Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And now Medicare three sixty.
Speaker 2 (00:45):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee, and we are actually going to finish our
journey on the Medicare and You handbook for twenty twenty five.
And actually the Medicare and You twenty twenty six just
came out, So if you do want this pdf, let
(01:07):
me know. I could definitely send it to you and
probably do a Medicare in your twenty twenty six guide
and so forth. But you are supposed to get this
in the mail and you.
Speaker 3 (01:23):
Could review everything.
Speaker 2 (01:25):
I will review all the updates if there is any,
and then at the end you're going to see a
bunch of different plans in your area.
Speaker 3 (01:36):
It may be confusing.
Speaker 2 (01:38):
So that's what I am here to help you with.
Speaker 3 (01:42):
So let's get started. We are on page.
Speaker 2 (01:46):
One hundred and thirteen on Railroad Retirement Board. So if
you get benefits from our RB, call to change your
address or name, check, eligibility to sign up for Medicare,
replace your Medicare card, or reporting death, and you could
actually have questions or comment about this book. You can't
email Medicare and you at CMS dot HHS dot gov. Okay,
(02:13):
let's talk about State Health Insurance Assistant ships. This is
going to be numbers depending on your state. I know
that they are trying to defund this program, so let's
just kind of look on the Medicare and New Handbook
right now and see if it's If it's on there.
Speaker 3 (02:32):
Right, might as well let me go to.
Speaker 2 (02:34):
The new Medicare and New Handbook. Do I see anything important? Contacts?
See you know what I actually don't, so uh.
Speaker 3 (02:56):
Yeah. After after that page basically where there.
Speaker 2 (03:02):
The let's see the Railroad Requirement Board number is the same,
but there's no more ship assistant programs that I see
on here, so maybe they have defunded it. Let me
get back to you guys on that to make sure
that is accurate. But of course, call your local agent
(03:23):
call me so we could go over your options instead
of SHIP which is basically what do they say. Visit
shiphelp dot org or use information below for free personalized
help with questions about appeals, buying other insurance, choosing a
health plan, buying a MEDIGAP policy, and Medicare rights and protections.
So the thing is these are volunteers. Okay, they're volunteers,
(03:48):
so they're not licensed. They're not life and Health license.
They don't take continuing education like a license agent does
every two years, an independent license insurance agents, they don't
do the a hip. A HIP is a certification that
(04:09):
medic that if you want to offer Medicare plans you
do have to take.
Speaker 3 (04:14):
So they don't have that. So how knowledgeable are they, right?
Speaker 2 (04:20):
I mean, yes, you may have your own plan, but
everyone is going to be different everyone's situation, so I
don't know what type of training they've had, so yeah,
I would just leave it at that that I think
(04:41):
they have been.
Speaker 3 (04:44):
Defunded.
Speaker 2 (04:45):
Let's see have they been defunded defunded? Let me just
make sure. Oh you know what, Actually it wasn't funded.
They did suggest maybe lowering the funds to the program,
(05:11):
and I bet, look at I don't see the Medicare
and New handbook, So I will next time just let
you know if I do see it, but I do
not see it on this one.
Speaker 3 (05:25):
Okay.
Speaker 2 (05:25):
So it's all the states on there. Not going to
read through the states. So let's go on page one nineteen,
which is the definitions. So I'm going to just kind
of list out the definitions that they have here. So
Accountable Care Organization ACO group of doctors, hospitals, and other
(05:48):
healthcare professionals working together to give you high quality, coordination
service and healthcare. Okay, assignment and agreement by your doctor
or supplier to be paid directly by Medicare, to accept
the payment amount Medicare poofs for the service, and not
to bill you for any more than the Medicare deductileund conscience.
(06:12):
This is definitely important because you don't want to go
to your doctor, specialists any other health facilities, and if
they don't accept assignment, you are going to be on
the hook for that service. So just keep in mind
that they should. It's normal practice, but you just never know, Okay.
(06:37):
Benefit period the way that Original Medicare measures your use
of hospital and skilled nursing facility services. A benefit period
begins a day you're admitted as an inpatient in a
hospital or skilled nursing facility. The benefit that period ends
when you have gotten any inpatient hospital care or skilled
(07:00):
care in a skilled nursing facility, or for sixty days
in a row. If you go into a hospital or
skilled nursing facility after one benefit period has ended, a
new benefit period begins.
