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The Differences Between Medicare and Medicaid

Health care insurance these days can be confusing with all the actual changes and proposed changes being discussed. Where does one start to get a good picture of the differences between Medicaid and Medicare?

The “most” important thing to know about Medicare and Medicaid is that that two programs, despite being close in name, are decidedly different and offer their various services to different types of individuals at different ages.

Medicare is

  • A federal health care program developed in the mid-1960s, part of the Social Security program
  • Social security took money from paychecks during working years, returned it as income after 65
  • Helps offer affordable health care for seniors and reduce health care costs
  • Part A covering nursing home care, hospice, and other inpatient and hospital stays
  • Part B covering out patient medical costs (medical supplies, doctor visits, etc.)
  • Part B means paying an out-of-pocket monthly fee
  • No plan B? Sign up later, but pay a 10 percent increase for every 12 months you do not have it
  • Part C offering a health plan from a private company (PPO, HMO) called Medicare Advantage. It covers Part A, B and sometimes prescriptions. This plan can be less expensive than paying premiums for other plans.
  • Part D covering drug costs and added to whatever other plans you choose
  • Medicare is funded by a tax added to a worker’s paycheck plus premiums paid by Medicare beneficiaries plus government funding

Medicaid is

  • Funded by the federal government, but the money passes down to each state to allocate as they see fit
  • Medicaid was “born” about the same time as Medicare and was intended to help lower income citizens afford health care
  • Set up so that the federal government matches state funding
  • Overseen by the Centers for Medicare & Medicaid Services in each state to pass out funding and endure the state meets the federal government’s minimum standards
  • Who it funds as opposed to Medicare. Medicaid serves those with limited resources and income and that includes seniors, low-income individuals, those at the poverty level by offering personal care services/nursing home care. Recipients do not have to be 65 years or older. Those served by Medicaid are a wide ranging swath of Americans needing and qualifying for such services
  • The ability of older Americans who subsist on just Social Security to also receive Medicare benefits and classified as low income while over the age of 65

Of course, Medicaid and Medicare are much more than just a summary of highlights on a page. It is best to research what you want and need, what suits your lifestyle and budget and to ask as many questions as you can to understand what you are likely going to purchase. There are highly trained health insurance brokers and health insurance agents that have answers right at their fingertips and can help you make informed choices. Just do not wait until the last minute to make a decision, as often the last minute purchases are those that are regretted.

Posted on Thursday, October 31st, 2019. Filed under Medicare.

Helpful Medicare Fraud Tips

You should be wary and suspicious if your provider informs you that:

  • Medicare wants you to have this service
  • Medicare want you to have this item
  • The higher the volume of tests they perform, the less expensive they are
  • The service is free and won’t cost you anything
  • The equipment is free and won’t cost anything
  • The test or tests are free and they only need your Medicare number
  • They know how to get Medicare to pay for it

Avoid fraud by:

  • Not allowing anyone but accredited medical professionals to recommend services/review your medical records
  • Never giving out your Medicare Health Insurance Claim Number unless it is to your doctor/other Medicare provider
  • Being wary of accepting Medicare services that are supposedly free
  • Exercising caution when you are told you get free testing if you provide your Medicare number
  • Being cautious if you are told the service/item is not usually covered, but they can bill Medicare anyhow
  • Being alert and wary if a provider says they are endorsed by Medicare or by the federal government
Posted on Tuesday, October 8th, 2019. Filed under Medicare.

Medicare Fraud is Alive and Well, Beware

Medicare fraud is far more common that we might expect. The definition is purposely invoicing Medicare for services that were never received or never provided. Some examples of this kind of fraud include:

  • Invoicing Medicare or other insurer for services/items never received
  • Invoicing Medicare for equipment/services that are not the same as what you received
  • Invoicing Medicare for home medical equipment once its been returned
  • Using another beneficiaries Medicare card to obtain equipment, medical care, supplies

While you may not be aware of such fraud going on, it may, overtime become clear that something is wrong. When in doubt, speak out. Defrauding Medicare means those who need it receive less benefits than they should be entitled to because someone defrauded the program.

If you do know someone intentionally defrauding Medicare, take the time to report it. Everyone benefits when you do.

Posted on Monday, October 7th, 2019. Filed under Medicare.

Larger Medicare Supplement Payment? Options for Seniors

Although many, if not all, Medicare supplements do increase on renewal, there are instances where some seniors are facing a 15 percent renewal. What does a Medicare beneficiary do in the face of such an increase?

