JustCare

Category: Your Coverage Options

  • Social Security and Medicare benefits for people with disabilities

    Social Security and Medicare benefits for people with disabilities

    About 10 million people qualify for Social Security and Medicare on the basis of a disability.  Here’s what you need to know about Social Security and Medicare benefits for people with disabilities:

    Apply for Social Security Disability Income at your local Social Security office or online. Call Social Security at 1-800-772-1213 to find out where to go. If you qualify for railroad disability annuity income, go to your local Railroad Retirement Board. (To learn more about Social Security disability policy and how it relates to the recent budget deal, click here.)

    Medicare: You automatically qualify for Medicare when you are under 65 once you have been receiving Social Security Disability Income for 24 months or railroad disability annuity checks. And, there is a five-month waiting period before your Medicare benefits kick in. You do not need to do anything to get Medicare Part A and B.  Your Part B premium will be deducted from your Social Security check. You should not turn down Part B unless you have primary insurance coverage through your or your partner’s current job and you confirm that with the employer offering the coverage and Social Security. You want to avoid being without medical coverage or paying a premium penalty for Part B. (And, keep in mind that Medicare covers only about half your health care costs, so you’ll need supplemental coverage. If your income is low, there are several programs that can help.)

    If you have ALS or Lou Gehrig’s disease, you will automatically be enrolled in Medicare the first month you receive Social Security Disability Income or railroad disability annuity income. There is a five-month waiting period after you are determined to be disabled until you begin receiving benefits. Be sure to make clear that you have ALS to avoid the additional 24-month waiting period for Medicare.

    If you have End Stage Renal Disease (ESRD), you should apply for Medicare through your Social Security office, even if you are a railroad worker. Social Security will need supporting documentation about your disease from your doctor and dialysis center. When Medicare begins depends on your treatment.

    • If you are in a self-dialysis training program, Medicare begins on the first day of the month you begin the program. You must begin the program before the third month of your dialysis and you will need support from your doctor that you will complete the training program and do self-dialysis. Otherwise, Medicare begins the first day of fourth month of your dialysis.
    • If you are receiving a kidney transplant, Medicare begins when you begin receiving health care services for the transplant. Medicare coverage begins no sooner than the two months before the month you receive the transplant.
  • Beware of Medicare and Medicaid fraud and, if you see it, report it

    Beware of Medicare and Medicaid fraud and, if you see it, report it

    Medicare fraud is prevalent. It wastes billions of dollars and drives up health care costs. It comes in all varieties but generally involves bills to Medicare for services that were never provided. You can help identify and report it to the Office of the Inspector General or Medicare if your doctor or hospital bills reflect services you never received.

    Earlier this year, the Justice Department and the U.S. Department of Health and Human Services announced charges against 243 people, including more than three dozen doctors and nurses, for participating in $712 million in Medicare and Medicaid fraud through inappropriate billings. In some cases, services were unnecessary and in others they were never performed.

    In this instance, fraud schemes involved a range of services, including home care, psychotherapy, physical therapy, durable medical equipment and pharmacy fraud.

    Since the inception of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) in 2007, the Medicare Fraud Strike Force operations have charged more than 2,300 people with falsely billing Medicare for more than $7 billion.

  • Medicare covers oxygen equipment and supplies

    Medicare covers oxygen equipment and supplies

    Medicare covers the rental of oxygen equipment and supplies if you meet the qualifying criteria—you must have a doctor’s visit, and your doctor must sign a written order for the equipment, explaining why it is medically necessary. You must also use a Medicare-certified supplier.  If you have traditional Medicare, you can call Medicare for a list of suppliers or visit this link:  www.medicare.gov/supplier. If you are in a Medicare Advantage plan, call the plan to find out which suppliers you can use.

    Medicare will not pay for you to own the equipment.  Here’s how it works:

    • Medicare covers 80 percent of the cost of a five-year rental term for oxygen equipment, oxygen and supplies under Part B.  You are responsible for the 20 percent, which a Medigap plan or retiree insurance should cover.
    • Medicare will pay its share of the cost of the rental for three years.  At that point, both Medicare and you have no financial obligations for the equipment during the next two years. While the supplier still owns the equipment during those two years, you can keep it. You will only need to cover the 20 percent of the cost of the liquid or gaseous oxygen you use each month.
    • After five years, if you still need oxygen you can choose whether to stick with your current supplier or switch to a different Medicare-certified supplier.
    • If you stop needing oxygen before the five-year rental term ends, you can simply let the supplier know it can be picked up.
  • Two tips to help you choose a health plan

    Two tips to help you choose a health plan

    During open enrollment season, many of us struggle to figure out which health plan to choose. People typically remain in their current health plans because that’s generally the easiest choice to make (it may also be our only choice).  But, it may not be the wisest. Your plan costs and benefits may be changing. And, there may be a better, less expensive plan, available to you.

