10 Questions About Medicare
Making decisions about health insurance can seem overwhelming at times. There is so much to consider, such as coverage, costs, and access to care.

If you are currently on Medicare, you should become acquainted with Medicare HMO (also known as Medicare Advantage) plans that many health insurance companies offer to seniors. These Medicare HMO plans offer a full range of health care services, while lowering your out-of-pocket expense and virtually eliminating your paperwork responsibilities.

Brown & Toland Medical Group has compiled "10 Questions About Medicare." These questions can help you analyze your options and determine what type of health plan is right for you.

1. What is traditional Medicare and who is eligible?

Traditional Medicare is one of the largest national health insurance programs in the world. In 1965, the Social Security Act established Medicare. It is administered by the federal government through the Centers for Medicare and Medicaid Services (CMS).

Currently, traditional Medicare provides coverage to approximately 40 million Americans. Medicare is the national health insurance program for:


-U.S. citizens or permanent residents of the United States;
People age 65 or older;
Some people under age 65 with disabilities;
People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant; and
People who have worked for at least 10 years of 40 quarters in Medicare-covered employment or whose spouse has worked for at least 10 years of 40 quarters in Medicare-covered employment.

Traditional Medicare is divided into two parts:

Part A - Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. If you meet the conditions mentioned above, there will be no premium for your Medicare Part A entitlement.

Part B - Medicare Part B (Medical Insurance) helps cover your doctors' services and outpatient hospital care. It also covers some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home health care. You pay the Medicare Part B premium each month* ($96.40 in 2008). In some cases, this amount may be higher if you did not sign up for Part B when you first became eligible.

2. Does Medicare cover everything?

No. There are financial gaps in Medicare coverage. Here is a brief summary of some of the out-of-pocket medical expenses you can expect to pay with Medicare coverage alone:

Traditional Medicare Part A financial gaps:


$1,024 deductible, for the first 60 days of a hospital stay (semi-private rooms only; TVs and telephones not included);
$256 per day co-payment for days 61-90 of your stay;
$512 per day co-payment for each lifetime reserve day used;
Non-emergency care in a hospital that does not participate in Medicare; and
Care received outside the United States and its territories, except under limited circumstances in Canada and Mexico.

Medicare Part B financial gaps:


$135 annual deductible;
Generally, 20% co-insurance and permissible charges in excess of Medicare-approved amount;
All charges for most prescription drugs and most immunizations;
Generally, 20% of Medicare-approved amount for routine physicals and other screening services, except for periodic mammograms and pap smears;
All charges for routine eye examinations or eyeglasses;
All charges for hearing aids or routine hearing loss examinations;
All charges for dental care and dentures (with a few exceptions); and
All charges for acupuncture and chiropractic services

* Rates based on Medicare 2008.


3. Should I supplement traditional Medicare?

Traditional Medicare alone does not absorb the total financial responsibility for medical care. Many people on traditional Medicare decide to supplement their coverage to limit their out-of-pocket expenses. Here are the most common options:


Enroll in a Medicare HMO;
Purchase a Medigap policy; or
Carry Medicare alone while setting aside an emergency fund for out-of-pocket expenses

Other alternatives, which apply only to specific individuals, are:


Employer-sponsored retiree benefits plans; or
Qualification for Medicare/Medi-Cal


4. What is Medigap?

Medigap policy is a health insurance policy sold by private companies to fill gaps in the original Medicare plan coverage. Medigap policies must follow federal and state laws, designed to protect patients. Medigap policies must be clearly identified as a "Medicare Supplemental Insurance" plan. You need both Medicare Parts A & B to buy a Medigap policy.

Although the benefits are identical for all Medigap plans of the same type, the premiums may vary from one insurance company to another and from area to area. The California State Insurance Department must approve the rates charges for all Medicare supplemental policies.


5. What is a Medicare HMO?

A Medicare HMO is another type of health plan for Medicare recipients. All Medicare HMOs are federally qualified, and like Medigap plans, they must comply with government standards set forth by CMS, the agency directly responsible for regulating Medicare. Medicare HMOs are also referred to as Medicare Advantage plans.


6. What does a Medicare Advantage plan cover?

Medicare Advantage plans, formally known as Medicare + Choice plans, provide comprehensive coverage with minimal out-of-pocket expenses. Medicare Advantage rules and payments have been improved to give you more health plan choices and better benefits. They may also offer other special benefit provisions such as discounted dental plans, vision care, and chiropractic care.

Medicare HMOs provide more coverage than traditional Medicare alone, and utilize the services of networks of selected doctors and hospitals in designated service areas. When you enroll in a Medicare HMO you agree to have your medical care coordinated by your primary care physician and provided to you within your primary care physician's medical network. Because there are more than 1,500 physicians in Brown & Toland, the likelihood of you needing an out-of-network provider is very small. If you elect to seek non-emergency care from a provider who is not in your primary care physician's network, neither Medicare nor the HMO will pay for your care.


7. What are medical groups, and how do they relate to Medicare Advantage plans?

Most Medicare Advantage plans work with networks of physicians and hospitals to provide coordinated care. In most cases, the Medicare Advantage plan will ask you to select a primary care physician who is part of a medical group. This physician will play an important role in your health care by referring you to specialists within the medical group and by helping to ensure that you receive the right level of medical care.

It is important to know what features the medical group to which your physician belongs has to offer. Some key considerations are:


The number of doctors in the group and where they are located;
Availability of special senior programs, such as wellness classes, health promotion, and education;
Hospitals, home health agencies, and skilled nursing facilities associated with the physician group;
History of the medical group and how long it has been working with Medicare Advantage plans; and
Whether the medical group has a primary care physician and specialists who are right for you.


8. Does Brown & Toland Medical Group contract with a Medicare Advantage Plan?

Yes. The physicians of Brown & Toland Medical Group provide medical care for members of Health Net Seniority Plus and Secure Horizons by United Healthcare. Our 1,500 plus physicians are located throughout San Francisco. Members also have access to San Francisco's best hospitals, including California Pacific Medical Center (California, Davies, St. Luke's and Pacific campuses), Saint Francis Memorial Hospital, St. Mary's Medical Center, the University of California - San Francisco (UCSF), UCSF Mt. Zion, Chinese Hospital, Seton Medical Center in Daly City, and Seton Coastside in Moss Beach.

9. If I enroll in a Medicare Advantage plan and change my mind, may I go back to Medicare?

Yes. Enrollment in a Medicare Advantage plan does not cause you to lose your Medicare beneficiary status. CMS has mandated that disenrollment be an easy process for Medicare Advantage members. Disenrollment may be handled by the health plan, Social Security, or Medicare. Reinstatement back to Medicare usually only takes about 30 days.


10. Who do I contact for more information?

Brown & Toland Customer Service
www.brownandtoland.com
800.225.5637

Health Net Seniority Plus Plan
www.healthnet.com
800.935.6565

Secure Horizons by United Healthcare
(formerly Pacificare's Secure Horizons)
www.securehorizons.com
800.698.7505

Medicare
www.medicare.gov
800.633.4227

Social Security
www.ssa.gov
800.772.1213


Sources:
www.cms.gov
www.medicare.gov