When faced with such a dramatic increase, it is usually best to start shopping around as soon as possible. Although, some industry watchers suggest anyone facing this kind of situation has to wait until Medicare Open Enrollment, which is typically in October. Contrary to popular opinion on when beneficiaries can change a Medicare supplement plan, the Medicare supplement underwriting rules start when beneficiaries have had their Medicare Part B longer than 6-months.

Put another way, any beneficiary who wants to make changes to their Medicare supplement plan can do so at any time during the year. Medicare Open Enrollment is the time to make changes to a Medicare Advantage or Medicare Part D prescription drug plan.

In other news for Medicare recipients, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) made, among other changes, a tweak to Medicare supplement’s plans F and C that kick in for 2020. Medicare plans F and C are available until January 1, 2020. You may also want to consider Plans G or N.

The Plans in brief:

  • Plan F: Has more benefits and higher premiums. If you enroll now or already have Plan F, you are not going to be forced to move because this change only affects newly eligible Medicare recipients with effective dates of January 1, 2020. Plan F is not going to be available to those new to Medicare.
  • Plan G: Has lower rates and same benefits as Plan F, but the Part B deductible is not covered – the beneficiary pays for it.
  • Plan N: Generally has lower premiums than Plan G, but more out-of-pocket expenses. For instance, there is a $20 co-pay for seeing a physician and $50 co-pay for using the ER. Part B deductible is not covered.

New to Medicare? Want to apply for a new Medicare supplement? Medicare Plan F and C are available until January 1, 2020.

Do not be in a rush to choose. Always ask questions to ensure your medical needs are met. Most importantly, do not cancel an existing Medicare supplement policy until a new insurance company has approved you. Remember, you can replace your Medicare supplement policy at any time.

Posted on Friday, September 20th, 2019. Filed under Medicare.

Medicare does not pay for all medical expenses

If you are close to your 65th birthday, then you may be wondering about Medicare and how it works. It is a good time to begin to figure out what you want and should need from your healthcare coverage. On average roughly 10,000 baby boomers turn 65 every day.

The two most important things you need to know about Medicare are: Medicare does not cover everything, so plan for extra expenses, and if you do not sign up when first eligible (and are without qualifying coverage elsewhere), you pay a life-long penalty for late enrollment.

Many people think that Medicare is free. This belief likely comes from the assumption that since they paid into Medicare while working, thanks to the employer withholding a sum of their earnings, Medicare is free. However, that is not true. Medicare has deductibles, premiums, co-pays and other assorted expenses.

The second reason, that may contribute to the belief that Medicare is free probably emerged from the trending talk about “Medicare for All.” Many assume that “Medicare for All” means that it is or will be free. That is not true. The slogan, “Medicare for All” is a call for Medicare to be open and available to all.

Currently Congress is sorting through various bills that hope to achieve a Medicare system with no co-pays, premiums or deductions. In the meantime, you need to know that the existing Medicare programs cost you money the instant you enroll. So, it is best to be prepared in advance, spend time doing cost comparisons, know what you want and need, make a list and ask questions before agreeing to buy Medicare. Moreover, remember that long-term care (if required), dental, over-the-counter medications and basic vision care are also extra expenses you need to cover as well.

If you have worked for ten years or more, you do not pay premiums for Medicare Part A, but it does have a deductible of $1,364 per benefit period and some caps on benefits. Ask your insurance agent to explain that to you in detail so you are familiar with what is and what is not covered. Part B has a standard monthly premium of $135.50 right now and comes with a $185 deductible for 2019. While Part B does not cover medications, Part D covers medications. You can also use a stand-alone plan in original Medicare or you could opt for Advantage Plan Part C to help you cover the costs of medications.

Planning for and determining you healthcare coverage in retirement is all about research. Knowledgeable and experienced insurance agents are great assets in helping seniors determine what is best for their budget and needs.

Posted on Friday, July 19th, 2019. Filed under Medicare.

Foreign Travel With Medicare May Be Problematic

Do you travel a lot? If so, make sure you check whether or not Medicare is in force when you are abroad.

Read over your insurance policy and find out what it does and does not cover. If, at any point you do not understand what the document encompasses, talk to a qualified insurance agent and have them walk you through your policy before you start to travel with Medicare.

