The Medicare beneficiary was not only dissatisfied with his insurance plan, but for personal reasons also wanted to leave Medicare Advantage insurance altogether. He talked with a senior health insurance benefits assistance counselor to learn more about Medicare supplement – Medigap – policies.
Two significant questions were raised: At age 75, would an insurance company sell him a Medigap policy? And, if so, how much would it cost?
The counselor reviewed premiums with the Medicare beneficiary, who was in relatively good health, after which the man called the company showing the lowest price. It turned out that, rather than asking a battery of health-related questions, this company asked relatively little and agreed to sell a policy for $175 a month.
The takeaway was that even at a somewhat advanced age, it was possible to buy a policy, and to do so from a lowest-price company that was somewhat less stringent about health screening.
A SHIBA counselor can help identify companies that ask fewer health questions, or you may identify them in the Oregon Guide to Medicare Insurance Plans (in the Medigap section, see the column headed Pre-ex LB/waiting period and look for 0/0).
As a side note: In the first six months of full Medicare, insurance companies cannot legally levy a premium surcharge on the customerbecause of a health condition.
If you would like to make an appointment with a SHIBA counselor, or to ask a question to be answered here, please see the end of this column.
Q. In reviewing insurance plans on the Medicare website, I see that many have a “drug deductible.” Is that an amount I must pay before the insurance starts paying?
It’s possible, but unlikely. Medicare Advantage and prescription drug plans often have a deductible, which indeed is an amount the patient pays before the insurance starts helping. However, the deductible usually applies only to certain drugs.
Insurance companies assign a tier level to every drug. For example, an inexpensive generic statin will very likely be assigned Tier 1. And an expensive, brand-name drug may be Tier 5. Insurance companies vary as to which drug tiers the drug deductible applies.
The best bet is to pay attention to the “Yearly Drug & Premium Cost” shown on the Medicare.gov website. This should take into account the insurance companies’ policies on drug deductibles, and provide an accurate price.
That dollar figure not only combines the drug and premium cost, but also is for the balance of the year. For example, if you were reviewing plans in March, the cost shown would be for the nine months April through December.
Q: How much will Medicare pay for nursing home care?
The short answer is that Medicare will pay nothing for long-term care in a nursing facility or assisted-living facility. A consumer may pay those costs out of pocket, or buy long-term-care insurance from companies that sell it.
However, your question raises a significant point where Medicare and Medicare insurance do get involved: skilled nursing care. This is temporary care as a result of an illness or injury. To be eligible for coverage, such care must follow at least three midnights of inpatient hospitalization and begin within 30 days of hospital discharge.
•A Medicare beneficiary who has Medicare only (original Medicare) would pay nothing for the first 20 days, then no more than $200 a day after that.
•A person with Medicare Advantage insurance would pay nothing for the first 20 days, then a daily amount after that (never more than $196 a day among companies selling plans in Marion and Polk counties). The daily charge would end once the insured reaches the insurance’s maximum out-of-pocket cost for medical.
•With most Medicare supplement (Medigap) policies the Medicare beneficiary would pay nothing for temporary skilled nursing care.
Jim Sellers of Salem is a certified Medicare counselor with the Senior Health Insurance Benefits Assistance (SHIBA) program. To ask a question to be answered in this column, e-mail [email protected] To schedule a free SHIBA phone appointment with a volunteer Medicare counselor, call 800-722-4134.
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