Understanding Medicare versus Medicare Advantage

As individuals approach retirement age, understanding their healthcare options becomes increasingly important. Medicare, the federal health insurance program for Americans aged 65 and older, offers two primary paths: Traditional Medicare and Medicare Advantage. Each option has its own set of pros and cons, making it essential for individuals to weigh their options carefully based on their unique healthcare needs and preferences.

Traditional Medicare, often referred to as Original Medicare, consists of Part A (Hospital Insurance) and Part B (Medical Insurance). It provides coverage for hospital stays, doctor visits, medical tests, and some preventive services. With Traditional Medicare, individuals have the freedom to choose any healthcare provider that accepts Medicare, giving them flexibility in accessing care nationwide. Additionally, enrollees can pair Traditional Medicare with a standalone Part D prescription drug plan and/or a supplemental Medigap policy to help cover out-of-pocket costs.

On the other hand, Medicare Advantage, also known as Medicare Part C, offers an alternative way to receive Medicare benefits through private insurance companies approved by Medicare. These plans typically include all the benefits of Traditional Medicare (Parts A and B) and often additional services such as prescription drug coverage (Part D), dental, vision, and hearing benefits. Medicare Advantage plans may also feature cost-saving measures like lower premiums, out-of-pocket maximums, and coordinated care networks, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs).

So, how do you decide between Medicare Advantage and Traditional Medicare? It ultimately boils down to individual preferences and healthcare needs. Traditional Medicare offers more flexibility in choosing healthcare providers, especially for individuals who travel frequently or have complex medical needs requiring specialist care. On the other hand, Medicare Advantage plans may offer additional benefits and cost-saving opportunities, but typically come with network restrictions and may require referrals for specialist visits.

When weighing your options, consider factors such as your budget, preferred doctors and hospitals, anticipated healthcare needs, prescription drug coverage requirements, and the level of coverage and additional benefits offered by each plan. Additionally, it’s essential to review plan details annually during the Medicare Open Enrollment Period (October 15th to December 7th) to ensure your chosen plan continues to meet your evolving healthcare needs.

In conclusion, both Medicare Advantage and Traditional Medicare offer comprehensive healthcare coverage for individuals aged 65 and older, each with its own set of advantages and considerations. By understanding the differences between the two options and carefully evaluating your priorities and healthcare needs, you can make an informed decision that best aligns with your long-term health and financial goals. Whether you opt for the flexibility of Traditional Medicare or the added benefits of Medicare Advantage, the key is to choose a plan that provides the coverage and peace of mind you deserve in your retirement years.

What makes someone eligible for Hospice? Part 1

Hospice care is a crucial aspect of healthcare designed to provide comfort, support, and dignity to individuals facing terminal illnesses. For those eligible for Medicare, understanding the coverage and services offered under Medicare Hospice benefits is essential. In this blog post, we will delve into the specifics of what Medicare pays for in hospice care, helping individuals and their families navigate this challenging but crucial aspect of end-of-life care.

I. Eligibility Criteria for Medicare Hospice Benefits:

Before exploring the services covered by Medicare Hospice benefits, it’s important to understand who qualifies for this support. Generally, individuals must meet the following criteria:

  1. Medicare Enrollment:
    • The patient should be eligible for Medicare Part A.
    • The patient should be receiving care from a Medicare-approved hospice provider.
  2. Terminal Illness Diagnosis:
    • A doctor and the hospice medical director must certify that the patient has a life expectancy of six months or less if the illness runs its normal course.

