Board on Aging and Long Term Care

Medigap

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1.   DO I HAVE TO APPLY FOR MEDICARE OR DO I GET IT AUTOMATICALLY?

If you are already collecting Social Security, either retirement benefits or disability benefits, when you become eligible for Medicare, you will be automatically enrolled in both Part A and Part B.  You become eligible for Medidare when you turn 65 or have been collecting Social Security Disability for 24 months.

If you are not collecting Social Security when you become eligible for Medicare, you must enroll through Social Security.  You can do this online at www.socialsecurity.gov, over the phone at 800-772-1213 or in person at your local Social Security Office.

If you want Medicare Part D prescription coverage, you must actively enroll in it yourself.  You can select a Part D plan by entering your medications in the Medicare plan finder at www.medicare.gov.

Keep in mind that people with Lou Gehrig's disease (ALS) or End-Stage Renal Disease (ESRD) do not have to collect Social Security Disability benefits for 24 months to qualify for Medicare.

 

2.   IF I WAIT TO TAKE PART B, WILL I FACE A PENALTY?

You will have to pay a monthly Part B late enrollment penalty if you do not sign up for Part B when you first become eligible for Medicare or during a Special Enrollment Period (SEP).  If you do have insurance from a current employer, you must enroll in Part B within eight months of retiring or losing coverage, or you will have to pay a penalty.

Before making any decisions about enrolling in, or opting out of Part B, talk to the Social Security Administration.  If you do have another form of health insurance, contact the plan's benefit administrator to find out how that plan works with Medicare.  Then, contact Social Security to confirm the plan's guidance.  Make sure to keep detailed notes of who you spoke with, when, and what they told you.

If you do not enroll in Medicare Part B during your initial Enrollment Period, you will have to wait until the next General Enrollment Period to enroll.  The General Enrollment Period begins January 1 and ends March 31 of each year.  If you sign up for Medicare Part B during a General Enrollment Period your coverage starts on July 1 of that year.  Your Medicare Part B premium may go up 10% for each 12 month period that you could have had Medicare Part B but did not take it.  The only exception is if you qualify for the Special Enrollment Period.  To see if you qualify for an SEP or to enroll in Part B, you must enroll through Social Security.  You can do this online at www.socialsecurity.gov, over the phone at 800-772-1213 or in person at your local Social Security office.

3.   DOES MEDICARE COVER DENTAL?

Medicare will not cover dental care that you need primarily for the health of your teeth.  For example, Medicare will not cover routine checkups, cleanings or pay for you to get fillings.  Medicare will never pay for dentures.  Even if Medicare has paid for you to have teeth pulled (extracted) as preparation for a medical procedure, you will be responsible for the cost of your dentures.

Note: Some Medicare private health plans cover routine dental services.  If you have a Medicare private health plan, check with your plan to see what dental services may be covered.

However, Medicare will cover some dental services if they are required to protect your general health, or you need dental care in order for another health service that Medicare  covers to be successful.

Medicare will pay for dental services if, for example:

  • you receive an oral examination in the hospital because you will be having a kidney transplant or are in a rural or federally qualified health clinic before a heart valve replacement;
  • you have a disease that involves the jaw (like oral cancer) and need dental services that are necessary for radiation treatment;
  • you had a facial tumor removed and had ride reconstruction (reconstruction of part of the jaw) as part of that procedure;
  • you need surgery to treat fractures of the jaw or face;
  • you need dental splints and wiring as a result of jaw surgery.

While Medicare may pay for these initial dental services, Medicare will not pay for any more follup-up dental care after the underlying health condition has bveen treated.  For example, if Medicare paid for a tooth to be removed (extracted) as part of surgery to repair a facial injury you got in a car accident, it will not pay for any other dental care you may need later because you had the tooth removed.

Medicare will pay for some dental-related hospitalizations, for example:

  • if you develop an infection after having a tooth pulled
  • if you require observations during a dental procedure because you have a health- threatening condition.

Note: Medicare will cover the costs of hospitalization (including room and board, anesthesia and x-rays).  It will not cover the dentist fee for treatment or fees for other physicians, such as radiologists or anesthesiologists.

Whle Medicare may pay for in-patient hospital care in these circumstances, Medicare will never cover any dental care specifically excluded from Original Medicare (ie. dentures) even if you are in the hospital.