    How do you choose a health plan? If you have Medicare, most people choose traditional Medicare, the public health plan administered by the federal government, because it covers your care from virtually any doctor or hospital in the U.S. And, so long as you have supplemental coverage, almost all of your costs are covered. Here are four tips to consider before choosing between traditional Medicare and a Medicare Advantage or private Medicare plan. If you are choosing among different private health plans–employer plans, exchange plans or Medicare Advantage plans–because you generally will not know your future health care needs or what services the health plan will cover and what you will need to pay out of pocket, it’s really not possible to choose a health plan that you can be sure will meet your needs.

    Here are two factors to consider:

    1. Your doctors and hospital: If you have doctors you know and trust, you likely want to call them to find out which health plans they are enrolled in and narrow down your options to those health plans. Keep in mind that doctors may switch from one health plan to another at any time during the year, so don’t assume that your doctor will remain in your health plan.  Also, if you travel a lot or live in different places at different times of the year, you probably want a health plan that will cover your care wherever you are. Traditional Medicare covers your care anywhere in the United States. Commercial (private) health insurance often limits your coverage to a particular geographic network and does not usually cover out-of-network care, except in emergencies. If you have Medicare, here are two questions to answer during the open enrollment period.
    2. The premium, deductible and copays: When you compare health plans based on costs, be sure to look at the deductible—the amount you pay out of pocket before coverage begins—as well as the premium and copays. Often health plans with low premiums have high deductibles and, if you do end up needing health care services, your costs can be far higher in one of those plans than in a health plan with a higher premium and a lower deductible. For example, a health plan with a $200 monthly premium and a $2500 deductible is effectively charging you $4900 for the year ($2400 plus $2500) if you need a bunch of health care services. A health plan with a $250 monthly premium and a $1000 deductible will cost you $4,000 for the year ($3000 plus $1000). Copays, the amount you pay out of pocket for a doctor’s visit can also add significantly to your costs if they are high and you have a complex condition that needs a lot of care. Keep in mind that your annual out-of-pocket cap can be quite high–it’s as much as $6,850 in a Medicare Advantage plan in 2016. For a crash course on five important health insurance terms, click here.

    Note: If you are enrolled in a Medicare Advantage Plan and would like to switch to traditional Medicare, you can until February 14. To learn more and get free advice, call your State Health Insurance Assistance Program.

    Here’s more from Just Care:

  • 7 questions you should answer before you turn 65

    7 questions you should answer before you turn 65

    Everyone has lots of questions about their health and financial security as they age. Here are seven questions you should answer before you turn 65 with links to simple information to help you decide what to do:

    1.     Do you need to sign up for Medicare?  Medicare provides health insurance for people 65 and over and people with disabilities, regardless of income.  Whether to enroll in Medicare depends on whether you have employer coverage and what kind you have. (If you have employer coverage through your job or your partner’s job, click here to learn more.) If you do need Medicare:

    • Enrollment in Medicare Part A, hospital insurance, and Part B, medical insurance, is generally automatic if you have signed up for Social Security. Part A is free if you or your spouse has paid into Medicare for at least 40 quarters. You pay the Part B premium unless you qualify for Medicaid. You need Medicare Part B if your employer coverage is no longer primary once you turn 65. (To avoid penalties for mistakenly turning down Part B, check with Social Security at 800-772-1213;  you can also contact your local area agency on aging at 800-677-1116.)
    • Understand your supplemental coverage options and how to choose among them. Medicare only covers about half of your health care costs. If you enroll in traditional Medicare (see below), you will want additional coverage, supplemental coverage, to fill gaps and limit your out-of-pocket costs. For an explanation of your options, click here.  If you enroll in a Medicare Advantage plan, you cannot buy insurance to cover your deductibles and copays and other out-of-pocket costs.

    2.   Should you enroll in traditional Medicare or a Medicare Advantage plan? It depends on the kind of coverage that’s important to you and whether you want as much choice of doctors and hospitals as possible. It also depends on how much you are willing and able to pay to get the coverage you need. Most people choose traditional Medicare because of the enormous choice of doctors and hospitals it offers anywhere in the country. (Note: Some insurers are involuntarily enrolling people in their Medicare Advantage plans when they turn 65. Make sure you’re not involuntarily enrolled.)

