MEDICARE ADVANTAGE PLANS
WHAT ARE MEDICARE ADVANTAGE PLANS AND MEDICARE BENEFITS?
It is that time of year again. The time for open enrollment in Medicare Advantage plans.
Medicare Advantage plans are run by private companies and Medicare is run by the federal government. However, both provide health insurance coverage. Everyone needs health insurance and this article should help you understand the differences between Medicare, Medicaid, and Medicare Advantage Plans.
Medicare is a health insurance program for people who are 65 years or older. However, if you are younger than 65 and you receive Social Security Disability benefits, then you qualify for Medicare benefits after a 29 month waiting period.
In order to obtain SSD benefits, you must apply. You can apply online at the Social Security website. It is easy to start your application for SSD benefits.
The Medicare program helps with the cost of health care, but it does not cover all medical expenses or most long term care costs. You have choices for how you get Medicare coverage. If you choose to have original Medicare (Part A and Part B) coverage, then you can buy a Medicare Supplement Insurance (Medigap) policy from a private insurance company.
Medicare benefits also come with Social Security retirement benefits. If you need more information about SSDI benefits and what happens to those benefits at retirement, read our article “When Do SSDI Benefits End?”
WHAT IS THE DIFFERENCE BETWEEN MEDICARE & MEDICAID?
Medicaid is a need based, state run program that provides for doctor visits and medications each month. It also provides nursing home care under certain conditions. Like SSI, Medicaid is subject to income and asset limits, and there are no age requirements either. Learn more about Medicaid benefits.
Medicaid usually covers doctor visits, lab work, x-rays, hospitalization, and, in some states, vision and dental appointments. Services are normally free, but in some states, patients must pay copays for some medical services.
Medicare is run by the federal government, not your state government. Medicare benefits are partly paid for with payroll taxes. There are no income or asset limits on Medicare benefits.
It covers hospitalization and skilled nursing stays (Part A), doctor visits (Part B), and medications (Part D). Medicare Advantage (Part C) is an alternative to Parts A and B (and sometimes Part D), where services are usually provided through an HMO at a low cost.
However, Medicare does require monthly premiums and sometimes deductibles and copays. But, Medicare Savings Programs can help pay the premiums for those with low income and low assets.
Not all doctors accept patients who have Medicare or Medicaid benefits. However, more doctors accept Medicare than Medicaid.
THERE IS A 29 MONTH WAITING PERIOD FOR MEDICARE BENEFITS
If you are found to be disabled by the SSA, then you will have to wait 29 months from your onset date of disability before you can get Medicare benefits. The waiting periods include a 5 month waiting period, that applies to every person who gets SSDI benefits.
Then, there is another two year waiting period after the 5 month waiting period. In other words, the 29 month waiting period will all need to go by (after the onset date of your disability) before you can get Medicare benefits.
This is the opposite of a person who receives SSI benefits. If they win SSI benefits, then they get Medicaid benefits on the date they filed their application. There is no waiting period for Medicaid benefits for those who also receive monthly SSI payments. Additionally, there is no five month waiting period for SSI benefits. Medicaid and SSI benefits begin on the date you file your application.
IS MEDICARE FAIR TO THE WORKER?
Medicaid is a social welfare program like SNAP food stamps or Temporary Assistance to Needy Families. As of 2022, nearly 89 million Americans get Medicaid. This should make you aware that a person who has worked their entire life and gets SSDI benefits at age 55, will have a 29 month waiting period before they can get Medicare benefits.
However, a person who has never worked and gets SSI benefits, will also get Medicaid benefits on the day they applied for SSI benefits. That means the person who has never worked has medical insurance as soon as they get SSI benefits. But, the person who worked from age 20 to 55, has to wait two years before they get medical insurance to cover their health problems. Does this sound fair to you?
CONGRESS FAILED TO HELP WORKING PEOPLE WHO PAID FOR THEIR BENEFITS
In so many ways, Congress failed when they created the 29 month waiting period for Medicare benefits. They left the people, who paid for their benefits through years of hard work, without health insurance. Therefore, without insurance, these workers are vulnerable to illness.
It is difficult to understand the thinking of Congress. Presumably, they are all rich people with very little understanding of how severe illness can result in the loss of a job and the loss of all savings. Not to mention the loss of a place to live.
