Adirondack Health Institute News

Six Important Reminders About Medicare

From the Medicare Rights Center – Getting Medicare right

1.  Choose Wisely – Choose wisely when you decide what kind of Medicare coverage you want. There are two ways to get Medicare health benefits: through Original Medicare or Medicare Advantage.

Original Medicare – This is health insurance from the government. It’s what most people choose. Its lets you go to almost any doctor or hospital. Many people chose to buy supplemental insurance (Medigap plans) to help cover coinsurance and deductible costs.

Medicare Advantage - Private insurance companies sell Medicare Advantage plans. They’re often HMOs or PPOs. They cover Medicare benefits, but each plan has its own rules and costs. These rules may restrict which providers you can see and require you to get permission before you can receive certain services.

Most people must stay with their choice for the calendar year. Make sure it meets your needs and works with your other drug and health insurance.

2.  “B” Careful

Part B is the part of Medicare that covers outpatient services and doctor’s visits.

Generally, you should sign up for Part B when you first become eligible for Medicare. If you are working, check with the Social Security Administration to find out if your current employer insurance is primary to Medicare. If it is, you may consider delaying enrollment into Part B, but you must sign up as soon as you stop working.

If you don’t sign up for Part B when you should, you may have gaps in your coverage. You may also have to pay a penalty.

3.   Prescription for Health

You may want to sign up for a Part D drug plan to get coverage for prescription drugs. If  you have Medicare Advantage, drug coverage is usually included in your health plan. If you have Original Medicare, you must chooose a separate drug plan from a private insurance company. Important reminders:

When choosing a drug plan, make sure it covers the drugs you take.

Find out if the plan has any restrictions on the drugs you take — such as quantity limits, prior approval, or a requirement that you try other drugs first.

Learn how much the monthly premium is, and check how much the deductible and copays are before you sign  up for a plan.

4.   Don’t Take No for an Answer

Whether you are in Original Medicare, a Medicare Advantage plan, or a drug plan, you can appeal if any of them denies coverage.

An appeal is a formal request asking a plan to change its decision and provide you with coverage.

Many people win their appeals.  If you don’t win at first, you can continue to appeal to the next level.

There are a number of reasons you may appeal a drug plan’s decision. You can appeal if the plan is restricting the quantity of the drug you can get, making you get prior approval, having  you try other drugs first, or if your drug is not on its list of covered drugs (formulary).

5.    Save Money Now

Apply for programs that can help you pay your Medicare costs. If you are eligible, these programs can help pay your premiums, copays and deductibles for both health and drug coverage.

Apply even if your income and assets seem to be above the limits; some income and assets may not count towards the limit.

Programs include:  Extra Help, Medicare Savings Programs (MSPs), State Pharmaceutical Assistance Programs (SPAPs) and Medicaid.

Contact your local SHIP (State Health Insurance Assistance Program) to find out which programs are available in your state, if you are eligible, and how to apply.

6.   What’s Not Covered

Medicare does not cover all health care services and products.

Those that are not covered include:

Most dental care

Alternative medicine

Most personal or custodial care at home or in a nursing home

Hearing aids

Most cosmetic surgery

Most vision care

Most care received outside of U.S.

Most nonemergency transportation

Medicare Advantage plans may cover some of the above services.

For more information, visit

Medicare Interactive is an online resource that provides answers to all your Medicare questions.

Three Things to Know About the Health Insurance Marketplace

1.  It’s an easier way to shop for health insurance.  The Health Insurance Marketplace simplifies your search for health insurance by gathering all your options in one place. One application, one time, and you and your family can explore every qualified insurance plan in your area, along with any free or low-cost insurance programs you may qualify for.

2. Most people will be able to get a break on costs. Programs that lower costs are available for almost everyone. You may be eligible for a free or low cost plan, or a new kind of tax credit that lowers your monthly premiums right away. New rules and expanded programs mean that even working families can get help paying for health insurance at the Marketplace.

3. Gives you control over your options with clear, apples-to-apples comparisons. All health insurance plans in the Marketplace present their price and benefit information in simple terms you can understand, so you don’t have to guess about your costs. You get a clear picture of what you’re paying and what you are getting before you make a choice.

For more information visit:

Five Things to Know About Health Insurance

1.  There are many kinds of private health insurance policies. Different kinds of policies can offer very different kinds of benefits, and some can limit which doctors, hospitals, or other providers  you can use.

2. You may have to pay coinsurance or a co-payment as your share of the cost when you get a medical service, like a doctor’s visit, hospital outpatient visit, or a prescription.  Coinsurance is usually a percentage amount (for example, 20% of the total cost). A co-payment is usually a set dollar amount (for example, you might pay $10 or $20 for a prescription or doctor’s visit).

3. You may have to pay a deductible each plan year before your insurance starts to pay. For example, let’s say you have a $200 deductible.  You go to the doctor and the total cost is $250.  You pay the first $200 to cover the deductible, and then your insurance starts to pay its share.

4. Health insurance plans contract with networks of hospitals, doctors, pharmacies, and health care providers to take care of people in the plan. Depending on the type of policy you buy, your plan may only pay for  your care when you get it from a provider in the plan’s network, or you may have to pay a bigger share of the bill.

5. You may see products that look and sound like health insurance, but don’t give you the same protection as full health insurance. Some examples are policies that only cover in an accident, or plans that offer you discounts on health services. Don’t mistake insurance-like products for full comprehensive insurance protection. Full health insurance usually covers most medical problems.

Get more information about how insurance works at



The Value of Health Insurance

Insurance helps pay costs when you need care - Insurance protects you from high costs when something bad happens. No one plans to get sick or hurt, but most people need to get treated for an illness or injury at some point, and health insurance helps pay these costs. You buy health insurance to protect you when you need medical care.

When you understand how health insurance works, it helps you be an informed consumer so you can find coverage that fits your needs.

What is health insurance? – Health insurance is a contract between you and your insurance company. You buy a plan or policy, and the company agrees to pay part of your medical expenses when you get sick or hurt.

Even when you need care that costs more than you pay in premiums and deductibles, insurance will cover the care you need. A standard health insurance policy also gives you access to preventive care to keep you healthy, like vaccines and check-ups. Many plans also cover prescription drugs.

Health insurance helps you pay for care –  Did you know the average cost of a 3-day hospital stay is $30,000? Or that fixing a broken leg can cost up to $7,500? Having health insurance can help protect you from unexpected costs like these.

Your insurance policy will show what types of care, treatments and services are covered, including how much the insurance company will pay for different treatments in different situations.

What you pay for health insurance – You’ll usually pay a premium every month for health insurance, and you may also have to meet a deductible once a year before the insurance company starts to pay its share. How much you pay for your premium and deductible is based on the type of insurance you have.

Just as important as the premium costs is how much you have to pay when you get services. Examples include:

— How much you pay before your insurance coverage starts (a deductible)

— What you pay out-of-pocket for services after you pay the deductible (coinsurance or co-payments)

— How much in total you’ll have to pay if you get sick (the out-of-pocket maximum)

What your policy covers is often directly related to how expensive the health insurance policy is. The policy with the cheapest premium may not cover many services and treatments.

For more information about how insurance works, visit

The above info was taken from a brochure written by CMS (product 11631 – December 2012)