    3.    Should you sign up for a Medicare Part D prescription drug plan? In most cases, yes, if you need drug coverage. But, you should understand the limits to that coverage and when your drugs will be covered. Here are six tips for keeping your drug costs down.

    4.     What about Medicaid? Medicaid can pick up many of your health care costs that Medicare does not cover, including your Medicare premium, if your income is low.  Whether you qualify for Medicaid might depend on where you live. You can have both Medicare and Medicaid. Here’s how they work together. And, here’s what you need to know about the ways Medicaid can help you.  Even if you don’t qualify for Medicaid, here are five programs that lower your costs if you have Medicare.

    5.     When should you sign up for Social Security benefits (if you have not already done so) and what will your  Social Security benefits be when you retire?  You should understand the benefits and risks of claiming Social Security early.

    6.     Are you prepared if you need long-term services and supports? Today, two in five people with Medicare needing these services do not receive them.

    7.     Do you have a living will and medical power of attorney, Advance Directives? You should. Get help from Caring Connections.

  • The “Cadillac” tax hurts millions of working people

    The “Cadillac” tax hurts millions of working people

    It seems fair to impose higher taxes on luxury goods. But, the “Cadillac” tax included in the Affordable Care Act taxes costly health insurance policies, even when they are not especially generous.  It assumes that insurance is excessive based on premiums charged; but, premiums stem in considerable part from doctor and hospital rates as well as from the health profile of the people the insurance is covering; they may have little or no bearing on the quality of the insurance.

    Tim Jost explains the policy rationale for the tax: “The Cadillac tax is intended to limit the generosity of employer coverage on the theory that excess coverage encourages excess health care expenditures and thus drives up the total cost of health care.” But, this tax does nothing to ensure people make smarter health care choices, as supporters of the tax would like people to believe. Rather, the tax simply requires people to spend more of their own money on health care, which can keep them from getting needed care. For a detailed critique of the tax by Tim Jost and Joe White, click here.

    There is a push to repeal the Cadillac tax because it will penalize working people. With a Cadillac tax, many employers are likely to provide less costly health insurance that includes higher deductibles (which are already up 67 percent since 2010) and copays, in order to avoid the tax. This will jeopardize access to care for many low-income workers and workers with costly conditions. The tax will apply to families with annual insurance premiums of $27,500 and individuals with annual insurance premiums of $10,200. If it is not repealed, it will go into effect in 2018.

    Bernie Sanders has opposed the tax since 2009.  And, Hillary Clinton has just taken a stand against it as well. But, the President and many members of Congress support it.

    Here’s the Kaiser Family Foundation’s chart showing the percentage of employers that could be affected by the tax.Screen Shot 2015-10-02 at 3.20.13 PM

  • How to get health insurance when you’re ineligible for both Medicaid and premium assistance in the state exchange

    How to get health insurance when you’re ineligible for both Medicaid and premium assistance in the state exchange

    Because the Supreme Court gave states the option of expanding Medicaid, it has forced about four million people today into an insurance no man’s land. These four million people live in states that have still chosen not to expand Medicaid. They have incomes too high to qualify for Medicaid and too low to qualify for a subsidy in their state exchanges. The federal government does not subsidize premiums of people who earn less than the federal poverty level in the state exchanges.

    The twenty states that have not expanded Medicaid to date have made it very hard for people caught in this “coverage gap.” Medicaid can be a life-saving benefit.  And, unless people in this coverage gap move to a state that has expanded Medicaid, they are ineligible for it. Today, more than half a million people cannot get needed mental health care because they live in states that have not expanded Medicaid.

    If they stay put, to get health insurance, people in states that have not expanded Medicaid have no choice but to take on more work. That can mean working two full-time jobs. But, according to the Kaiser Family Foundation, more than half of people caught in this gap have full-time or part-time jobs already and 86 percent of them live in the south.

    In Texas, to qualify for Medicaid, your income must be less than 20 percent of the federal poverty level. Only if people can raise their income above 100 percent of the federal poverty level will the federal government pick up a large percentage of their insurance premium through the exchange.

    To apply for a subsidy in the state exchanges, you must project your annual income. Fortunately, if your income ends up being less than the federal poverty level, the current rules do not require you to pay back the subsidy. For free or low-cost resources in your community, click here.

