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It’s estimated that one in eight Americans is age 65 or older, comprising about 12% of the population. According to the CDC (Centers for Disease Control) by the year 2050, that figure is expected to increase to 20% of the overall population. As baby boomers age, health insurance alternatives become an increasing concern. As it stands now, your health insurance alternatives when you reach age 65 are largely determined by your income, assets and budget. The less you have of all three, the fewer your options. Let’s look at what’s available. Medicare – This is the government-administered health insurance program for people 65 and older, some younger people with disabilities and people with end-stage Renal Disease (ESRD). Approximately 40 million people are currently enrolled in Medicare. Basic Medicare is a traditional fee-for-services program, which simply means you can go to any health care provider that accepts Medicare. You pay deductible and your share of cost, and Medicare pays the rest. There are two parts to Medicare: Part A and Part B. Part A is the “hospital insurance” portion that pays for things like inpatient hospital care, skilled nursing facility and home health care and hospice, within certain limits. Part B is the “medical insurance” portion that pays for X-Rays, prescription drugs, doctors, ambulance and the like. Medicaid – is the jointly funded federal and state program that fills in some of the gaps under Medicare. Each state administers its own Medicaid program, setting its own guidelines for who is eligible as well as individual co-payments and deductibles. Because each state is responsible for its own eligibility criteria, there are... read more
The National Council on Aging conducted a survey that concluded “more Americans worry about paying for long-term care than paying for retirement”, but the study also found that 70 percent of those surveyed flunked a quiz about the basic facts of long-term care. Almost half of those surveyed said they had done little or no long-term care planning. As America ages, long-term care becomes a critical issue. The assumption that a close relative (daughter, son, etc.) will provide care may not be a valid one. Pressures of jobs, work-related issues such as travel, lifestyle changes and impact on the caregiver; all can make caring for a family member impractical or undesirable. As a consumer, you can’t rely on Medicare, Medicare supplements or basic health insurance plans to pick up the cost of long-term care. Long term care provides to the needs of people with disabilities or chronic illnesses. If you develop Alzheimer’s, have a stroke or advanced diabetes, for example, you may need assistance with every-day tasks such as bathing, dressing, eating and toileting (moving on or off the toilet). Long-term care insurance helps compensate for some of these services, depending on the coverage you choose, in a variety of settings: from your own home to a skilled nursing facility or an assisted living facility. In most cases, health insurance plans through your employer won’t cover long-term care costs. Neither does Medicare in any significant way, although it will pay for some short term professional care. Medicaid, the federal/state program for people on limited incomes and having minimal assets, will pay for long-term care, but you must use up... read more
A PPO (Preferred Provider Organization) is a managed healthcare system popular throughout the United States. Similar to its cousin the HMO, Health Maintenance Organization, PPO’s provide a high level of healthcare, as well as a variety of medical facilities available to all participants. Unlike the HMO however, a PPO is actually a group of doctors and hospitals that work under one umbrella (called the PPO), to provide medical services at a discount to the PPO participants. By granting discounts to the participants via an insurance company, the insurance companies are able to entice people to join the PPO by offering financial incentives. These incentives may include: greater discounts for medical services performed by in-system doctors; lower deductibles and lower co-payments. Also different from traditional HMO’s is that PPO users pay for services at the time of the visit and are reimbursed some of the cost by the health care provider at a later time (though many PPO doctors prefer to invoice the healthcare provider directly). The percentage of reimbursement depends on the healthcare policy, a previously established rate agreement, and whether the doctor/hospital is within the PPO network. Unlike the HMO systems, PPO participants may utilize any doctor they wish, and are not required to select a primary care physician (PCP), and do not require authorization from that PCP before the enrollee seeks medical assistance for any ailment or malady. However, PPO enrollees are urged to select doctors within the PPO system, by way of higher reimbursement and lower co-payments. The disadvantage of a PPO healthcare system is the out-of-pocket expense to the enrollee. Because a percentage of each... read more