At our firm, we meet people every week who became ill, lost their job and health insurance and then spent all of their money on medical care. Once their savings is gone, they are no longer able to pay their bills, and so they lose their home. This happens to people who work their whole lives. The Social Security system is in place so that it doesn’t happen.
Sadly, the government programs that are there to help are too slow to really offer assistance before a person loses their home or their life. Additionally, whether or not you get health insurance coverage is random. Therefore, many hard working people must rely on family for assistance while they await benefits. Finally, many die while waiting for benefits.
ARE THERE ANY EXCEPTIONS TO THE TWO YEAR WAITING PERIOD?
Yes. The SSA recognizes two exceptions to the two year waiting period rule.
First, you do not have a 2 year waiting period if you have permanent kidney failure (known as end stage renal disease or ESRD). Second, you also do not have a 2 year waiting period if you have amyotrophic lateral sclerosis (ALS). You would think that other diseases, like terminal cancer, would also be an exception to the 2 year rule. But, they they are not.
WHY IS THERE A 29 MONTH WAITING PERIOD TO GET MEDICARE?
At the outset, Medicare benefits were intended to only be paid to those people who reach the age of 65 and who will get retirement benefits from the federal government. When Medicare expanded to include people getting disability benefits, it was an expensive expansion. Congress added the two year waiting period as a cost saving measure. So, if you don’t like the waiting period, call Congress.
When Congress expanded Medicare to those with disabilities, it was their hope that during the two year waiting period people on SSDI benefits would stay insured under their former employers’ COBRA or qualify for Medicaid. However, monthly Cobra premiums are very high. Most people cannot afford such a high monthly premium. So, they choose to go without insurance.
Similarly, only a third of SSD recipients receive Medicaid coverage during the waiting period. You need to be getting SSI benefits to receive Medicaid benefits in most states. To get Medicaid, you have to have less than $2000 in the bank and very few assets.
Most people who need medical insurance and who also qualify for Medicare, have too much money to get Medicaid while waiting for Medicare. Why should the worker need to be destitute to qualify for Medicaid when they need medical insurance? Congress should fix this.
MANY SSDI RECIPIENTS DIE WHILE WAITING FOR MEDICARE BENEFITS
Over a third of SSDI recipients don’t have health insurance at some point during the Medicare waiting period. As almost 4% of those who receive SSDI benefits die while waiting for Medicare coverage. These are the people who need insurance coverage the most.
Our law firm agrees with the recent attempts to eliminate the waiting period. Unfortunately, these attempts have not been successful. Our guess is that it has not been successful because of the high cost of ending the waiting period. The cost of eliminating the waiting period is estimated to be about $10 billion per year.
Another way to put this is, the federal government saved $10 billion per year, by giving SSDI recipients a 29 month waiting period. Congress saved money, but they did it at the expense of people who need Medicare benefits the most. And worse, they saved money on the back of the people who paid for it.
IS THERE ANY OTHER WAY TO GET INSURANCE COVERAGE?
Yes. There are other ways to get medical insurance coverage.
For example, most states have a “medically needy” program that gives certain people Medicaid benefits. If you have high medical bills, but too much income to qualify for regular Medicaid, then you can still qualify for Medicaid.
In these states, Medicaid applicants can subtract their medical costs from their income in order to meet that state’s Medically Needy Income Limit (MNIL).
As another option, you can apply for Obamacare. Technically, Obamacare is just a nickname for the Affordable Care Act (ACA). Here are the things that Obamacare includes:
- All the changes that apply to the individual health insurance market (both on-exchange and off-exchange).
- Changes that apply to the small group and large group markets for employer sponsored plans.
- Medicaid expansion.
- The individual mandate and employer mandate.
- Other reforms that apply to health insurance.
DO I HAVE TO USE MEDICARE BENEFITS IF I ALREADY HAVE INSURANCE?
You cannot decline Medicare Part A, unless you are willing to pay back all the SSDI benefits you received. So you will most likely need to keep it, even if there is coverage from a spouse’s employer insurance. However, Medicare Part A is premium free for most people.
Since it is likely that it won’t cost you anything, even if you elect not to use it, you should not decline Part A. If you have employer coverage, then you have the freedom to disenroll from Part B.
