one source logo
Home | Personal Risk | Employee Benefits | Commercial Risk | Our Team | Contact Us

 

Senior Services



senior services


Who is eligible for Medicare benefits?

If you get benefits from Social Security or the Railroad Retirement Board, you are automatically eligible for Medicare starting the first day of the month you turn 65. 
If you are under 65 you are eligible to receive Part A benefits under the following circumstances:

  • You have been receiving Social Security Disability Insurance for more than two years.
  • You have permanent kidney failure (end-stage renal disease requiring ongoing dialysis or a kidney transplant. You have been diagnosed with amyotrophic lateral sclerosis (Lou Gehrig’s disease). 

Resources:

Back to Top

What does Medicare Part A cover?

Medicare Part A, also known as the Hospital Insurance program, helps cover the costs of care in the following facilities:

  • Inpatient care in hospitals
  • Inpatient care in a skilled nursing facility
  • Inpatient rehabilitation facility
  • Hospice care services
  • Some home health care services
  • Inpatient mental health and psychiatric care

If you are eligible for Medicare you will not have to pay a monthly premium for Part A if you or your spouse paid Medicare payroll taxes while working.

Resources:

Back to Top

Do I have to pay a premium for Medicare Part A?

If you are eligible for Medicare you will not have to pay a monthly premium for Part A if you or your spouse paid Medicare payroll taxes while working. If you and your spouse did not work or did not pay enough Medicare payroll taxes you may not be eligible for premium-free Part A. However, you may be able to purchase Part A by paying a monthly premium, which is up to $461 in 2010.
You should contact your local Social Security office 3 months before your 65th birthday to sign up.

Resources:

Back to Top

What does Medicare Part B cover?

Medicare Part B is also known as the Medical Insurance program. In general, Part B covers two types of services:

  • Medical services – healthcare that you may need to diagnose and treat a medical condition. Medicare will only pay for services that they define as being medically necessary.
  • Preventive services – healthcare to prevent illness (such as a flu shot) or help detect an illness in an early stage so it can be managed before getting worse (such as screening for colon cancer).

Under Part B, Medicare helps pay for durable medical equipment such as oxygen equipment, wheelchairs, walkers, and other medically necessary equipment that your doctor prescribes to use in your home.

Resources:

Back to Top

What is the Medicare Part D coverage gap?

Most Medicare drug plans have a coverage gap, also known as the “doughnut hole.” This means that after you and your drug plan have spent a certain amount of money for covered medications, you have to pay all out-of-pocket costs for your drugs (up to a limit). Your yearly deductible, your co-insurance or copayments, and what you pay in the coverage gap all count toward this limit.

Resources:

Back to Top

What is Medigap coverage?

Original Medicare (Part A and Part B) pays for many, but not all, health-related services and medical supplies. You can purchase an insurance policy to cover the “gaps” that are not paid for by Medicare, such as copayments, coinsurance, and deductibles - which can add up to a lot of out-of-pocket expenses
Some Medigap policies also will pay for certain health services outside the United States and additional preventive services not covered by Medicare. Medigap insurance (also known as Medicare Supplement Insurance) is voluntary and you are responsible for the monthly or quarterly premium. Medicare will not pay any of your costs to purchase a Medigap policy.
Resources:

Back to Top

What is a Medicare Advantage Plan?

Medicare Part C, also known as the Medicare Advantage program, allows you to choose a health plan offered by a private insurance company that is approved by Medicare. Medicare Advantage plans include:

Medicare Advantage plans receive payments from Medicare to provide you with the benefits covered by Medicare, including Part A and Part B. Most Medicare Advantage plans include Part D drug coverage and many offer extra coverage, such as vision and hearing care, dental services, and wellness programs.

Resources:

Back to Top

What happens to Medicare under health reform?

The Affordable Care Act makes several changes to Medicare that most likely will improve your benefits and your access to primary care services. Some significant changes include:

  • Coverage Gap Savings: If you reach the coverage gap in 2010 you will receive a one-time rebate check of $250 from Medicare. In 2011, you will be able to get a 50% discount on brand-name drugs and a 7% discount on generic drugs in the coverage gap. There will be additional savings in the coverage gap each year until it's completely closed by 2020.
  • Preventive Care: Beginning in 2011, Medicare will pay for an annual checkup, including a physical examination and a total elimination of cost sharing for appropriate preventive services and screenings.
Back to Top

I will soon be 65, what are my Medicare choices?

You have two main choices for how you get your Medicare – Original Medicare or a Medicare Advantage Plan. If you choose Original Medicare (which includes Part A Hospital Insurance and Part B Medical Insurance), you will also have the option to enroll in a Part D Prescription Plan. You will also need to decide if you want to purchase Medicare Supplement Insurance (Medigap) to pay for the “gaps” in Medicare coverage.
If you choose a Medicare Advantage Plan, you will have the option to select a plan that includes prescription drug coverage. If you have a Medicare Advantage Plan, you do not need Medigap coverage.

