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Another Medicare "HELP!?!?" topic


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#1 TOT

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Posted 14 January 2013 - 06:13 PM

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Edited by TOT, 19 March 2013 - 03:59 PM.



#2 larkspur

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Posted 14 January 2013 - 07:54 PM

I do not have Medicare yet, but I am an insurance agent who deals in Medicare supplement/drug plans. 

 

Yes, you choose part B as well if you have MediCal. This is because Medicare A&B will be your primary insurance, then MediCal will be your secondary insurance, paying all or some of what is left over. If you have a spend down on MediCal, your Medicare part B premium will count towards your spend down. If you end up not having MediCal or you have a spend-down that is too much for you to manage, a lot of disabled folks will choose Medicare Advantage if there is a plan that best meets your needs. Advantage plans are like choosing an insurance company subcontractor (like Kaiser or Aetna) to administer your Medicare benefits to you. You will usually have fixed copays instead of percentages, and MA plans usually have a network or function as an HMO (as in Kaiser Medicare). Typically your part B and part D premiums will be withheld from your monthly social security check. 

 

When you are applying for plans within 3 months of your Medicare effective date, you can't be denied for preexisting conditions except for end stage renal disease. 

 

The best way to choose a drug plan/explore MA options is to enter your prescriptions and pharmacy information at medicare.gov, which will then generate a report showing you your estimated costs under MA and Part D plans. Medicare Supplement coverage is also an option to consider, which would be in addition to a Part D plan and your Part B premium. Supplement plans typically pay the 20% that is left over when Medicare pays its 80%, but plans will vary in terms of which Medicare deductibles will be paid and the premium may vary drastically between plans too. They can be very expensive for someone who's on disability, but they don't have network limitations. You can't have a Medicare supplement AND MediCal unless MediCal has agreed to pay the supplement plan's premium for you. 


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#3 TOT

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Posted 14 January 2013 - 08:50 PM

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Edited by TOT, 19 March 2013 - 04:00 PM.


#4 Wooster

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Posted 15 January 2013 - 12:44 AM

Medicare part A covers inpatient. Part B covers outpatient. Part D covers prescriptions.

 

Part C replaces parts A and B, and sometimes part D depending on the plan you choose.


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#5 saveyoursanity

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Posted 15 January 2013 - 02:00 AM

I have Medicare and I also know quite a lot about it because of something I'm not willing to share publicly.  If anyone wants to know where my knowledge base comes from, you're welcome to PM me, but I'm not willing to claim it on the forum!  That having been said, I'm going to go through all of your questions as much as I can, without linking to medicare.gov or other gov't websites to back me up because that would take forever, but if you want citations or more information on ANYTHING I say, please please ask.

 

That having been said, if you called 1-800-Medicare and whoever it was was frustrated with you, it was likely because people who work at Medicare generally WANT to help you, but are forbidden from saying "opting out of part b is really fucking stupid, don't do it!"  and so they get frustrated.  (You may be able to make a guess now as to how I know that and why I also know so much about Medicare.  ^_^ )  Moving onto your questions, but first, a disclaimer.

 

I AM NOT INVOLVED WITH MEDICARE.  I do not work for Medicare.  I am only a layperson who knows a LOT about Medicare.  Please take this explanation as a mere explanation, and advice as ADVICE, neither of which are meant to be written in stone and followed without question.  If you don't understand anything I'm saying, let me know and I'll try to explain again in a different way, but what's important here is that YOU NEED TO EVENTUALLY UNDERSTAND, not that you just do what I tell you, because I might be totally right about 90% of this and wrong about 10% and that 10% is going to fuck you up.  Take what I say as a starting point!  Please!

 

First off, parts A and B TOGETHER cover your doctor and hospital bills.  Part A only covers what happens when you are admitted into a hospital or skilled nursing facility.  Part B covers almost everything else.  Do not take only part A.  DO NOT OPT OUT OF PART B.  GET PART B.  I repeat this:  if you only take part A, nothing beyond actually being admitted into a hospital will be covered--basically your room and board at the hospital.  Part A doesn't even cover the doctor who sees you INSIDE the hospital.

