Medicare supplement insurance helps some residents of Texas, but not every senior citizen needs it. I belong to the latter group.
First, my Health Maintenance Organization (HMO) covers most needs of my wife and I, and we feel comfortable with the reasonable co-payments.
In addition, when the South Florida newspaper where I worked for more than three decades reneged on a free $20,000 life insurance after my retirement because of cost cutting, it did set up a $10,000 medical account that covers what my HMO in San Antonio doesn’t pay, including prescriptions.
The reason not every Texan needs a supplement policy is certain other types of health insurance cover the gaps. Seniors probably don’t need additional coverage if they:
*Have group insurance through an employer or former employer, including government or military retirement plans. That’s because those continuing to work after their 65th birthday can keep their group health insurance; likewise those covered by their employed spouse’s policy.
Many retirees who decided to remain in Greater San Antonio served in the Armed Forces and were stationed in bases around the area.
*Belong to a Medicare Advantage plan. In order to qualify, you must have both Medicare Part A and Part B, no end-stage renal disease and live in an area that offers it.
Medicare pays a monthly premium to the Medicare Advantage plan to provide health care like it does to my HMO. However, an additional premium and co-payment might be required each time the service is used.
*Receive Medicaid or are a Qualified Medicare Beneficiary. This program is for beneficiaries needing help to pay for Medicare services. First, they must have Medicare Part A, plus limited income and resources.
For those who qualify, Medicaid pays Part A and Part B premiums, plus deductibles and co-insurance amounts for Medicare services.
To refresh your memory, Medicare Part A pays for in-patient hospital services, a skilled nursing care facility after a hospital stay, plus home health and hospice care. It pays for all but the first three pints of blood in a calendar year.
Medicare Part B covers medical expenses, clinical laboratory services and outpatient hospital treatment. In most cases, Medicare pays 80 percent of covered services, including physician services and supplies. Some services are paid as a fixed co-payment under the outpatient prospective system.
To cover additional expenses, there are 10 standardized Medicare supplement insurance plans in Texas labeled “A” through “J.” Each plan offers a different combination of benefits. Plans “F” and “J” also have a high-deductible option.
Supplement insurance, which can be purchased from more companies than provide HMOs for Medicare in areas of Texas such as San Antonio, cover:
*Custodial care, such as help walking, getting in and out of bed, dressing, bathing, toileting, shopping, eating and taking medicine.
*More than 100 days of skilled nursing home care during a benefit period following a hospital stay. Medicare Part A benefit period begins the first day you receive a Medicare-covered service and ends when you’ve been out of the hospital or a skilled nursing facility for 60 consecutive days.
*Private duty nursing care.
*Most outpatient prescription drugs.
*Most dental care and dentures.
*Health care received while traveling outside the United States except under limited circumstances.
*Routine eye care, eyeglasses (except after cataract surgery) and hearing aids.
There’s an alternative to HMOs: the Preferred Provider Organization (PPO), a managed care plan available in 23 states, including Texas.
A PPO lets you go directly to a network specialist without a referral from your primary care doctor under the HMO plan.
You also have access to providers outside the network, but at higher cost-sharing amounts than network providers. These costs vary from plan to plan, but can be very high. A higher PPO premium plan usually results in a more favorable cost-sharing arrangement for the policyholder.
Seniors have only two choices of HMOs in San Antonio: Secure Horizons and Humana. Both outfits also provide supplement insurance. While every company must offer Plan A, not all plans are available in Texas.
For instance, Secure Horizons offers Plans A, C, F, high deductible F and G in the Lone Star State. E But the policy remains in effect when you move to one of two-dozen states from California to Florida.
Humana offers Plans A, B, C, F high deductible F in three areas of Texas with different rates for man and women until age 70-74. Rates rise in five-year segments until 85, but stay the same after that.
Area 3, which includes Bexar County where San Antonio is located, will cost policyholders from $30 to $45 higher than Area 1 and from $14 to $22 more in Area 2 for 2005.
Mutual of Omaha offers Plans A, C, D, F and high deductible F, plus G. Rates also differ for men and women up to age 80.
If you’re a smoker and male, charges vary according to areas. For example, 70-year-old men who use tobacco fork over more than $347 a year than non-smokers in one of four sections of the state. Female smokers in the same group pay $206 higher than their counterparts. Non-smoking 70-year-old women pay $206 more a year than those who light up.
It’s important to fully understand the policy because it can be a bit complicated. Since the Texas Department of Insurance approves Medicare senior supplement insurance sold in the state, you’re encouraged to contact the agency for any unresolved questions.
Here Are Useful Links
Texas Department of Insurance: Click on the website http://www.tdi.state.tx.us to find how to contact different units of the agency.
Secure Horizons: Phone 1-800-292-7865 or click on website www.securehorizons.com/commonPortal.
Humana: Phone 866-672-9165 or go to website http://www.humana-one.com.
Mutual of Omaha: Phone 800-775-6000 or check http://www.mutualofomaha.com.
Ace Texas Insurance: Phone 800-497-4090 or go to http://www.tex-health.com/about.html.
DiMi of Texas: Phone 800-879-1054 or check out firstname.lastname@example.org.
Texas Medicare Supplements: Phone 888-876-8798 or click on www.ValuePositive.com/r.php.