Medicare benefits are some of the most valuable retirement and disability benefits that our country offers.
Here’s some basic information about Medicare in WA State. Medicare is a type of health insurance that is available from the federal government for people who are 65 years old or older, people with certain disabilities and those at any age with End State Renal disease (ESRD) which is a disease when one’s kidneys have failed and dialysis or a kidney transplant is required. Medicare covers the lion’s share of expenses, however there are gaps in the coverage and that is when a WA Medicare supplement plan or policy steps in.
Medicare is divided into two parts:
Part A is hospital insurance. This covers the patient in the hospital, skilled nursing facilities hospice care and some limited home health care.
Part B covers outpatient care. It covers when the patient sees a doctor or goes for other outpatient care such as a physical therapist or for preventive help.
Part C includes the newer Medicare Advantage plans offered in Washington State through private health insurance companies. These plans are typically very comprehensive and replace parts A and B Medicare. The benefits of Advantage plans must be at least as good as parts A and B Medicare and typically including much of what Medicare supplement plans offer. You must still pay for the Medicare part B premium to be on any of these plans. These plans can be structured as an HMO or as a PPO or as a traditional fee for service plan, or as a special needs plan (SNP). Many plans also include the Part D prescription coverage as described below.
For those who are disabled and on Medicare, the Medicare Advantage plans may be the only options available to add coverage. In WA State, Medicare supplements or Medicare gap plans will not generally be available to the disabled and under 65. As long as the subscriber has parts A & B Medicare, lives in the service area and does not have End Stage Renal Disease, a Medicare advantage plan if available, is a viable option. Anyone researching coverage options should compare Medicare Advantage plans and decide what provider and coverage fit their needs best.
Part D covers the prescription drug portion and is optional for people to have. These prescription plans cost additional and there are good catastrophic drug plans to consider from private insurance companies. There is a govt. penalty on premiums if one doesn’t sign up for a Part D plan during the open enrollment season. Specific rules apply and we advise going to www.medicare.gov for additional details.
Medicare allows the member to choose the plan that will best meet his needs. It is important that as the needs change that the coverage changes over time. Typically you can make changes once a year during the months of October, November and December.
A Medicare supplement or Medigap policy is a health insurance plan sold by private insurance companies in Washington to supplement Medicare Plan coverage. A Medicare supplement or Medicare gap plan is secondary to government Medicare coverage. This insurance policy helps you pay your share for deductibles, coinsurance, and copays when applicable when you have Parts A and B of Medicare. It fills in the “gaps” for Medicare. Medicare is primary and the supplement plan is secondary on paying claims.
Medicare supplement plans & policies help pay some of the health care costs that Medicare alone will not pay. Insurance companies in Washington can only sell you a standardized Medicare supplement plan. Medicare supplement policies must follow Federal and State laws. These Medicare supplement policies must all have specific benefits so you can compare them easily. You have the choice up to 11 unique standardized Medicare supplement plans (supplement Plans A through N) in Washington. A Medicare supplement policy must be clearly identified on the cover as Medicare Supplement Insurance. Each plan, A through N, has a different set of basic and extra benefits.
It’s important to compare Medicare supplement policies because costs can vary from one carrier to the next. The benefits in any Medicare supplement Plan A through N are the same for any insurance company. Each insurance company decides which supplement policies it wants to sell. So it is easy to compare plans by comparing rates.
For example: Plan D from XYZ company will be the identical policy for Plan D from ABC company. The one difference is the financial strength of each company and their level of customer service.
When you are aging into Medicare at 65, you have a limited amount of time in Washington State to buy a supplement or gap plan without passing a health questionnaire. If you attempt to buy a supplement outside this open enrolment period, you may be rejected if you have too many or too serious health conditions. This is a once in a lifetime opportunity. We advise Medicare beneficiaries to contact a knowledgeable broker who can advise your options.
Generally, when you buy a Medicare supplement policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medicare supplement insurance company.
You and your spouse must each buy separate Medicare supplement policies. Your supplement policy wont cover any health care costs for your spouse.
Medicare Advantage Plans:
If you have a Medicare supplement or Medigap policy and you are changing from the original Medicare Plan to a Medicare Advantage or Medadvantage Plan, you don’t need and can’t use the Medigap policy to cover deductibles, copayments, or coinsurance under the Medicare Advantage Plan. You may want to drop your Medicare supplement or Medigap policy, but you should talk to your health insurance broker before you do because you may not be able to get it back. If you already have a Medicare Advantage Plan in Washington State, it is illegal for anyone to sell you a Medicare supplement or Medigap policy unless you are switching back to the original Medicare Plan.
Medicare plan alternatives in Washington State
There are Medicare plans in Washington State that aren’t Medicare supplement, Medigap or Medicare Advantage Plans, but are still part of the Medicare Program. These include Medicare Cost Plans, Demonstrations/Pilot Programs, and Programs of All-Inclusive Care for the Elderly (PACE). These plans provide Part A and Part B coverage, and some also provide Part D (Medicare prescription drug coverage).