Medicare Decisions For Healthcare System Issues For The Elderly

Medicare Part A

Discuss about the Medicare Decisions for Healthcare System Issues for the Elderly.

Medicare is widely known as a health insurance program for people 65 years and older. It is also for people under 65 with certain disabilities and covers any age with End-Stage Renal Disease (case of a kidney failure and kidney transplant). The CMS popularly known as ‘The Centers for Medicare and Medicaid Services’ is the federal agency which administers the Medicare program and besides this Social Security Administration also provides information and handles enrollment of consumers (Diane, 1995)

Medicare covers various services that help consumers to improve and maintain health and save life. It includes all kind of services extending from expensive to non- expensive procedures and treatments. Long term and large services like transplants, delicate surgeries, cancer treatments and many  small services like routine checkups, which are not expensive at all (Barry 2015)

On turning 65, one would need to choose a plan that fit all the requirements during getting into the insurance. The plan should fulfill all the healthcare needs and should match the particular benefits that one is looking for.  Let’s discuss the 4 plans of Medicare and decide which plan is most suitable for Zip code: 90001(Los Angeles), where all the plans seem to be available. 

Medicare Part A known widely as hospital insurance is the one which provides the care at hospital inpatient care, home health services, nursing facility and Hospice care. Hospital care (Inpatient) services include all the inpatient services that are needed and hospital expenses like meals, nursing care, semi-private room facilities, services and supplies from the hospital. The Inpatient care that is received through Critical access hospitals, mental health care, acute care hospitals, rehabilitation facilities (inpatient) and long term care hospitals is also included in Part A hospital services. Home health care services may include intermittent or part-time nursing care, Speech-language pathology services, therapies which are Physical and Occupational, Medical social services, Medical equipment which are durable and ordered by doctor. It also includes Part-time or intermittent home health aide services. SNF which is known as Skilled nursing facility, under Medicare Part A, is considered only after a hospital inpatient stay for minimum three days for a related illness or injury. It involves skilled nursing services, medical supplies and equipment used during SNF care, rehabilitation services, semi-private room, dietary counseling, ambulance transportation and medications given while SNF care. Hospice care in Medicare includes care of terminally ill patient who is expected to live six months or less. It has Doctor Services, Nursing care, social worker services, counseling services and many more which focus on supportive care, comfort and quality of life, rather than cure during the final phase of a terminally ill patient. Medicare Part A does not include private-room costs, private nursing service and personal care items cost. It does not cover services that are unrelated to the treatment like meals, 24-hour home care and homemaker services. It also does not cover Personal care services, like help bathing and dressing are also not covered under Medicare Part A., if this is the only care that one  need. Medicare Part B (Medical insurance) includes doctor, clinical lab services and supplies that are needed to treat health condition. Therefore, Part B mainly covers hospital outpatient services, preventive care, durable medical equipment, ambulance services, laboratory tests, some Medicare part B also covers one time physical exam, cancer , diabetes and cardiovascular screenings. It also includes mental health care, laboratory tests and x-rays. Part time or intermittent rehabilitative and home health services are also covered when they are ordered by a doctor (Centers for Medicare & Medicaid services, 2012)

Medicare Part B

Medicare Part C (Medicare Advantage) is a part of Medicare policy in which Medicare benefits are allowed to be provided by private health insurance companies. Part C Medicare is just a blend of both Medicare Part A and Part B, hence it includes hospital insurance and medical insurance. HMO (Health Maintenance Organization plan), PPO (Preferred Provider Organization plan), PFFS (Private Fee-for-Service plan), SNP (Special Needs Plans) are all branches of Medicare advantage plan. Best part of Medicare Advantage Plans is that it covers prescription of drugs as well (Medicare Part D).

Medicare Part D:  It is provided by Medicare approved Private insurance companies and is called as prescription drug coverage. It can be combined with Medicare advantage plan and to take the drug benefits through a plan known as Medicare Advantage Prescription Drug Plan. There is a list of covered drugs in every Medicare prescription drug plan.

As per the situation where a plan needs to be selected for Medicare insurance, there are few things which should be kept in mind while making a decision.

1. How is the Coverage? It means how well the plan covers the service required. How will the Coverage work with Medicare if there is other health or prescription drug coverage included?

2. Costs, like how much will be the deductibles, costs and how much premiums will need to be paid and are there any limits yearly for the use of these medical services.

3. Hospital and Doctor Choice: Do they accept the coverage and does the plan demand to choose hospital and health care providers from the network only or if the referrals are required.

4. Is it required to join Drugs Prescription plan or is it already present as creditable prescription drug coverage. Sometimes there is also a eligibility for a free Medication Therapy Management (MTM) program.

5. How good is the quality of care and how satisfied the person is from the services offered by chosen plan and healthcare providers?

6. Convenience and Travel: Some general concerns like where is the doctor’s office located and what are their availability hours? Will they provide prescriptions through mail and do the doctor’s use electronic health records or E prescribe? Which pharmacies can be used and are they a part of plan’s network. What about the plan coverage if there is a travelling to other state and outside the U.S.? (Medicare.gov.)