WHAT IS A MEDICARE ADVANTAGE PLAN?
A Medicare Advantage plan is another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies that must follow rules set by Medicare and that are approved by the Medicare program.
If you join a Medicare Advantage Plan, then you will still have Medicare. However, with a Medicare Advantage plan, you will get the most of your Part A and Part B coverage.
Medicare Advantage Plans are “bundled” plans that include Medicare Part A. Part A covers hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B covers most doctor visits, outpatient care, medical supplies, and preventive services. Additionally, the bundled plan usually includes Medicare Part D (drug coverage).
With a Medicare Advantage Plan, you may have coverage for things original Medicare doesn’t cover. For example, vision, hearing, and dental services may be part of a bundled plan. Some plans may offer to pay to transport your to the doctor. They might also pay for drugs sold over the counter and other services that have to do with your health.
Bundled plans provide benefits to treat specific conditions. You will need to check with each private plan before you enroll to see what benefits it offers. At our law firm, we have a Medicare expert who can help you for free.
RULES FOR MEDICARE ADVANTAGE PLANS
There are rules for Medicare Advantage Plans that are set by Medicare. Medicare pays a fixed amount for your care each month to the private companies who offer these plans, so they set the rules.
However, each Medicare Advantage Plan can charge different out-of-pocket costs. Likewise, each plan can have different rules for how you get your medical services. For example, they might have rules about whether you need a referral from your primary care doctor to see a medical expert. Or, they may have rules about whether you need to go to their hospitals or use one of their doctors.
Many people don’t want to change doctors, just because their insurance changes. If you are one of the people who needs to see a certain doctor, then before you choose a Medicare Advantage plan, make sure your doctor is one they will pay for.
The other thing you need to know before you buy one of these plans, is that the rules of each plan can change year to year. Therefore, it is crucial that you examine your medical needs and what your plans offers on a yearly basis. Our law firm offers all of our clients a free review of Medicare options with our agent, Andria Summers.
ENROLLMENT FOR MEDICARE ADVANTAGE PLANS
There is also an enrollment period for the plans. For example, if you are getting SSDI benefits, after the 29 month waiting period, you can sign up for a Medicare Advantage Plan or a Medicare drug plan. You can do that during the 7-month period that:
- Starts 3 months before your 25th month of getting SSDI benefits
- Includes your 25th month of getting SSDI benefits
- Ends 3 months after your 25th month of getting SSDI benefits
CAN YOU SWITCH OR DROP A MEDICARE ADVANTAGE PLAN?
Additionally, you can join, switch, or drop a Medicare Health Plan with or without drug coverage during these times:
- Initial Enrollment Period. When you first qualify for Medicare, you can join a plan.
- Open Enrollment Period. From October 15 – December 7 each year, you can join, switch, or drop a plan. Your coverage will begin on January 1 (as long as the plan gets your request by December 7).
- Medicare Advantage Open Enrollment Period. From January 1 – March 31 each year, if you are enrolled in a Medicare Advantage Plan, then you can switch to a different Medicare Advantage Plan or switch to original Medicare (and join a separate Medicare drug plan) once during this time.
- Please note: You can only switch plans once during this period.
COSTS FOR MEDICARE ADVANTAGE PLANS
What you pay in a Medicare Advantage Plan depends on several factors. In most cases, you will need to use the doctors who are part of the plan’s network. Some plans won’t cover services from doctors outside of the plan’s network and service area.
Finally, Medicare Advantage Plans have a yearly limit on your out of pocket costs for all Part A and Part B services. Once you reach this limit, you will pay nothing for the medical and other services that Part A and Part B cover. If you have questions about taxes on SSDI and SSI benefits, read here.
DRUG COVERAGE IN MEDICARE ADVANTAGE PLANS
Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare drug plan with certain types of plans that:
- Cannot offer drug coverage (like Medicare Medical Savings Account plans)
- Choose not to offer drug coverage (like some Private Fee-for-Service plans)
You will be disenrolled from your Medicare Advantage Plan and returned to original Medicare if both of these apply: 1) You are in a Medicare Advantage HMO or PPO. 2) If you decide to join a separate Medicare drug plan.
Remember, if you join an HMO or PPO that doesn’t cover drugs, you cannot join a separate Medicare drug plan. In this case, you will need to use other medication drug coverage you have (like employer or retiree coverage), or go without drug coverage.
