Medicare Advantage plan

What is a Medicare Advantage plan? Also referred to as Medicare Part C this an alternative to original Medicare. Medicare Advantage plans are available through private insurance companies that contract with Medicare.

To be eligible for one of these plans, you must have:

  1. Original Medicare(Part A and B).
  2. Live in the service area of the plan that you are looking to purchase.
  3. Not have end-stage renal disease(with a few exceptions).


These plans must, by law, provide at least the same level of coverage as Original Medicare(Part A and B). Most of these plans also have prescription drug coverage, though there a some that do not, which is why it is important to have a good understanding of the plan you are considering. These plans may also offer additional benefits such as vision , hearing or dental coverage. If you do want prescription drug coverage, you should not enroll in a separate Medicare Prescription Drug plan.

The costs of these plans will vary from plan to plan. There are many factors to consider when purchasing a plan such as:

  1. The monthly premium for each plan. Some may be as low as $0 a month.
  2. Each plan will have a different annual deductible amount.
  3. Each plan will have a different maximum out of pocket limit that you will need to consider.
  4. Do you need vision, dental or vision coverage?
  5. Are your prescription drugs covered under the plan? What about your doctors?

A Medicare Advantage Plan may be a good choice for you, but careful review of your budget and health needs will help guide you to the right choice. Please reach out to me, Bob Jeffreys, if you would like help in reviewing what options you have. As a licensed insurance agent, I can help provide information that will help you make an informed decision.

Dysphagia

Dysphagia simply means difficulty swallowing. This is a very complex condition that can be quite serious and requires the expertise of a medical professional trained in diagnosing and treating people with this condition. It is usually a Speech Pathologist or a medical doctor. Dysphagia can occur at any age, from a wide variety of diseases, accidents or illnesses. While it is reported that approximately 22% of adults over the age of 50 years old have dysphagia, it is felt that the total number of incidents are underestimated.

There are basically three stages to the swallow mechanism which involve approximately 50 pairs of muscles and many nerves all working together to help get the food and liquids into our stomach and avoid getting into the airway. The oral stage which occurs in your mouth, involves chewing and manipulating foods and preparing to move the foods/liquids into the throat. The next stage, the pharyngeal stage, is where the foods and liquids are moved through your throat and assisted by various muscles to advance into the esophagus. The third stage, the esophageal stage, is where foods and liquids move through the esophagus into the stomach. While this is a very simplified description, be aware that this is a very complex process that involves many muscles and nerves and occurs very quickly.

Problems can occur at any point during the process and depending upon where it occurs, you will have different symptoms. Some common symptoms that someone may have would include difficulty chewing foods, holding foods or liquids(pocketing) in their mouth for extended periods of time, coughing or choking when swallowing, feeling as if something is stuck in the throat, wet sounding voice after swallowing, shortness of breath after eating/drinking, having foods “come back up” after swallowing, chest pain with meals, weight loss and developing pneumonia. While this is not an exhaustive list, this is an example of some of the things that someone may experience.

There are many different causes of dysphagia, such as a stroke, Parkinson’s disease, ALS, dementia/Alzheimer’s disease, head and neck cancer, COPD, multiple sclerosis and brain injury. Again this is not a full list, but rather just some of the reasons that may cause someone to have difficulty swallowing.

There are various tests that can help to further understand how someone is swallowing. These include a Modified Barium Swallow(MBS) which is a test where you are given various foods and liquids that have barium in them. You will then swallow these during an X-ray procedure to help determine what is happening when you swallow. A barium swallow is very similar but usually you are given just barium liquids to swallow, again during an X-ray procedure. This test usually looks at the esophagus and into the stomach for problems whereas the MBS looks more at the throat area. There are additional tests that may be needed to further evaluate the swallowing mechanism.

Just as there are various causes of dysphagia, there are various ways to treat it. Usually a Speech Pathologist is the one who will be providing this treatment. There are different ways you may be instructed to hold your head or eat/drink that can help minimize the swallow difficulty. The food or liquid texture may be altered to help compensate for the swallowing problems or you may be given exercises, targeting certain areas, that can help improve the swallow mechanism.

Dysphagia is a complex and potentially very dangerous condition that requires prompt diagnosis and treatment. Should you have any of these symptoms or know of someone who has, it is recommended that you contact your physician and discuss these issues.

ASHA is a great place to find out more information on this issue and help provide additional resources.

Medicare HMO vs PPO

What is the difference between a Medicare HMO and PPO plan? Well an HMO stands for Health Maintenance Organization and PPO stands for Preferred Provider Organization. Let’s go over some of the major differences between these two plans.