 

Part A is free from month to month.  If you go into a hospital, you will pay the first (roughly) 1200 dollars of the cost of each hospital stay (it's more complicated than that in reality but that's a good rule of thumb).  That first 1200 dollars cost is called a deductible.

 

Part B is $104.90 every month.  That's the premium.  For any year in which you access medical services, from the first of the year until the 31st of December, you have to pay the first 147 dollars of your medical expenses.  Again, that is a deductible.  For Part B you may also pay 20% of most services.  That is your copayment or sometimes called coinsurance.

 

I know that this probably sounds like Medicare doesn't cover anything and what even is the point, but try not to get frustrated, because a lot of things ARE covered.  They cover 80% of your dr's bills for most services and more for some of them, they cover all of your hospital charges except for the first 1200 dollars, and the good news is that you can get help with the rest of the costs .

 

If you are under a certain income / resource limit (the usual) and apply via the route of the same place you got Medicaid help or MediCal, the state will pay your Medicare premium.  They may also pay your deductibles (the 1200 dollars I mentioned above) and your copayments.

 

THIS CAN HAPPEN EVEN IF YOU DON'T QUALIFY FOR MEDICAID/MEDICAL.  The programs where the state pays your Medicare premiums/deductibles/copayments are federally mandated at certain level of income.  Medicaid/MediCal is NOT federally mandated at the same level of income and so they have way more wiggle room to deny you because people are assholes and believe people with disabilities are so lazy they're just not bootstrapping fast enough or what---  erm.  I appear to have wondered into my capitalism rant, sorry.  I hope you get the point.

 

You CANNOT keep "Medical" and ignore Medicare.  Let me repeat that:  the state will not let you keep your former state-sponsored insurance and ignore using Medicare.  The "choice" of getting Part B is not really a choice.  YOU NEED IT.  GET IT.  If you don't get it, the state will take away your MediCal.  Yes, I'm serious.  The reason that they do this is because Medicare is federally funded and MediCal is funded by the state.  You know how California (and just about every other state) runs out of money every year, right, but the federal gov't doesn't really? Yep, they're offloading costs onto the feds.  That means you do not get a choice about which insurance option to take.  You are effectively required to take Medicare.  I'm sorry, but it's the truth, and I would rather just tell you flat-out.

 

Medicare Advantage plans (sometimes referred to as Part C) are NOT NECESSARY.  I don't recommend you get one if you can avoid it, to be honest, but obviously you have the choice to.  Almost every public hospital and doctor takes Original Medicare, which is the part A and Part B you originally receive.  I can explain the differences in more detail, but Medicare Advantage plans are run by private companies and offered THROUGH Medicare and have been found to offer no real benefits as compared to original Medicare.  Just avoid, imo.

 

You need a drug plan.  Much like getting Part B or not getting Part B, this IS NOT REALLY A CHOICE.  The only choice you have is which drug plan is the best for you, and THAT varies by which drugs you take and what area you live in.  So go to medicare.gov and go through the plan finder.  It's pretty simple and you should be fine.  Drug plans with premiums below a certain amount of money per month are paid for by Medicare if you either a) get help from the state through Medicaid/MediCal or the state paying your Part B premiums, or b) apply for extra help and are approved. 

 

If you want to know whether the drug plan you choose is free with the extra help, start off the plan finder with just general information (zip code is all that's required, I believe), then make sure you tick the box that says "I get extra help" and proceed as normal.  That way the info you get will reflect the amount of premium money that is paid by Medicare when you qualify.  If this makes no sense to you, tell me what state you live in (I'm guessing CA) and I can probably find the exact amount of premium that will be paid by Medicare if you get extra help, but it's a pain in the ass to find and it varies by state.  :(

 

You do not need to worry about pre-existing conditions at all, in any way.  No private plans available through Medicare are allowed to reject you for conditions you have.  You also probably do NOT need to worry about a Medicare supplement.  Remember how earlier I said that the state will pick up your premiums, copayments, and deductibles if you apply for it?  Yeah, that's exactly what a supplement plan does, and you don't have to pay the state to do it.  Don't get a supplement unless and until you know that you do not qualify for state payment of any of your Medicare-related expenses.

