doctor talking with elderly patient

Like many new seniors, you may start wondering about health insurance and what it can do for you. Can health insurance cover your hospitalizations, or your prescription drugs? Can it help cover long-term care? All of these are valid and important questions. It is important to note what services you will need covered by insurance as you begin to look for a policy. But what insurance can you get, and what do you qualify for? There are many programs out there, and this article will help guide you through finding the right one for your needs.

Why Do You Need Health Insurance?

Many seniors might find themselves needing quality health care to maintain a healthy lifestyle, but many have concerns about the cost of such care. This can become especially concerning for those living with a limited income due to retirement. This is where health insurance and having the proper coverage can lend a helping hand. There are many suitable health insurance options on the market right now, lending themselves to the various needs of seniors. Choosing the right program can protect seniors against rising healthcare costs and can help reduce the burden brought on by medical debt. In a time where healthcare is so essential, it’s important for it to be accessible and affordable.

Medicare

The first option to be discussed is Medicare. This is a joint federal and state government program that provides free or low-cost coverage to many. The federal government subsidizes a portion of funding for the program while also setting the guidelines. This program is available to seniors citizens aged 65 years and up, disabled citizens of all ages, and those suffering from end-stage renal disease. There are various parts to the Medicare program and each one offers different coverage. These four parts are known as Medicare Part A, B, C, and D.

Medicare Part A

Medicare Part A is hospital insurance, meaning it helps cover hospitalizations, home healthcare, skilled nursing facilities, and hospice care for those that are terminally ill. Unfortunately, this coverage does not extend to long-term care in said facilities. To qualify one must be a senior citizen aged 65 and older, must have worked for at least 10 years, and must have paid social security taxes during this time. This program is free and requires an application, which can be done online.

Medicare Part B

Medicare Part B is medical insurance that covers most medically necessary services like: doctor’s services, annual checkups, outpatient care, laboratory services, and other services that are not included in Part A’s coverage. As of 2015, this program has an annual premium of $104.90 with a deductible of $147.00. Additionally, Seniors are automatically enrolled in Part B when they are eligible to claim social security.

Medicare Part C

Medicare Part C is known as Medicare Advantage. This program allows those eligible to buy government-subsidized health insurance policies through private companies, and can at times provide better coverage than Part A and B alone. To be eligible one must already be enrolled in Medicare Part A and Part B. The price of Medicare Advantage can vary from state to state, and coverage can vary from policy to policy. Before choosing a policy, it is important to know what one requires in their coverage to pick the policy best tailored to their needs. With this in mind, it is important to note that although a Medicare Advantage Plan may have different rules, as stated by Medicare, “your plan must give you at least the same coverage as Original Medicare.”

Medicare Part D

Medicare Part D, also known as the Medicare Drug Plan, is an optional program that helps cover the rising cost of prescription drugs to all those with Medicare. The Medicare Drug Plan is very helpful to those that take medications regularly as it helps cover the price, and it can also help provide greater access to necessary prescription drugs. This program can be used as an add on to one’s Medicare Plan at a monthly premium, or can be included in a Medicare Advantage plan.

Benefits

Due to the fact that coverage depends on federal and state laws, national decisions made by Medicare, and local coverage decisions from companies processing claims, it is important to check with your provider and consult with the Medicare website to find out if what you need is covered. That being said, there are certain general things that Medicare will cover. Medicare Part A covers the following: inpatient care in a hospital, skilled nursing facility care, hospice care, home health care, and inpatient care in a skilled nursing facility – but this does not include custodial or long-term care.

Medicare Part B covers 2 types of services: medically necessary services or supplies that are needed for diagnosing or treating medical conditions, and healthcare to prevent illness or to detect illness early on. For example, Part B can cover things like yearly wellness examinations, clinical research, ambulance services, durable medical equipment (DME), limited outpatient prescription drugs, and inpatient and outpatient mental health services. As a part of Medicare Part B’s preventive services, screenings for the following are also covered:

  • Abdominal aortic aneurysm
  • Alcohol misuse
  • Cardiovascular disease
  • Cervical and vaginal cancer
  • Colorectal cancer
  • Depression
  • Diabetes
  • Hepatitis B virus
  • Hepatitis C
  • HIV
  • Lung cancer
  • Mammograms
  • Obesity
  • Prostate cancer
  • Sexually transmitted infections

Although Medicare Parts A and B do cover plenty, there are certain things that are not covered. These include:

  • Long-term or custodial care
  • Most dental care
  • Eye exams for glasses prescriptions
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids
  • Hearing aid fitting exams
  • Routine foot care

Application Process

Deciding Medicare is the right fit is only the first step. Next is the application process. One can sign up for Part A and Part B together, although one can always opt out of the optional Part B. The initial enrollment period begins three months before the 65th birthday, and will end three months after said birthday. To apply online one has to be at least 64 years and 9 months old, have no Medicare coverage at all, not want to begin receiving Social Security benefits at the current time, and cannot currently be receiving Social Security retirement, disability or survivors benefits.

