Let’s Talk About Medicare

As of 2023, an estimated 19% of US population was covered by Medicare. Many, if not most of our clients at Starlight Caregivers are using one of the Medicare health insurance programs offered by the Federal Government which become available to people that are 65 years old and up. Most people reaching out for home care services have questions about what Medicare exactly covers as it is challenging to understand the complexities of Medicare for aging life care services. I reached out to a consultant, Paula Wolfson, Licensed Clinical Social Worker and Manager of Avenidas Care Partners (an eldercare consultation service) for a Q&A discussion.

Duanni Hurd: Hi Paula, please provide a mile-high view of Medicare for readers not yet on the program.

Paula Wolfson: Medicare is your tax dollars at work for you in the form of health insurance for those 65 plus and it only covers care provided in the USA.

One can review the Medicare online portal at www.ssa.gov/medicare and sign up for Parts A and B, when one turns 64 and a half years old. Your coverage will become effective on your 65th birthday. If you prefer to apply in-person, contact Social Security at 1-877-772-5772 before you turn 65.

There are also other “Parts” to consider when reviewing options, but A and B are most common. It is critical to note that one should apply first for Part A upon their 65th birthday which covers inpatient hospital care. Part B covers outpatient care, co-pays and medications. If you take out Medicare Part A at the age of 65 and continue to work, you need to review the special fees associated with having Medicare while working.

The newer Medicare Senior Advantage is a combined package and includes all skilled care. One does not have to research the supplemental Medigap plans sold by private insurance companies. If you want to apply for the Original Medicare plan, you will need to do comprehensive research on the Medigap plans.

Duanni: What are some of the action items to do before turning 65?

Paula: For a comprehensive understanding of Medicare, first order the updated official government Medicare handbook. This is best to do so when you are approaching the age of 64. Read Sections 1 and 2 slowly. Take your time.

In preparation for applying for Medicare, take inventory on your health and financial status.

What is your budget and the current cost of your health care?

What is your health care status?

Do you intend to retire when you apply for Medicare and or retire at 67 or later?

Do you want to keep your work insurance and delay applying for Medicare B and the supplemental plans?

Duanni: Let’s review the pros and cons of the different Medicare plans.

Paula: Original Medicare (Parts A and B) and Medicare Senior Advantage are the two main coverages for those 65 plus. The pros and cons depend on interconnected factors: your health status, your long-term care goals, end-of-life treatment plans and your budget.

Original Medicare tends to cost more than the Medicare Senior Advantage plan (which is essentially like an HMO.)

A Pro for Medicare Senior Advantage plan is that it costs less. For instance, if you have Kaiser Medicare Senior Advantage, it is a one-stop-shop but you must use Kaiser services for all your care. The monthly premium cost for Kaiser is much less than it is for original Medicare. A Con for Medicare Senior Advantage is that it’s hard to get a second opinion outside of your plan.

If you have highly complicated healthcare conditions, you might want to first research your local providers to ascertain if their services meet your needs. If you need a heart transplant, you need to consider where you can get the best care and thus select the Medicare plan offered by that local provider.

If you have cognitive and physical decline, then research which local provider has comprehensive geriatric care services: dementia care, neurology, geropsychiatry, cognitive status and capacity exams, palliative and hospice care, as well as Medical Aid in Dying services.

The point of this is that before you select a Medicare option: research the local health providers in your vicinity and select the coverage aligned with your health care needs, long-term care plans, EOL (end of life) care values and of course your budget.

Duanni: Are there other Medicare options?

Paula: Yes, this includes Part D for drug coverage, and Medicare Supplemental Insurance (Medigap). Part D helps cover the cost of prescription drugs and is run by private insurance companies that follow rules set by Medicare. Medigap is extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare.

Duanni: Thank you Paula, and other tidbits to share?

Paula: Yes, tax season is here. Certain medical expenses are deductible so check with your tax accountant and financial advisor. Most medical expenses that are deductible require a prescription from your MD such as the cost of a wheelchair, a hospital bed and medical transport.

Medicare general enrollment is from January 1 to March 31 and open enrollment is from October 15 to December 7. Certain life events allow you to change plans at any time, for instance if you move or lose a private insurance coverage.

Duanni: Paula, the ins and outs of applying for Medicare is so complicated. What can people do if they are feeling overwhelmed?

Paula: I agree, it can be a complex undertaking, but here are a few things that can help break it down.

1. 1. Review the Medicare booklet at https://www.ssa.gov/medicare or get a paper copy of the booklet in late September.

For those living in Santa Clara County, you can book a free appointment with a Health Insurance Counseling & Advocacy Program (HICAP) counselor, to talk about benefits and health insurance. Call the main number for Avenidas at 650-289-5400 to book a HICAP appointment. They will review the plans with you and answer your specific questions.

1. 2. Give me a call at Avenidas Care Partners at 650-289-5438, and we can review your unique situation together.

In conclusion, whether you are approaching eligibility or managing your own coverage under Medicare, it is crucial to understand different parts of Medicare and stay updated on changes of Medicare to make sound decisions for your healthcare coverage. Do not hesitate to seek assistance to explore all available options to ensure the most beneficial coverages for a healthier future.