    People who are uninsured because their states have not expanded Medicaid must complete a form to avoid paying a penalty for not having insurance.

  • How safe are outpatient surgery centers?

    How safe are outpatient surgery centers?

    Medicare now covers surgeries in some 5,500 outpatient surgical centers. Patients often like receiving care from these surgical centers because they say they are often more convenient than hospitals, they don’t have to wait as long for treatment and they get more personalized care. And, according to Consumer Reports, about 54 million surgeries are performed each year at these facilities. The question remains are they as safe as hospitals?

    Lisa McGiffert, who runs the Safe Patient Project at Consumer Reports questions their safety. Outpatient surgery centers like hospitals are breeding grounds for bacteria that can cause serious infections if the facilities are not kept clean. But, these centers tend not to be as tightly regulated or monitored to the same degree as hospitals. So, it’s not possible to know as much about what’s going on inside them.

    In addition, these centers may not have the safety equipment available at a hospital in case of an emergency such as a defibrillator and other lifesaving equipment. Moreover, they may not have staff with the level of training and skills to handle an emergency that are on hand in hospitals.

    Before getting care at an outpatient surgery center, do some research. Try to learn about the center’s infection rates. Make sure that the center is accredited, that your surgeon has experience with the procedure you are getting and that your anesthesiologist is board-certified.

    Right now, it may be hard to find good data on outpatient surgery centers. We should expect it over time. If you have a serious health condition, you may be better off getting your surgery in a hospital, because they are better equipped to address complications. (You should also choose your doctors carefully.)

    We are beginning to see more data rating hospitals, surgeons and doctors on a number of different metrics, including patient safety data from Consumer Reports.

    If you get treated in an ambulatory surgical center, be sure you understand what will happen after you leave. Leaving has its own set of risks if you are not prepared.

    The Agency for Healthcare Research and Quality is currently funding a 12-month patient safety program in which outpatient surgical centers can participate. And in 2014, Medicare began asking these centers for reports on quality, providing payment increases for those centers that comply.

  • Benefits and risks of telemedicine

    Benefits and risks of telemedicine

    Telemedicine allows doctors to remotely assess the conditions of patients via telephone or video. Medicare covers some telemedicine services, both real-time audio and video, for some conditions in certain situations. If you don’t have Medicare, check with your commercial insurer about the coverage available through your plan.

    What are the benefits of telemedicine? There’s no denying that telemedicine is convenient, saves time and generally saves money. Through telemedicine, you can see a doctor and get a prescription with ease, even if you live in a rural community or a community with few doctors. Moreover, you don’t generally have to wait for an appointment. You also don’t have to leave your home or leave work to get a diagnosis.

    Does telemedicine improve health outcomes? According to Cochrane, based on the research to date, the jury’s still out on the benefits and risks of telemedicine. A series of studies show overall patient satisfaction. But, the evidence is still scant on the clinical benefits of telemedicine or the effects of telemedicine on health outcomes.

    One analysis of 80 reviews of telemedicine revealed that 21 reviews found telemedicine effective, 18 reviews found telemedicine “promising but incomplete,” and others still found that the evidence was still limited and not consistent.

    What are the risks of telemedicine? It can be difficult for doctors to evaluate patients remotely. Doctors get a better sense of patients’ conditions in person, through a physical evaluation. So, there is a real likelihood of misdiagnosis with telemedicine.

    While Medicare only covers limited home care services, it is now in the midst of a demonstration project that pays for doctors and nurse practitioners to make house calls. That could be a better option than telemedicine.

  • Pneumonia vaccine: Medicare covers it

    Pneumonia vaccine: Medicare covers it

    You should do what you can to avoid getting pneumonia, especially if you’re older. Pneumonia is a lung infection that can cause fever and chills;  it can make it hard to breathe, and it can be life-threatening. One way to avoid getting pneumonia is by getting a vaccine. Fortunately, Medicare covers the pneumonia vaccine without a deductible or coinsurance.

    • If you are enrolled in traditional Medicare, your costs are fully covered through Medicare Part B, so long as you use a doctor who takes assignment, accepts Medicare’s payment as payment in full.
    • If you are enrolled in a Medicare HMO, PPO or other Medicare Advantage plan, the plan should cover the full cost so long as you use an in-network doctor.

    Talk to your primary care doctor about getting the pneumonia vaccine. You should also discuss the flu shot, another important vaccine.  Medicare covers the flu shot, along with most of the preventive care you need. 

    Here are more ways to keep yourself and the people you love safe and healthy.