HMO :

  1. You will need to choose a primary care doctor
  2. If you need to see a specialist, you will need to go to your primary care doctor first to get a referral.
  3. Generally will have co pays for your doctor visits and services you use
  4. You will need to use the network of hospitals and doctors to obtain your medical care. If you choose to go outside of that network, your HMO plan may not cover the costs of your visit.
  5. Tends to be more affordable with lower premiums and deductibles

PPO:

  1. You do not need to choose a primary care doctor.
  2. You may see a specialist without the need of a referral from your primary care doctor
  3. May likely also have co pays for doctors visits and other services.
  4. You may see any doctor within the insurance company’s network without need of a referral.
  5. Will likely have an annual deductible and larger premiums
  6. Can generally see doctors and obtain services out of network, though you will likely pay for more of the cost of the services compared to in-network doctors and hospitals.

It is important to understand what your current healthcare needs are, as well as, what your future costs may be to help decide which type of plan may be right for you. If you choose an HMO, you will need to make certain that your list of doctors are included in that HMO plan.

You will have choices to make when it comes to choosing the type of Medicare plan that is right for you. To help make sure you are choosing the right plan for you, contact me so we can go over your options and help you make the best decision. As always, there is no cost to sit down and discuss your options.

PACE/PACENET

Do these sound familiar? They stand for Pharmaceutical Assistance Contract for the Elderly and Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier. These are Pennsylvania’s prescription assistance programs for older adults.

There are some requirements you will need to meet and your eligibility for these programs is determined by your prior year’s income. Some of the requirements are:

1)You must be 65 years of age or older

2)Be a Pennsylvania resident for at least 90 days prior to applying

3)You cannot be enrolled in Medicaid’s prescription benefit

Income eligibility for PACE is as follows: Income for PACENET is as follows:

Single person: Total income $14,500 or less Income between $14,500 and $27,500

Married: Combined income under $17,700 Combined income $17,700 and $35,500

While you are not required to have Part D coverage, you are encouraged to purchase a Part D plan as it could help you save even more money on your prescriptions. If you have PACE, then the PACE program will pay the Part D premiums for a plan that has a premium assistance agreement. If you have PACENET, then you will pay for the premium at the pharmacy when you are getting your medications. For 2019, the PACENET premium is $37.03. Also under PACENET, if you do purchase a Part D plan, you will pay the premium for the plan and not pay the PACENET premium.

There is no “donut hole” with PACE or PACENET.

For more information, you can go to the PACE/PACENET website here.

If you need help understanding how the program works just call me at 814-242-3389 or contact me here.

More information can be found below.

https://pace.now.site/

Medicare Part D

Medicare Part D otherwise known as a Prescription Drug Plan is a part of Medicare. Sometimes this is part of your Medicare Insurance, for example, if you chose a Medicare Advantage Plan. However, if you have Original Medicare, you will need to sign up for Part D.

When you first turn 65, you enter your Initial Enrollment period. This is a 7 month period of time(3 months prior to your birthday, the month of your birthday and three months after your birthday). If you will not have employer coverage, you will need to sign up for Medicare. If you just choose Part A and Part B you must sign up for Part D, otherwise you will be subject to a penalty. In 2019 that penalty is 1% of the national base premium($33.19) times the number of months you went without Part D coverage. Now this penalty is added to your monthly premium and continues every month.

So don’t forget that you will need credible Prescription Drug coverage, otherwise you will be subject to a penalty.

If you have questions, please reach out to me and I’ll help guide you through the process.

Medicare-Basics

Do you know the different parts of Medicare? There are 4 main parts. Let’s go over them very briefly here.

Part A: This is your hospital insurance. It helps to pay for things such as the cost of a semi-private room, nursing care, meals, home health, hospice and skilled nursing facility stays.

Part B: This helps to pay for things outside of the hospital such as doctor’s visits, outpatient procedures, diagnostic tests, bloodwork, chemotherapy and radiation. You will pay a premium in order to have Part B. In 2019, the premium will cost you $135.50/month.

Together, Part A and B are referred to as Original Medicare.

Part C: This is where you can purchase a Medicare Advantage Plan. These plans are private health plans that will cover your Part A, B, and sometimes Part D, all in one “bundle.” You will still pay your Part B premium if you purchase one of these plans. These Advantage Plans may also offer additional benefits such as vision, dental and hearing coverage. There are usually different options you have when choosing one of these plans so it is important to look at all of your options before deciding on one. There is much more to talk about with these Advantage Plans which will be covered in future posts.

Part D: This is for your prescription drugs. You will need to choose a plan offered by a private insurance carrier. You will also pay a premium for Part D. You may have to pay a penalty if you do not sign up when you are first eligible. Keep in mind that a prescription drug plan may be included in your Medicare Advantage plan. Again, there is much more here to cover, which will be done in future posts.

This is a brief overview of the parts of Medicare. Putting it all together can take some time to understand. If you are getting ready to turn 65, reach out, and I can help guide you through the process to help you understand what choices you have.