NVC Newsletter

October Speaker Series: The Medicare Maze

by Ken Mochizuki
November 2018, Volume 68, Issue 10

During her tenure as Director of Home and Community Based Services for Nikkei Concerns (now Keiro Northwest), Kara Mayeda saw the piles of healthcare-related papers on the tabletops within the homes of our Nisei elders. They were intimidated by the health insurance maze and uncertain as to what to do.          

"There was a huge need," she said at the October Speakers Series program on October 13. "There were no resources."          

She went on to become a Licensed Independent Insurance Agent and Medicare broker, joining another broker, Jerry Fujita, to address that huge need with their own company, "Retire Living Well." They work as consultants to help steer clients into appropriate health insurance plans.            

Medicare is a federally-funded program for those 65 years old or older. In her presentation, Navigating the Medicare Maze, Kara first explained the difference between "Original Medicare" and "Medicare Advantage." She also explained the “Parts" of Medicare: Part A covers hospital stays, Part B covers doctor visits and outpatient services, Part D covers prescription drugs, and Part C is Medicare Advantage.          

Under Original Medicare, Part A (funded by the federal government if the employment requirement of working for 10 years is met) covers 80 percent of the costs for hospital stays and Part B covers 80 percent of clinic and doctor visit costs. Part B requires a premium to be paid of $135.50 per month in 2019. Part D requires purchase from a private insurance company, ranging from $15 to $90 per month, depending on the drug plan, and is mandatory unless you opt for Part C, Medicare Advantage.          

Then there is the option to enroll in a Medicare Supplement or Medigap plan, which covers the 20 percent that Original Medicare does not cover. The Medigap plan is not required, but its omission would result in out-of-pocket expenses to cover that remaining 20 percent. Medigap plans, which are also provided by private insurers, range in price from $120 per month to $360 per month or more in premiums.          

Total cost per month for Original Medicare (Parts A and B) plus a Medigap plan plus Part D to cover prescriptions, would result in $271 to $536 per month in premiums. However, "everything is covered," Kara said. Under Original Medicare, there are no networks -- enabling a patient to go to any hospital or see any doctor -- and no referrals, which allows a patient to utilize the services of any specialist.          

Under Medicare Advantage (referred to as Part C), which is sold by private insurance companies, both Part A and Part B are covered, and prescription drugs are also wrapped into the plan, though they may be subject to deductible payments or co-pays with a maximum of $450 in 2019. Medicare Advantage also includes Additional Benefits, for example fitness programs (such as gym membership), vision, dental and hearing coverage – none of which is included under Original Medicare. Depending on the size of the co-pay and deductible and the number and types of Additional Benefits offered, the Medicare Advantage plans can range from $0 to $175 per month or more, depending on options selected.          

The total monthly cost for Medicare Advantage would range, on the average, from $135.50 to $311 per month, Kara said.          

However, under Medicare Advantage, coverage would be through a health care network or Health Maintenance Organization (HMO). Most Medicare Advantage plans are HMOs, Kara said, which keep patients' medical records in the HMO network and prioritizes preventative health care. HMOs require (1) a primary care doctor who provides the referrals to other specialists; and (2) there are "co-pays," out-of-pocket payments or "pay as you go" -- the patient paying only when the medical visit occurs, Kara said.          

Under Medicare Advantage, besides the HMOs, there are also some Preferred Provider Organizations (PPO) which avoid the use of (and referrals from) a primary care doctor.          

Additional Benefits under Medicare Advantage may also cover chiropractic care and naturopathy. Under Medicare Advantage, billing is through the insurance company.          

"Premiums can change year to year," she said.          

Judging from the plethora of questions directed at Kara from the sparse audience during and after her presentation, Medicare and healthcare insurance is an issue that those who are over age 65 or approaching that age need to pay attention to.          

Kara's website is www.retirelivingwell.com and she can be reached at kara@retirelivingwell.com.