To apply for Medicare online, visit the Social Security Administration website and follow the on-screen instructions.

To apply over the phone, call 1-800-722-1213 between 7:00 AM – 7:00 PM, Monday through Friday. For those applying who are deaf or hard of hearing, call TTY 1-800-325-0778.

To apply in person, make an appointment and visit your local Social Security office.

Medicaid

Medicaid is a federally subsidized program that provides medical insurance for low income adults, children, pregnant women, people with disabilities, and seniors. It is often used hand in hand with Medicare. In most cases Medicaid helps provide coverage for certain medical services and prescriptions that Medicare might not cover. Medicaid, similarly to Medicare, is administered by the states while acting in accordance to federal requirements. Because Medicaid is administered and operated on a state level, programs will vary from state to state. Most often, eligibility is based on income. But some states have expanded their programs in recent years. The best way to know if you’re eligible is to apply.

Benefits

Under federal law, states are mandated to cover the following benefits:

  • Inpatient and outpatient hospital services
  • Nursing facility services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse midwife services
  • Certified pediatric and family nurse practitioner services
  • Freestanding birth center services
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women
  • EPSDT: early and periodic screening, diagnostic, and treatment services

These services and benefits are protected under federal law and are mandatory Medicaid benefits that states must cover.

Along with Medicaid’s mandated benefits, there are certain optional benefits that states may choose to cover. The list of optional benefits that may be covered is as follows:

  • Prescription drugs
  • Clinic services
  • Physical therapy
  • Occupational therapy
  • Respiratory care services
  • Podiatry services
  • Optometry services
  • Dental services
  • Dentures
  • Prosthetics
  • Eyeglasses
  • Chiropractic services
  • Other practitioner services
  • Private duty nursing services
  • Personal care
  • Hospice
  • Case management
  • TB related services
  • Speech services
  • Hearing services
  • Language disorder services
  • Other diagnostic, screening, preventive and rehabilitative services

Additional optional benefits include:

  • Services for individuals aged 65 and up in an Institution for Mental Disease
  • Services in an intermediate care facility for individuals with Intellectual Disability
  • State Plan Home and Community Based Services
  • Self-Directed Personal Assistance Services
  • Community First Choice Option,
  • Health Homes for Enrollees with Chronic Conditions, and
  • Inpatient psychiatric services for individuals under age 21

Application Process

There are two ways to apply for Medicaid. The first is to fill out an application through the Health Insurance Marketplace, who will in turn send your information to the state agency if they believe someone in the household qualifies. This can be done online by creating an account and submitting a Marketplace application at HealthCare.gov.

The second process is done by applying directly with one’s local state Medicaid agency. To access one’s state agency: just visit the HealthCare.gov Medicaid & CHIP web page, follow prompts to select one’s state, and a link to the state agency will be generated automatically for you.

Private Health Insurance Options

The third insurance option to be discussed is private health insurance. This is insurance not provided by a state or federal government but instead is purchased from a private organization, like an insurance company. There are many ways to obtain private health insurance, such as through an employer or through licensed brokers or agents. Another way of obtaining private health insurance is through the federal or state marketplace. Individual private policies can vary in price and coverage, allowing for the purchase of one fitted to one’s needs. Private health insurance plans can be paired with Medicare to assure sufficient coverage. When shopping for private health insurance, it is important to check if the plan’s benefits meet the minimum essential coverage required by the Affordable Care Act.

Benefits

Benefits vary from one individual private health insurance to another.

Application Process

The application process varies from one private health insurer to another. Often, carriers will evaluate an applicant’s current age, health, and risk factors. As well, serious medical conditions and preexisting conditions can also be taken into account.

Medigap

The final option to be dissected is Medicare supplemental health insurance, called Medigap. This policy can be purchased through a private insurance company and does have a premium. As the name would suggest, this option is used to provide coverage when Medicare doesn’t. It can also be used to pay Medicare coinsurance, copayments, and deductibles for medical services that would have to be paid out of pocket. To qualify, one must already be enrolled in both Medicare Part A and Part B.

Benefits

Benefits vary from Medigap policy to policy. There are various types of policies, like for example Plan M, Plan A, or Plan F, and each one offers its own set of standardized benefits. This then means that benefits will depend on what type of Medigap policy chosen to fit one’s needs. Most Medigap policies don’t cover long-term care, vision care, dental care, hearing aids, eyeglasses, or private duty nursing.

Application Process

Medigap has a state by state variability. To get started looking for a policy, follow the prompts on the Medicare.gov Medigap web portal.

Choosing the Right Plan

It can feel a little overwhelming when reading about so many insurance plan options. Some might even feel disheartened. But health insurance is important and essential – so it should be comforting and encouraging to know that there are so many options out there waiting. Before starting the search for the right health insurance policy, make a list of what benefits and services you need. Once the list is done, find a policy best tailored to your needs to help you on your way to a healthy life.

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