Know what mental health services your insurance covers
In challenging times like these, access to mental health care is very important.
Jennifer Spengler, health and wellness writer for Sharp Health News and marketing specialist with Sharp HealthCare
There are a few things I assumed wouldn't cross my radar until I was much older but have found myself to be mistaken. For example, which seed mix backyard birds like best. While staying at home due to the COVID-19 pandemic, I've found it very important to keep my new feathered friends eager to come back for our morning visits. And then there's the importance of sunscreen - for hands. Who knew sun spots are just as happy to find their way onto a 40-year-old's hands as they are onto a 60-year-old's?
Another topic I thought I could forego until my mid-60s: Medicare - what it is, how one gets it and which plan to choose.
As we find ourselves approaching Medicare's annual open enrollment period, also known as the annual election period or AEP, many Gen Xers like myself - and a few millennials too - are realizing that they should learn about Medicare and the many options available. This isn't because we're a generation of independent go-getters, eager to get a jump-start on our retirement needs - which we are, by the way - but rather because many of us need to be able to help our aging parents make some important decisions about this often confusing issue.
"Navigating Medicare can be challenging, but with the right help from experts and loved ones, it can be manageable," says
Don Truong, director of sales at
Sharp Health Plan. "Luckily, there are resources dedicated to helping you understand everything you need to know about Medicare."
What is Medicare?
Medicare is the federal health insurance program for people who are 65 or older and certain younger people with disabilities. There are three different parts of Medicare to help cover specific services:
Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care. You usually don't pay a monthly premium or fee for Part A if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called "premium-free Part A." If you don't qualify for premium-free Part A, you can buy Part A for an amount up to $458 each month.
Medicare Part B covers certain doctors' services, outpatient care, medical supplies and preventive services. Most people will pay the standard Part B premium amount, which is currently about $145, but may be more if you earned more than a certain amount for the past two years.
Medicare Part D helps cover the cost of prescription drugs, including many recommended shots or vaccines. If you want this type of coverage, you must join a Medicare-approved plan that offers drug coverage. Each plan can vary in cost and the specific drugs that are covered. How much you pay for each drug depends on which plan you choose.
How do my parents get Medicare?
Some people get Medicare automatically and some have to sign up. If your parents are receiving Social Security benefits, they should automatically be enrolled in Medicare Part A and receive their Medicare card in the mail around their 65th birthday. However, they may have to sign up if they are 65 (or almost 65) and not receiving Social Security. They can apply for Part A as soon as three months before their 65th birthday either
online or in person at their local
Social Security office.
While your parents' coverage options can seem overwhelming, there are two main ways for them to get Medicare:
This includes Medicare Part A and Medicare Part B. You pay for services as you get them. When you get services, you'll pay a deductible at the start of each year. This is the amount you have to pay before Medicare, your drug plan or any other insurance will pay. You will also usually pay 20% of the cost of the Medicare-approved services - known as your copayment or copay - and pay a premium each month for Part B. If you want drug coverage, you have to add a separate Medicare Part D plan.
A Medicare supplement insurance (Medigap) policy can help pay some of the remaining health care costs, such as copayments, coinsurance and deductibles. Some Medigap policies also cover services that Original Medicare doesn't cover, such as medical care when you travel outside the U.S.
In most cases, you can go to any doctor, health care provider, hospital or facility that is enrolled in Medicare and is accepting new Medicare patients.
This is an "all-in-one" alternative to Original Medicare.
Medicare Advantage plans are "bundled" plans offered by Medicare-approved private companies and include Part A, Part B and usually Part D. They are sometimes called "Medicare Part C." They also offer extra benefits that Original Medicare doesn't cover, such as vision, hearing, dental and more. Each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get services.
In many cases, you'll need to use health care providers who participate in the plan's network and service area for the lowest costs. Some plans offer out-of-network coverage, but sometimes at a higher cost.
According to AARP, instead of paying the 20% coinsurance amount for doctor visits and other Part B services like you would with Original Medicare plans, most Medicare Advantage plans have set copay amounts for a doctor visit. Typically that means lower out-of-pocket costs than Original Medicare.
What's more, many Medicare Advantage plans in San Diego have $0 premiums, while still offering these extra benefits not included in Original Medicare. You can
compare the quality of Medicare health and drug plans using Medicare's Star Ratings system, which rates plans on a one-to-five scale. To join a Medicare Advantage plan, you must enroll and provide your Medicare information.
Can Medicare coverage be combined with other insurance?
It is possible to have Medicare and other health insurance or coverage. In this case, each type of coverage is called a "payer" and coordination of benefits rules decide which one pays first. The "primary payer" pays what it owes on your bills first up to the limits of its coverage, and then sends the rest to the "secondary payer" to pay if there are costs the primary insurer didn't cover. In some cases, there may also be a third payer.
If your parents have group health plan coverage from one of their current employers and the employer has 20 or more employees, the group health plan is usually the primary payer. If the employer has fewer than 20 employees or if your parent is retired and has coverage from their former employer, Medicare generally pays first. However, there are several exceptions to these general payer guidelines and some employers might offer retirees group Medicare plans.
Still have questions about Medicare?
Sharp hosts free online seminars, where you'll learn more about enrollment periods and how Medicare works.
Sign up for the "Understanding How Medicare Works" seminar or the
"Understanding Your Medicare Open Enrollment Options" seminar.
These classes are also available in Spanish. Please visit
Entienda Cómo Funciona Medicare and
Entienda Sus Opciones de Medicare Durante la Inscripción Abierta for more information.
Truong recommends the following additional resources to assist with navigating Medicare:
Social Security provides help with signing up for Medicare or applying for Extra Help benefits in the Part D drug program.
State Health Insurance Assistance Program (SHIP) offers counsel and advice on Medicare and long-term care insurance. In California, the SHIP is called the Health Insurance Counseling & Advocacy Program (HICAP). Call HICAP at
1-800-434-0222 to find a location near you.
official Medicare website offers information and answers to just about every question one might have about Medicare.
"Do your research and don't be afraid to reach out for help from experts," says Truong. "If your parents choose the right Medicare plan for their needs, it could save them money in the long run."
Learn more about Medicare health insurance at Sharp HealthCare.
This story was updated January 20, 2021, to reflect the most up-to-date Medicare information.
The Sharp Health News Team are content authors who write and produce stories about Sharp HealthCare and its hospitals, clinics, medical groups and health plan.
Jennifer Spengler is a health and wellness writer for Sharp Health News and a marketing specialist with Sharp HealthCare.
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