You may not know that Medicare Advantage Plans and Original Medicare do cover urgent or emergency medical services anywhere in the United States and its territories. So if you have a Medicare Advantage Plan, you are getting urgently or emergency medical care that:

  • Limits on how much the plan bills you by being out of network
  • Must cover follow-up care in relation to the emergency if delaying it puts your health in danger
  • Your plan cannot demand you see an in-network provider
  • You can appeal if your plan denies care costs
  • You do not need a referral
  • That if the condition was not an emergency but looked/felt like it was, Original Medicare/ Medicare Advantage must cover care

What happens if you are denied coverage of an urgent or emergency medical assistance because you went to an out-of-network provider without an OK or a referral? Appeal the denial and get the physician to provide the appropriate documentation that the medical services rendered were urgently needed or in response to an emergency. Your State Health Insurance Assistance Program can help you in putting together an appeal.

Medicare does not cover medical costs while you are travelling outside of the United States. However, the plans must cover care in certain circumstances, including: paying for care received on a cruise ship while that vessel is in U.S. territorial waters; paying for E.R. services in Canada while traveling a direct route between Alaska and another state and the nearest treating medical facility is in Canada; and in certain limited cases, Medicare may also pay for non-emergency inpatient care in a foreign hospital.

There are a few Medigap policies that offer coverage for travelers’ abroad and they include Medigap plans C through G, M and N and offer 80 percent of the cost of emergency care.

If you do not know what your plan does and does not cover, check your policy for specific rules, and if that is not clear, contact the insurance agent and ask them to discuss the relevant sections and what they mean when you are travelling outside the United States.

Posted on Friday, May 31st, 2019. Filed under Medicare.

Open Enrollment Period for Medicare and What to Consider

Did you know there was a special enrollment period for senior citizens from January 1 until the end of March? It is supposed to be the same for next year, so mark it on your calendars.

The most important thing to remember about this special three-month period is that it offers beneficiaries a window during which they can switch some of their Medicare arrangements. During this time, it is not a bad idea for seniors to consider their options regarding their Medicare plans. This is even more crucial if you are soon to be turning 65.

Around enrollment time, solicitations for Medicare Advantage come flying into mailboxes with light speed, each offering something special, unique. All the information is intended to inform readers that if they have a Medicare Advantage plan, they can switch to another Medicare Advantage plan or drop a plan, return to the Original Medicare and buy a Part D stand-alone drug benefit. There seems to be quite a bit of flexibility for seniors looking to make changes in their Medicare plans.

A word of caution, along with all the things that seniors can do, beware there is one thing you cannot do, and that is if you happen to have traditional Medicare partnered with a stand-alone drug plan, you cannot switch to a new drug benefit that may save you money on prescriptions. That may only be accomplished during open enrollment in the fall. So, the special enrollment period is actually a second chance for seniors to save on drug costs – one of the most sought after benefits in this age of expensive pharmaceuticals.

Remember though, if you choose to divest yourself of a Medicare Advantage policy and cut over to traditional Medicare, you might find it difficult to buy a Medigap policy to plug the holes. In fact, there are only four states that offer guaranteed issue Medigap insurance, even if beneficiaries have pre-existing conditions – Maine, New York, Massachusetts and Connecticut. This may not be possible in other locations.

The little known trick to getting good drug benefits that actually saves money is to shop ahead of needing a drug plan benefit and find out which one can save the most. If you research that information before you hit the next special enrollment period, you could end up saving upon switching plans. Research and asking a lot of questions are two of the most important things seniors need to do when it is time for special enrollment.

Posted on Friday, May 17th, 2019. Filed under Medicare.

Medicare Policy Non-Renewal Notices Can Be Confusing and End in Cancellation

Due to the confusing nature of letters and notifications from insurers about changes to Medicare, often, Medicare Advantage beneficiaries end up not renewing their contracts. Moreover, what happens if a Medicare Advantage plan was not renewed by the insurer and the beneficiary did not understand that?

While this situation can be confusing, the beneficiary does have a special enrollment period available to make changes to their Medicare coverage. Most years, that special enrollment lasts until February 28. If the beneficiary opts to remain in the Original Medicare, they would typically enroll in a Medicare Part D drug plan and a Medigap plan. Most insurers advise Medicare beneficiaries when they discontinue coverage that the insured has a “guaranteed issue right” for Medigap plans.

The beneficiary would also be well advised to consider a Medicare Part D drug plan to handle the cost of prescription drugs. There are numerous Part D options that can be compared by using the Find Health and Drug Plan tool at In the alternative it is always easy to call 1-800-MEDICARE to get assistance in comparing costs and coverage options.

