Toni King is an author, columnist and radio and TV personality, and has spent more than 27 years as a top sales leader in the Medicare and health insurance fields. She has also conducted “Confused about Medicare “ workshops throughout Texas and the southeastern United States. In 2009, Toni was holding a Medicare workshop in Greenville, Mississippi, when a member of the audience asked a question about his not needing Medicare Part B. Toni met with the gentleman after the workshop and it didn’t take her long to find out that he had received wrong information from his local Social Security office. It took a couple of days to get this overwhelming problem straightened out and get him his Medicare Part B. When it was all finished, her role as an insurance agent had changed to that of advocate for people on Medicare. It was then that she took the Medicare and You handbook and put it into “people terms” so the average person could understand Medicare.
Whether Toni is consulting with a client in the office or giving a “Confused about Medicare” workshop to hundreds of people, she emphasizes her mottos: “Medicare is NOT Cookie-Cutter” and “What You Don’t Know WILL Hurt You!” Not understanding the rules and guidelines of Medicare can cause you to make costly mistakes that will last a lifetime. Whether you are helping your parents understand Medicare or choosing a plan for yourself, let Toni show you how to navigate your way through what has become the Medicare maze!
My husband, David, has been laid-off because of what is happening to the economy and rising gas prices. He is 68 and has never enrolled in Medicare. I am turning 65 this September and we both are covered under his employer’s health plan which is ending June 30.
We have been told that he will get a penalty because he is over 65 and never enrolled in Part B. I really hope NOT! I will have to enroll in COBRA until I turn 65 in September. Please explain what our Medicare enrollment options are since we are different ages and have different enrollment situations. Thanks
Great Question, Paula:
There are 2 different rules regarding enrolling in Medicare Parts A and B in your household and I will keep how to enroll in Medicare for both you and David SIMPLE!
1) David needs to apply for a SEP (Special Enrollment Period) by downloading the form CMS-L564 (Request for Employment Information) from socialsecurity.gov or email email@example.com and we will email you a form.
Have David’s Human Resources department sign off on the form and attach it to CMS- 40B (application for Medicare Part B). File both forms with your local Social Security office when applying for Medicare Part B. Advise the Social Security representative that David is losing his company benefits and needs his Part B to begin July 1.
2) Paula, your way to enroll in Medicare is simple and quite different from David’s because you are turning 65 in September. Go to www.socialsecurity.gov/benefits/medicare at least 90 days prior to turning 65 and apply online for a September 1 effective date.
This is an ALERT to the public because local Social Security offices, which were closed due to the pandemic, recently reopened. The public should call their local Social Security office directly for help filing forms to apply for Medicare Part B. Most Social Security direct phone numbers can be located by searching online for that specific office’s 800-number. Generally, the wait while holding is less than calling the main Social Security 800-number.
Below is a checklist for those enrolling in Medicare:
1) Original Medicare Part A: Covers in-patient hospital stay, skilled nursing/rehab stay, blood transfusions, home health and hospice.
2) Original Medicare Part B: Covers primary care or specialist, whether in the office or performing surgery, outpatient surgery, durable medical equipment, x-rays, CAT scans, MRIs, chemotherapy, etc.
3) Original Medicare/Medicare Advantage: Discuss with your healthcare facilities and medical professionals which Medicare plans they accept such as Original/Traditional Medicare with a Medicare Supplement or a Medicare Part C (Medicare Advantage plan such as HMO, PPO or PFFS). Research the Medicare Advantage plan’s hospital/provider online directory to be sure your physicians and hospitals are in that specific plan’s network. Call to verify they are currently in network.
4) Medicare Prescription Drug plans: Research drug plans every year to see if your standalone Prescription Drug or Medicare Advantage Plan with prescription’s formulary covers all your brand name or generic prescription drugs.
5) Long-Term Care (LTC): Consider an LTC option such as standalone LTC policies, hybrid annuities or life insurance with LTC riders, Veterans Affairs aid and attendant benefits or applying for financial help from your specific state’s Medicaid for LTC.
6) Always make copies of every document given to the Social Security office or received from the Social Security office.
Good morning, Toni:
Have been reading your column for over a year and now I need some Medicare help. I am retiring and turning 65 in October. I had a triple bi-pass January of this year. Last week I talked with the office manager at my cardiologist’s office about getting on Medicare and what I should do. She said to enroll in “Traditional Medicare.” I have no idea what “Traditional Medicare” is.
Could you please explain this and make it easy to understand? I do not want to enroll in the wrong plan and need guidance. Thank you.
— Samuel from Tampa, Fla.