See "Managing Dental Care Costs" under Medigap Press Releases.

 

4.   WILL MEDICARE COVER NURSING HOME STAYS?

That depends.  These are the requirements for Medicare to cover your skilled nursing facility (SNF) care.

  • You must have spent three days as an inpatient in the hospital before you go to the SNF (called a qualifying hospital stay)
  • You must enter the SNF within 30 days after leaving the hospital
  • You must require a certain amount of skilled nursing care or skilled therapy services
  • You must go to a Medicare-certified SNF

Medicare will only pay for your skilled nursing facility care if you've spent at least three days in the hospital as an inpatient during the 30 days before you're admitted to the facility.  The day you are admitted as an inpatient counts towards your qualifying stay, but the day you are discharged does not.  It's important to know that just because you spent the night in the hospital does not mean you wer admitted as an inpatient.  You may have been in the hospital under observation.  You are still considered an outpatient when you are under observation, and that time does not count toward your qualifying hospital stay.  You are only an inpatient when your docotr signs an order admitting you.  During any hospital stay, it's a good idea to ask your doctor if you have been admitted as an inpatient  or if you are under observation.

In addition to the qualifying hospital stay, you must need skilled care in order for Medicare to cover your skilled nursing facility care.  You must need skilled nursing care every day or skilled therapy sevices at least five days a week.  In your case, that skilled need is physical therapy.  Other types of skilled care include speech therapy and skilled nursing services like intravenous injections and catheter placement.  Speak with your doctor and the hospital discharge planner to figure out if your needs qualify you for Medicare-covered skilled nursing facility care.

If you meet all the criteria above, Medicare Part A will pay for upto 100 days in a skilled nursing facility per benefit period.  A benefit period starts the day you begin getting inpatient care (when you are officially admitted to the hospital) and ends when you have been out of the hospital or skilled nursing facility for 60 days in a row.  In 2012, you pay a deductible of $1,156 at the start of each new benefit period.  You pay nothing for the first 20 days of skilled nursing facility care after you meed your Part A deductible.  For stays 21 through 100 days in the skilled nursing facility, you pay a copay of $144.50 per day.

The coverage rules and costs may be different if you're in a Medicare Advantage plan.

5.   DOES MEDICARE COVER ......

Medicare .gov has an online search tool to find out what is coverd.

Medicare also has publications that can be requested.

You can also call Medicare at 1-800-633-4227 to speak with someone directly.

6.   MEDICARE DIDN'T PAY FOR MY CLAIM OR MEDICARE DENIED MY CLAIM. Those who are under the age of 60 need to contact their local Aging and Disability Resource Center.   For those over the of 60 please contact your local county elderly benefit specialist.

7.   I LOST MY MEDICARE CARD. Contact your Social Security at ssa.gov

8.   MY PARENTS MOVED TO THIS COUNTRY 2 YEARS AGO AND THEY NEED INSURANCE. Medicare makes aliens wait 5 years before they can purchase Medicare. If you are coming to the U.S., plan on having your own insurance for 5 years.  Contact your local County Benefit Specialist.

9.   I DON'T QUALIFY FOR MEDICARE YET, WHAT KIND OF INSURANCE IS AVAILABLE? Call insurance companies and ask about individual major medical poicies. If you've been rejected for an individual policy, contact the contact the Health Insurance Marketplace. For U.S. Citizens or U.S. Residents without Medicare A or B, contact The Bridge Plan at 800-345-8816.

10.   SHOULD I SIGN UP FOR MEDICARE PART A & PART B IF I OR MY SPOUSE ARE STILL WORKING AND ARE COVERED BY EMPLOYER OR UNION HEALTH INSURANCE?

You may want to wait to sign up for Medicare Part B if you or your spouse are working and have health coverage through you or your spouse's employer or union. (See FAQ: I work for a small employer,if you work for a small company)  If you enroll now, you would have to pay the monthly Medicare Part B premium, and the Medicare Part B benefits may be of limited value to you as long as the group health plan is the primary payer of your medical bills.