What if the beneficiary wants to choose another Medicare Advantage plan? It is a good idea to figure out precisely how the plan is to be used before making any calls or doing research. Some Medicare Advantage plans have hearing, vision and dental services, services that a beneficiary may not need. Or they may wish to choose a plan that offers all three. Again, beneficiaries have the option of going online to see what kinds of Medicare Advantage plans are available for 2019 and use Find Health and Drug Plan tool at

It is worth noting that Medicare Advantage plans usually have a contracted network of hospitals and physicians and also have out-of-pocket expenses that the beneficiary is responsible to pay. It is worth asking for a summary of benefits for any chosen option in order to compare various alternatives.

Medicare is changing but it is not clear yet how. That leaves beneficiaries struggling to make the best available choices open to them at the time they come up for enrolment or when they first become eligible for Medicare. The one thing to know with certainty is that whatever is purchased now is likely to be portable later and that in buying the best option(s) now is likely to mean cost savings in the long run. Always know that if you are having trouble figuring out what your best Medicare options are, you can always call a knowledgeable insurance agent who can help you make an informed choice.

Posted on Tuesday, April 2nd, 2019. Filed under Medicare.

If You Are New to Medicare Consider Medigap Plan G As an Option

With the current uncertainty in the health care industry and questions about what changes may come to the Medicare program, it is tough to know what Medigap plan to choose if you are new to Medicare.

While it is good to have a variety of choices when making health care decisions, it is often confusing to know which one may be the best for what you may need. Medigap consists of numerous supplemental plans for those that are eligible. Moreover, 2019 has brought changes in offerings for beneficiaries, so it is best to review what those are before making a final decision.

Medicare Part A and B provide hospital and medical insurance, but involve a lot of out-of-pocket expenses. To get a handle on the costs, you can buy a Medigap policy, also referred to as Medicare supplement insurance. These policies help cover costs that Medicare Parts A and B do not pay. For 2019 and 2020 it may be a good idea for beneficiaries to consider Plan G.

Doing research will benefit any beneficiaries considering switching or new Medicare customers who need a comprehensive Medigap pan. Choosing a Medigap plan, however, can prove to be confusing and complex. Additionally, Medigap plans change year to year, and what you once had may no longer be offered and/or you are not happy with what replaced your previous plan. When plans change, it is difficult for beneficiaries to compare and contrast them. What was once popular may not be offered or has changed in ways you are not comfortable with and want something else.

It is important to note that Medigap policies are standardized in 47 states and each has a letter to identify it. Three states, Wisconsin, Massachusetts and Minnesota, have their own standardization for Medigap policies, meaning there is no Plan F in those states.

Each plan has different benefits and cost sharing levels. For instance, Plans K and L, cover six benefits, but for five out of the six benefits, the beneficiary pays anywhere from 25 percent to 50 percent of the cost. On the other hand, Plan F covers the maximum permitted for all nine benefits and for this reason Plan F is often referred to as the “Cadillac of Medigap plans.” This means that once the premium is paid, the plan pays from day one due to first dollar coverage.

Another option to consider is Plan G that covers eight of nine benefits. The plan holder is responsible for the Part B deductible. For 2019 the Part B deductible is $185. Once the first $185 is paid, Medicare covers costs for the rest of the year. However, beginning January 1, 2020 insurance companies will no longer sell new Medicare beneficiaries a Medigap policy that covers the Part B deductible. That would be Plans F and C. However, if you have one of those plans now you can continue with it.

If you are going to be new to Medicare and Medigap by 2020, do your research early as Plan F is losing its competitive edge pricing and there are some question as to whether or not Plan F will remain viable until December 2019. Currently many plans charge more to cover Part B deductible, much more than $185. If you are in Wisconsin, Massachusetts or Minnesota there is not going to be coverage available for Part B deductible sold to beneficiaries in 2020.

It is obvious the health insurance industry is in transition and must remain responsive to government changes relating to eligibility and payment schedules. In the meantime, if you have Plan G or are about to be eligible for Medicare now, try Plan G, which will continue past 2020 if you enroll now.

Posted on Tuesday, March 12th, 2019. Filed under Medicare.

More Things to Know About Your New Medicare Card

Even though your new Medicare cards have a specific new number, unique only to you, and you think no one could ever be able to use it, be wary. There is a lot of Medicare fraud in the United States.

To avoid any potential problems with your new card, only give the new Medicare Number to insurers, pharmacists, physicians and other health care providers that you know are medical personnel. People you know and trust with your card.

Forget your card at home? It happens. You, another health care provider or your doctor’s office may be able to look your new number up online.

Use your new Medicare cards right away and destroy the old one. However, if you do not have your new card yet, you may still use the old one until January 1, 2020. If you do not have your card, write, call or long into and find out if it was sent to the right address.

Posted on Thursday, February 28th, 2019. Filed under Medicare.