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.
Medicare and Medicaid can be a tricky subject to navigate, but they are important for a lot of people.
Sommer explained, “There’s four types of Medicare. Part A, that is your inpatient hospital coverage. Part B is what you use at the doctor’s office for the outpatient medical coverage, if you got to go to your primary care, a specialist that is all under Part B. Part C, it offers an alternative way to receive your Medicare benefits. And then Part D is your prescription drug plan. Really the it’s Part A, Part B and Part D are the important ones, because they’re the ones that are going to do your hospital, your doctor and your drugs. Those are the three main ones that you look to have when you are eligible for Medicare. And of course, this is for anyone ages 65 or older.”
It can all get pretty confusing.
Sommer said, “Sometimes people get confused when they talk about Medicare and Medicaid. Medicare is a federally funded program that you get when you’re over the age of 65. Medicaid is state by state and you have to meet certain financial hardships, usually, to get Medicaid. Not everybody can get Medicaid. Then it also is not transferable from state to state. So a lot of times, if you have Medicaid, like, say, in the state of Florida, and you decide you want to move to, I don’t know, the state of New Jersey, your Medicaid doesn’t transfer. You would have to go through all the steps in the state that you move to to continue to receive those Medicaid benefits.”
It’s important to make the distinction between some of the terms, like deductible, copay, etc.
Sommer said, “When we get into commercial plans, that’s usually what could be offered through your employer, or if you’re going to go through the open market, Obamacare, the Affordable Care, these are the commercial plans that you’re going to end up getting. Be careful to these terms, deductible, co pay, co insurance and out of pocket max. This is where commercial insurance get confusing. It can have one of these, two of these, three of these, all of these. So these are the terms you need to look at. If you’re talking to a private insurance agent or you’re getting insurance through your employer, you need to look at the plans to try and understand if all of these are going to be applicable to you, and what are the costs that come with them?”
A deductible is usually the amount you pay for your covered health care services before the insurance kicks in.
Sommer said, “So I’m sure you’ve heard like, oh, you have $1,000 out of pocket deductible, meaning every time you go to a doctor, the hospital, or if you need some type of radiology study, all of that, all of those charges get applied to your deductible, so you will have to pay more out of pocket until that deductible is met. Then sometimes you have a co pay, which is a fixed amount. Years ago, insurance companies were really good. They’d print right on your card, that your co pay at your regular doctor would say between $30 to $50 and then a lot of times, specialists can be $50 to $100 and it used to be printed right on the card. Now there’s so many different plans and insurances. I don’t see that as often, but it’s usually a fixed amount. A co insurance is a percentage of the covered healthcare cost after you pay your deductible, so that can depend on the plan. Again, you need to look for those terms. It could be 20%, 30% and sometimes you can even have a co insurance and a co pay, which makes it really confusing for people, because they think, oh, I met my deductible. I just have my co pay to pay. But then even sometimes, there’s even an additional co insurance that goes with it.”
Enrollment Dates include November 1, 2024 when open enrollment began, December 15 for coverage to start January 1 and January 15 is a deadline for open enrollment for 2025 coverage to start on February 1.
Sommer said, “When you look at commercial plans, PPO and an HMO, you’ll hear these terms a lot, especially in the Keys you have to be careful, because I know that there are a lot of HMO plans that are not accepted, and that goes for Medicare as well. You can have a Medicare HMO plan. I believe United is one of them, and Humana, you have to be careful with those, because not every provider in the Keys takes an HMO plan. It’s a Health Management Organization. PPO means it’s a Preferred Provider Organization and you can pick whatever provider you want, as long as they are in network with that plan, and you usually don’t need a referral if you need to see a specialist. An HMO, it’s a health managed organization. They manage your health care, including the network of providers. So you have to pick a provider, and then you usually need to see that provider to be referred to a specialist. So if you are having say, for example, say, you have hernia, a lot of times, you may have to go to your primary care provider first, and they have to send the referral, say to us, because you just can’t call us and say, with that type of plan, and say, I need to see the doctor. I think I have a hernia where, if you have the PPO, you can. So if you’re coming up on Medicare, like we talked about the last time, just check in with your provider, if you have one on what insurances or Medicare plans they take. It’s a lot. You really need to do your homework, because patients don’t know and they come in here very confused. They don’t even understand what they have.”
Catastrophic and short term limited plans can be tough.
Sommer said, “A lot of times younger people will get talked into these plans and basically if you’re kind of on a budget, and you don’t think you can afford, like a commercial PPO or HMO plan, they somehow find these catastrophic plans, meaning that in the event that there’s a catastrophe, life event, like an accident, or you get hurt, or, say, you come down with a sudden illness, that’s when the catastrophic plan kicks in, but they provide limited coverage, so it’s really only for an emergent situation. So for example, here in the surgery office, people will come in with hernias or a gallbladder that needs to be removed and that is considered elective, so their insurance will not cover it. So it’s almost like paying at a pocket, paying an uninsured rate because the plan you have doesn’t cover it, and they’re not cheap either. They’re pretty expensive to maintain. So those plans, they don’t cover your routine care, checkups, like I said, surgical benefits, preventative care, or any type of testing. It’s only usually on an emergent basis.”
For more information, click here: https://www.keywestsurgicalgroup.com/