COBRA, or the Consolidated Omnibus Budget Reconciliation Act of 1985, is a statute that guarantees employees and their families continued insurance coverage for a specified amount of time after termination of group health insurance coverage with the company. In layman’s terms, to be covered by COBRA means that after a person has lost his/her job, or experienced another qualifying event, the company’s group health insurance will continue to be offered to the employee and family until they can obtain alternative health insurance or until the COBRA benefits expire. Though most people associate COBRA benefits with loss of a job, there are several qualifying events the make a person/family eligible for COBRA: termination from job (as long as it is not “gross misconduct”); voluntary resignation from a job or reduction of hours ensure an employee and family 18 months of COBRA coverage. * The COBRA coverage may be extended to the spouse and dependent children of an employee for 36 months in case of: divorce/legal separation; employee becomes entitled to Medicare; death of employee or loss of dependent child status (available to child only). COBRA health insurance coverage is advantageous for several reasons, the most obvious, of course, is that a family can continue to have health insurance, even if the employee has lost his/her eligibility for the company health insurance. Many families also use the COBRA coverage to continue health insurance coverage if they have been, or will be, denied new health insurance coverage due to a pre-existing condition of one or several family members. The only overwhelming drawback to COBRA is the cost. Like individual and small business... read more
Student Health Insurance is an individual health insurance product available to full time college students. Many universities and colleges offer their students a group health insurance policy through the school. Each university policy is different, so check with each prospective university to answer any specific student health insurance questions. If your prospective university does not offer a plan, or the college’s plan does not satisfy your needs, student insurance may also be obtained through traditional health insurance companies. Obviously, it is important to have health insurance in case of accident or illness, no matter what age or stage in life, and students are no exception. Many different student plans are available directly through insurance companies, the Internet or your insurance agent. Though there are hundreds of available student insurance policies, and each one has its own unique set of eligibility requirements, most require the below listed qualifications in order to meet eligibility: Participant must be a full-time undergraduate student -OR- Participant must be a full-time graduate student(Check the specific policy for number of hours considered full-time) Why would a student need a student policy instead of an individual health insurance plan? There are many benefits to a student policy, the most apparent being cost. Most student policies have lower premiums and reasonable deductibles for students who have limited resources. (What student do you know who doesn’t have limited resources?) Also, most student health insurance policies purchased through traditional insurance companies travel with the student if they change schools, eliminated the unnecessary chore of reapplying for heath insurance if education plans change. Students may wish to obtain their own health... read more
In the USA, senior citizens over the age of 65 are offered medical care by your state and federal government’s Medicare Health Insurance program. All basic medical costs are covered from doctor’s visits to hospitalization. It is the early retiree that may have a problem with insurance. At the age of 65, in the United States, residents are eligible for Medicare and are automatically enrolled if already receiving Social Security. Though Medicare provides adequate medical coverage for many people, it does not cover all co-payments, pharmacy expenses etc. Seniors have the option to purchase extra insurance through the government, called Medigap. Medigap offers 10 different levels of supplementary insurance in groups called Medigap A – Medigap J, each level offering higher coverage for an additional expense. If you are not yet 65 and have retired or plan to retire soon, you should plan ahead. Many seniors, who are not yet eligible, have a challenging time obtaining reliable health care insurance, or may find private insurance too expensive to bear. If you must retire before you are eligible for Medicare, there are several options to consider. Some employers offer their company’s group healthcare plan to retirees. Though this is not the norm, larger companies or corporations involved with unions, may offer this option to retirees as an ongoing benefit, and is generally the least expensive healthcare alternative until Medicare kicks in. To find out if your company’s healthcare plan is available after retirement, contact your Human Resources Department. A second option, but much more costly than your current insurance, is to opt for COBRA benefits once you have left your... read more
You’ve just had an expensive medical procedure, and your health care plan won’t cover it. You probably have some options to resolve the dispute. The best defensive against having a health care plan from denying a claim is being informed before you have the procedure. This includes reading your plan description to determine if the procedure is covered, calling your benefits administrator to ask any questions, and communicating with your health care provider about exactly what procedures you will undergo. There are several reasons a health care plan will not cover a procedure. Here are a few of the most common: Failing to get a pre-certification for non-emergency surgery. Most insurance companies require physicians to obtain a pre-certification before the surgery and will send you a letter stating that the surgery has been approved. Be sure to have a copy of the letter before the surgery. If you must have emergency surgery, make sure to let your health care plan know as soon as possible. Make sure a family member or friend has a copy of your insurance card and is willing to call your health care provider and your plan’s benefits administrator. Pre-existing conditions. If you have an individual policy or had a lapse in coverage between group health care plans, some conditions you were treated for in the past may not be covered for a designated period of time. When you change health insurance plans, be sure to ask if any of your conditions will be considered pre-existing and the length of time the conditions will not be covered by your plan. Treatment for a condition related... read more
