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This chapter explained the health insurance products available to senior citizens and special needs individuals: Medicare, Medicare Supplements, and Medi-Cal. Let's recap some of the key points.
Medicare
Topic
Key Points
Basics
Federal medical expense insurance program for people who are age 65 or older, have been entitled to Social Security disability income benefits for 2 years, or have permanent kidney failure (ESRD). Has 4 parts: Part A (Hospital Insurance, financed through payroll tax); Part B (Medical Insurance, financed by insureds and general revenues); Part C (Medicare Advantage, health care through available provider organizations); and Part D (Prescription Drug coverage).
Part A
Enrollment: initial enrollment period (3 months before to 3 months after the 65th birthday), general enrollment period (January 1 – March 31), and special enrollment period (any time while still employed and covered under a group health plan). Coverage: inpatient hospital care, skilled nursing facility care, home health care, and hospice care.
Part B
Optional; offered to everyone who enrolls in Part A. Coverage: doctor services, outpatient hospital services, home health visits, other medical and health services, limited prescription drugs, outpatient treatment of mental illness, and a yearly wellness visit.
Part C
Medicare Advantage — requires enrollment in Parts A and B. Provided by an approved HMO or PPO.
Part D
Prescription drug benefit — optional coverage through private prescription drug plans that contract with Medicare.
Primary/Secondary Payor
For individuals eligible for Medicare who continue to work, the employer's health plan is generally primary coverage, while Medicare is secondary coverage.
Medicare Supplement Policies
Topic
Key Points
Basics
Referred to as Medigap. Policies issued by private insurance companies to fill in gaps in Medicare. Open enrollment period of 6 months.
Coverage
Plan A: core benefits, such as coinsurance/copayment, additional Part A hospital costs, hospice care coinsurance/copayment, Part B coinsurance/copayment, and 3 pints of blood under Parts A and B. Plans B – N: core benefits plus various additional benefits.
Other Options for Individuals with Medicare
Topic
Key Points
Medi-Cal
Medical care for those whose income and resources are insufficient. Federal and state funded. Eligibility determined by an asset spend-down test. Full benefit enrollment provides full Medi-Cal benefits; partial benefit enrollment provides assistance to pay for Medicare premiums/cost-sharing obligations. Not a Medicare Supplement plan.
Health Insurance and Counseling Advocacy Program (HICAP)
Free consumer counseling for those who receive Social Security or Medicare coverage. Federal and state funded. Does not sell, recommend, or transact insurance.