medicare health insurance

Si alguna vez revisó sus Avisos Generales de Seguro de Salud de Medicare, probablemente haya visto que la «Cantidad Cargada» por su proveedor de Medicare por sus facturas médicas puede no ser la misma cantidad que el cargo de «Medicare Aprobado». Esto se debe a que Medicare aprobará solamente la cantidad que aparece en el plan de tarifas de Medicare para cada tipo particular de servicio de Medicare.

El plan de cuotas de Medicare es una lista que estipula la cantidad máxima que Medicare ha acordado pagar a sus proveedores contratados por Medicare por sus servicios y productos. Esto incluye a médicos, instituciones, proveedores de equipos médicos, etc. El Congreso de los Estados Unidos es responsable de establecer el plan de cuotas de Medicare. Esto se hace a través de la legislación federal, y puede cambiar de año en año.

Por qué existe

El plan de cuotas de Medicare se implementó originalmente como un método para proteger a los beneficiarios de Medicare. Antes de la existencia del plan de cuotas de Medicare, los proveedores de Medicare fueron compensados por sus servicios y productos basados en la cantidad que facturaron. Si Medicare no estuvo de acuerdo en pagar el monto total del cargo, se le permitió a los proveedores facturar al beneficiario de Medicare por el monto restante. El plan de cuotas de Medicare se implementó para ayudar a proteger a los beneficiarios de Medicare de ser responsables de los saldos pendientes de sus facturas médicas. Al establecer el plan de cuotas de Medicare, Medicare pudo limitar el monto que los proveedores de Medicare podrían pagar por cada tipo de servicio. Este límite restringió efectivamente la cantidad que los beneficiarios de Medicare podrían cargar también.

Controversia

En el 2010, el Congreso de los Estados Unidos consideró cortar muchos de los pagos en el plan de cuotas de Medicare hasta en un 25 por ciento de un esfuerzo por controlar los crecientes costos de atención médica. La propuesta fue controversial por varias razones. Principalmente, los médicos y otros proveedores médicos estaban descontentos con la perspectiva de recibir menos de Medicare por su trabajo con los beneficiarios de Medicare. Además, algunas asociaciones estaban preocupadas de que si los médicos que estuvieron con Medicare fueran obligados a tomar un importante corte en el pago de los servicios médicos, entonces los médicos decidian cancelar sus contratos con Medicare. Las asociaciones estaban preocupadas porque esto podría dejar a los beneficiarios de Medicare con menos opciones para los proveedores de Medicare en sus áreas. Debido al fuerte debate, el Congreso aprobó una legislación que amplió el actual programa de tarifas de Medicare hasta finales de 2011, dejando así tiempo para una consideración continua.

Consecuencia a las primas del seguro médico

El plan de cuotas de Medicare no afecta directamente sus primas de Medicare o sus copagos de Medicare. Sus primas de seguro médico suelen basarse en el número de beneficiarios inscritos en su plan y el costo de proporcionar seguro médico en su área. Además, las primas de Medicare para la Parte A y la Parte B de Medicare se basan principalmente en el nivel de ingresos de cada beneficiario. Sin embargo, el costo de proporcionar atención médica en su área también puede ser un factor en sus primas de seguro médico. Por lo tanto, los cambios en el programa de tarifas de Medicare pueden provocar cambios leves en su prima de seguro médico en años futuros, especialmente si tiene un Plan Medicare Advantage.

Consecuencia en la elección del proveedor

El plan de cuotas de Medicare podría afectar indirectamente a su elección de proveedores de Medicare. Los médicos de los Estados Unidos que deseen prestar servicios médicos a los beneficiarios de Medicare tienen la opción de contratar con Medicare como médico participante o no participante. Un médico participante acepta el cargo aprobado por Medicare incluido en la lista de tarifas de Medicare como pago completo por cualquier servicio médico proporcionado a un beneficiario de Medicare. Un médico no participante puede determinar caso por caso si aceptará el cargo aprobado por Medicare incluido en el plan de cuotas de Medicare como pago completo por servicios médicos proporcionados a un beneficiario de Medicare o si facturará al paciente de Medicare directamente y cobrará más que la cantidad aprobada por Medicare. Los médicos también pueden optar por el sistema de Medicare por completo y optar por ser un médico privado. Los médicos que hacen esto no pueden recibir los pagos de Medicare por los servicios médicos que proporcionan a los pacientes. Los pacientes de un médico privado también no pueden presentar reclamaciones de Medicare para el reembolso de sus facturas médicas.

