Medicare 101 - Learn About the Basics of Medicare

SUMMARY 
As a contractor for Medicare, Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Acentra Health provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare.  

This episode is a conversation with our guest, Juan Garcia, Health Insurance Specialist for the Centers for Medicare & Medicaid Services, Region 10. He has a primary focus on establishing and maintaining positive, collaborative relationships with stakeholders in the Latino and Asian Pacific Islanders Communities in WA, OR, ID, and AK, Language Access Project. He is also the Liaison for the State Health Insurance Programs in Region 10. He serves as CMS Regional Chair for the Employee Resource Group (ERG). Juan has worked for the Centers for Medicare & Medicaid Services since 1997. He received his BA from Eastern Washington University in Sociology and Social Work in 1989, and he received his Master's in Public Administration with an emphasis in Health Care Management in 1996 from Eastern Washington University.  

In this podcast, Mr. Garcia will share information about the parts of Medicare, Medicare Advantage plans, Medigap policies, and benefit periods/reserve days. 

 For more information about Acentra Health BFCC-QIO, please visit www.acentraqio.com. 

KEY TOPICS
00:24: Overview, introduction of guest, Juan Garcia
01:47: Intro to the parts of Medicare
10:10: Medicare Advantage plans
13:25: Medigap policies
14:52: Benefit periods/reserve days
16:53: Summary and final thoughts 

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RESOURCES
BFCC-QIO Information for stakeholders: www.acentraqio.com/partners 

BFCC-QIO Information for people who have Medicare: www.acentraqio.com/bene 

Office of the Insurance Commissioner: www.insurance.wa.gov/ 

State Health Insurance Assistance Program (SHIP) and Senior Health Insurance Benefits Assistance Program (SHIBA): www.shiphelp.org/ 

Medicare: www.medicare.gov 

Music: Motivational Upbeat Corporate by RinkevichMusic
https://soundcloud.com/rinkevichmusic
https://protunes.net/
Video Link: https://bit.ly/3NNqGTs 

Transcript

Welcome to Aging Health Matters, a podcast from Acentra Health, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. Information in today’s show may help you or someone you know in their healthcare journey. Thanks for joining us. Now let’s get started. 

Nancy Jobe 
Hello everyone. I'm Nancy Jobe, an Outreach Specialist for Acentra Health, and Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization providing services for Medicare beneficiaries in 29 states. We have three key services for people who have Medicare: beneficiaries have a right to appeal discharges from the hospital and skilled service terminations. Acentra Health helps beneficiaries with Immediate Advocacy to resolve medical care issues they may encounter, and beneficiaries can file a quality of care complaint. More information is available on our website at  www.acentraqio.com. 

That's www.acentraqio.com. Well today, I'm excited to be telling you that we are going be learning about the different parts of Medicare, and we have Juan Garcia representing the CMS Region 10 office, and he's going to tell us a lot about  all those different parts of Medicare, but Juan before we get started, could you tell us a little bit about your background? 

Juan Garcia 

Sure. Again, my name is Juan Garcia, and I'm with the Centers for Medicare & Medicaid Services in Region 10 that's located in Seattle. And I’m a Health Insurance Specialist. 

Nancy Jobe 
Awesome. Well, a lot of people get so confused with all these different parts of Medicare, and I thought this is a great opportunity to hear from the source what the different parts are. You know, we hear about ABCD, all of those different parts. Can you enlighten us a little bit? Let's just start with that Part A. What in the world is that? 

Juan Garcia 

Part A is hospital insurance. I can just back up just a sec, to enroll in Medicare, you have to be 65, or have a disability, or have one of the what they call exceptions, end-stage renal disease or Lou Gehrig's disease, that allows you to get into the program. 

You go to Social Security, and you enroll, and a lot of times, if you're already in Medicare or I should say if you're already receiving your Social Security check, Social Security already has you in their system. So you'll start getting information three months before your birthday, the month of your birthday, and you’ll start getting enrollment information to sign up for Medicare. 

