Healthcare has always been one of the leading pain points in the US. The healthcare system, already infamous for its high costs, limited eligibility, and workforce shortage, has only worsened in the post-pandemic era.
A 2023 study found that the biggest challenges facing the US healthcare system were treatment costs, understaffing, poor access to treatment, bureaucracy, and long waiting times.
As the US doesn’t have universal health coverage, people usually have to find their health insurance options and determine whether they are eligible, what the insurance covers, and what additional expenses they may incur.
One such healthcare program is Medicare.
Medicare is a national health insurance program designed to assist the elderly with hospital, medical, and other health care costs.
The program includes numerous benefits without additional costs. However, many of these benefits are overlooked or misunderstood.
So, if you — or your loved one — are one of the over 65 million Medicare beneficiaries — this article is for you.
Read on to learn how to navigate the health program’s complexities and get the most out of your Medicare coverage.
What is Medicare?
Medicare is a health insurance program established in 1965 to help elderly Americans cover their medical, hospital, and other health-related expenses.
The program primarily provides health insurance for individuals aged 65 and above but also covers younger people with certain disabilities, including those with end-stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease).
Medicare is made up of four parts: A, B, C, and D.
Part A of Medicare covers hospital care, nursing facility care, hospice care, and home health care, whereas Part B covers doctor services, outpatient care, and preventive services. Together, these parts make up what is commonly known as Original or Traditional Medicare.
Medicare Part C, also known as Medicare Advantage, provides coverage through Medicare-approved private insurance companies. It includes the same benefits as Medicare Part A and Part B, with additional perks.
Medicare Part D is a prescription drug plan offered through private insurance carriers approved by Medicare and works with Medicare Part A and B coverage. This benefit provides coverage for outpatient prescription medications.
For all Medicare plans explained in-depth, check out the health program’s website or websites of official Medicare providers.
(Why) Is Medicare Confusing?
Medicare is envisioned to include different parts to offer healthcare coverage based on beneficiaries’ unique needs and lifestyles.
Yet, the exact thing that was supposed to make Medicare extraordinary is what makes it confusing — and underutilized.
Namely, a survey conducted by MedicareAdvantage.com revealed that 65% of Medicare beneficiaries find the program difficult to understand due to moving parts, terms, and exceptions.
For instance, to get Part C or D, you need to contact different health insurers and compare the Medicare costs and benefits they offer. Moreover, in 2024, Part A and B beneficiaries will get to choose between over 700 stand-alone prescription drug plans.
Additionally, many healthy seniors miss out on free preventive services such as bone mass measurement, cancer screening, and annual “wellness” visits. Other benefits, like home health care, go unused because of complex eligibility requirements.
But why do Medicare users not reap the many amazing benefits they are paying for? Well, it’s due to confusion surrounding their coverage.
Medicare users often don’t know which medical services are covered or if they are even eligible for coverage. This uncertainty over unexpected bills for uncovered services or higher-than-expected out-of-pocket costs makes beneficiaries refrain from maximizing their plan’s potential.
However, it’s important to understand your benefits and enroll in the right coverage to make the most out of it. You don’t want to end up paying more for your healthcare than necessary or miss out on the coverage benefits available.
Tips for Getting the Most Out of Your Medicare Coverage
Remember, knowledge is power when it comes to managing your Medicare benefits. Therefore, in this section, we’re sharing our knowledge with you.
#1 Enroll in Medicare on Time
Sign up for Medicare Parts A, B, and D during your Initial Enrollment Period (IEP) to avoid penalties.
IEP encompasses the seven months when a person is first eligible for Medicare.
So, for those eligible due to age, the Initial Enrollment Period begins three months before they turn 65, includes the month they turn 65, and ends three months after they turn 65.
#2 Choose the Right Coverage Plan
Consult with your primary care providers to help you determine whether Original Medicare or Medicare Advantage is the right choice for you.
Find out if your preferred medical staff accepts the assignment or if they’re in-network doctors for a private plan.
Make a list of your regular care needs, such as doctors, therapy services, and prescription drugs, and compare the benefits offered by each plan to identify the one that meets your needs.
#3 Sign Up for a Medigap
If you have Original Medicare, a Medigap will help cover the costs of your copays, coinsurances, and more.
Medigap has monthly premiums, so find out whether supplemental insurance will lower your overall healthcare costs before you purchase a plan.
#4 Stay Informed About Your Health
To avoid receiving an unexpected bill, make sure any treatments or prescriptions your doctor suggests are covered by your plan.
Know what’s going on every step of the way during your doctor’s visits, get a second opinion if needed, and keep track of your appointments and medical charges.
#5 Leverage Medicare’s Preventive Care Benefits
Medicare offers a range of preventive screenings, including mammograms, colonoscopies, screenings for cardiovascular disease and depression, counseling to help quit smoking, and getting flu and pneumonia vaccines, which are usually free.
Additionally, the yearly Medicare Wellness Visit provides an excellent opportunity to sit down with your doctor and create a plan to manage your health for the upcoming year.
Furthermore, many Medicare Advantage plans, included in Part C, offer additional benefits apart from Original Medicare services, such as dental, hearing, and vision coverage.
There is also a free ™welcome to Medicare” preventive visit within the first 12 months of becoming a Medicare Part B user.