A menudo se supone que si el plan de tarifas de Medicare cambia para reflejar un recorte significativo en los pagos de Medicare a los médicos, entonces muchos médicos elegirán optar por el sistema de Medicare por completo y trabajar simplemente como médicos privados. Si esto sucede, los beneficiarios de Medicare pueden encontrar que su elección de proveedores de Medicare limitada

Medicare Supplement Plan A

Medicare Supplement Plan A is also referred to as Medigap Plan A. This plan is sometimes overlooked because it has fewer benefits than other Medigap insurance plans.

What does Medicare Plan A cover though? It still covers the most important benefit, which is the 20% of outpatient medical care that Medicare doesn’t cover.

Make no mistake. Medicare Plan A pays this, so it is still a very good plan.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	❌
Medicare Part A deductible	❌
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	❌

Medicare Supplement Plan B

Medicare Supplement Plan B, also called Medigap Plan B, offers the same benefits as Plan A. In addition, it will also pay your Part A hospital deductible for you. This is a significant benefit as the deductible in 2017 is $1,316, and tends to go up slightly each year. Having Medigap Plan B means that you will never have to worry about that deductible going up.

Your hospital deductible is a per-incident deductible, not an annual one, so this is an important benefit. Medicare Plan B will pay the deductible even if you incur it more than once in the same year.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	❌
Medicare Part A deductible	✔
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	❌

Medicare Supplement Plan C

Medicare Supplement Plan C is a policy which covers nearly all of the Medicare gaps that you would usually be required to pay. The only exception is the Part B excess charges.

Excess charges are surcharges that your doctor can charge above and beyond what Medicare will reimburse. They are limited to 15% beyond what Medicare pays. Many doctors do not charge excess charges, but occasionally they do. If this concerns you, the Medigap Plan F or G might be a better choice for you than Medicare Plan C. Those two plans cover excess charges, so you won’t have to worry about asking.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	✔
Medicare Part A deductible	✔
Medicare Part B deductible	✔
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	✔

Medicare Supplement Plan D

Medicare Supplement Plan D is one of the ten Medigap options you can purchase to supplement your Original Medicare benefits. (It is not to be confused with PART D, which is for prescription drugs. You can read about Part D drug policies here.)

A Medigap Plan D policy covers most of the gaps in Medicare for you, with the exception of the Part B deductible and also any excess charges. An excess charge is an additional amount you will pay if a provider charges more than the Medicare allowed amount. You will pay out of pocket for these two minor items if you purchase a Medicare Plan D. However, the policy does cover all of the most important things, like the 20% of outpatient services that you would otherwise owe.

It’s important to compare pricing between Medigap Plan D and Plans F or G, which have richer benefits. This will help you determine if the savings is worth the additional financial exposure to you. Some people would rather pay more for their supplement if they know that all the gaps will be covered. Others don’t mind a little cost-sharing to get lower premiums.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	✔
Medicare Part A deductible	✔
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	✔

Medicare Supplement Plan F

Medicare Supplement Plan F has also been the #1 seller with The Benefit Link for many years. According to a report from America’s Health Insurance professionals, about 57% of all Medigap policies in force were a premium Medicare Plan F policy. (In recent years, Plan G has been the second most popular Medicare supplement plan, and you can read more on that below.)

A Medigap plan, or Medicare Supplement, pays after Medicare to help cover your deductibles, copays, and coinsurance that you would otherwise be responsible for. Medigap plans do not replace your Medicare Part B. You must be enrolled in both Part A and Part B first, then you are eligible to enroll in Medicare supplement Plan F.

When you add a Medicare Supplement Plan F or G to your Original Medicare benefits, your coverage will be quite comprehensive. By definition, Medigap Plan F is the Medicare supplement with the most benefits.

Medicare – Plan F

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	✔
Medicare Part A deductible	✔
Medicare Part B deductible	✔
Medicare Part B excess charges	✔
Foreign Travel Emergency (up to plan limits)	✔

Medicare Supplement Plan G

Did you know that Medicare Supplement Plan G is the second most popular Medicare supplement (next to Plan F) with our Baby Boomer clients? Today we’re going to tell you why. Everyone has heard of Plan F, but what is Medicare Supplement Plan G? What does Plan G cover?