If you decide not to get Medicare drug coverage when you are first qualify and your other drug coverage isn’t creditable prescription drug coverage, then you may have to pay a late enrollment penalty if you join a plan later.
As you can see, Medicare Advantage plans are complex. That is why we recommend speaking to our expert, Andria Summers. She provides her services for free to all of our clients.
GET A FREE REVIEW OF YOUR BENEFITS
When you contact our law firm, you will receive a free review of your benefits. Even better, you do not have to pay any money upfront to hire us to help you with your case. We represent all of our clients on a “pay only if you win” basis. This means that if we do not win your SSDI or SSI case, you do not owe us an attorney fee.
We can also give you a free interview and discussion about your options for Medicare Advantage plans. If you have a change in circumstances, like marriage, it may also impact your Medicare benefits. Learn more about marriage and Medicare benefits.
What does a free review mean? It means that we will answer your questions about your Social Security case for free. If you don’t know how to apply for benefits, then we will help you. Likewise, if you want to become a client or you are wondering if you have a good SSD case, then we will tell you.
WHAT IS A FREE REVIEW OF YOUR BENEFITS?
You need SSD and SSI benefits and you want a great attorney to help you. As SSD attorneys, we offer a free review of your case. But, a free review does not mean we automatically become your attorney. First, we have to accept your case. We only take cases that we think have a chance of winning. Why? Because we are only paid if we win.
How do we decide whether or not to take your case? Much of our decision depends on what you tell us. Therefore, when you call, explain all of your physical and mental conditions. You also need to tell us if you have already filed for benefits. If you have, then where are you in the appeal process? Have you received a denial yet? Be ready to tell us this information.
Additionally, you will need to tell us about your medical conditions. For example, if you have anxiety, then tell us that. But also, if you have a physical condition, like back pain, then don’t forget to tell us about a back operation you may have had.
We need to know about every medical condition that keeps your from working. For some reason, people who call will usually focus on one single condition and fail to tell us all of their medical problems. Don’t do that. Help us understand everything you are going through.
WIN BENEFITS WITH OUR LAW FIRM
Our lawyers have won over 20,000 SSDI and SSI cases. This means that we have helped over 20,000 people to win Medicaid and Medicare benefits too. Also, in 30 years we have won over $100 million in back due and ongoing benefits for our clients.
You are three times more likely to win your benefits if you hire an attorney. However, you need to hire an attorney who has legal experience and understands the law. Hire a law firm, like us, that focuses only on Social Security law.
If you have a mental or physical condition that prevents you from working for over 12 months, then we can help win your benefits. You can apply for SSDI and SSI benefits on Social Security’s website.
If you need help filing your claim, then call us today. Every day you wait to file your claim is a day you lose money. Because, as you know, SSI benefits and Medicaid begin on the date of your application.
Contact us today. Take advantage of our free review of your case. Call and we will answer your questions. You can explain why your physical or mental condition prevents you from working. We will be able to tell you if you qualify for benefits.
WE WILL HELP YOU WITH YOUR MEDICARE & SSD BENEFITS
If you want to learn more about the lawyers and staff at our law firm, then read our About Us page. There you will find more information about each of our attorneys and our staff. For example, Andria Summers can help you with your Medicare plan. She can advise you how to choose the best Medicare Advantage plan. Likewise, she has also won thousands of Social Security cases.
Dianna Cannon also has over 30 years of experience helping her clients win benefits in court. Ms. Cannon also has law licenses in a number of states. For example, she has law licenses in California, Utah, and Nevada.
If you need help filing for benefits or you need to appeal a decision from the SSA, then contact our firm. We also have information about filing for benefits in California. Utah SSDI benefits information is also here on our website. Likewise, you can learn more about Nevada SSD and SSI benefits. We can help you no matter where you live.
Additionally, Brett Bunkall has experience helping people obtain their SSI and SSD benefits. He is also has a license to practice law in Utah and in Idaho. Find out more about SSD benefits in Idaho. Similarly, all of our lawyers and staff are Social Security law experts.
You can trust us to help you win benefits. Additionally, you can also trust us to help you with any questions you have about Medicare Advantage plans. Contact us today.