Making Sense (and Dollars) of Medicare

Sifting through the rubble and trying to make sense of Medicare and Medigap isn’t easy, which is why nonprofit agencies are out there for free consultations. They’ll explain all the options to you, look at your specific circumstances and try to point you in the right direction.

You’re 65 or older, and here are your options:
Climb the highest mountain.
Go skydiving.
Play quarterback for the Eagles. (Hey, if Sam Bradford doesn’t want the job … .)
Make sense of Medicare.
Before you answer, know that the mountain is really, really steep, the parachute’s been a bit cranky of late and Eagles’ fans aren’t the most patient, especially if they think their grandma can throw the ball better than you.
So, Medicare it is. Gulp.
For starters, you’re wondering, “Why do I keep getting all this mail, and what am I supposed to do with it?” It’s as if a little bird told every insurance company in the country you’re turning 65. Instead of sending you birthday greetings, they’re sending you Medicare and Medigap — we’ll get into all that later — plans.
Sifting through the rubble and trying to make sense of it isn’t easy, which is why nonprofit agencies like APPRISE are out there for free consultations. They’ll explain all the options to you, look at your specific circumstances and try to point you in the right direction.
The only thing they won’t do is make an actual recommendation.
“We go through an overview of Medicare and how it works,” explained Barbara Rutberg, a former Upper Dublin High English teacher who’s been volunteering for APPRISE the past four years. “We offer all services and counseling.
“Depending upon the needs of the individual and specific conditions, we’ll suggest several choices. But we do not recommend. We’re unbiased. We try to point out the pluses or minuses.”
According to Rutberg, there’s so much confusion about just what Medicare is and what benefits you’re getting, depending on which part of the plan you sign up.
And there’s no easy answer to all this.
The simplified version is that when you turn 65 you are automatically enrolled in coverage for Part A, which deals with hospitalization, nursing care and home health services.
From there, it gets complicated.
Part B covers lab tests, surgeries and doctor visits — assuming that your doctor accepts Medicare, which has become more the exception than the rule in recent years. That’s because of the low fee reimbursements and hassles in filing claims.
For most people, there’s a $121.80 monthly premium to belong to Part B, but because it only covers so much — leaving patients with huge deductibles and other costs — many look to supplement that.
That’s where things get even more muddled, as folks decide whether to supplement with a Medicare Advantage Plan, aka Part C, or go with a Medigap plan.
Under Part C, you may pay a smaller yearly deductible and a small co-pay for doctor visits. But the cost of that annual premium could skyrocket. That why you’re getting besieged with mail from insurance companies touting that plan you’ve simply got to have. 
The problem is that what might work best for your best friend or your neighbor might not work best for you.
“The number of people who come to us because they made mistakes is depressing,” said Donna Omdahl of 65 Incorporated, a Milwaukee company that charges $399 for complete Medicare counseling. “We go through the process with each applicant, starting with where they are now. And try to figure out what might work best for them.
“Through education, they’re able to decide.”
Much of that education can come straight from the horse’s mouthpiece itself — — which offers step-by-step instructions about how to proceed when applying for Medicare.
It tells you what services are offered under each plan, gives you an approximate cost and provides names and addresses for doctors, hospitals, nursing facilities, medical equipment suppliers and other important information.
And in case you’re not computer savvy, they can actually snail mail all this information to you — assuming you can find someone to help request it.
But, according to Omdahl, there’s a glitch in the system (surprise!) that confuses people who don’t understand the difference between original Medicare and a Medicare Advantage Plan.
They assume that once they choose one they’re covered, along with a reliable prescription drug plan (Part D), across the board. That’s not necessarily true.
While most Medicare Advantage Plans include some kind of drug coverage, original Medicare requires signing up right away. Otherwise, you may have to pay a penalty. Then you pick the plan you want, with the monthly premium added to your Medicare premium.
Got all that?
“The thing is with the original Medicare, you have to pick two of the options,” said Omdahl, whose company offers education seminars to clarify the misconceptions. “But it isn’t clear on the website. Consequently, people think they have to pick one of each.
“The basic idea is we need to have proper care as we get older. Once you understand that and understand there are two distinct parts to the decision of how to package it, things become clearer.”
When you go with a Medicare Advantage Plan, it supplements the costs basic Medicare doesn’t cover. Of course, there’s a hefty premium for that on top of the basic Medicare fee. And there’s likely a deductible, too.
Medigap plans, on the other hand, have a considerably lower premium and little or no deductible. But if you wind up in the hospital for surgery or some other condition that requires a stay and various tests, your out-of-pocket costs can be prohibitive.
In essence, those on Medigap are betting on themselves that they won’t have any major issues. While it’s nice to be optimistic rather than thinking the sky is falling any minute, it may not be the most pragmatic.
Logic suggests the older we get, the more likely our bodies are to break down in some way. To deny that to save a few bucks up front may not be the smartest move — especially if six months or so later you’re paying big bucks because something went wrong.
But it’s your life.
And it’s up to you to decide how Medicare should work for you. That’s assuming you’re not still under your working spouse’s health care plan, which would limit you to Part A, because the rest is already covered by insurance. In that case, the two of you need to figure out the best way to proceed.
But don’t listen to just anyone. Listen to those who know your situation and will help make the best choice for your particular circumstance.
“Many people tell us, ‘My neighbor said this,’ or ‘My brother-in-law said that,’” explained Rutberg, who said the local APPRISE office includes volunteers with legal backgrounds, as well as those in pharmaceuticals and health care. “If you listen to them, you can choose something much more costly as a result.
“But in many ways with Medicare and Medicaid and all the different drug plans, they couldn’t have made it more confusing.”
Hopefully, some of this will clear up the confusion.
If not, try to set up a meeting with a representative of APPRISE, which often can take place in your local library or another public venue. And if you think it’s worth it to spend the money up front to ensure you won’t be spending a whole lot more money later for making the wrong decisions, contact one of the fee-based companies.
If none of that helps, there’s only one question left:
Can you avoid the blitz and throw the deep ball?
Contact: [email protected]; 215-832-0729


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