Speaker 3 (07:15):
You must pay the.
Speaker 2 (07:16):
Inpatient hospital deductible for each benefit period. There's no limit
to the number of benefit periods.
Speaker 3 (07:24):
So this is when you don't have a cap.
Speaker 2 (07:29):
Right, if you go to the hospital at all and
you're on Original Medicare, you do not have a cap
if you go there again in five ten days.
Speaker 3 (07:38):
So keep that in mind. Also keep in mind that just.
Speaker 2 (07:45):
If let's just say your plan says, oh, you have
unlimited day's day or ninety day or whatever stay you have,
that doesn't necessarily mean that the hospital is going to keep.
Speaker 3 (07:58):
You there because you're covered.
Speaker 2 (08:00):
Right, if you think of it on the hospital's point
of view, it is racking cost.
Speaker 3 (08:08):
For them right for you to be there, So.
Speaker 2 (08:14):
You have to be your own advocate on that, meaning
if you don't want to be discharged, if you're not
quite ready to go home, you need to advocate for
yourself on that. Some case managers, I would say, they're
really good. They will help you, they'll advocate for you.
But there's just some that aren't, and maybe it's based
(08:38):
on what they're told to do, right, So I'm not
really involved in that side, but what I could say
is that definitely advocate for yourself. Like I had a
situation where my client has been at the hospital for
a long time, maybe during sixteen ninety days, and the
(09:02):
hospital's trying to kick him out. They're trying to get
him more care, like at a skilled nursing facility or
rehab place, and they're just like, yeah, I know, you
have to go home. We're I mean, in so much
words right, like emotionally you're already feeling distraught, but we're
gonna have to discharge you because insurance didn't approve it.
(09:28):
So I'm like, it doesn't sound right. This person had
unlimited care coverage for the hospital, so we did call
the insurance company and come to find out, the insurance
company says, we never received a referral for the requests
to get into a skilled nursing facility. So things like that,
(09:54):
I mean, come on, now, the case manager could have
helped and figured it out, well, like why was.
Speaker 3 (10:01):
In it approved?
Speaker 2 (10:03):
Well, it wasn't approved because they never received the request, right,
So things like that, you definitely need to just keep
your ducks in a row, give us a call. We're
here to advocate for you and figure out what's going on, right,
(10:23):
especially for those that this is not your line of field. Healthcare,
I mean healthcare on just taking care of the patient
is not my line of field like I would I
wouldn't know, right, But on the insurance side, this is
something where we could follow appeals complaints help you get
the care that you deserve and that is actually on
(10:46):
your evidence of coverage. So things like that that we
could definitely help you out with. So that was my
rant for that. Let's go to co insurance. So co
insurance is an amount you pay an amount you may
be required to pay as your share of the costs
(11:07):
for benefits after you pay deductibles. Co insurance is usually
a percentage, for example twenty percent. So let's take for example,
on Part B medical right, if you were on Original Medicare,
there is a deductible for the whole year, and this
is the calendar year, not like when you got on
(11:30):
the plan in one year. It is the candle can
a calendar year. You do have to pay that deductible.
Then after that you have a co insurance of twenty percent.
So meaning if you had one hundred thousand dollars surgery,
(11:51):
you would pay twenty percent of that, which is twenty thousand.
That's a big amount for most people, I would say,
So that's why I really don't recommend you stay on
Original Medicare. So co payments. What's the difference between a
(12:11):
co payment and a co insurance? So a co payment
is amount you may be required to pay as your
share of the cost for benefits after you pay any deductibles.
Co payment is a fixed amount, like thirty dollars. So
sometimes you'll see, oh, I want to see a specialist,
(12:32):
it's going to cost you five dollars, ten dollars, twenty thirty,
or like it's going to cost you zero. So kind
of just depends on the plane itself. Okay, So credible
prescription drug coverage. Prescription drug coverage that's expected to pay
(12:53):
on average at least as much as Medicare drug coverage.
This could include drug coverage a current or former employer, union, Tricare,
Indian Health Service VA, or individual health insurance coverage.
