Medicare is not medical insurance. It is not a complete health coverage plan, and it was never meant to be. Medicare covers a limited portion of an individual's health care costs - and only a portion of other medically-related services. It was originally designed to supplement the health coverage plans offered through retirmenet programs.

What does basic Medicare cover? Under Parts A and B, if you go into the hospital, you pay the first $1024 for the first 60 days; this is your per benefit period deductible (a new benefit period starts every 60 days). After day 60, if you’re still hospitalized, you are responsible for the first $256 per day for the next 30 days. If you are still hospitalized after that, you are responsible for the first $512 per day of the next 60 days. If you are hospitalized beyond that, you are on your own; Medicare pays nothing. This $1024 deductible recurs every 60 days if you are hospitalized more than once.

If you go into a skilled nursing facility and are considered in "recovery mode" (too well to remain in the hospital but too ill to return home), Medicare picks up 100% of an approved amount for the first 20 days. From day 21 through day 100, you are responsible for the first $128 per day. Beyond day 100, Medicare pays nothing - you are on your own. If you are looking for long term care (an insurance plan geared toward nursing home, adult day care, assisted living facilities, home health care, etc..... ), that is not part of Medicare nor is it covered by Medicare; you need to talk to your insurance agent about a "long term care plan." Like many forms of insurance, long term care coverage is never as inexpensive as it is the day you apply for it, and rates usually lock in for the duration. Underwriting is substantially more liberal than it is for regular health coverage.

Of medical expenses, doctor's fees and outpatient hospital services, Medicare pays 80% of the "approved" amount, after a $135 per calendar year deductible. You are responsible for 20% of the total cost of these expenses. If the doctor you see does not take Medicare assignment, you will also be responsible for any charges over the amount that Medicare does allow.

The above describes Medicare Parts A and B, the basic plan which all Medicare-qualified applicants receive. Medicare is not always automatic; in many cases you must apply for it. And to be eligible for Medicare benefits at all, you must have paid into Social Security a specific number of quarters during your working years. However, if you are 62 and already receiving Social Security benefits, you are automatically enrolled in Medicare Parts A and B starting with the first day of the month in which you turn 65. Note that enrollment simply means you don't have to make formal application when you turn 65; Medicare benefits cannot be used until the month in which you turn 65. If you are working and are covered by a group insurance plan, you can postpone enrolling in Part B; then, your open enrollment for a Medicare supplement will start the month in which you enroll in Part B. Supplements are not automatic; they must be applied for.

Again, basic Medicare Parts A and B (not to be confused with Plan A and B) cover a portion of actual medical costs you are likely to incur.

If you want additional at-home recovery health care costs covered, or foreign travel medical expenses.... then you will need to get a Medicare supplement.

Medicare Plan C picks up that $128 per day of skilled nursing facility care which Medicare Part A does not cover (beyond the first 20 days), as well as your $952 per benefit period hospital deductible and $124 per calendar year medical expenses deductible. It will also provide limited coverage if you travel outside the United States.

Medicare Plan D picks up $128 per day of skilled nursing facility care and the first $1024 of a hospital stay, but does not pick up your annual $135 medical expenses deductible. It does, however, provide some coverage for at-home recovery following a hospitalization. It also provides some foreign travel coverage.

Medicare Plan E covers the same things Plan D does but not the at-home recovery. It also provides for preventative care (check-ups, physicals, etc).

Medicare Plan F covers the same things as Plan C and also picks up the 20% coinsurance from Medicare Part B's medical expenses. It does not provide for any at home recovery expenses or preventative care.

The "high option" Plan F, are as described above but have a $1990 deductible and are significantly lower in price, due to the fact that you take responsibility for the first $1900 of allowable medical expenses before the supplement kicks in (medications are not inluded in this coverage). Mathematically, this option makes great sense, as the amount you would save on High Option F over regular F is over $1000 per year.

Plan G (my personal favorite) does not cover the doctor deductible but does cover at home recovery, and usually costs about 10% less than Plan F.

Plan H resembles Plan E but has no At Home Recovery benefit.

Plan I resembles G but picks up 100% of the excess doctor fees as opposed to 80%.

Plan J resembles F but includes At Home Recovery and Preventative Care. Plan J also offers a high deductible option similar to High Deductible Plan F.
 