Resources:

Back to Top

What does "medically necessary" mean?

Medicare will only pay for services that are considered to be medically necessary. According to Medicare, services or supplies are considered medically necessary if they:

  • Are proper and needed for diagnosis, or treatment of your medical condition.
  • Are provided for the diagnosis, direct care, and treatment of your medical condition.
  • Meet the standards of good medical practice in the medical community of your local area.
  • Are not mainly for the convenience of you or your doctor.
Back to Top

What if I need a drug that isn't on the formulary or costs too much?

According to Medicare, if you need a drug that is not on your Part D formulary, or that is on the list but you think it should be covered for a lower copayment, you can do the following:

  • Contact the plan and ask for an exception. You will probably have to provide information from your doctor about why you need the drug your plan won’t cover.
  • If your plan denies the exception, you can appeal. Your Part D plan must give you information on how to appeal.

Resources:

Back to Top

My Part D Prescription Plan has a drug formulary with tiers. What does it mean?

Drugs on a Part D formulary are usually grouped into tiers, and your copayment is determined by the tier that your medication is on. A typical Part D drug formulary includes three tiers.

Tier 1 has the lowest co-payment and usually includes generic medications.
Tier 2 has a higher co-payment than tier 1 and usually includes preferred brand name medications.
Tier 3 has the highest co-payment and usually includes non-preferred brand name medications. Your plan may place a medication in tier 3 because there is a similar drug on a lower tier of the formulary that may provide you with the same benefit at a lower cost.

Back to Top

I can't afford my Medicare and Drug Coverage premiums. What can I do?

You have several options if you need help with medical and drug costs, such as premiums, deductibles, and other out-of-pocket expenses. These options include:

  • Medicaid
  • Medicare Savings Program
  • Extra Help and Low-Income Subsidy
  • State Pharmaceutical Assistance Program
  • Pharmaceutical Assistance Program
Back to Top

Should I buy long-term care insurance?

  • Four key reasons to buy long-term care insurance

    1. Preserve your assets for your family instead of spending the money on long-term care.

    2. The odds are one-in-three that a man over 65 will need long-term care; for a woman over 65, the odds are one in two.

    3. New rules make it hard to qualify for Medicaid.

    4. Premiums may be partially tax-deductible
  • Typical policy features

    The best policies pay for care in a nursing home, assisted living facility or at home. Benefits are typically expressed in daily amounts, with a lifetime maximum. Some policies pay half as much per day for at-home care as for nursing home care. Others pay the same amount, or have a "pool of benefits" that can be tapped as needed.
  • Elgibility triggers

    Make sure you know when benefits kick in. The policy should state the various conditions that must be met.

    1. The inability to perform two or three specific "activities of daily living" without help. These include bathing, dressing, eating, toileting and "transferring" or being able to move from place to place or between bed and chair.

    2. Cognitive impairment. Most policies cover stroke, Alzheimer's and Parkinson's disease, but other forms of mental incapacity may be excluded.

    3. Medical necessity, or certification by a doctor that long-term care is necessary.

    4. Prior hospitalization. Some older policies require a hospital stay of at least three days before benefits can be paid. This requirement is very restrictive and should be avoided.

    5. A benefit period that may range from two years to lifetime. You can keep premiums down by electing coverage for three to four years -- longer than the average nursing home stay -- instead of lifetime.

    6. A waiting or "elimination" period. Premiums will be lower if you pay for an initial period of care yourself instead of electing first-day coverage.

    7. Inflation protection is an important feature, especially if you are under 65 when you buy benefits that you may not use for 20 years or more. The best inflation provision compounds benefits at 5% a year.

    8. Guaranteed renewable policies must be renewed by the insurance company, although premiums can go up if they are increased for an entire class of policyholders.

    9. Waiver of premium, so that no further premiums are due once you start to receive benefits.

    10. Third-party notification, so that a relative, friend or professional adviser will be notified if the policyholder forgets to pay a premium.
  • Optional Features

1. Restoration of benefits. This feature ensures that maximum benefits are put back in place if you receive benefits for a time, then recover, and go for a specified period (typically six months) without benefits.

2. Nonforfeiture benefits return a portion of premiums or keep a lesser amount of insurance in force if you let the policy lapse. This provision, required by some states, adds to the cost of the policy.

Back to Top

OneSource Insurance Group • 5315 N. Towne Centre Dr. • Ozark. Missouri 65721 • Phone: 417-724-1700 • Fax: 417-724-1723 • Email: mark.acre@onesourcegroup.net