II. Covered Services under Medicare Hospice Benefits:

Medicare Hospice benefits provide a comprehensive range of services to address the physical, emotional, and spiritual needs of patients during their end-of-life journey. Some of the key services covered include:

  1. Medical Care:
    • All necessary medical services related to the terminal illness are covered, including doctor visits, nursing care, and medical equipment.
  2. Prescription Drugs:
    • Medications directly related to the terminal illness and symptom management are covered. This includes pain relief, symptom control, and other necessary drugs.
  3. Hospice Aide and Homemaker Services:
    • Trained hospice aides assist with personal care, bathing, and other daily activities. Homemaker services may include light housekeeping.
  4. Counseling Services:
    • Medicare covers counseling services, including emotional and spiritual support for both the patient and their family members.
  5. Respite Care:
    • In situations where caregivers need a break, Medicare provides short-term respite care in a Medicare-approved facility.
  6. Medical Social Services:
    • Social workers can provide counseling and help navigate the emotional and practical challenges associated with end-of-life care.
  7. Grief and Loss Counseling:
    • After the patient’s passing, Medicare continues to offer bereavement counseling and support for the family.

III. What Medicare Hospice Does Not Cover:

While Medicare Hospice benefits cover a wide array of services, it’s important to note that certain services are not included. These may include:

  1. Treatment for the Terminal Illness:
    • Hospice focuses on comfort care rather than curative treatment. Therefore, Medicare does not cover treatments intended to cure the terminal illness.
  2. Room and Board:
    • If a patient resides in a nursing home or hospice facility, Medicare does not cover the costs of room and board.
  3. Emergency Room Visits and Hospital Stays:
    • Unless pre-approved by the hospice team, Medicare does not cover emergency room visits or hospital stays unrelated to the terminal illness.

Navigating the complexities of end-of-life care can be challenging, but understanding the comprehensive support offered by Medicare Hospice benefits can provide much-needed clarity and assistance during a difficult time. By ensuring eligibility and being aware of the covered services, individuals and their families can make informed decisions that prioritize comfort, dignity, and support for their loved ones in their final months.

What are the quality ratings for hospice?

Medicare is intentional to provide open and transparent information about agencies that serve hospice as part of the Medicare benefit.

Agencies must convey the typical conditions they treat and therefore can claim expertise in providing services for end-of-life. Diagnoses that are typically identified for hospice services under Medicare include:

  1. Cancer
  2. Renal Failure
  3. Dementia
  4. Cardiac Disease
  6. Liver Disease
  7. Pulmonary Disease
  8. Neurologic Disease
  9. Stroke or Coma

Medicare requires agencies display where they provide services. This information is different from where they are eligible to provide services. Typical location include: home, assisted living facility, skilled nursing facility, inpatient hospital facility, inpatient hospice facility, or other locations.

Hospice includes 4 levels of care. Those are:

a) Routine home care which is the most common and is provided with the patient is generally stable and symptoms are adequately controlled.

b) General inpatient care is a crisis-like level of care that is implemented for the short-term to support controlling pain and other symptoms. It is usually provided in the hospital or skilled nursing facility.

c) Continuous home care is a crisis-like level of care that is implemented for the short-term to support out of control pain and symptoms in the home setting.

d) Respite care is a temporary care level in a nursing home, hospice facility, or hospital to allow a family member or caregiver some time off. This level of care is not tied to the patient’s symptoms.

Hospice agencies must report what levels of care they engage in to support their patients.

Another rating is the family and caregiver experience. This rating involves the family review of communication, timeliness of services, respect for the patient, providing emotional and spiritual support, help with pain and symptoms, the training provided for the care of the patient, an overall rating, and the willingness to recommend the agency.

Medicare reviews all agency documentation and identifies the completeness of the initial nursing assessment and the visit frequencies from a nurse or social worker in the last 3 days of life. Medicare will also identify if the agency is accepting Medicare, Medicaid, and/or Medicare Advantage patients, as well as report on average how long people access hospice services through the particular agency.

For example, Elite serves both Medicare and Medicaid patients, as well as Medicare Advantage Plan recipients. Patient with Elite’s hospice services are typically receiving hospice for 56 days. The information is updated with Medicare review and state surveys. If you would like to review agencies that you are considering for hospice services, please go to medicare.gov/care-compare/