The four parts of Medicare: first part is Part A, and that's inpatient hospital care, and that covers your days in the hospital. So when you're in the hospital, there is a deductible of $1200. And then they also cover skilled nursing facility care. But one of the caveats to that is you have got to have a three-day hospital stay. During COVID, we waived that stay, but we're getting back to normal now. Now you got to go back to three day stay, and we also have hospice care,  and hospice care, you can do that in the facility, or you can do that at home and that's covered under Part A as well. 

Then we got home health care, and it's limited, but you can still get some care if you get out of a facility to assist you at home. Those are some parts of Part A. Now Part B, that helps cover services from your doctor and other healthcare providers that you may see, pretty much outpatient care. There are some services that home health care pays for under Part B. 

What's also important is that people can also get access to durable medical equipment, like wheelchairs, walkers, and if they need a hospital bed they can get one and other equipment to help you be mobile or assist you at home. We cover a lot of preventive services like screenings, your yearly wellness, COVID shots. 

So there's a lot of preventive care that goes into Part B. So Part D, if people didn't realize that it's only been around for not a whole lot of years. There was a time when we did not have a prescription drug program, and seniors had to pick between buying food or paying a bill or paying their prescriptions. But we do have Part D now, and that really helped a lot of seniors over the year pay for their prescription drugs. 

And it also includes many, many shots and vaccines that people can get access through Part D. Within that, there are plans within Part D, private insurance companies that cover  prescriptions, and people join those plans and then get coverage through their prescriptions through that particular plan. 

There are some plans that are reasonable in cost depending on your need of course, and there are some plans that are more robust that will probably cover more prescriptions depending on your healthcare needs. So you probably want to go into the Medicare Plan Finder to kind of take a look at what plan is best for you. 

Under our programs, we have another program, Part C, which is the Medicare Advantage program. Basically, what we do with those plans, you're handing off your Medicare to an insurance company that covers ABC and D for you. You can carve out, sometimes carve out your part, to see your prescription drugs, but most of the time it's all encompassing. 

These Medicare Advantage plans are pretty good at covering your health care. They also charge a premium. They have to be approved by Medicare or CMS. And most cases, you can pick your doctor, and you must stay within their network. Plans have a lower or higher out-of-pocket cost depending on what you're into. 

You may have or may not have additional premiums depending on what plan you have. A lot of these Medicare Advantage plans have what’s called an added value, and they come with extra benefits, to kind of ask beneficiaries to see come and join our plan, look what we have. We cover vision that Medicare doesn't cover. We cover hearing aids that Medicare doesn't cover, and we also cover some dental. So those are kind of incentives or the added value these particular Medicare Advantage plans have. 

There's a deductible for Medicare Part B. Right now, the deductible is $174.70. Excuse me, that was the premium, and the deductible was $240. I'm sorry I had that backwards. Within our program, we also have something that's called a Medigap policy, and it's also called a Medicare supplemental insurance, which fills in the gap because we all know that Medicare doesn't pay 100%. 

For example, if you had a bill of $100, we traditionally pay $80 of that, and $20 is your responsibility. But if you had a Medigap policy or a Medicare supplement insurance policy, that particular policy will cover that gap, will cover the 20%. It would also cover your deductibles and co-insurances. These particular Medigap policies are regulated by the state insurance commissioner’s office in your particular state. So you can probably go to the website and see what companies are within that particular state. 

So generally, you must have original Medicare to buy a Medigap policy. Some Medigap policies cover services that original Medicare does not cover, like emergency medical care when you travel outside the United States. And that's been real popular with seniors, so when they go on vacation, they know that they have some type of coverage when they're out of the country.  

Medigap policies don't cover your share of cost under other types of healthcare coverage like Medicare Advantage plans, standalone Medicare drug plans, and employee union group health coverage. If you have a Medigap policy and you get Medicare, it will pay its share of the Medicare-approved amount for covered health care cost. And then your Medigap policy will pay its share, and that's the gap that we're talking about, kind of fills in, and makes everything whole for you. Medicare doesn't pay for any cost of buying a Medigap policy, so that's pretty much on your own. 