Speaker 3 (13:10):
So this is what you need.
Speaker 2 (13:14):
Credible prescription drug coverage so you don't get penalized when
you get your Medicare, because remember, if you don't have
a credible drug coverage when you get on Medicare, you
will pay one percent for every single month that you
(13:35):
weren't on one And I think the average right now
is about thirty two dollars annual. So while it could
just be pennies, this actually is monthly penalty and you're
going to pay it for the rest of your life.
Speaker 3 (13:52):
So who wants that.
Speaker 2 (13:54):
Let us know and we get to help you with
that as well. Critical access hospital a small facility located
in a rural area more than thirty five miles or
fifteen miles if in mountainous terrain, or in areas with
only secondary roads from another hospital or critical access hospital,
(14:17):
this facility provides twenty four to seven emergency care. Has
twenty five or fewer inpatient beds and maintains an average
state of ninety six hours or less for acute patients.
Speaker 3 (14:31):
Okay.
Speaker 2 (14:33):
Deductible the amount you must pay for healthcare or prescriptions.
Before original Medicare you pay Medicare Advantage plan, your Medicare
drug plan, or your other insurance begins to pay. So
keep in mind that you do have like a part
(14:55):
be deductible. Some plans, if you get on a Medicare advantage,
don't have deductibles. Some do more so maybe like an
IPPO model. And remember you do have a deductible on
your drug plan. The drug plan is the deductible could
(15:18):
go up or down every single year. It is going
to go up next year. So that's why it's good
to review your drugs and make sure that you're not paying.
Speaker 3 (15:34):
A lot for that if you don't have to. Okay.
Speaker 2 (15:38):
Demonstrations special projects sometimes called pilot programs or research studies
that test improvements in Medicare coverage, payment, and quality of care.
They usually operate only for limited time for specific group
of people and specific areas. Okay. Extra Help a Medicare
(16:01):
program to help people with limited income and resources pay
Medicare prescription drug program costs like premiums, deductis, and consurance.
Speaker 3 (16:13):
So yes, if.
Speaker 2 (16:14):
You have lower income, you are on Medicaid or medical
in California, you will receive extra help. So example, let's
just say your prescription drug costs forty five dollars, but
on this plan you're going to be paying ten dollars
the Part B premium.
Speaker 3 (16:32):
These plans may.
Speaker 2 (16:34):
Be able to pay for that premium as well, so
you don't have to worry about it. So those are
the nice things about the plans. Formulay a list of
prescription drug covered by prescription drug plan or another insurance
plan offering prescription drug benefits, also called a drug list.
So the biggest thing is that every insurance company will
(16:57):
have their own formulary. From one drug on one plan
to a different plan might not have the same costs.
It might not even be on the formulay, which means
it's not on their list and it's not going to
be covered, and then the pricing is going to be different,
So just keep that in mind. Not everything's always covered.
(17:22):
Most of the time, the generics and the preferred generics
are covered. Brand name could be shaky, but sometimes one
company will have a discount or make a brand name
drug cheaper. Things like that to look out for, okay.
Impatient rehabilitation facility a hospital or part of a hospital
(17:45):
that provides an intensive rehabilitation program to two in patience
lifetime reserve days in original Medicare, there are additional days
that Medicare will pay for. When you're in a hospital
for more than ninety days, you have a total of
(18:06):
sixty reserve days that could be used during your lifetime.
For each lifetime reserve day, Medicare pace all cover costs
except for daily coinsurance. Okay, so you have a total
of sixty reserve days right during your lifetime. So that's
(18:28):
kind of crazy. Imagine being at the hospital last five years, next, ten, fifteen, Right,
you're going to be on the hook for that if
you don't have a plan. So definitely suggest not being
on original Medicare. You never know your expenses. Long term
(18:48):
care hospital acute care hospitals that provide treatment for patients
who stay on average more than twenty five days. Most
patients are transferred for from an intensive or critical care unit.
So yes, like when you're at the hospital and you
need more care, it's just going to a long term
(19:13):
care hospital. Of course, you may need approvals and referrals
to go to one, so that's why your plan is
very important to that and making sure everything connects together
when you are at a hospital and you get those approvals.