 

If you have a problem, call someone back at 1-800-Medicare.  If you don't understand the first person you talk to, ask for a supervisor.  If you're lucky, you'll end up with my mother I mean someone who knows what they're doing.  If the 1st person is rude and condescending, tell the supervisor.

 

I hate to say that there's a reason that people are rude and condescending, but it's super frustrating to try and help someone over the phone who's using terms wrong (people do not like to be corrected, but the terminology is hard enough without words meaning different things), which inevitably leads to confusing things that the agent has spent literally weeks of their life learning the differences between, and nobody ever understands what the agent is trying to say because this shit is so confusing it took the agent weeks to learn it and now they're expected to be able to get other people to understand it in 3 minutes...  

 

AND it can often be impossible to explain what's going on well enough for the caller to understand why the terminology they're using is bad or the assumptions that the caller has are flat out wrong because the agent is NOT allowed to say things like YOU NEED PART B GODDAMNIT, plus the agent can't see the papers or pamphlet the caller is referring to (seriously, I may or may not have known people who ordered the yearly Medicare handbook to their own house just to see what it fucking looked like), the agent is required to read lines from a script or they will be fired, this is their 20th call of the day and the agent is expected to get all callers off the phone in five minutes.  It's not RIGHT, but it's also understandable.  Please try to keep this in mind if at all possible.

 
 

Edited by saveyoursanity, 15 January 2013 - 02:17 AM.

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#6 TOT

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Posted 15 January 2013 - 01:18 PM

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Edited by TOT, 19 March 2013 - 04:01 PM.


#7 saveyoursanity

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Posted 15 January 2013 - 05:23 PM

The program where your state pays your Medicare premiums (and if you qualify, your deductibles and copayments) are called in general Medicare Savings Plans or more specifically, Qualified Medicare Beneficiary, Specified Low-income Medicare Beneficiaries.  OFTEN these are referred to as MSP or QMB/SLMB (given as initials or said "quimby and slimby").

 

You should apply for a drug plan as soon as you get everything sorted out with Medicaid/MediCal, but not until 3 months before your Medicare starts, because that's the earliest you can actually apply.  The drug plan will start the same month as your Medicare does.

 

I'm glad to be able to help!


CAPS LOCK IS HOW I FEEL INSIDE ALL THE TIME.

"There will be coffee and cookies in the Gandhi Room after the revolution."

 

Dx and Psych Rx in profile.

I am NOT a medical professional, merely experienced from a consumer perspective.
I strongly urge fact checking with your own research and consulting an actual medical professional.


#8 TOT

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Posted 15 January 2013 - 10:07 PM

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Edited by TOT, 19 March 2013 - 04:02 PM.


#9 saveyoursanity

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Posted 16 January 2013 - 04:02 AM

Do you still have your other insurance?  I'm sorry, I should've asked before.


CAPS LOCK IS HOW I FEEL INSIDE ALL THE TIME.

"There will be coffee and cookies in the Gandhi Room after the revolution."

 

Dx and Psych Rx in profile.

I am NOT a medical professional, merely experienced from a consumer perspective.
I strongly urge fact checking with your own research and consulting an actual medical professional.


#10 Retromancer

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Posted 16 January 2013 - 09:11 AM

OP: May I ask why you expect to lose your SSDI in November?


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#11 TOT

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Posted 16 January 2013 - 01:03 PM

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Edited by TOT, 19 March 2013 - 04:02 PM.


#12 saveyoursanity

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Posted 17 January 2013 - 08:32 AM

Even if you dont' have medical, you seem to have gotten the correct impression that the state may very well pay your premiums, which is definitely 100+ dollars off your mind.  PLUS that automatically qualifies you for extra help with medication premiums and copayments, so instead of paying 30+ dollars a month and 20 bucks+ for every prescription, you probably won't have a premium and your prescriptions will cost like 2.60 and 6.60 each (generic vs brand).

