare is a government program designed to ensure people older than 65 have access to affordable health insurance. The program can also cover people younger than 65 who have certain disabilities.

The Medicare program has four parts, according to Medicare.gov: A, B, C and D.

* Medicare Part A helps pay for in-patient hospital stays, care in a skilled nursing facility and hospice care.

Drawing of Medicare with Stick Men and Clipping Path

* Medicare Part B helps cover care by doctors or other health care providers, outpatient services, some medical equipment and some preventive services.

* Medicare Part C (also known as Medicare Advantage) covers everything included in parts A and B, and usually includes Medicare prescription drug coverage as part of the plan. Medicare Advantage plans may include extra benefits and services for an extra cost. Medicare-approved private insurance companies, such as Alignment Healthcare’s Alignment Health Plan, run Medicare Advantage plans.

* Medicare Part D helps cover the cost of prescription medications and is run by Medicare-approved private insurance companies.

Original Medicare versus Medicare Advantage

Most people think of Medicare parts A and B as Original Medicare, in which the government pays directly for the health care services received. People with Original Medicare can see any doctor and hospital that accepts Medicare in the country, without prior approval from Medicare or their primary care physician. Most people do not pay a monthly premium for Part A if they paid taxes while working; everyone pays a monthly premium for Part B, based on income. The standard premium for Part B in 2017 was $134 per month, which is deducted from the individual’s Social Security benefits.

Original Medicare pays for about 80 percent of the total costs of health care. The patient is responsible for the remaining 20 percent, which can mean high out-of-pocket costs in the event of a hospitalization or other events requiring significant medical attention. To offset the financial burden of that 20 percent, some people choose to purchase supplemental insurance, called Medigap.

Private insurance companies offer Medigap to cover things Medicare doesn’t, such as deductibles, co-pays and co-insurance — but, keep in mind, Medigap only supplements Original Medicare benefits. Further, if you do not apply for Medigap in the first six months of becoming eligible, there’s no guarantee that an insurance company will sell you a Medigap policy.

 

With Medicare Advantage, government-approved private companies administer health plans that cover everything Original Medicare does, but can do so with different rules, costs and restrictions that can change every year. For example, a private Medicare plan may require your physician to request permission before performing a procedure in order to be paid by the plan. Medicare Advantage plans, however, usually cover extras that Original Medicare does not, like dental care, vision services, hearing exams and gym memberships.

Most Medicare Advantage plans also include prescription drug coverage (Medicare Part D), which is not included in Original Medicare, at no additional cost. If you elect to enroll in a Medicare Advantage plan, you still have Medicare — this means that you must still pay your monthly premiums for parts A and B, in addition to a monthly premium for Part C, if applicable. Many Medicare Advantage plans are available for no additional monthly premium.

When choosing between Original Medicare and Medicare Advantage, you should consider these questions:

* How likely is it your health needs will change down the road? Since health changes as you age, chances are your treatment needs will, too. If you don’t enroll in the additional insurance and drug coverage when you first sign up for Original Medicare, you may pay a monthly penalty for enrolling later and may not be eligible for additional Medigap coverage.

* Are you still working past age 65? If so, you will probably want to enroll in Part A, because there generally are no monthly premiums, and it may supplement your employer’s insurance plan. You might choose to delay enrolling in Part B, but it depends on your health coverage. Everyone has to pay a monthly premium for Part B.

* Is it more important to you to have lower or no premiums or lower out-of-pocket costs? With Original Medicare, you may pay more out of pocket without supplemental insurance and prescription drug coverage. Medicare Advantage includes supplemental insurance and sometimes prescription drug coverage, too.

* How important is it to keep your doctor? Original Medicare is accepted by any doctor or hospital that accepts Medicare, without referral. Medicare Advantage plans allow you to select a doctor from the plan network, which is usually very large; your current health care providers are likely to be in the network already.

* Do you regularly take prescription medication for chronic conditions? Prescription drug coverage is not included in Original Medicare, and if you fail to sign up for Part D at the time you enroll, you could pay a penalty for adding it later. Most Medicare Advantage plans do cover prescription drugs.

“Medicare Advantage allows patients to receive the care they need to stay well and keeps their budgets in check with set costs and annual maximums,” Maroney says. “It’s an ideal solution for patients who need frequent care or who struggle to meet medical expenses.”

To learn more about Medicare, visit www.Medicare.gov. For information about Alignment Healthcare and its affiliated Medicare Advantage plans, visit www.alignmenthealthcare.com.

 

Source: Tips for choosing the Medicare plan that’s right for you