(19:34):
Medicaid a joint federal and state program that helps with
medical costs for some people with limited income and in
some cases resources. Medicaid programs vary from state to state,
but most healthcare costs are covered if you qualify for
both Medicare and Medicaid. Medically necessary health care services or
(19:56):
supplies needed to help needed to diagnose or treat an illness, injury, condition, disease,
or symptoms that are accepted standards of medicine. Okay, so
medically necessary typically that is you know a term that
Medicare will use. They won't pay out if it's not
(20:17):
medical unnecessary, like a cosmetic surgery. Medicaid I kind of
just breeze by that. So let's read that again. Medicaid
a joint federal and state program that helps with medical
costs for some people with limited income and in some
cases resources. Medicaid programs vary from state to state, but
most healthcare costs are covered if you quaifer for both
(20:39):
Medicare and Medicaid. So remember this is for low income
and there's going to be different requirements based on your state,
and then you are able to have more resources. You
may get more on your plan because you're on Medicaid
(21:02):
and in California medical Okay. Medicare Advantage plan parts C
a type of medical health plan offered by private company
that contracts with Medicare. Medicare advantaged plans provide all of
your Part A and B benefits with a few exclusions,
for example, certain aspects of clinical trials which are covered
(21:26):
by original Medicare even though you're still on a plan.
Medicare advantage plans include health maintenance organizations, preferred provider organizations,
private fee for service, special needs plants, and Medical Savings
account plans. So Acraman's on that health maintenance organization is HMO.
(21:48):
Preferred provider organizations are PPOs, private fee for service plans
aref SP plans, special needsplans are SNPs, and Medical savings
accounts are msas. If you are enrolled in a Medicare
advantaged plan, most Medicare services are covered through the plan.
(22:12):
Most Medicare services aren't paid by original Medicare. Most Medicare
advantage plans offer prescription drug coverage. Medicare approved amount the
payment amount that original Medicare sets for a covered service
or item. When the provider accepts assignment, Medicare pays, it's
(22:33):
shared and you pay your share of themount.
Speaker 3 (22:36):
Okay, let's straightforward.
Speaker 2 (22:38):
Medicare health plan plans offered by private companies that contract
with Medicare to provide Part A Part B in many
cases Part D benefits includes Medicare advantage plans and certain
types of coverage like Medicare cost plans, pays programs, and
demonstration slash pilot programs. Medicare plan any way other than
(23:03):
Medicare original Medicare that you could get your Medicare health
or drug coverage. This term includes all Medicare health plans
and Medicare driplanes, medic Gap Medicare supplements insurance sold by
private insurance companies to fill gaps in original Medicare. So
(23:23):
these plans aren't Medicare advantage plans.
Speaker 3 (23:27):
They just fill in the coals or.
Speaker 2 (23:29):
The gaps that original Medicare doesn't cover. So very different
from Medicare.
Speaker 3 (23:39):
Plan. Let's see heay.
Speaker 2 (23:45):
Original Medicare a fee for health service insurance program that
has two parts, Part A hostile insurance and Part B
medical insurance. You typically pay a portion of the cost
for covered services as you get them under original Medicare.
You don't have original you don't have coverage through Medicare
Advantage or any other type of Medicare health plans. So
(24:08):
that's om which is original Medicare. I thought we were
going to finish this episode, but I guess not.
Speaker 3 (24:18):
So wow.
Speaker 2 (24:19):
We will continue next week on page so going over
the definitions, and I think we will be done by
next week and at least I could definitely just give
a recap on it as well. Well. Once again, thank
you for joining us. I'm your host, Jennifer Lee with
(24:39):
Medicare three sixty. Look forward to seeing next week. You
have a great day.
Speaker 1 (24:46):
Thank you for joining the program Medicare three sixty. Hope
you found today's episode insightful and empowering. Remember understanding your
Medicare options is key to making the right choices for
your health, health and financial well being. If you have
questions or topics you would like covered in future episodes
of Medicare three sixty, don't hesitate to reach out and
(25:09):
speak with our licensed insurance agent. Until next time, stay
informed and take charge of your healthcare journey. This has
been Medicare three sixty, your trusted source for all things
Medicare take care,
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And now Medicare three sixty.