Note: If you are 65 or over and working for a small company (less than 20 employees) you should talk to your employee health benefits administrator before making any decision not to take Medicare Part B.  If your employer has less than 20 employees, Medicare is the primary payer and your group health insurance would be the secondary payer.  If you are under 65 and disabled, a company of less than 100 employees would be secondary to Medicare.

You may also wish to read our publication: Medicare and other Health Benefits: Your Guide to Who Pays First.

If you don't take Medicare Part B when you are first eligible because you or your spouse are working and have group health plan coverage through your or your spouse's employer or union that is primary, you will have a Special Enrollment period to sign up later for medicare Part B.

If you are disabled and working (or you have group health coverage from a working family member), the Special Enrollment Period rules also apply.

Special Election Period Rules or when you can sign up:
     Anytime you are still covered by the employer or union
     group health plan through your or your spouse's (or if you
     are disabled, a family member's) current or active
     employment, or

     During 8 months following the month the employer or union
     group health plan coverage ends, or when the employment
     ends (whichever is first).

Most people who sign up for Medicare Part B during a Special Enrollment Period do not pay higher premiums.  The Social Security Administration handles Medicare enrollments.  If you have more questions about enrolling in Medicare Part B, you should call the Social Security Administration at 1-800-772-1213.  You can visit their Web Site.

 

 

 

11.   I WORK FOR A SMALL EMPLOYER. DO I NEED MEDICARE? If you work for a small employer with fewer than 20 employees (fewer than 100 employees if you are under 65 and disabled) and become eligible for Medicare, you should take Medicare A & B.  This is because Medicare will be your primary insurance once you become eligible.

12.   I HAVE RETIREE INSURANCE. HOW DOES THAT WORK WITH MEDICARE?

Retiree insurance is always secondary to Medicare.  This means that it only pays after Medicare pays.  If you do not take Medicare Part A and Part B when you become eligible for it, it will be as if you have no insurance.  Since each retiree plan is different, you should contact your plan's benefit's administrator to find out about your plan's out-of-pocket costs and the services it covers.

Whether you keep your retiree insurance is up to you.  Retiree insurance can act as supplemental insurance to Medicare.  This means that it may pay out-of-pocket costs that Medicare does not pay for.  It may also cover things that Medicare does not cover such as routine vision or dental care.  Remember, you are responsible for paying your Medicare premiums as weel as your retiree plan's premiums.

13.   I HAVE A HEALTH SAVINGS ACCOUNT (HSA).

If you are part of a high-deductible health plan and have a Health Savings Account (HSA) to pay for medical expense, you nor your employer can no longer contribute to your HSA if you enroll in Medicare Part A and/or B.  You may, howerver, continue withdraweing money from your HSA after you enroll in Medicare to pay medical expenses.

14.   HOW DOES MEDICARE WORK WITH COBRA?

Whether you can have COBRA and Medicare depends on which one you had first.  If you have COBRA and then become eligible for Medicare, your COBRA may end.  If you have Medicare and then become eligible for COBRA, you can sign up for COBRA insurance and it will be secondary to Medicare.

If you have COBRA and Medicare, you should consider whether continuing with COBRA is worth the expense.

If you have dependents covered by your COBRA plan you should consider how their coverage will be affected if you lose or drop your COBRA.

15.   I HAVE ACCESS TO VA BENEFITS, HOW DOES THAT WORK WITH MEDICARE? See Press release entitled  I am a Veteran.... Do I need Medicare?

16.   WHAT IS A MEDIGAP POLICY?

In Wisconsin, a Medigap policy is a medicare supplement policy issued under the approval of the State of Wisconsin Insurance Commissioner's office.  This is individual health insurance sold by private insurance companies. A supplemental policy is designed to pay the deductibles, copayments, and coinsurance amounts after the original Medicare A&B.  Medigap policies help pay some of the health care costs that the original Medicare program does not cover.

In Wisconsin, there are 9 basic core benefits that every policy must provide. There are 5 optional benefit riders that you can choose to add to the basic policy for an additional premium.  The optional riders will increase your coverage and premium costs.

To read more about Medigap (Medicare Supplement) plans go to Medigap Helpline/SHIP listed under HOME on the main menu and click on Medicare Supplement Insurance.