Medicare Plan G coverage is very similar to Plan F. It offers great value for beneficiaries who are willing to pay a small annual deductible. After that, Plan G provides full coverage for all of the gaps in Medicare. It pays for your hospital deductible, copays and coinsurance. It also covers the 20% that Part B does’t cover.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	✔
Medicare Part A deductible	✔
Medicare Part B deductible	❌
Medicare Part B excess charges	✔
Foreign Travel Emergency (up to plan limits)	✔

Medicare Supplement Plan K

Medicare Supplement Plan K offers you the same basic benefits as other supplements, but with lower premiums. For example, this plan will still cover preventive care services and give you an extra year in the hospital. However, you split the cost-sharing with the insurance carrier on certain items like the Part A deductible. You also agree to pay the Part B deductible and any excess charges.

Medicare Plan K also includes a cap on your spending called an out-of-pocket maximum. For instance, let’s say you have a year with a lot of medical treatments. If your out-of-pocket spending reaches the maximum limit, then your Medigap K policy will kick in to pay all of the rest for that year.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	50%
Blood (first three pints)	50%
Hospice Care coinsurance or copayment	50%
Skilled Nursing Facility Care coinsurance	50%
Medicare Part A deductible	50%
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	❌

Medicare Supplement Plan L

Medicare Supplement Plan L policy also includes a cap on your expenses. This is referred to as your out-of-pocket limit or maximum. Medicare sets this limit annually, and in 2018, the limit for Plan L is $2,620. This means that if in any one calendar year your spending reaches $2,480 in Medicare-approved covered expenses, then the Medigap insurance carrier pays the rest. The cap makes it much easier to agree to share in 25% of the costs on the items listed because you know that even if a year of bad health occurs, you won’t have more exposure than the maximum cap figure.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	75%
Blood (first three pints)	75%
Hospice Care coinsurance or copayment	75%
Skilled Nursing Facility Care coinsurance	75%
Medicare Part A deductible	75%
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	❌

Medicare Supplement Plan M

Medicare Supplement Plan M is one of the new supplements created by the Medicare Modernization Act. It first hit the Medicare insurance market in the summer of 2010. (Sometimes we hear people call it Medicare Part M or Medigap Part M, but the correct term is Plan M.)

Medicare Plan M provides the same basic benefits as other supplements. However, it has a slightly reduced monthly premium in exchange for your willingness to pay half of your hospital deductible and all of your annual outpatient deductible. By sharing in these deductibles as well as excess charges, you get the benefit of reduced premiums.

Plan M could be a good fit for someone who doesn’t expect to visit the hospital often and feels he can afford the occasional cost-sharing. However, it’s important to have a licensed agent who specializes in Medicare supplements to help you. He or she will evaluate the differences in premiums and make sure that the savings are worth the risk of some expenses.

Medicare Part A coinsurance and coverage for hospital benefits	✔
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	✔
Medicare Part A deductible	50%
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	✔

Medicare Supplement Plan N

Medicare Supplement Plan N has been popular since it was first introduced in 2010. Also called Medigap Plan N, this option was created for consumers who like the idea of paying a lower premium in exchange for taking on a small annual deductible and some copays.

All Medicare supplement Plan N policies are the same, no matter which insurance company you choose. You can find Plan N available in many states from various well-know insurance companies.

In 2015, AHIP reported that Plan N enrollment grew by 33% between 2013 – 2014.

(You will find that sometimes people refer to Plan N as Part N, but the proper term is Plan N. Medicare itself has Parts, but when you are referring to supplemental insurance, use the word Plans.)

Medicare Part A coinsurance and coverage for hospital benefits	$20 copay for office visits; $50 copay for ER
Medicare Part B coinsurance or copayment	✔
Blood (first three pints)	✔
Hospice Care coinsurance or copayment	✔
Skilled Nursing Facility Care coinsurance	✔
Medicare Part A deductible	✔
Medicare Part B deductible	❌
Medicare Part B excess charges	❌
Foreign Travel Emergency (up to plan limits)	✔

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