Nikki Sommer, a nurse with Key West Surgical Group, joined Good Morning Keys on KeysTalk 96.9/102.5 FM for Medical Matters this morning.
If you need health insurance, now is the time to pick a plan.
Sommer said, “If you’re uninsured, self insured or Medicare eligible, this is the time, right now we’re in the middle of the thick of it to pick your plan. So Medicare eligible patients, open enrollment started October 15, and will run through December 7. So it’s crunch time. You should really look into, if you’re a Medicare eligible to look at the different plans that are available. If you are looking for Obamacare through the Affordable Care Act, you can go to healthcare.gov, the enrollment period started November 1, and that will continue until January 15. Now, if you want coverage to start January 1 of 2025, the cutoff date for that is December 15, and then if you push it off until January 15, your coverage will start February 1 of next year.”
After the cut off date of January 15, can people still enroll?
Sommer said, “I don’t believe so. You can call insurance companies individually and try and get your own plan. I know healthcare.gov offers plans based on income, and can help guide you to the correct plan. I do believe if you do it on your own and called different individual companies, however, you’ve got to be careful with that.”
Medicare has four different plans – Part A, Part B, Part C and Part D.
Sommer said, “Part A provides your inpatient hospital coverage. Part B provides the outpatient medical coverage. That is the one when you go to the doctor, they use your Part B coverage. Part C offers an alternate way to receive your Medicare benefits, and Part D is your prescription drug coverage. So this is usually for people ages 65 or older, if you receive Medicare due to a disability, coverage may vary depending on how many quarters you put in.”
It covers 80% of Medicare contracted rate after the annual deductible is met.
Sommer said, “For years, we just had the blue and white Medicare card, it was 80/20. Medicare would cover 80% and then 20% would be your co insurance for the pharmacy, vision, dental, all of that. Now they have multiple different plans, which makes it a little complicated.”
What about supplemental plans?
Sommer said, “I always use them as an example, because just going back to my grandparents, that’s what they opted for. They had the Medicare their blue and white card, and then AARP, I guess they paid a fee every month, and that would cover your 20% and that makes it so you don’t really have to pay that much out of pocket.”
There are also private plans.
Sommer said, “This is where you it gets tricky, because there are Medicare Advantage plans. So they’re usually run by an insurance company like United or Blue Cross, Blue Shield. I think Cigna has some. But these plans, you need to make sure that your provider is participating in these plans before you go in and jump on a Medicare Advantage plan.”
Anytime you look at any kind of change in your insurance coverage, you have to make sure your providers and pharmacies recognize the plans.
Sommer said, “Medicare Advantage plans, it kind of makes it easy, because they bundle everything all in one plan. So you can get your dental, your vision, your pharmacy, along with medical that’ll cover both your doctor and the hospital in one plan without having to think about a supplemental, or I have to pay this amount for Medicare and this amount for my supplemental. So they tend to have a lower monthly premium. However, depending on the coverage, it’s in or out of network. So you if you have a Medicare Advantage plan, down here, they’re very tricky. I know that because a lot of people have plans that are accepted outside of the Keys, but in here, they tend to be out of network, so that means they have a higher co pay, higher co insurance, and a higher deductible. So sometimes a kind of backfire. So that’s why I say, if you’re here living in the Keys, and you’re looking at a Medicare Advantage plan, and you have a provider, speak to their billing department to know what advantage plans they take or do not take. AARP is always very informative, and personally, and this is just what I most likely will do when I will hit that age, unless something happens, I will probably do the blue and white card, AARP as a supplemental just to make it easy, because that tends to be taken almost everywhere, in my experience.”
Medicare and Medicaid are not the same thing.
Sommer explained, “Medicaid is state funded, and you’re eligible for Medicaid based on your income or disability. You have to have annual verification when you enroll. Medicaid also has been privatized as well, so it doesn’t transfer from state to state. So if you have Florida Medicaid and you go out of state and you go to Ohio, Ohio is not going to accept your Medicaid plan, whereas Medicare is universal, it’s more federal backing, accepted. It transfers state to state.”
Medicare is available to anybody over 65 but Medicaid is typically based on income or disability requirements.
Sommer said, “If you’re uninsured and you need immediate health care, and if you qualify, you could qualify for Medicaid.”
There are also commercial plans that are administered through employment or the open market, but that shouldn’t be confused with the market place.
Sommer said, “It is confusing. This is depending on your employer contribution. Premiums can be lower than the open market. So the open market is kind of like affordable care. Commercial plans are usually offered through your employer. But you can call Blue Cross, Blue Shield and Cigna and see what plan they can offer you, but they tend to be higher premiums. So what are the differences between these common insurance terms? You will hear these a lot, and people get these confused, what is a deductible? What is a co pay? What is a co insurance? They can be very confusing and depending on your plan, you can have one of them, you can have all of them. A deductible is the amount you pay for covered health services before your insurance pays. So a lot of times, say your insurance plan will pay 70/30 which means they pay 70% you pay 30% but sometimes you have $1,000 deductible that needs to be met. So that deductible needs to be met before they start kicking in that 70%.”
What is a co pay?
Sommer said, “Some insurances will say, we’ll pay 70%, 80% but you’re going to have a fixed co pay of $30, $40, $50. So a fixed amount is what you pay for covered health care services. Specialty services tend to have a higher co pay. So say you see a general practitioner, it can be like $30 and then sometimes when you see a specialist, it could be anywhere from $50 to $100, just depending on what you’ve negotiated or what your plan that is being offered to you, covers. Co pay and co insurance get confused all the time, because a lot of times people have a co insurance and they don’t realize it. So it’s the percentage of the cost of a covered health care cost after you pay your deductible. So 20% to 30% varies upon the plan. So it gets confusing. There are plans that have a co insurance. So when you look for insurance, a commercial insurance, you need to ask them if they all three of these things, or one of them, or two of them, however, because co insurance can really become tricky,”
For more information on Key West Surgical Group, click here: https://www.keywestsurgicalgroup.com/