How much you pay for a Medicare supplement will depend on how old you are when you apply for it and if you are still medically qualified. You can be declined supplemental coverage based on health history if you wait until after you are 65-1/2 to apply for your supplement (exception: HMOs will always take an applicant, where HMOs are offered, so long as the applicant does not have ESRD; End Stage Renal Disorder). Cost of a supplemental plan will depend on whom you choose to provide coverage. Coverage can be purchased through HMO's in the more populated areas (primarily Maricopa, Pinal and Pima counties) or some of the regular health insurance carriers. We work with a number of both, and are always happy to provide information to you. Again, there is NO medical underwriting for a supplement if applied for during the open enrollment period and none ever for HMOs, aside from ESRD.

The most frequently-asked question we hear is why basic Medicare doesn't cover prescription drugs (which the new Part D does as of January 1, 2006, for a small monthly premium) and how come long term care/nursing home isn't covered except in a "recovery mode"? Statistically, less than 4% of all nursing home or extended care facility charges are covered by Medicare. Most of those costs are paid for by private long term care plans. And the younger you are when you apply for one (rates are age-sensitive), less such a plan costs.
 

Long term care plans cover not only nursing home but other charges, such as at-home health care, assisted living and adult day care, and other long term care-related medical expenses - services that Medicare won't provide. If you were diagnosed with Alzheimer's or Parkinson's, or any number of other physical ailments, Medicare wouldn't cover any of the medical costs - because these are not conditions from which one recovers, they are progressive or degenerative conditions.

You should receive information related to Medicare within six months of your birthday - that is when everyone starts being inundated with brochures, applications, etc. The sooner you have information on Medicare, the better decision you will make between now and when you need it. Best time to apply: within 30 to 60 days of your birth month.
 
 

The three most popular plans are D, F and G. Most carriers only sell three or four supplements (usually A, C and F, or C, D and F), but Equitable Life & Casualty, with whom we also work, offers all seven supplements plus the high deductible option supplement. in Arizona this carrier is not as competitively priced as several others.

D does not cover the $128 annual deductible for doctor appointments nor any of the excess for doctor appointments. So long as you are using a doctor who takes Medicare assignment, your "excess" should only be 20% of what Medicare allows the doctor to charge - relatively little. It also provides At Home Recovery benefits. It is also the least expensive of the more popular plans.

F covers the $128 deductible and the excess (not just the 20% but, if using a doctor who does not take Medicare assignment, anything over that) for about 40-50% more premium than Plan D and 30-40% more than Plan G. Plan F offers no At Home Recovery benefits.

G does not cover the $128 annual deductible but does cover the 20% excess. It generally costs less than Plan F and maybe $10 more per month than Plan D. It does provide At Home Recovery benefits.

Our recommendation: one of the first three mentioned above or high Option F.
 
 

 In January 2006, Medicare came out with Part D (not to be confused with Plan D), an option offering prescription benefits. This costs between $20 - $40 per month, depending on where you purchase it. Under the original  Medicare guidelines, you would be responsible for the first $250 in drug costs - some Part D plans waive this deductible. Of the firstext $2400 in drug costs, Medicare will cover approximately 75%. Once you and Medicare have paid out a [combined] total of $2400, you are on your own until your out-of-pocket reaches $4,000. At that point, Medicare will cover 90%-95% of the drugs on their approved formulary list. If your prescription is not on the list, it will not receive any discount.

HOWEVER - most carriers came out with their own version of Part D, and most of them did away with the deductible and put everything on a co-pay level.

PACIFICARE'S Part D plans, called Prescription Solutions, waives the $250 deductible and covers most drugs - see next section.  Note: it does not matter who you have your supplemental benefits through - you may buy Part D from any entity offering it. The exception is those who are on an HMO - they cannot buy Part D as it is incorporated into their HMO benefits automatically.

Call for further information or application.
 
 

In Maricopa County, call Dick Miller at 623-939-8759

Dick has over 25 years' experience in long term care - in addition to having had to use it himself and knowing first hand just how well it works. However, Dick does not go travel outside of Maricopa county
 

Outside Maricopa County, call Rick Steiman at 480-228-5165

Rick doesn't have as many years in the industry as Dick, but does travel throughout the state and works exclusively with long term care products.
 

Don't wait until you or a loved one has a need for long term care, at home assistance, or nursing home or adult day care; once the need has been established, these plans cannot be obtained. Like any other type of insurance, it must be purchased while the individual is in fairly good health.