Speaker 2 (00:45):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee, and we are actually going to finish our
journey on the Medicare and You handbook for twenty twenty five.
And actually the Medicare and You twenty twenty six just
came out, So if you do want this pdf, let
(01:07):
me know. I could definitely send it to you and
probably do a Medicare in your twenty twenty six guide
and so forth. But you are supposed to get this
in the mail and you.
Speaker 3 (01:23):
Could review everything.
Speaker 2 (01:25):
I will review all the updates if there is any,
and then at the end you're going to see a
bunch of different plans in your area.
Speaker 3 (01:36):
It may be confusing.
Speaker 2 (01:38):
So that's what I am here to help you with.
Speaker 3 (01:42):
So let's get started. We are on page.
Speaker 2 (01:46):
One hundred and thirteen on Railroad Retirement Board. So if
you get benefits from our RB, call to change your
address or name, check, eligibility to sign up for Medicare,
replace your Medicare card, or reporting death, and you could
actually have questions or comment about this book. You can't
email Medicare and you at CMS dot HHS dot gov. Okay,
(02:13):
let's talk about State Health Insurance Assistant ships. This is
going to be numbers depending on your state. I know
that they are trying to defund this program, so let's
just kind of look on the Medicare and New Handbook
right now and see if it's If it's on there.
Speaker 3 (02:32):
Right, might as well let me go to.
Speaker 2 (02:34):
The new Medicare and New Handbook. Do I see anything important? Contacts?
See you know what I actually don't, so uh.
Speaker 3 (02:56):
Yeah. After after that page basically where there.
Speaker 2 (03:02):
The let's see the Railroad Requirement Board number is the same,
but there's no more ship assistant programs that I see
on here, so maybe they have defunded it. Let me
get back to you guys on that to make sure
that is accurate. But of course, call your local agent
(03:23):
call me so we could go over your options instead
of SHIP which is basically what do they say. Visit
shiphelp dot org or use information below for free personalized
help with questions about appeals, buying other insurance, choosing a
health plan, buying a MEDIGAP policy, and Medicare rights and protections.
So the thing is these are volunteers. Okay, they're volunteers,
(03:48):
so they're not licensed. They're not life and Health license.
They don't take continuing education like a license agent does
every two years, an independent license insurance agents, they don't
do the a hip. A HIP is a certification that
(04:09):
medic that if you want to offer Medicare plans you
do have to take.
Speaker 3 (04:14):
So they don't have that. So how knowledgeable are they, right?
Speaker 2 (04:20):
I mean, yes, you may have your own plan, but
everyone is going to be different everyone's situation, so I
don't know what type of training they've had, so yeah,
I would just leave it at that that I think
(04:41):
they have been.
Speaker 3 (04:44):
Defunded.
Speaker 2 (04:45):
Let's see have they been defunded defunded? Let me just
make sure. Oh you know what, Actually it wasn't funded.
They did suggest maybe lowering the funds to the program,
(05:11):
and I bet, look at I don't see the Medicare
and New handbook, So I will next time just let
you know if I do see it, but I do
not see it on this one.
Speaker 3 (05:25):
Okay.
Speaker 2 (05:25):
So it's all the states on there. Not going to
read through the states. So let's go on page one nineteen,
which is the definitions. So I'm going to just kind
of list out the definitions that they have here. So
Accountable Care Organization ACO group of doctors, hospitals, and other
(05:48):
healthcare professionals working together to give you high quality, coordination
service and healthcare. Okay, assignment and agreement by your doctor
or supplier to be paid directly by Medicare, to accept
the payment amount Medicare poofs for the service, and not
to bill you for any more than the Medicare deductileund conscience.
(06:12):
This is definitely important because you don't want to go
to your doctor, specialists any other health facilities, and if
they don't accept assignment, you are going to be on
the hook for that service. So just keep in mind
that they should. It's normal practice, but you just never know, Okay.
(06:37):
Benefit period the way that Original Medicare measures your use
of hospital and skilled nursing facility services. A benefit period
begins a day you're admitted as an inpatient in a
hospital or skilled nursing facility. The benefit that period ends
when you have gotten any inpatient hospital care or skilled
(07:00):
care in a skilled nursing facility, or for sixty days
in a row. If you go into a hospital or
skilled nursing facility after one benefit period has ended, a
new benefit period begins.