And for those with a Medicare Advantage plan, there is access to free wellness benefits, like a basic gym membership and access to group exercise classes designed for seniors.
Take advantage of covered preventive care screenings to maintain good health by detecting and addressing problems before they become significant.
#6 Understand Health Care Costs
Medicare expenses can differ significantly depending on an individual’s particular situation and the coverage options they select.
The overall cost of healthcare is impacted by three factors:
- Medicare premiums
- Copay, deductible, and coinsurance rates
- The frequency and types of health services and items that are used throughout the year
Make sure to stay in the know regarding all three to ensure you pay for the health coverage you actually need.
#7 Use Medicare Network Providers
Medicare Advantage plans typically work with a network of doctors and hospitals.
Thus, you need to know whether your chosen doctor accepts the Medicare-approved amount as full payment for services — known as “assignment”. This means you can’t be billed for more than your Medicare deductible and co-insurance.
Most doctors treating Medicare patients accept assignments. Those who don’t can charge up to 15% more than a reduced Medicare-approved amount for Medicare-covered services and leave you responsible for the extra charges, while others can charge whatever they want, as per a private contract with the patient.
To find doctors in your area who accept assignments, search for doctors and other health professionals at Medicare.gov; however, keep in mind that medical professionals may be added to or removed from the network at any time.
#8 Look for Additional Discounts
Certain Medicare Advantage plans provide discounts on items and services you may already use or need, such as vitamins, hearing aids, fitness programs, and alternative medicine services like acupuncture.
#9 Check Eligibility for Money-Saving Programs
Seniors living on a limited income may qualify for Medicare Savings Programs that will help cover Medicare Part B premiums and, in some cases, can lower premiums, coinsurances, and deductibles for Parts A, B, and D.
Several additional programs help ease the burden of Medicare costs for qualifying individuals, like:
- The Medicare Savings Program (MSP)
- Extra Help
- Pharmaceutical Assistance Programs (PAPs)
- State Pharmaceutical Assistance Programs (SPAPs)
To see if you qualify for a money-saving program, contact your SHIP or go to benefitscheckup.org.
#10 Take Advantage of Prescription Drug Benefits
Original Medicare (Parts A & B) does not cover prescription drugs. Therefore, you may need to look for coverage elsewhere: either opt for a Medicare Advantage plan or purchase a stand-alone prescription drug plan (Part D).
Even if you have Medicare Part D prescription drug coverage, you may still have to pay a lot of money, as Part D doesn’t have a cap on out-of-pocket spending.
#11 Be Aware of the Medicare Hospice Benefit
If a Medicare beneficiary is diagnosed with a terminal illness and is expected to live six months or less, the hospice benefit can provide necessary care in the comfort of their own home.
Medicare’s hospice benefits include drugs for controlling symptoms and relieving pain, respite care that allows family caregivers some time off, and other support services.
However, it’s important to note that under the hospice benefit, Medicare won’t cover treatments intended to cure the terminal illness but will ensure the patient receives treatment for other medical conditions.
#12 Check for Changes in Your Plan
Once your annual Medicare plan comes to an end, it’s important to stay informed about any potential changes in your coverage for the upcoming year.
Be sure to check if your current coverage is still the best option for you, and also keep an eye out for other plans that may better meet your healthcare needs.
During this time, you can make changes to your Medicare coverage, which will take effect from January 1 of the following year.
#13 Keep Your Medicare Information Private
Never provide your information to anyone except a reputable healthcare provider.
If someone calls you and requests your Social Security or Medicare information, there is a high chance that they are attempting to commit billing fraud.
Note that Social Security and Medicare will never contact you via phone and ask for your personal information.
#14 Know Your Resources & Fight for Your Rights
If you ever encounter a problem receiving your Medicare benefits, turn to Medicare Rights and your local SHIP. There’s also 1-800-MEDICARE or your plan’s telephone number and website.
If your claim has been denied, call the Medicare provider. Often, the issue can be as simple as the provider having entered the wrong billing code.
However, if the claim was submitted correctly but still denied, you can consider filing an official appeal.
To Sum Up
In 2024, there will be 3,959 Medicare Advantage plans available nationwide. The average Medicare beneficiary will have access to 43 healthcare plans to choose from.
When Medicare was established in 1965, the program was over 1,400 pages long. Since then, tens of thousands of rules and regulations have been added.
As Medicare is a crucial healthcare program for over 60 million Americans, understanding it is crucial.
Here are some of the best Medicare resources:
– Medicare.gov is the official government website that explains how Medicare works and how to enroll or switch plans. It also offers the Medicare Plan Finder tool, which allows you to find and compare Medicare Advantage plans, Part D drug plans, and Medigap policies.
– 1-800-MEDICARE (800-633-4227) is Medicare’s toll-free number, where you can speak to a human to get answers to your questions. The quickest way to get through the phone tree to get assistance is to say “Coverage and Benefits” or press 5 on your phone keypad.
– The government’s free Medicare & You 2024 handbook is a useful resource. You can read it online or get a copy mailed to you. This guide is written in plain English and has a helpful index.
– State Health Insurance Assistance Programs (SHIPs) offer free, unbiased phone help about Medicare from state government experts.