Medigap policies are different from Medicare Advantage plans. They're working in conjunction with the Medicare original traditional Medicare plan. 

So it just fills in the gap of what coverages, what costs aren't covered by original Medicare. And usually sending in your bill into that company, and they'll go ahead and pay the 20%. Some of these Medigap policies have something called a crossover in the business, and they usually send that directly to that particular insurance company. You get that paid for. Sometimes you'll get it in the mail, and you have to do it yourself. So that added value of that added policy is important because sometimes seniors don't want to deal with sending anything to your insurance company. They have that also. 

Every Medigap policy must follow both federal and state laws designed to protect you, and the policy must be clearly identified as a Medicare supplemental insurance. A Medicare- approved plan for private companies that offer alternatives to original Medicare. In many cases, you can only use doctors who are in those plan or plan networks. So it's important that you make sure that you go over your healthcare needs and try to find a plan that's best for you. 

Again, original Medicare, AB, they also cover some standalone Part C plans. Medicare Advantage plans are encompassing, and again, the Medigap policies all work together with traditional Medicare. So there's a lot of choices out there for seniors, and hopefully our website, medicare.gov, can help seniors navigate through this kind of maze of insurance Nancy. 

Nancy Jobe 
That's a lot of information there, I tell you what Juan. But it was such valuable information. Let me see if I can just kind of summarize a little bit just for my clarification. I know a lot of people believe that Ohh, I got Medicare, and now my insurance is paid for. 

Well, as you pointed out, there are expenses with Medicare such as the Part B premium, the deductibles, those are things that need to be covered, like the Part A deductible and the Part B deductible. And you made a point of talking about that Medigap or Medicare supplement policy that would cover that, correct? 

Juan Garcia 
Correct. That’ll fill in that hole right there for them, if they get a policy, a Medigap policy. They're traditional Medicare, correct. 

Nancy Jobe 
Because I've talked to many beneficiaries, and they get a little bit confused when they first come on to Medicare, not realizing because they just think everything's paid, for and they don't realize that. 

And then that Medicare Advantage plan, you know, that's of course another piece that they could take advantage of if they don't want to go the original Medicare and the Medicare supplement side, and they still would have premiums and out-of-pocket expenses probably similar to what they have on employee plans as far as those out-of-pocket expenses like when they go to the doctor and having to pay for different items with that Medicare Advantage plan, that's kind of how I tried to explain that a little bit to people as similar to the employee plan. Would you agree with that assessment of how the Medicare Advantage plan works? 

Juan Garcia 
Exactly. We can hand off our AB and C and D to Medicare Advantage plan. You say hey, you guys take care of my Medicare now. And the reason why those are so popular is that the premiums are very attractive for seniors. 

And so there's some plans out there that have 0 premiums, and there's some plans out there, very robust that cover a lot. So it really depends on the healthcare needs of the individual and trying to pick an Advantage plan that's best for them. 

Nancy Jobe 
A lot of those Medicare Advantage plans actually include the Part D as well, correct? 

Juan Garcia 
That's correct. So prescription drugs are inclusive in those plans, and again, there's some seniors that if they are low income, they do get some benefits of getting the cost-sharing program through Medicaid. So there's some choices out there. 

Going back to our Plan Finder, a lot of seniors can go ahead and put in their prescriptions, it will spit out plans that are in their zip code. So it will kind of design a plan for you and give you some choices of what plans might be best for you within your area. There's some national plans, and there's some local plans. And so that's why our Medicare Plan Finder is so helpful to seniors because we know navigating to these insurance policies can be a bit confusing. 

Nancy Jobe 
So if a person has a Medicare Advantage plan, do they still have to pay that Part B premium as well? 

Juan Garcia 
Yes, they do. That's part of the contract that we have with them that they have to have Part A and B before they can join a Medicare Advantage plan. The system won’t allow them to join if they don’t have Part B. 

Nancy Jobe 
OK. Well, then that makes sense. Now I believe there were some changes in some of the Medigap policies a couple of years back, in that they used to cover, and some people are still grandfathered in, to cover their Part B premium. But the new plans, I don't think any of them really include the Part B premium in the Medigap policy. Is that correct? I think that happened a couple years back. 