When your doctor says you need an operation, there are a hundred details you must address before you can be sidelined for awhile to undergo the procedure and recover. As you get ready for surgery, make sure you have all the bases covered with your insurance company. Knowing what your financial responsibilities will be can help ensure you won’t have any surprises afterwards. The following steps will help you be prepared: Read your benefits plan or visit with your human resources department as soon as you know you need surgery. Learn the answers to the following: What are your deductibles or co-payments for my particular surgery? If you are admitted to the hospital, what does your insurance cover? If you want a private room, who will responsible for the cost difference between it and a semi-private room? Is a pre-certification required? Most insurance companies require physicians to obtain a pre-certification before the surgery and will send you a letter stating that the surgery has been approved. Be sure to have a copy of the letter before the surgery. Your insurance company may refuse to pay non-emergency surgical expenses if no pre-certification was obtained. If you have a health care plan that requires you to use a network of physicians, will you be covered if your doctor uses an out-of-network anesthesiologist? Surgeons usually choose these specialists, so it’s important to know if you will be covered if an out-of-network physician is caring for you. How does the insurance company handle longer hospital stays if there are complications? If you are having outpatient surgery, is the surgical facility in your insurance... read more
HMOs are nothing but Health Maintenance Organizations. In case of traditional health insurance, you can choose any physician you wish, and you can also decide which health service to obtain, but in case of HMOs, you have to choose a Primary Care Physician (PCP) from a list of doctors that your health plan has contracted with to provide services. This doctor will be your primary contact for all health services. He or she will manage your care by coordinating the services you should receive on your behalf. So here, your choice is restricted to the providers list. In simple words, an HMO is an organization that arrange hospitals and doctors into a organization. Members pay a set per-person fee, giving them access to the HMO’s services. Unlike traditional health insurance or PPOs (the second most popular managed care system), HMOs require participants to pick a Primary Care Physician (PCP), who performs necessary health check ups and allows all visits to medical specialists. It is evident that these HMOs are one of the two most popular forms of managed care networks. According to American Association of Health Plans during their last count, there were 89 million Americans enrolled in HMOs in July. In other words, more than 30% of all insured people are enrolled in HMOs. Under these plans you pay a fixed amount for all of your medical care. You must use the HMOs doctors and facilities and all specialized care must be approved by your PCP. Advantages and Disadvantages: In case of HMOs, this arrangement helps lower general costs, it can still be disliked with some patients. For... read more
Medicare beneficiaries may elect to join an HMO as an alternative to traditional fee-for-service Medicare. Medicare HMOs contract with the Centers for Medicare & Medicaid to provide the full range of Medicare-covered services to Medicare beneficiaries for a fixed monthly fee from the government. Generally you have coverage for care only from providers who are part of the HMO network. The only exceptions are for emergency services, which you may receive anywhere in the United States and urgently needed services, which you may receive while temporarily away from your HMO’s service area. Therefore, if you spend part of the year (more than 90 days) outside the HMO’s service plan area, joining an HMO may not be in your best interest. When you first enroll in an HMO, you will be asked to select a primary care physician from the HMO’s list of doctors. A primary care doctor is responsible for managing all of your medical care, including referrals to a specialist like a cardiologist or gastroenterologist, when your doctor thinks you need it. Some HMOs offer a Point of Service (POS) option for an additional cost. Under the POS option, you will be allowed to see providers outside the network, and the HMO usually pays 70 or 80% of the cost. Some HMOs also offer coverage for services that Original Medicare doesn’t provide, including prescription drugs, routine physical exams, eyeglasses and hearing aids. However, there has been an upward direction in costs for Medicare HMO subscribers. This has finally reached heavily competitive areas such as New York City in recent years. The result is that more HMOs charge premiums,... read more
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MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.
Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
Every year, Medicare evaluates plans based on a 5-star rating system.
