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Healthcare insurance: Medicare vs. Managed Medicare vs. Secondary Policies

Healthcare insurance seems complicated and may overwhelm patients and families, especially when they need help for a medically complex child. Here’s what you need to know about Medicare and Managed Medicare, as well as secondary policies.

What is Medicare?

Medicare is a government health insurance offered to US citizens over the age of 65, certain people with disabilities, and people with end-stage renal disease (ESRD). Part A covers care in a hospital or facility, such as Nexus Health Systems, and also covers home health; Part B covers other medically necessary services such as preventative services; Part D covers prescription drugs.

Most people like having Medicare because it offers a wide variety of providers, does not require prior authorization for services or providers, and is accepted at most facilities. There are copays associated with Medicare, such as provider services or extended inpatient services. For instance, you are responsible for 20% of the Medicare-approved amount for most doctor services, including doctor services while you are in the hospital.

What is Managed Medicare?

Managed Medicare, also called Medicare Advantage Plans, are plans offered by private companies that work with Medicare. They provide Part A and Part B benefits, but they pay doctors and facilities directly, and they also require prior authorization for some services and referrals to see some specialists. Patients who have Advantage plans generally have lower out-of-pocket costs than patients with straight Medicare but may have fewer choices of doctors and hospitals. Nexus Health Systems accepts most Medicare Advantage Plans.

What are Medicare Supplemental Policies?

Medicare supplemental policies are policies sold by private companies that cover some costs that original Medicare does not cover such as copayments, coinsurance, and deductibles. You must be enrolled in Medicare to get these plans. These policies may require a monthly premium but will help avoid surprise expenses. For instance, Medicare covers 60 days of inpatient care a year at 100%. After 60 days, Medicare will cover an additional 30 days, but there is a copay of $341.00 a day. Supplemental policies cover these kinds of copayments. Nexus Health Systems accepts almost all secondary policies.

Insurance & Treatment Planning

Treatment plans and length of stay at any facility are determined by a patient’s illness and needs. All facilities, however, have to follow Medicare guidelines when considering levels of care or care plans. Medicare Advantage plans may have some extra requirements regarding which levels of care and which facilities are covered by a particular plan.

Case managers at Nexus Health Systems are available to help explain what is available and the anticipated length of stay on a case-by-case basis. They can also discuss your care plan with your providers and help you coordinate your next steps. Our goal is not just to get you to the next level of care, but to help you and your family develop a full plan to manage your chronic and acute conditions to keep you out of the hospital. When you come to a Nexus facility, a case manager should visit you within 48 hours of your arrival, or the next business day if you arrive on a weekend.

Nexus Health Systems cannot recommend any type or brand of insurance, but case managers can help you evaluate your health and try to anticipate medical needs. Open enrollment generally takes place at the end of every year, and, at that time, members can evaluate their coverage and compare Medicare and Medicare Advantage plans. There are many things to consider including out-of-pocket costs, premium costs, planned surgeries, and chronic conditions. Don’t be influenced by television commercials, free lunches, or immediate perks. Carefully weigh your estimated medical costs for the year against income, premium costs and plan benefits. Medicare.gov is the official government website and has user-friendly information. Be very careful not to just type “Medicare” into the internet and hope for unbiased information; you have to use the Medicare.gov website to make sure you are getting accurate information.

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