I will make this as simple as I can. I have consulted with confused Americans who have PhDs in higher education and understanding Medicare just makes them want to cry!
Let’s examine just what “Traditional Medicare” is.
Most healthcare professionals call Medicare, “Traditional” Medicare, but Medicare refers to it as “Original” Medicare. You will not find “Traditional” Medicare anywhere on the medicare.gov website or in the Medicare & You handbook.
Original Medicare consists of only Medicare Parts A and B, and not the rest of the alphabet soup such as Parts C or D. Original Medicare is also known as your Medicare card or as many on Medicare refer it as the “red, white and blue card.”
There is not a network with Original Medicare, and this is very hard for those who have retired with employer group health insurance to understand, “NO Network”! If your hospital, doctor, or healthcare provider accepts Original Medicare or Medicare assignment, then they will accept “Traditional” Medicare because both are the same thing.
Now to the differences between Medicare Parts A and B:
MEDICARE PART A (In-patient Hospital Insurance) is for an in-patient hospital stay. Part A deductible for 2022 is $1,556 and has 6 deductibles in a year. Yes, Part A has a benefit period of 60 days, so every 60 days; there is a new deductible of $1556. Skilled nursing has a $0 co-pay for days 1-20, but from days 21-100, there is $194.50 co-pay per day. After day 100 in a skilled nursing facility, you pay the cost. Medicare Part A also includes hospice and home healthcare with a $0 co-pay.
MEDICARE PART B (Medical Insurance) has a premium of $170.10 which is based on income. One must enroll in Part B the correct way, especially after turning 65 and still working. Part B covers “medically necessary” services such as doctor charges for office visits, surgery for inpatient or outpatient hospital stays, outpatient hospital care/services, tests, durable medical equipment, and other medical services.
Part B has a yearly one-time deductible of $233 for 2022. Medicare pays 80% of the Medicare approved amount and you or will pay 20% of the Medicare approved amount. A Medical provider may charge $1,000 for a service, but Medicare may approve $623. It is the $623 that the 20% is applied to.
Ten days ago, I placed my mother who has Medicare in a «rehab facility» for approximately three weeks, thinking that her post-hospital therapy would go better there than it would here at home. WRONG. I enrolled my poor mother into The Halls of H*ll and now I desperately need to spring her OUT OF THERE!
My problem is this: We are fearful that she will be penalized in some way for NOT staying the entire 20 days.
Thank you in advance for the advice/help.
— Loretta from Denver
I have never seen a Medicare penalty for not spending the 20 days in a skilled nursing or rehab facility. If you feel the facility is not giving your mother the care she needs, it is her right to leave. I would report her unhappiness to the facility’s administrator.
Before trying to release her from the rehab facility, I would talk with your mother’s doctor or facility’s case manager. A better alternative than bringing her home, is hiring a personal care provider to spend time with your mother and make sure that your mother is taken care of at the rehab facility. This will take some of the burden from you since you cannot be at the rehab center 24/7.
Medicare will pay only for medically necessary health related claims. Many believe that Medicare helps with Long Term Care, but Medicare will only pay for a skilled nursing/rehab facility stay. If one cannot qualify or does not meet Medicare’s qualification for skilled nursing/rehab facility care, then they may have to pay 100% of the cost.
Skilled nursing/rehab facility has 100 days of benefit with days 1-20 having $0 co-pay per day and days 21-100 with a daily co-pay that changes each year. Medicare pays absolutely nothing for assisted living, personal care homes or extra provider care that is not medically necessary at home.
Confused and stressed-out Americans need help at home with daily routines, involving functional mobility and personal care, such as bathing, dressing, toileting, and meal preparation.
If your mother has a Long-Term Care policy, then it can help pay for non-medical service. If not, then she will have to pay for it herself until she spends down to qualify for Medicaid
There is financial help, known as the Aid and Attendant benefit from the Department of Veterans Affairs for vets and their spouses. This program is a secret that many do not know about. Over $20 billion is available to Veterans as a pension, so that a veteran or his or her spouse who needs additional care at home can get help to pay for an assisted living facility or non-medical personal care at home.
Here are tips to help you choose a non-medical provider:
— Decide if “At Home Care” is the right choice. Non-medical or At Home Care is different from home health care provided with Medicare.
— Evaluate the pros and cons of “at home non-medical caregivers,” assisted living, personal care, or nursing homes.
— Determine the cost of Long-Term Care options.
New At-Home Care Short-Term plans with very few medical underwriting questions are available nationwide. When one cannot qualify for Long-Term Care underwriting, this Short-Term Care plan is a new option.