Speaker 3 (07:15):
You must pay the.
Speaker 2 (07:16):
Inpatient hospital deductible for each benefit period. There's no limit
to the number of benefit periods.
Speaker 3 (07:24):
So this is when you don't have a cap.
Speaker 2 (07:29):
Right, if you go to the hospital at all and
you're on Original Medicare, you do not have a cap
if you go there again in five ten days.
Speaker 3 (07:38):
So keep that in mind. Also keep in mind that just.
Speaker 2 (07:45):
If let's just say your plan says, oh, you have
unlimited day's day or ninety day or whatever stay you have,
that doesn't necessarily mean that the hospital is going to keep.
Speaker 3 (07:58):
You there because you're covered.
Speaker 2 (08:00):
Right, if you think of it on the hospital's point
of view, it is racking cost.
Speaker 3 (08:08):
For them right for you to be there, So.
Speaker 2 (08:14):
You have to be your own advocate on that, meaning
if you don't want to be discharged, if you're not
quite ready to go home, you need to advocate for
yourself on that. Some case managers, I would say, they're
really good. They will help you, they'll advocate for you.
But there's just some that aren't, and maybe it's based
(08:38):
on what they're told to do, right, So I'm not
really involved in that side, but what I could say
is that definitely advocate for yourself. Like I had a
situation where my client has been at the hospital for
a long time, maybe during sixteen ninety days, and the
(09:02):
hospital's trying to kick him out. They're trying to get
him more care, like at a skilled nursing facility or
rehab place, and they're just like, yeah, I know, you
have to go home. We're I mean, in so much
words right, like emotionally you're already feeling distraught, but we're
gonna have to discharge you because insurance didn't approve it.
(09:28):
So I'm like, it doesn't sound right. This person had
unlimited care coverage for the hospital, so we did call
the insurance company and come to find out, the insurance
company says, we never received a referral for the requests
to get into a skilled nursing facility. So things like that,
(09:54):
I mean, come on, now, the case manager could have
helped and figured it out, well, like why was.
Speaker 3 (10:01):
In it approved?
Speaker 2 (10:03):
Well, it wasn't approved because they never received the request, right,
So things like that, you definitely need to just keep
your ducks in a row, give us a call. We're
here to advocate for you and figure out what's going on, right,
(10:23):
especially for those that this is not your line of field. Healthcare,
I mean healthcare on just taking care of the patient
is not my line of field like I would I
wouldn't know, right, But on the insurance side, this is
something where we could follow appeals complaints help you get
the care that you deserve and that is actually on
(10:46):
your evidence of coverage. So things like that that we
could definitely help you out with. So that was my
rant for that. Let's go to co insurance. So co
insurance is an amount you pay an amount you may
be required to pay as your share of the costs
(11:07):
for benefits after you pay deductibles. Co insurance is usually
a percentage, for example twenty percent. So let's take for example,
on Part B medical right, if you were on Original Medicare,
there is a deductible for the whole year, and this
is the calendar year, not like when you got on
(11:30):
the plan in one year. It is the candle can
a calendar year. You do have to pay that deductible.
Then after that you have a co insurance of twenty percent.
So meaning if you had one hundred thousand dollars surgery,
(11:51):
you would pay twenty percent of that, which is twenty thousand.
That's a big amount for most people, I would say,
So that's why I really don't recommend you stay on
Original Medicare. So co payments. What's the difference between a
(12:11):
co payment and a co insurance? So a co payment
is amount you may be required to pay as your
share of the cost for benefits after you pay any deductibles.
Co payment is a fixed amount, like thirty dollars. So
sometimes you'll see, oh, I want to see a specialist,
(12:32):
it's going to cost you five dollars, ten dollars, twenty thirty,
or like it's going to cost you zero. So kind
of just depends on the plane itself. Okay, So credible
prescription drug coverage. Prescription drug coverage that's expected to pay
(12:53):
on average at least as much as Medicare drug coverage.
This could include drug coverage a current or former employer, union, Tricare,
Indian Health Service VA, or individual health insurance coverage.
