Medicare

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Medicare is a health insurance program for persons age 65 and older, people who have received Social Security Disability benefits for 24 consecutive months, or individuals of any age with permanent kidney damage. It is administered by the Centers for Medicare and Medicaid Services (CMS) and enrollment is handled by the federal Social Security Administration. Medicare is available regardless of income or the asset levels of the individual or family.

Anyone who is a U.S. citizen or legal resident and is turning 65 is entitled to an initial enrollment period that lasts seven months. The initial enrollment period is from three (3) months before the month of their 65th birthday to three (3) months after that month. For example, if you turn 65 in June, your enrollment period is March 1 to September 30.

The different parts of Medicare:

Medicare A (Hospital Insurance)
You usually do not pay a premium for Medicare Part A coverage if you or your spouse paid Medicare taxes while working.

Medicare B (Medical Insurance)
Part B Medicare is voluntary and covers the service of doctors, out-patient care, durable medical equipment, routine mammograms for the elderly, and some other services. You are automatically enrolled in Part B when you become entitled to premium Part A benefits, unless you specify that you do not want this component. Contact the SHINE office closest to you for more information about appeals and Medicare coverage.

    What's not covered by Part A & Part B
     Medicare does not cover everything. Even if Medicare covers a service or item, you will generally have to pay your deductible, coinsurance, and/or copayments.

     Some of the items and services not covered by Medicare include:

Medicare C (Medicare Health Plans)
Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You'll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare.

    Covered services in Medicare Advantage Plans:

The plan may choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service. You can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won't pay for a service you are contemplating you will be responsible for paying all of the costs if you do not receive an advance coverage approval.

Medicare Part D (Prescription Drug Coverage)
Medicare Part D plans are prescription drug plans that work like insurance, and they're open to anyone with Medicare. Each Part D plan is different - each can cover different drugs known as formularies or be available only in a certain area. Medicare doesn't operate the plans; they are run by Medicare-approved private insurance companies.

Donut Hole - Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs.
Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs, this amount may change each year. People with Medicare who receive Extra Help paying Part D costs won't enter the coverage gap.

What Providers May & May Not Do
Unfortunately, not everyone who contacts you about Medicare coverage has the best intentions. Scam artists also follow the headlines, and they are reportedly contacting eligible people claiming to represent a Medicare Part C or D provider. In most instances what they really want is your personal information, such as your Social Security Number or your checking or credit card account numbers, which they use to try to commit financial fraud.

To protect consumers, the law is very specific about what people representing Medicare plans are NOT allowed to:

PLEASE NOTE:
Independent a
gents and brokers selling plans must be licensed by the South Dakota Division of Insurance, and the plan must tell the state which agents are selling their plans. If you suspect the person you are dealing with is not a licensed agent contact the Division of Insurance at 605-773-3563.

Protecting Your Personal Information
It's important to protect your personal information, even when you are shopping for Medicare plans. If your personal information (your Social Security, Medicare ID, credit card or bank account numbers) gets into the wrong hands, it can be misused.

Medicare Supplement (Medigap) Insurance

Medicare supplement (Medigap) Insurance is sold by private companies that can help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.

Some Medigap policies also offer coverage for services that Original Medicare doesn't cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share.

PLEASE NOTE: A Medigap policy is different from a Medicare Advantage Plan. Advantage plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.

Things to know about Medigap policies:

Insurance plans that aren't Medigap:

Private Fee-For-Service (PFFS) Plans

A Medicare Private Fee-For-Services Plan (PFFS) is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren't the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Some wonder if they can get health care from any doctor, other health care provider, or hospital? In some cases, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but you may pay more.

General Information about PFFS Plans:

Other facts you should know about this type of plan:

For more information, contact Medicare at 1-800-633-4227 or SHINE at 1-800-536-8197.

Long-Term Care Insurance

There are many different types of long-term care insurance policies on the market. Long-term care includes non-medical care for people who have a chronic illness or disability. This includes non-skilled personal care assistance with everyday activities, such as dressing, bathing, and using the bathroom. At least 70% of people over 65 will need long-term care services and support at some point. These policies cover a wide range of services including nursing home care, home health care, respite care, and adult day care. Long-term care costs can be very expensive. Medicare and most health insurance plans, including Medicare Supplement Policies (Medigap) policies don't usually pay for long-term care costs. This is why many people depend on the state Medicaid program, a long-term care policy, or their own assets to pay for long-term care.

Things to consider when purchasing a long-term care policy:

The sale of long-term care insurance is regulated by the South Dakota Division of Insurance. The Division has established some rules that carriers must meet when selling long-term care policies.
The Division has established some rules that carriers must meet when selling long-term care policies.
These rules are designed to protect consumers and to ensure seniors are getting a quality product.

Some of these include:

Once issued, the policy may not be canceled, non-renewed or otherwise terminated. Other laws and protections do exist. For more information, to file an insurance complaint, or to obtain a shopper's guide, contact the South Dakota Division of Insurance at 605-773-3563.

South Dakota's Long-Term Care Partnership Program
The South Dakota Long-Term Care Partnership Program, administered by the Department of Social Services (605-773-3165) and Division of Insurance (605-773-3563), provides an alternative to spending down or transferring assets by forming a partnership between Medicaid and private long-term care insurers.

What is long-term care & where is it provided?
Long-term care includes a wide range of services provided to people who need continued help with Activities of Daily Living, such as: bathing, dressing, eating, using the toilet, continence, transferring from a bed to a chair.

Long-term care can be provided in a variety of places, including a person's home, an assisted living facility or a nursing home. For more information please contact SD Department of Social Services at 605-773-3165.