- Last Updated: 08 November 2015 08 November 2015
Medicare and COBRA
COBRA is a federal law that allows persons on Long-term Disability (LTD) or Unemployment Compensation to purchase medical insurance at a Group rate, thus reducing the cost one would pay for an individual policy.
Medicare is the federal health insurance system for people on Social Security Retirement and Disability Insurance. For those on disability insurance, an individual becomes eligible for Medicare two years after the date s/he became disabled as determined by Social Security. For instance, Social Security might determine a person became disabled one year before they applied. It may actually have taken eight months for the application to be approved, so after approval the wait might actually only be four months.
Once the waiting period is over, an individual will receive a letter of notification of eligibility for Medicare. No matter what a person does next, s/he will automatically be signed up for Medicare Part A, which is the hospitalization portion of the insurance.
What happens next with the other portions and options of Medicare becomes the decision of the individual. This next section will summarize the various choices involved in obtaining Medicare.
Obtaining Medicare means making a choice between two different Medicare Medical Insurance systems: Original Medicare, and Medicare Advantage.
Original Medicare works directly through Social Security Medicare and consists of Part A—Hospitalization; Part B—Doctors' visits and outpatient services; and Part D— Prescription Drug benefits.
Under this Original Medicare system you can choose any doctor who is "Medicare approved." About 80% of all doctors in the U.S. are Medicare approved. Most doctors affiliated with hospitals take Medicare patients. Doctors are paid a fixed amount for each medical service as determined by Medicare. They agree, under most circumstances, to accept the fee Medicare will pay. These fees are generally lower than what a doctor will charge privately on a fee-per-service basis. Yet doctors participate because so many patients are covered, or because of medical institutional imperatives.
Unlike a Managed Care system or HMO you can choose any doctor or specialist that you wish to see. There is no necessity for choosing an in-plan doctor, or needing a plan referral for a specialist. In many cases, you can go to a doctor yourself; in other cases you simply need your own doctor to say that a procedure or a visit to a specialist is "medically-necessary." This is one of the advantages of Original Medicare as opposed to Medicare Advantage; see below.
Medicare Supplement policies
Part A and Part B cover only 80% of covered medical costs. Hence a person would be required to pay 20% of most medical bills. To meet these extra costs, private insurance companies offer what are generically called Medicare supplement policies. These policies for a premium cost paid by you cover the 20% gap, as well as deductibles, and offer some extra services as well. To be effectively covered, one should, if possible, buy a Medicare supplement policy. Under Medicare Parts A and B, with a Medicare supplement policy, most medical procedures and visits are covered. Institutional nursing home care, except for skilled nursing care, is not covered.
Prescription Drug Coverage—Part D
The last part of Original Medicare is prescription coverage—Part D. When you are accepted by Medicare, you will be given an opportunity to purchase, for a monthly premium, Medicare Part D prescription drug coverage from a private insurance company. You should do so if at all possible, since to do so at a later time incurs significant financial penalties. Some companies offer only one plan; other companies have different plans at different costs which offer a either decreased or increased benefit options.
Most prescription drug plans offer three levels of coverage. The costs can vary considerably amongst the Medicare contracted companies and by plan selected.
These plans use formularies (preferred drug and price lists) and a tier system, usually three tiers, with an additional top tier for specialty drugs (advanced treatments for illnesses like cancer or MS) which are paid at a determined percentage of cost. It is important to compare coverage for your routine medications under several company plans, because some plan formularies can be quite limited.
Co-payments can also vary by plan and increase by each tier, and those in the highest tier can be quite costly. This is another important consideration or even challenge when doctors might like to try you on some of the newly released drugs. Bring your formulary book with you to appointments, so you can determine whether you can afford a particular medication.
There is cap on the money spent by yourself and your plan towards covered drugs—this amount can change (in 2016, the cap was $3310), at which point, you enter "coverage gap" (a.k.a. a "donut hole"). You will then have to pay approximately the next $3,000 out-of-pocket. After this threshold is reached, you will obtain comprehensive coverage. Some "premier" plans provide some coverage within the "donut hole."
Paying for Medicare
Under Original Medicare, in addition to the cost for a Medicare supplement policy, Social Security deducts money from your Social Security check as a payment for Part B. When you are first offered Medicare insurance, you are given an option whether or not to take Part B. Some people who are insured on another policy or feel they cannot afford the deduction will consider not accepting Part B. However, it must be considered that there will be a heavy dollar penalty which increases with each month, should the person later want or need Part B. The same is the case with Part D. There is a premium for Part D. If you do not take Part D when it is first offered, again there will be a serious penalty should you want it or need it in the future.
Unlike Original Medicare, which is administered through Medicare (Social Security Administration), Medicare Advantage plans are obtained through major private insurance companies. These plans roll Medicare Parts A, B, and D into one policy which you purchase for a certain amount per month. These are managed care plans of some sort, so you can only see permitted providers. Some of these plans are perferred-provider only (PPO), so the choice is wider, but the cost is more expensive. These plans may have a few more, and sometimes less, services than Original Medicare. You will need to check the policies and compare them carefully with original Medicare. These Advantage Plans also have deductibles and co-payments for most services, including major yearly deductibles for hospitalizations. Therefore, although the monthly premium may be less than a combined Part B, a Medex policy and the premium for Part D under original Medicare, you may end up paying more after the one premium, co-payments and deductibles. These plans may also include Part D, depending on which plan you buy. The lower the premium the less coverage and vice-versa.
Medicare Advantage Plans make money by contracting with Social Security to pay for a portion your coverage, plus your monthly premium, plus deductibles and co-payments. You should compare costs, benefits, and access to physicians carefully before choosing one of the two Medicare approaches. Many insurance companies provide a variety of plans; again for a lower premium you receive less coverage and vice-versa.