Speaker 3 (13:10):
So this is what you need.
Speaker 2 (13:14):
Credible prescription drug coverage so you don't get penalized when
you get your Medicare, because remember, if you don't have
a credible drug coverage when you get on Medicare, you
will pay one percent for every single month that you
(13:35):
weren't on one And I think the average right now
is about thirty two dollars annual. So while it could
just be pennies, this actually is monthly penalty and you're
going to pay it for the rest of your life.
Speaker 3 (13:52):
So who wants that.
Speaker 2 (13:54):
Let us know and we get to help you with
that as well. Critical access hospital a small facility located
in a rural area more than thirty five miles or
fifteen miles if in mountainous terrain, or in areas with
only secondary roads from another hospital or critical access hospital,
(14:17):
this facility provides twenty four to seven emergency care. Has
twenty five or fewer inpatient beds and maintains an average
state of ninety six hours or less for acute patients.
Speaker 3 (14:31):
Okay.
Speaker 2 (14:33):
Deductible the amount you must pay for healthcare or prescriptions.
Before original Medicare you pay Medicare Advantage plan, your Medicare
drug plan, or your other insurance begins to pay. So
keep in mind that you do have like a part
(14:55):
be deductible. Some plans, if you get on a Medicare advantage,
don't have deductibles. Some do more so maybe like an
IPPO model. And remember you do have a deductible on
your drug plan. The drug plan is the deductible could
(15:18):
go up or down every single year. It is going
to go up next year. So that's why it's good
to review your drugs and make sure that you're not paying.
Speaker 3 (15:34):
A lot for that if you don't have to. Okay.
Speaker 2 (15:38):
Demonstrations special projects sometimes called pilot programs or research studies
that test improvements in Medicare coverage, payment, and quality of care.
They usually operate only for limited time for specific group
of people and specific areas. Okay. Extra Help a Medicare
(16:01):
program to help people with limited income and resources pay
Medicare prescription drug program costs like premiums, deductis, and consurance.
Speaker 3 (16:13):
So yes, if.
Speaker 2 (16:14):
You have lower income, you are on Medicaid or medical
in California, you will receive extra help. So example, let's
just say your prescription drug costs forty five dollars, but
on this plan you're going to be paying ten dollars
the Part B premium.
Speaker 3 (16:32):
These plans may.
Speaker 2 (16:34):
Be able to pay for that premium as well, so
you don't have to worry about it. So those are
the nice things about the plans. Formulay a list of
prescription drug covered by prescription drug plan or another insurance
plan offering prescription drug benefits, also called a drug list.
So the biggest thing is that every insurance company will
(16:57):
have their own formulary. From one drug on one plan
to a different plan might not have the same costs.
It might not even be on the formulay, which means
it's not on their list and it's not going to
be covered, and then the pricing is going to be different,
So just keep that in mind. Not everything's always covered.
(17:22):
Most of the time, the generics and the preferred generics
are covered. Brand name could be shaky, but sometimes one
company will have a discount or make a brand name
drug cheaper. Things like that to look out for, okay.
Impatient rehabilitation facility a hospital or part of a hospital
(17:45):
that provides an intensive rehabilitation program to two in patience
lifetime reserve days in original Medicare, there are additional days
that Medicare will pay for. When you're in a hospital
for more than ninety days, you have a total of
(18:06):
sixty reserve days that could be used during your lifetime.
For each lifetime reserve day, Medicare pace all cover costs
except for daily coinsurance. Okay, so you have a total
of sixty reserve days right during your lifetime. So that's
(18:28):
kind of crazy. Imagine being at the hospital last five years, next, ten, fifteen, Right,
you're going to be on the hook for that if
you don't have a plan. So definitely suggest not being
on original Medicare. You never know your expenses. Long term
(18:48):
care hospital acute care hospitals that provide treatment for patients
who stay on average more than twenty five days. Most
patients are transferred for from an intensive or critical care unit.
So yes, like when you're at the hospital and you
need more care, it's just going to a long term
(19:13):
care hospital. Of course, you may need approvals and referrals
to go to one, so that's why your plan is
very important to that and making sure everything connects together
when you are at a hospital and you get those approvals.
