Summing Up Medicare In Five Paragraphs

As December 7 rapidly approaches, I am going to get down to the nitty gritty of signing up for Parts C and D. But every once in a while it's important to go up to the 30,000-foot level and remind yourself how all the Medicare alphabet soup fits together. This is especially important because there is all kinds of bad information floating around this time of year. 

The following sums up the 115-page Medicare and You booklet in just a few paragraphs:

• Almost everyone on Medicare gets Part A Medicare. It's for ADMITTED acute and skilled-nursing-facility (SNF)/rehabilitation care (see NOTE), hospice, blood and emergency ambulance. Almost everyone of Part A gets it for free as long as they worked and contributed through payroll taxes any 10 years in their life. (Others can buy in.)

• Almost everyone on A (and a very few not on A) choose to get optional Part B Medicare. It's for OBSERVED acute care, outpatient charges, ER charges, doctors, durable medical equipment, drugs administered at doctors' offices or outpatient, and a few other things -- particularly some good preventive tests.
• -- 70% of the people on B paid $104.90 a month in 2013 and will pay exactly the same in 2014
• -- 15%-20% of the people on Part B get Part B for free or near free (or at least qualify for it free even if they have not asked) through Medicaid. 
• -- 10%-15% of people on B pay a surtax on top of the $104.90 because they make over a certain amount of money in retirement.

• Almost everyone (97%) on A and B feel the need to supplement A and B because it is not very good insurance compared to what you got from your employer before you turned in 65 (and even compared to the new Obamacare insurance). Medicare Parts A and B -- called Original Medicare -- have no catastrophic coverage, no annual out of pocket (OOP) limit, no drug coverage, no annual physical, no vision benefits, high deductibles, high co-pays, and a long list of other problems.
• -- One of the ways to supplement Original Medicare (if you do not get a supplement from a former employer) is through a private Medigap plan. Private Medigap plans like Blue Cross Medex in Massachusetts cover almost all the high co-pays and deductibles not covered by Original Medicare but they do not cover anything that Original Medicare itself does not cover, particularly drugs. For drugs, you go to Part D (see other posts on this blog) or you get drug insurance from a former employer or union or the VA.
• -- Another way to supplement Original Medicare -- but not good for everyone -- is a public Part C Medicare Advantage health plan such as Tufts Medicare Preferred. Part C plans cover almost the entire amount of the co-pays and deductibles not covered by Original Medicare -- but not the entire amount like Medigap covers -- and also usually provides some of the things missing from Original Medicare noted above -- particularly providing an annual OOP limit. But Part C plans are networked plans, usually HMOs. So, unlike Original Medicare and most private Medicare supplements, you are limited to a network of providers and must sign up for -- and see -- a primary care physician. (This is because it is an HMO, which has nothing directly to do with Medicare.) Most of these plans charge an additional premium. Some have zero premium, usually in lieu of a high annual OOP limit and/or higher copays than most Part C plans (but still much less than Original Medicare by itself).

Remember, this is just a 300-word summary of a  115-page book. Read the book to make sure you getting everything you deserve.

(NOTE: You have to have been ADMITTED to an acute care hospital for three nights -- rule changing to two nights sometime soon -- in order to get the rehab/SNF covered by Medicare.)