17.   WHAT'S THE DIFFERENCE BETWEEN A MEDIGAP/MEDICARE SUPPLEMENT AND AN ADVANTAGE PLAN (PART C)?

Original Medicare has out of pocket expenses: deductibles, co-payments and co-insurance amounts.

A Medicare Supplement policy is paying those Medicare out of pocket expenses.  Changing to a Medicare Advantage plan will change how you receive your Medicare benefits and services.  You will still have Medicare out of pocket expenses: deductibles, co-payments and co-insurance amounts.  You must pay these expenses yourself.

The Medicare Supplement policy is governed by the State of Wisconsin.  There are consumer protections in place and enforced by the Office of the Commissioner of Insurance.  The plans are guaranteed renewable which means as long as you pay the premium the policy will stay in force and the company cannot terminate the insurance.  Your premium will increase and the benefits will keep up with Medicare out of pocket expenses.  If it is a traditional medicare supplement, it will allow you to see any doctor that accepts Medicare and it follows you if you move out of state or are a "snowbird".  It allows the most feedon and flexiblity.  You can move at any time to another medicare supplement however, you WILL be subject to udnerwriting (health questions asked).  If you successfully  move from one medicare supplement to another you cannot be asked to serve a pre-existing condition waiting period.

With an Advantage plan (Part C), this becomes your Medicare plan.  It may have low or no premium but there are copays for most services.  The cost sharing amount and the benefit structure can chagne from year to year.  The Advantage plan is not guaranteed renewable.  The plan can leave your area or the company can choose to close the plan entirely.  There are some consumer protections in place if this happens.  Advantage plans are governed by the federal government.  The state has no jurisdiction.

You can apply for an Advantage Plan during the Annual Election Period which begins October 15th and ends December 5th of each year.  Anyone can qualify as long as you are not on active dialysis.

18.   THE PREMIUMS KEEP GOING UP ON MY MEDICARE SUPPLEMENT . SHOULD I SWITCH TO A DIFFERENT SUPPLEMENT?

That depends.  The prices vary widely among supplement policies.  In general the options are:

  1)  You can apply for a different Medicare supplement at any time, but there is no guarantee the company will issue a policy to you.  They will ask health questions and if you do not pass health underwriting the company will not issue a policy.  However, if you successfully move from one Medicare Supplement to another you cannot be asked to serve a pre-existing condition waiting period.  The average cost at 65 years old is $130 a month.  For individuals over 70, the average cost is between $150 and $170 a month.  Over 80 years old costs will range from $190 to over $200 a month.

  2)  There are other options that can lower your monthly premium cost but you will pay more out of pocket as you incur medical expenses.  Call to discuss managed care Medicare Supplements, cost sharing Supplements or Medicare Health Plans.

  3)  If you decide to drop your Supplement policy and have no secondary insurance then you will only have Medicare Part A and Part B.  You could incur medical bills of $20,000 or more which you will have to pay out of pocket.

  4)  You may decide to keep your current policy and pay the increased premium.

 You can request Medicare Supplement Insurance Approved Policies and compare annual premiums.

If you want to speak to an insurance counselor call 1 800 242-1060.

19.   WHAT IS THE DIFFERENCE BETWEEN MEDICARE AND MEDICAID?

While Medicaid and Medicare sound similar, they are in fact very different programs.  Medicaid is a federal and state government program and Medicare is a federal government only program.  Medicaid is for low income: pregnant women, children under the age of 19, people 65 and over, blind, disabled and people who need nursing home care.

Medicare is for people 65 and over, disabled individuals of any age and those who have kidney failure or long term kidney disease.

The Medicare publication, What is Medicare/Medicaid, provides additional information.

21.   HOW DOES WISCONSIN SENIORCARE PROGRAM FOR MEDICATIONS WORK? If you are a Wisconsin resident 65 years old or older, you may benefit from the Wisconsin SeniorCare program.  It is a drug only program.  ANY income can join and some higher income seniors enjoy this option as they will pay only $30 a year to avoid a Part D penalty.  This is especially helpful if you are taking no medications or are only on one or two generic medications.  You can join a Part D plan at any time of the year if you are already on SeniorCare.  See SeniorCare for more information.

22.   I AM PAYING FOR A LONG TERM CARE POLICY, IS IT WORTH IT?

See the Publication:  Long Term Care Insurance: Should I or Shouldn't I?