(19:34):
Medicaid a joint federal and state program that helps with
medical costs for some people with limited income and in
some cases resources. Medicaid programs vary from state to state,
but most healthcare costs are covered if you qualify for
both Medicare and Medicaid. Medically necessary health care services or
(19:56):
supplies needed to help needed to diagnose or treat an illness, injury, condition, disease,
or symptoms that are accepted standards of medicine. Okay, so
medically necessary typically that is you know a term that
Medicare will use. They won't pay out if it's not
(20:17):
medical unnecessary, like a cosmetic surgery. Medicaid I kind of
just breeze by that. So let's read that again. Medicaid
a joint federal and state program that helps with medical
costs for some people with limited income and in some
cases resources. Medicaid programs vary from state to state, but
most healthcare costs are covered if you quaifer for both
(20:39):
Medicare and Medicaid. So remember this is for low income
and there's going to be different requirements based on your state,
and then you are able to have more resources. You
may get more on your plan because you're on Medicaid
(21:02):
and in California medical Okay. Medicare Advantage plan parts C
a type of medical health plan offered by private company
that contracts with Medicare. Medicare advantaged plans provide all of
your Part A and B benefits with a few exclusions,
for example, certain aspects of clinical trials which are covered
(21:26):
by original Medicare even though you're still on a plan.
Medicare advantage plans include health maintenance organizations, preferred provider organizations,
private fee for service, special needs plants, and Medical Savings
account plans. So Acraman's on that health maintenance organization is HMO.
(21:48):
Preferred provider organizations are PPOs, private fee for service plans
aref SP plans, special needsplans are SNPs, and Medical savings
accounts are msas. If you are enrolled in a Medicare
advantaged plan, most Medicare services are covered through the plan.
(22:12):
Most Medicare services aren't paid by original Medicare. Most Medicare
advantage plans offer prescription drug coverage. Medicare approved amount the
payment amount that original Medicare sets for a covered service
or item. When the provider accepts assignment, Medicare pays, it's
(22:33):
shared and you pay your share of themount.
Speaker 3 (22:36):
Okay, let's straightforward.
Speaker 2 (22:38):
Medicare health plan plans offered by private companies that contract
with Medicare to provide Part A Part B in many
cases Part D benefits includes Medicare advantage plans and certain
types of coverage like Medicare cost plans, pays programs, and
demonstration slash pilot programs. Medicare plan any way other than
(23:03):
Medicare original Medicare that you could get your Medicare health
or drug coverage. This term includes all Medicare health plans
and Medicare driplanes, medic Gap Medicare supplements insurance sold by
private insurance companies to fill gaps in original Medicare. So
(23:23):
these plans aren't Medicare advantage plans.
Speaker 3 (23:27):
They just fill in the coals or.
Speaker 2 (23:29):
The gaps that original Medicare doesn't cover. So very different
from Medicare.
Speaker 3 (23:39):
Plan. Let's see heay.
Speaker 2 (23:45):
Original Medicare a fee for health service insurance program that
has two parts, Part A hostile insurance and Part B
medical insurance. You typically pay a portion of the cost
for covered services as you get them under original Medicare.
You don't have original you don't have coverage through Medicare
Advantage or any other type of Medicare health plans. So
(24:08):
that's om which is original Medicare. I thought we were
going to finish this episode, but I guess not.
Speaker 3 (24:18):
So wow.
Speaker 2 (24:19):
We will continue next week on page so going over
the definitions, and I think we will be done by
next week and at least I could definitely just give
a recap on it as well. Well. Once again, thank
you for joining us. I'm your host, Jennifer Lee with
(24:39):
Medicare three sixty. Look forward to seeing next week. You
have a great day.
Speaker 1 (24:46):
Thank you for joining the program Medicare three sixty. Hope
you found today's episode insightful and empowering. Remember understanding your
Medicare options is key to making the right choices for
your health, health and financial well being. If you have
questions or topics you would like covered in future episodes
of Medicare three sixty, don't hesitate to reach out and
(25:09):
speak with our licensed insurance agent. Until next time, stay
informed and take charge of your healthcare journey. This has
been Medicare three sixty, your trusted source for all things
Medicare take care,
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