Medicare advantage Plan is one good plan to choose after all this discussion. On turning 65, one is eligible for Original Medicare i.e. for Hospital insurance and for Medical insurance which are part A and part B. But one may also choose Medicare Part C which is called as Medicare advantage as it includes some added coverage which seems quite exclusive and beneficial in case of long term treatments. The plan will be available from private insurance companies and benefits of Part A and Part B will be offered into it along with some added coverage such as eye exams, dental and hearing aids. Medicare Advantage plans have extra benefits and mostly they offer low premiums than traditional Medicare insurance. Hence, Medicare Part C, Out-of-Pocket Limits are considered as a safety net (eHealth 2014).  Such limits under Medicare advantage plan are quite beneficial in which private health insurance plans put a limit on the amount of money which needs to be paid by your own pocket during any medical service unlike original Medicare and they are named as Maximum out of pocket limit. In 2015, by the government, the maximum out of pocket limit was $6700. The insurance plan will pay 100% of additional covered charges in the remaining year when the plan’s maximum out of pocket limit is reached.

	Original Medicare	Medicare advantage plans
Costs	Medicare premiums, deductibles, and coinsurances need to be paid.	Medicare premiums and plan’s premium are paid if it charges one. The plan sets its own copays and deductibles.
Any add-on or extra services	Doesn’t cover additional services like routine vision, hearing, dental care.	Covers additional services that original services doesn’t cover but covers the same inpatient and outpatient services like original care.
Drugs Coverage (Decision about Part D)	A separate Part D plan is required to get Medicare prescription drug coverage.	The plans under Medical Advantage plan include Part D drug coverage.
Out-of-pocket limit?	Not  provided	Yes, there is an out of pocket limit which can protect from expensive care expenses. The full cost of care is paid by plan once the limit is reached.

Medicare Part C

Transition has been done in traditional practices of Medicare program in past few years. Various private health plan alternatives have been introduced. Due to less enrollments and interest from consumer, the Medicare Modernization Act of 2003 started to increase payments to add few more managed care plans which could increase beneficiary choices and hence it was renamed as Medicare Advantage program. These increase in payments resulted in proliferation of number of plans availability, less costs and improved benefits with lower premiums for Medicare advantage consumers (Gold M 2006)

Ease of making these decisions:  The decision making can be made easier if the basic requirements and expectations are clear in mind while choosing the appropriate plan which is good in terms of health and money. This is an overview of the decision making:

Step 1: Decide what kind of coverage is required

Step 2: Decide if drug coverage needs to be added

The most important learning lesson in this whole discussion is that senior citizens should be confident and contended while making a decision for choosing the best Medicare Plan. Many may find it difficult to compare the plans due to the large amount of information they receive through different sources. In fact, according to many consumers information available at Medicare government website is lacking information and is quite confusing (Jacobson,G, Swoope,C, 2014). This is the reason that insurance agents, trusted advisors or suggestions from doctors, friends or pharmacists must help elderly consumers to narrow down the options and choose the best Medicare plan for them.

References

Berry, P, 2015, Medicare for dummies, John Wiley and Sons.

Centers for Medicare & Medicaid services, 2012, Enrolling in Medicare Part A & Part B, Retrieved from <https://www.medicare.gov/Pubs/pdf/11036-Enrolling-Medicare-Part-A-Part-B.pdf

Diane, 1995, Guide to Health Insurance for People with Medicare, Diane Publishing.

eHealth Medicare , Facts About Medicare, available at <https://www.ehealthmedicare.com/about-medicare/medicare-part-b/

eHealth 2014, Medicare Advantage Maximum Out-of-Pocket Limits, available at <https://resources.ehealthinsurance.com/medicare-options/medicare-advantage-maximum-pocket-limits

Gold M, 2006, Kaiser Family Foundation, The growth of private plans in Medicare, Washington (DC): (Report No.7473).

Jacobson,G, Swoope,C 2014, The Henry Kaiser family foundation, How are Seniors Choosing and Changing Health Insurance Plans

Make Medicare work coalition 2011, Medicare and Employer based coverage-The Basics, available at < https://www.medicarerights.org/PartB-Enrollment-Toolkit/Medicare-and-Employer-Based-Insurance-The-Basics.pdf

Medicare.com, I’m Turning 65, What Do I Need to Do? available at <https://medicare.com/enrollment/im-turning-65-what-do-i-need-to-do/

Medicare.gov.(n.d.). 8 things to consider when choosing or changing your coverage, available at <https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/things-to-consider/8-things-to-consider.html

Medicare Payment Advisory Commission 2010, Report to the Congress: Medicare payment policy, available at <https://www.medpac.gov/documents/Mar10_EntireReport.pdf

Medicare Rights Center 2016, Differences between Original Medicare and Medicare Advantage Plans, available at https://www.medicarerights.org/fliers/MedicareAdvantage/Differences-Between-OM-and-MA.pdf?nrd=1