Medicare and Other Health Insurance
Trying to find the truth about how the Affordable Care Act affects older adults? This short, animated video explains the problems with the current health care system, the changes that are happening now, and the big changes coming in 2014.
Health care costs can be a major concern for older people but there are several programs that provide health care coverage to older adults. While these programs can be complex, it is important to understand all your options for health care coverage before making critical decisions.
Before Age 65
If you are concerned about health insurance options for someone under age 65 without employer-provided health insurance, here are a few possibilities:
- A comprehensive place to start your search is maintained by the U.S. Department of Health and Human Services. Healthcare.gov contains the federally-run marketplace where Wisconsin residents can obtain Marketplace plans, also known as qualified health plans (QHPs).
- QHPs cannot deny people based upon a pre-existing condition and additionally provide these essential health benefits:
- Pediatric services
- Emergency services and hospitalization
- Ambulatory patient services
- Maternity and newborn care
- Preventive and wellness services
- Chronic disease management
- Laboratory services
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services
- Enrollment in the Marketplace for 2014 ended on March 31. To obtain health insurance on the Marketplace you must either wait until the next enrollment period (November 15, 2014 to February 15, 2015), or gain a Special Enrollment Period. Special Enrollment Periods (SEPs) will allow an eligible person to enroll at certain periods throughout the year.
- For more information: Marketplace SEPs
- QHPs cannot deny people based upon a pre-existing condition and additionally provide these essential health benefits:
- If you are losing health insurance from an employer, you may qualify for COBRA or enroll in the marketplace. If the health insurance loss is outside of the marketplace open enrollment period you may receive a special enrollment period to enroll in the marketplace for a QHP.
- Individual Mandate Penalty: If you are without minimum essential coverage, (not being insured or are underinsured), you may face a tax penalty. Unless you fall under an exception, in 2014 the individual mandate will charge $95 per un/underinsured adult and $14.50 per un/underinsured child in the household or 1% of the individual household income—whichever is greater. The fee increases every year. In 2016 the fee will be 2.5% of income or $695 per person ($347.50 per child)—whichever is higher.
Medicare is a federal health insurance program for people who are 65 or older, some people with disabilities under age 65, and people with end-stage renal disease or ALS. The Medicare program is best known by its four parts:
- Part A (hospital, hospice, and skilled nursing rehabilitation insurance)
- Part B (medical insurance)
- Part C (Medicare Advantage plans)
- Part D (prescription drug plans)
Most beneficiaries receive their Part A coverage with no premium. They have a monthly premium for Part B (physician and other medical services) deducted from their social security checks. Original Medicare (Parts A and B) can be replaced with a Part C Medicare Advantage Plan which is a managed care health plan from a private insurer. Private insurers also provide Part D prescription drug plans.
IMPORTANT: If you have Medicare A or B and do not have any source of creditable drug coverage (at least as good as Part D), don't ignore Part D just because you don't take prescription drugs. Go to the section on Part D and SeniorCare below to learn more.
What if you’re still working?
Baby Boomers who are employed and turning 65 are still eligible for Medicare. If you have health insurance from active employment yourself or by your spouse, you may not need to take Medicare B at this time. If the company has fewer than 20 employees, however, you need to take Medicare A and B as your primary coverage or face possible problems and penalties later. You can sign up for Medicare on the Social Security Website or in-person at your local office.
On the other hand, people who take early Social Security should get their Medicare card automatically about three months before their 65th birthday. To check on a missing card or discuss whether you should decline Part B, call Social Security's general number at 800-772-1213.
Think you can’t afford Part B?
Programs called Medicare Savings Programs or buy-ins may help pay your Part B—and perhaps even your Medicare copays or coinsurance. Special efforts recently to find eligible beneficiaries have meant that over 10,000 more disabled or older adults save at least the cost of their Part B premium each month. Income limits range between the four Medicare Savings Programs. For 2014 if your monthly income is at or below 200% of the federal poverty level ($1,945) and you meet the other requirements of the program, you may be eligible. (If at least some of your income is from working, you could still qualify with higher earnings.) See whether you might be eligible.
- Learn more about Medicare, its benefits, and your eligibility from the official Medicare Website. The site includes a number of tools you can use to compare the quality of hospitals or nursing homes and to select plans or providers.
- For many of your questions, you may also call 1-800-MEDICARE (800-633-4227). Beneficiaries or family members may also find it very helpful to register an account on MyMedicare to monitor their claims, check enrollment in plans, review their schedule for preventive benefits, and much more.
- Speaking of preventive benefits, Medicare covers an increasing number of screenings and wellness benefits.
- Another site with easy-to-understand Medicare information run by the National Council on Aging is called My Medicare Matters.
- Medicare Made Clear is a site full of resources jointly supported by NCOA (the National Council On Aging) and an insurance company.
- Finally, the Medicare Rights Center has a rich site with interactive lessons for consumers, good advocacy information, and experts to answer your questions. Of course, you can always also contact your local Elder Benefit Specialist for assistance!
- Medicare and Marketplace FAQs
Medigap (Medicare Supplement) Insurance
Because Medicare has deductibles and co-insurance costs, beneficiaries have the option of getting an insurance plan to cover some or all of the costs that Medicare doesn’t cover. Sometimes retiree-group health plans coordinate with Original Medicare to cover more costs (but sometimes retiree-group coverage is from a Medicare Advantage Plan).
Individuals who don't have retiree coverage from an employer or union may purchase a Medigap (Medicare Supplement) plan to cover all or some percentage of their portion of health care costs in exchange for a monthly premium. Premiums increase as you age, but Medigap policies protect against the risk of high Medicare out of pocket costs.
