If you are a caregiver to an older, qualified loved one who has not yet applied for Medicare, then December 7 is looming large for both of you. Or if you are a caregiver whose deadline is not this year, but is next year, then it is time for a crash course in what Medicare covers and what parts do what for your older loved one. You can refer to the basics as the ABCs, but you also need to add a D. The rest gets easier.
Medicare Part A very simply is the part of the federally-sponsored plan that covers hospitalization for those enrolled. For all those over age 65, this is the longstanding part of the coverage that has no premium to be paid and covers what Medicare will pay to providers for inpatient stays. This is the easiest part, because you will not find too many hospital providers who do not accept Medicare’s inpatient coverage. These outsiders are pretty much just military or VA hospitals along with the Shriners’ Children’s Hospitals.
Medicare Part B covers generally the doctors’ billings and outpatient care for those who are age-qualified and have enrolled, and it costs about $104.90 a month to enroll. But – and this is a critical but – the providers in these settings have to “accept Medicare assignment.” In large part, because Medicare has such strong negotiating power, not every provider wants to accept what they will pay for services. These doctors and others who most likely will be holdouts on Medicare assignment typically are psychiatrists or some specialties. With some exceptions, the Mayo Clinics will not accept Medicare patients, so it is important that you help your older loved one check to be sure the providers they use are on the list. You can do this by going to WWW.medicare.gov and clicking on “Find doctors and other health professionals.”
Medicare Part C was originally called Medicare Advantage. It is available through private insurance carriers who create panels of physicians in Independent Practice Organizations or Preferred Provider Organizations and more to cover what Part B does not cover. They also will charge a premium. There is an alternative sometimes referred to as Medigap, and you will want to check out which offers the best coverage and access to the providers your older loved one will want.
Medicare Part D is an optional plan that offers prescription drug coverage which none of the first three offer. Your loved one will have to “opt in” to this plan as offered by private insurers. Some of this will be changing under Affordable Care Act, so stay tuned for changes that will help to close what often is referred to as the “donut hole,” the part that the covered person must pay after the initial coverage is exhausted and before the next threshold of coverage kicks in.
So that is your crash course in getting your older loved one enrolled in Medicare, but you need to be alert to some potential landmines along the path:
• Just because your loved one’s doctors or hospitals are in the covered network this year does not mean they will be in the network next year;
• Not every carrier’s prescription coverage will be the same – be alert to language about coinsurance versus copays, step therapy and prior authorization, all of which will impact the out of pocket costs of medicines;
• Make sure that when your loved one is hospitalized that it is an “inpatient stay” (covered) and not “observation” (not covered);
• Know the rules on how you can appeal decisions on coverage.
Charlotte Bishop is a Geriatric Care Manager and founder of Creative Care Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago. Please email your questions to info@creativecaremanagement.com.
