And finally, Medicare pays zero toward long-term care.
“There are several myths about Medicare, and the first is that it is free,” said consultant Diane Omdahl, adding that the coverage does not take care of all medical needs. “People just think Medicare is going to be a cure-all. That’s really, really wrong.”
The good news is that there’s plenty of free help available. And even with its cost and coverage limits, Medicare is a good deal for most older people.
“If I am paying health insurance based on my age in my early 60s, it’s astronomically expensive,” said Robert Spicknall, an employee benefits broker and adviser for the Virginia State Bar Members’ Insurance Center. “If I am one of those people, I can’t wait to get to 65 because Medicare is heavily subsidized by the federal government and much cheaper than private insurance.”
Count me among those who are not eager to turn 65.
I turned 64 last month and started researching Medicare in anticipation of joining the program’s 60 million users. I knew next to nothing about it. I still know next to nothing about it. But I am learning.
I naively thought that I could present a Medicare card to whatever doctor, hospital or pharmacy I chose and get the service or drugs I required. That is not the case.
Please consider this column the first of many bites at the Medicare apple. The subject is so massive and complicated that it is best approached piecemeal.
There are a number of personal considerations to factor in when formulating your approach to Medicare, starting with your health, wealth and lifestyle.
There are also things to know upfront. This is not easy stuff, and the stakes are high. You can make big mistakes, potentially putting your life on the line.
For example, Original Medicare (Part A and Part B only) has no out-of-pocket maximum. Translation: There is no limit to what you might have to pay for certain services such as an extended hospital stay or chemotherapy.
There are enrollment timing rules. You have a seven-month window to enroll in Medicare, beginning three months before your 65th birthday. If you do not enroll within that window, you may be looking at higher costs and fewer options forever.
As with everything about Medicare, there is an asterisk attached to enrollment: If you have group insurance through a company with 20 or more employees, you do not have to enroll during the initial eligibility window.
The entry points for Medicare are Medicare.gov and the Social Security Administration (SocialSecurity.gov).
You can make contact in one of three ways: phone, online or in person.
“You enroll . . . and they send you a card,” Spicknall said. “The key is to be on top of it.”
My head is spinning from the various options, risks, combinations, fees, deductibles and premiums that are part of Medicare. There’s Medicare, Medicare Advantage, prescription drug coverage and Medigap. Some you get through the federal government. Some you buy from private insurers. Some are a combination of both.
You will need help navigating the system. “Nobody knows this stuff themselves,” Spicknall said. “People rattle off terms like Part A and Part B, and Medicare and Medicaid, but there are few who really know.”
In addition to Medicare.gov and the Social Security Administration, there are other sources of free help. A national network of State Health Insurance Assistance Programs (SHIPs) has trained counselors to offer local, personalized assistance to Medicare enrollees and their families.
SHIPs can help answer questions about coverage, premiums, deductibles, coinsurance, or complaints and appeals. They can also advise you on joining or leaving a Medicare Advantage plan (similar to a health maintenance organization), any other Medicare plan or prescription drug plan.
A friend who spoke on the condition of anonymity to be candid said he and his wife had good luck with the SHIPs. “We found our session very informative and productive,” he said.
His one tip: Once you have a counselor on the telephone, don’t let them go. “Never rely on anyone to call you back who assures you they will,” he said.
“Having whacked our way through the brush with machete and pith helmet to enroll my wife,” he said, “I am in a much better position to deal with ‘the process’ that has so many moving parts and different entities when I am eligible in June. I honestly don’t know how others deal with this.”
If you enroll but don’t get it right the first time around, you can tweak your Medicare coverage once a year during open enrollment. The annual sign-up period runs from Oct. 15 to Dec. 7.
I asked Omdahl to provide some Medicare CliffsNotes to ease the process. Here are the highlights:
●Timing is everything.
Three months before your 65th birthday, start thinking about whether you want to enroll in Medicare. You will want to enroll in Medicare if you are retiring and will no longer be covered by your employer’s insurance plan.
●Medicare is not free.
Everyone must pay Part B (medical services and supplies) insurance premiums, $135.50 a month in 2019.
There are also premiums for additional coverage: the Part D prescription drug plan, Medigap policies to supplement Medicare insurance, and some Medicare Advantage plans. (Part A, hospital insurance, is generally premium-free, according to the Medicare website.)
●Some people pay more.
Higher-income beneficiaries pay more for Parts B and D. This is known as the “income-related monthly adjustment amount,” or IRMAA. IRMAA can add as much as $400 a month to your Medicare premium costs.
●Lower premiums do not mean lower out-of-pocket costs.
The average Medicare Advantage premium is $29 a month. Zero-premium plans, which charge no more than regular Medicare Part B, also are available to most beneficiaries. However, these plans come with additional co-payments for health-care services.
Medicare Advantage plans put a limit on out-of-pocket costs. Medicare sets a maximum of $6,700 a year for in-network services, those performed by participating doctors and other providers. Some Medicare Advantage plans offer lower limits.
●Medicare pays nothing for long-term (custodial) care, whether provided in a facility or in the home.
Long-term care comprises a range of services to meet health- or personal-care needs over an extended period. Most of this care involves assistance with personal tasks, such as bathing, dressing, eating, getting in and out of bed or a chair, moving around, and using the bathroom. Medicare does not pay for these services. There is a 70 percent chance that someone turning 65 today will need long-term care services in their remaining years.
Like I said, I am not eager to turn 65.