 

And yes, you're right about QMB vs SLMB.  It sucks.  :(


Edited by saveyoursanity, 17 January 2013 - 08:32 AM.

CAPS LOCK IS HOW I FEEL INSIDE ALL THE TIME.

"There will be coffee and cookies in the Gandhi Room after the revolution."

 

Dx and Psych Rx in profile.

I am NOT a medical professional, merely experienced from a consumer perspective.
I strongly urge fact checking with your own research and consulting an actual medical professional.


#13 TOT

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Posted 25 January 2013 - 08:17 PM

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Edited by TOT, 19 March 2013 - 04:02 PM.


#14 saveyoursanity

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Posted 25 January 2013 - 09:04 PM

The letter may say that they will PUT you in a plan IF you don't choose one yourself, but it's not going to choose the RIGHT plan for you.  It's just random.  Seriously.  Re-read it if you want =x

 

The Medicare Advantage plans (they're not called medicare part C anymore, if you're wondering why I use that term instead) in your area may give you benefits that original medicare doesn't, but they are also allowed to have limits on services like 'normal' insurance companies.  For a random off the wall example, Medicare (original, thru the gov't) would keep paying for your psychiatrist even if you went 12 times a month, as long as the paperwork was submitted properly.  There's no prior authorization to visit a specialist required, and no limit on the number of visits.

 

Medicare Advantage plans, like most insurance plans in this country, don't work that way.  However, there could be other benefits...  like lower copays, one plan I remember offers dental cleanings and a small eyeglass benefit...  I would absolutely recommend talking to HICAP about it.


Edited by saveyoursanity, 25 January 2013 - 09:07 PM.

CAPS LOCK IS HOW I FEEL INSIDE ALL THE TIME.

"There will be coffee and cookies in the Gandhi Room after the revolution."

 

Dx and Psych Rx in profile.

I am NOT a medical professional, merely experienced from a consumer perspective.
I strongly urge fact checking with your own research and consulting an actual medical professional.


#15 TOT

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Posted 25 January 2013 - 10:47 PM

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Edited by TOT, 19 March 2013 - 04:03 PM.


#16 saveyoursanity

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Posted 26 January 2013 - 11:34 AM

Right...  if Medicare enrolls you, it's just a random plan.  It's not the best plan for you.  So imo it's still best to choose your own.


CAPS LOCK IS HOW I FEEL INSIDE ALL THE TIME.

"There will be coffee and cookies in the Gandhi Room after the revolution."

 

Dx and Psych Rx in profile.

I am NOT a medical professional, merely experienced from a consumer perspective.
I strongly urge fact checking with your own research and consulting an actual medical professional.


#17 TOT

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Posted 26 January 2013 - 08:14 PM

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Edited by TOT, 19 March 2013 - 04:04 PM.


#18 TOT

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Posted 28 January 2013 - 01:36 PM

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Edited by TOT, 19 March 2013 - 04:05 PM.


#19 TOT

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Posted 06 March 2013 - 07:28 PM

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Edited by TOT, 19 March 2013 - 04:05 PM.


#20 saveyoursanity

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Posted 06 March 2013 - 09:41 PM

Wow, that's bullshit.  They were able to set up my QMB before I paid a cent.  ...  wait, I think I /might/ have had the first month's premium automatically taken out and then it got refunded.

 

If you get your premium automatically taken out, you may want to request a letter from SSA stating that on May whatever, they took out xx dollars for Medicare premium.  I would go in person at that time.  Calling Social Security should be classified as a form of torture outlawed by the Geneva convention.


CAPS LOCK IS HOW I FEEL INSIDE ALL THE TIME.

"There will be coffee and cookies in the Gandhi Room after the revolution."

 

Dx and Psych Rx in profile.

I am NOT a medical professional, merely experienced from a consumer perspective.
I strongly urge fact checking with your own research and consulting an actual medical professional.






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