Juan Garcia 

I would have to look into that. The state insurance commissioner’s office regulates those plans, but there were some Medigap policies that if you had one years back, you were grandfathered in, and they covered way more robust benefits that they do now. As you know that these plans are standardized A through G, I think now, and depending on your healthcare needs depends on what policy you pick from. But they're all standardized in the country, so each state has the same standardized policies. And you're correct, there were some grandfathered policies if you didn't disenroll, try to join, and you couldn't get back in them no more. But there are some policies that were grandfathered in at one time. 

Nancy Jobe 
Actually if anybody wants to know a little bit more about the Medigap policies, we did do a podcast on that. So you can check on our website to find the podcast on Medigap policies and learn a little bit more about that as well. 

Juan Garcia 
Yes. And the OIC is very good to put that information on their website. 

Nancy Jobe 
Perfect. So we learned about Part ABC and D, and you talked about the skilled nursing facilities, that was in the Part A, and that there are several different qualifications to get in the skilled nursing facility, you also mentioned that, but I also hear people talk about these reserve days and benefit periods and all of this stuff. Can you explain a little bit how that all works? 

Juan Garcia 
Well, a benefit period begins the day you're admitted into the inpatient hospital or skilled nursing facility. The benefit period ends when you when you have not got any more inpatient hospital care. So if you're within those 100 days, you still get the care. 

If you're out more than 60 days, you will start a new benefit period, and then that 100 days would begin again. You have a total of 60 reserve hospital days. They can be used during your lifetime. 

For each lifetime reserve day, Medicare pays all covered costs except for daily coinsurance. Also, when you exhaust your benefits, Medicare does not pay anymore. And you are going to be 100% responsible for any type of medical bills. The good thing about these benefits here, most hospitals that I've had experiences with do have a navigator that will work with you and kind of guide you through these days and these benefit periods. But if you come home and you're home for more than 60 days, you're going to start a new benefit period, and you're going to have that deductible actually and that coinsurance that you're going to have to pay again. So a lot of people want to to make sure that they're ready to go home. 

And if you feel like you're not ready to go home, you do have a quality care agency you can call. 

Nancy Jobe 
Thanks for that input Juan. That is correct. If you are being discharged from the hospital or skilled nursing facility and feel like you're not ready, you have the right to file an appeal. 

Juan Garcia 
That's correct. And thank you. 

Nancy Jobe 
Is there anything else that you'd like to summarize or tell about what we talked about today? 

Juan Garcia 

I would like to just let everybody know that we have a good relationship with the State Health Benefit Advisors, and they're also located in the Office of Insurance Commissioner. And if you really want to to sit down with the counselor, the Shiba counselors are very informed, well-educated to help seniors navigate through their insurance needs, and we also have our Medicare 800 number, which I like people to know that they can call Medicare, seven days a week. 24 hours a day, and they could be assisted by a live person. And we also have individuals that have language needs. 

They can just let them know what language they speak, and they'll get a translator on the line for them to help them out to assist them with any questions they have about their Medicare issues. 

Nancy Jobe 
Oh perfect. That’s a good point, definitely. I really appreciate all the information that you've given us today Juan, and I know that this information is extremely important and helpful for those beneficiaries starting with Medicare and actually for those stakeholders that are working with beneficiaries trying to start like the state health insurance programs, and there's one in every state, and they work with all of the future beneficiaries to get everything set up. 

So definitely check into your state organizations, and they can help you with a lot of the programs that Medicare has to offer for you. So once again Juan, thank you so much.  

Juan Garcia 
Thank you, Nancy. 

Kia Weaver 

If you would like more information about our services for Medicare beneficiaries, please feel free to sign up for our newsletter and subscribe to our YouTube channel. Our Helpline phone number and the link to sign up for our newsletter are available on our website, which will be in the Show Notes. We also have helpful resources available on our website as well. Thank you for joining us today and please stay tuned for the next episode of Aging Health Matters.