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Healthcare Umbrella

By Michelle Fortune

 

Take advantage today!

A dear friend recently turned 65; for her, it was almost a rite of passage to sign up for Medicare. She’s worked in healthcare for many years and told me she was still “drinking from the firehose” of information overload that came from beginning her journey with Medicare coverage. The requirements and options can feel overwhelming when comparing one plan to another. But doing early homework ensures that you have time to make the wisest decision for yourself. So, today, I wanted to share some information about Medicare that may be helpful to you.

WHAT IS MEDICARE?

Medicare is a federal health insurance program for people who are 65 or older, younger people with approved disabilities, and people with permanent kidney disease.

You are encouraged to sign up for Medicare three months before your 65th birthday. However, the benefits won’t begin until the first day of your birth month at age 65 (Example: If you were born on July 26, your benefits would begin on July 1). You are automatically enrolled in Medicare Parts A and B once you reach age 65 if you’re currently receiving Social Security. But because Part B requires you to pay for coverage, you may elect to decline this option. Your Medicare card can arrive as early as two months before your 65th birthday.

THE MEDICARE ALPHABET

The fun begins now. There are ten Medigap policies (A, B, C, D, G, F, K, L, M, and N). The primary plans are:

Medicare Part A (Hospital Insurance)

 Part A covers approximately 80% of inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)

 Part B covers approximately 80% of approved doctors’ services, lab fees, outpatient care, medical supplies, and preventive services.

Medicare Part C (Medicare Advantage)

Medicare-approved private insurance companies provide Advantage Plans. These plans offer the same coverage as Parts A and B, plus additional benefits like prescriptions, vision, dental, hearing, and more.

Medicare Part D (prescription drug coverage)

Part D helps to cover the cost of prescription drugs (including many shots and vaccines).

The focus of my article today is the Medicare Advantage Plans (Part C). 

Both North and South Carolina require enrollment in Medicare Part A and Part B as a prerequisite to an Advantage Plan. You must also be a U.S. citizen or permanent legal resident who has lived in the U.S. for five straight years. You’ll likely be required to use a healthcare provider within your plan’s network. Some plans offer non-emergency coverage out of network at a higher cost. 

What if you live in SC, but your provider is in NC? The St. Luke’s Network resides on the state line, bordering South Carolina. So, when selecting an Advantage Plan, it’s essential to understand the requirements specific to each plan, the rules, costs, network boundaries, and other provisions.

Many local Medicare Advantage enrollees live south of the border in Landrum, Campobello, and even Inman. While they would prefer to use a provider or service from the St. Luke’s Network, they find themselves limited by state border network rules of their specific plan. If you use Part A and Part B, you don’t have to do anything to use Medicare in North Carolina so long as your provider participates in Medicare. However, if you want to use an Advantage Plan, you’ll need to enroll in a plan that allows you to cross the state line.

To learn more about the various Advantage Plans, visit the Medicare’s Plan Finder at: https://www.medicare.gov/plan-compare.

There are three primary enrollment periods for Medicare plans:

Initial Enrollment Period (IEP). The IEP begins three months before the month of your 65th birthday and ends three months after.

General Enrollment Period (GEP). The GEP begins on January 1 and ends on March 31. However, your coverage will not start until July 1, and there may be a late enrollment fee.

Annual Election Period (AEP). The Annual Election Period runs from October 15 through December 7. During this period, you have the option of making changes to your plan.

During AEP, you can make the following changes: replace your Original Medicare plan with a Medicare Advantage plan; add prescription drug coverage to your Original Medicare; switch to an Original Medicare plan; enroll in a Medicare Supplement (Medigap) plan or cancel your existing plans

NOTE: Special Enrollment Period (or “SEP”). Certain life circumstances may qualify you to enroll in a Medicare plan at any time. Qualifying situations include moving to a new area or a nursing home or qualifying for Medicare and Medicaid.

Most providers of Advantage plans offer Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. All have different deductibles, network boundaries, and providers. Therefore, you must ask many questions to make sure that you select the plan that best suits your individual needs.

Again, there is an Advantage Plan in South Carolina that permits you to use providers in North Carolina. But you’ll need to act quickly (before December 7) to take advantage of the AEP.

If you have a healthcare topic of interest, send me a note at Michelle.Fortune@slhnc.org. Also, please follow us on Facebook, Twitter, LinkedIn, or visit StLukesNC.org to learn about top-rated St. Luke’s Hospital and our new world-class services.