How I Navigated the Medicare System…

I was diagnosed with stage 4 breast cancer in May/June of 2010. My employer at the time terminated me when I told them of the diagnosis and I went on Cobra. This was supposed to continue up to 18 months after it began without a change in premium… mine was terminated at 14 months leaving me owing $16k to my Dr’s office for the month of September 2011. I was unable to obtain coverage from any other insurance company with my diagnosis and I was in the middle of my treatment – I couldn’t stop, but I also couldn’t afford it.

I was very fortunate to qualify for a program through Sarasota County and Sarasota Memorial Hospital called Community Medical – they paid for my Dr’s visits, my continued Chemotherapy, and my testing at no cost to me. I am now at 25 months of disability and I am eligible for Medicare coverage – this will begin on October 1st.

The Center for Medicare Services (CMS) sent me the paperwork and information book mid-August; I had until October 1 to make all my decisions.
For those of you who don’t know what I’m talking about you’re not alone. To say its confusing is a huge understatement. I’ve worked in the Insurance field for 20 years and it was hard for me to understand. I don’t understand how they can expect the elderly to navigate this system and know what they’re doing.

First off, there are multiple parts to Medicare: There are parts A, B, C and D. If you are under 65 and disabled (like me) you are automatically signed up for Parts A & B and these benefits will kick in after your 25th month of disability.

Part A is hospitalization – it covers hospital stays, skilled nursing facility care, home health care services and hospice care.

Part B is medical coverage – it is optional and costs $99.90 a month for 2012 if your yearly income* is less than $85,000 for an individual or $170,000 for a married couple. (*They go back 2 years) You can opt out of Part B, but if you wanted it back you would have to pay a penalty if you did it before the next open enrollment period (October 15th – December 7th).

Part B covers Dr’s services, outpatient medical & surgical services & supplies, diagnostic tests, durable medical equipment, clinical lab services, home health care services, outpatient hospital services & preventative services such as:
Aneurysm screenings, bone mass measurement, cardiovascular, diabetes, colorectal & prostate cancer screenings. It also covers screening mammograms, glaucoma testing, flu & Hep B shots & a few more.
The books do not say anything about PET Scans, CT Scans, or MRI’s specifically, although these might fall under diagnostic tests.

The next coverage is Part C – These are the Medicare supplemental insurance & Medigap policies. There are two types of supplemental coverage to parts A & B. One is a medigap policy for which you pay a monthly premium & can cost several hundred dollars a month, or the HMO/PPO policies where you could have a monthly premium plus co-pays but that varies by policy & there are way too many to list here. For example; the HMO policy I chose has a premium this year, but not for 2013, so all I would have to pay then would be the co-pays.

Part D is the Drug coverage, you will have a monthly premium for this coverage and will have to pay co-pays for your meds and satisfy a yearly deductible. You can get “Extra help” paying your Medicare Rx drug coverage premium but only if you fit within the income guidelines. In 2012 you have to have earned less than $16,335 a year if single, & $22,065 if married. You can opt out of this coverage if you choose a supplemental policy – but be advised, if you decline it and want to return to Medicare part D coverage you will pay a late enrollment penalty if you do it before the next open enrollment period and go 63 days or more without Rx drug coverage.

Choose wisely and get help from an agent you trust – some hospitals will not accept certain providers and you could be stuck going to a facility you don’t want by getting the wrong plan. I wanted to go to Sarasota Memorial Hospital and they only accept one provider. Also some of the HMO/PPO plans have yearly deductibles you must satisfy, and some have higher out of pocket limits than others.

Organizations for help:
Medicare, 800-Medicare (800-633-4227),
SHINE (Serving Health Insurance needs of Elders) 800-963-5337
Social Security Administration: 800-772-1213
by Norma Pitzer-Kelly


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