When you first start on Medicare—especially if you have chronic health problems—check your options carefully. There are only certain times when you are guaranteed acceptance by a Medigap insurer. All Medigap policies in Wisconsin must offer the same benefit structure and are guaranteed renewable for life. Some also offer additional benefits such as coverage for annual comprehensive physicals or membership in health clubs. Medicare Supplement plans ARE NOT the same as Medicare Advantage plans and Medigap plans sold after 2005 do not include prescription drug coverage.
Medicare Advantage Plans
Also known as Medicare Health—or Part C plans—these are private, managed health plans (usually HMOs or PPOs) that contract with Medicare to provide benefits and services (many may even include prescription drug coverage). Some add benefits not covered by Medicare such as dental care, routine vision checks, or health club memberships.
Unlike a traditional Medicare Supplement, however, Medicare Advantage Plans have co-payments and cost shares that you need to pay for most services. Although some plans have no or a low monthly premium others have higher premiums (usually with lower coinsurance costs). Advantage Plans may require you to stay within a provider network and can have different costs and authorization requirements than Original Medicare. And where Medicare Supplements retain the same coverage for the life of the policy, Medicare Advantage Plans can change their costs, network, and coverage every year. This worksheet can help you evaluate your personal needs when looking at Advantage Plans.
For a simple explanation of the difference between Original Medicare, Medicare Supplements, and Medicare Advantage Plans, see Medicare Explained in Cheese.
Assistance understanding the Medicare Advantage options in your county can be obtained from your local Benefit Specialist or by calling the Medigap Helpline at 1-800-242-1060.
Medicare Part D & SeniorCare Rx
Prescription drug costs are often a major concern for older people. Wisconsin seniors over 65 have access to two programs to help with drug costs, Medicare Part D, or Wisconsin SeniorCare. (If you have drug coverage from an employer or retiree group plan or the VA or Tricare, you probably don’t need SeniorCare and joining Part D could actually cause problems with your other coverage.)
Medicare Part D is the federal program that provides insurance coverage for both brand-name and generic prescription drugs. Those enrolled will likely pay some combination of premiums, co-payments, and deductibles—depending on the drug plan chosen. About one in three people will also qualify to have zero premium, subsidized Part D because of Extra Help. Those aged 60 and older can get help with Part D and other drug coverage from the Wisconsin Medigap Prescription Drug Helpline at 1-855-67 PART D. (If under age 60, call the Disability Drug Benefit Helpline at 1-800-926-4862.)
Wisconsin’s SeniorCare Rx program, approved by the federal government to continue through 2015, provides Wisconsin residents who are 65 or older with prescription coverage for a $30 annual enrollment fee. Program benefits vary based on income, but those who qualify for the SeniorCare rates pay $5 a month for generics and $15 a month for brand names in most cases.
Don’t Forget the Penalty! What if you don't take any prescription drugs or just some cheap generics? If you are on Medicare, there is a penalty if you don't have drug coverage—just in case you might need it. The penalty is one percent of the national average premium for Part D plans that year for every month you could have had drug coverage but chose not to. That can add up because the average plan each year has cost over $30. So if you go without drug coverage for a year and a half, you will have an 18% penalty. You will pay more than $5.40 extra each month for as long as you are on Part D. A good alternative may be to enroll in SeniorCare for just $30 a year. SeniorCare counts as coverage at least as good as Medicare's, so you are protected from the penalty.
Finally, SeniorCare can coordinate with a Part D plan to lower your costs in the “donut hole” as long as your monthly income isn’t more than about $2,334 if single or $3,146 if married. Even in the levels of SeniorCare where you would have a deductible to pay before getting the reduced rates of $5 for generics or $15 for brand names, what you pay toward your drugs in the Part D plan can count toward your SeniorCare deductible. As long as the pharmacist bills both Part D and SeniorCare, SeniorCare will provide coverage secondary to your Part D plan once you have met your SeniorCare deductible by what you have paid for your Part D copayments.
Medicare and Family Care or Other Long-Term Care Programs
If you enroll in one of the programs Wisconsin has that provides community services for those who would otherwise need nursing home care, there may be important changes to your prescription drug coverage. You cannot stay on SeniorCare if you are on it. You will need to join a Part D plan (or get coverage as part of your program). 2014 will be the third year in which all Family Care members at a nursing home level of care with Part D coverage should have no cost-sharing (no copayment or coinsurance) for drugs covered by their Part D plans. An excellent resource to understand the Medicare considerations and implications of enrolling in Family Care is now available on the Web: Family Care and Medicare - What You Should Know for 2015.
ForwardHealth: Wisconsin Medicaid Program
Medicaid is a program that covers the health care costs of people who qualify based on their financial need. Wisconsin’s ForwardHealth Medicaid plans for elderly, blind, or disabled U.S. citizens or legal immigrants provide health care to those who are:
- Aged 65 or older, blind, or disabled.
- With family income at or below the monthly program limit.
There are several different programs connected with the ForwardHealth Care, with various eligibility criteria. The ForwardHealth link above provides more information, as can your local ADRC or aging office (aging and disability resource center). Programs that can help older adults include:
- Assistance for long term care needs in the community (Family Care, IRIS, Partnership).
- Well Woman Medicaid.
- Medicare Savings Programs (to help with Medicare costs).
- Medical Assistance Purchase Plan (MAPP).
- Institutional Medicaid.
For additional information or help to apply, contact your local ADRC or aging office or your Elder Benefit Specialist. Just return to the home page and click on the map of Wisconsin.