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HEALTH INSURANCE 101 FOR THE FIRST-TIME MEDICARE ENROLLEE

Updated: Nov 14, 2023



Choosing a new health insurance plan can be a tricky process for a seasoned policy holder, let alone for a first-time buyer. With so many plan options, endless jargon, and countless figures to compare, finding that just-right Medicare coverage could present some challenges. For those who’ve spent decades with employer-provided coverage and are now looking at signing up for Medicare for the first time, the process could feel especially daunting. Zinc is here to tell you that it’s well within reach. Let’s get into some basics along with specific things you’ll need to know, no matter your healthcare needs. Our helpful guide will answer some big questions about what to know when you’re shopping for a Medicare policy. Why Is Health Insurance So Important? No matter your age––whether you’re young in years, or young at heart––that accident or serious illness you never expected could be lurking right around the proverbial corner. Sooner or later we’re all touched by the rougher side of life, in the form of health conditions that require professional attention and care. And of course that skilled care comes at a cost that’s often higher than the average person can comfortably afford. Folks who have a solid healthcare policy can avoid severe financial burdens while also having access to preventive services that can go far to preserve and protect health and wellbeing. In the end, it’s a net positive to have health insurance you can trust. And here’s a fact that might supersede other reasons––your state might require it. Public vs. Private Health Insurance If you’re working on your 65th spin around the sun, congratulations! That’s a great thing to celebrate. With age, comes change, and that’s definitely true in the healthcare arena, where there are distinct differences you’ll note when transitioning between private and public health insurance. Just as it sounds, private health insurance is a product/service offered by privately-held companies who offer various levels of plans that anyone eligible can purchase for themselves or their family. These companies are subject to government regulations, but they differ from public healthcare in several ways. Some plans that are typical include: Exclusive Provider Organization (EPO); Health Maintenance Organization (HMO); Point of Service (POS); and Preferred Provider Organization (PPO). A Zinc agent will be happy to explain the differences, and stay tuned to this space for upcoming articles that delve a bit deeper into this topic. On the other hand, public healthcare–e.g., Medicaid, Medicare and the Child’s Health Insurance Program (CHIP)–is run by The Centers for Medicare & Medicaid Services and funded by a combination of social security, Medicare taxes, Medicare premiums, and the federal government. Typical plan types include: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-for-Service (PFFS), and Special Needs Plans (SNPs). One fundamental difference between public and private health insurance is eligibility, and criteria for public healthcare include age, income level, disability, or certain chronic illnesses. Another difference is that Medicare is individual insurance, not family insurance, and usually does not include spouses and children––each person must qualify on their own. It’s a misnomer that public healthcare is free. You’re still responsible for premiums, deductibles, and out-of-pocket expenses but they’re typically much lower than they would be with private insurance. Recent years and legislation have expanded Medicare benefits to include more preventive care, drug coverage, cancer screenings, telehealth counseling, and an annual wellness visit. In general, any American who is turning 65 years old will want to take the time to enroll for Medicare coverage, even if they already have their own policy. It’s pretty easy to switch coverage over, and your trusted Zinc agent is always on hand to help and make sure you’re working within the initial enrollment period and don’t encounter any gap in coverage. If you’re still working and unsure of whether to keep your current personal or employer-provided policy, chat with a benefits administrator or an insurance agent to get a grasp on any rules at play that could affect coverage for you or your dependents before deciding to enroll for Medicare. What Benefits Can Health Insurance Provide? The premiums you pay to hold a health insurance policy entitle you to countless benefits. If you qualify for Medicare coverage, you should expect to have these essential health benefits, as they apply to your circumstances:

  • Outpatient care

  • Emergency services

  • Hospitalization

  • Pregnancy, maternity, and newborn care

  • Mental health and substance use help

  • Prescription drug availability

  • Rehabilitative services and devices

  • Laboratory services

  • Preventive and wellness services

  • Chronic disease management

  • Pediatric services

Unlike private health insurance plans that restrict your health provider network, you can go to any doctor or hospital that takes Medicare, anywhere in the country. And in general, you can see specialists without a referral. But very much like traditional private insurance, Medicare is split into various plans, each of which offers its own unique coverage options. Other than the very real practical help that insurance offers, through lower rates for care and some care being offered at no cost, having a reliable policy also enables you to have regular contact with a personal physician. That builds a relationship and a health history that can be invaluable when you do need help. What Factors Determine the Cost of Health Insurance? Health insurance premiums can vary greatly, and some of the factors behind the difference are often out of our control. Because Medicare health plans are offered by private companies that contract with the program, variations factor into each company’s parameters for underwriting. For instance, age and location of residence are generally large players in deciding the price. Certain state and local rules, cost of living, and competition can also play a role. Others are more within the policyholder’s control, like tobacco use and the level of deductible you choose. But there are two important factors that cannot be used by companies to increase your premiums: gender and medical history. What are Supplemental Health Insurance Benefits? It’s a bit counterintuitive, but even though your dental, eye, and auditory health are tied up in your overall physical health, they aren’t generally included in a traditional healthcare policy, Medicare or otherwise. For this and other reasons, supplemental health policies exist, offering specific coverage options for dental care, vision care, and other specific coverage options. For new Medicare enrollees, you’ll want to investigate the coverage options available in the various Medicare Advantage plans as add-ons to your original Medicare policy. They basically tack on additional coverage that kicks in when the financial demand or the care needed is beyond what your main policy can handle and when you need additional funds for out-of-pocket costs. When Is the Best Time to Buy Medicare Insurance? Most everyone has heard the term “open enrollment,” and to put it simply that just means that there is a set aside time frame during which insurance companies allow folks to apply for and open new policies. For Medicare plans, that time runs annually from October 15 to December 7 for main policies, and January 1 through March 31 for Medicare Advantage Plans. But there are some special exceptions that will enable you to apply for coverage outside of these dates. If you are signing up for the first time, there is a special Initial Enrollment time frame that applies. How to Compare Medicare Health Insurance Plans Online Searching for the right health insurance plan can be complicated, to say the least. But if you’re armed with a few points of knowledge, you’ll fare far better. For traditional plans and Medicare coverage alike, experts recommend determining how much you can afford to pay, and whether that’s upfront or at the time of service. It’s also important to focus on total annual cost, which includes premiums, deductibles, and maximum out-of-pocket expenses. Of course you’ll also need to consider how you generally use your health insurance. While you can’t foresee a car accident or the diagnosis of a chronic illness, you do know which doctors and specialists you regularly see, along with medications that you regularly take. If medication coverage is important to you, that should also be factored into your plan. One vital point is to make sure that all the doctors you see accept Medicare, even those who only require visits every few years. This will help to avoid exorbitant out-of-pocket costs for care. Defining Terms While you’re perusing available coverage options, you’ll probably come across your fair share of jargon and insurance-heavy terminology. Depending on your background and experience with purchasing insurance, you could be able to rattle off definitions, no problem. But sometimes we need a little refresher. So here are some basic definitions for some common terms:

  • Deductible: the amount of money you need to pay out-of-pocket before the plan kicks in and offers cost sharing or a discounted rate of care

  • Copayment: the set rate for standard care like office visits, ER visits, ambulance transportation, prescriptions, and more

  • Coinsurance: after the deductible is met and cost sharing starts, the percentage that you pay for medical care, typically from 10% to 40% of the total cost

  • Out-of-pocket limit/maximum: the highest out-of-pocket amount you will ever pay per year

  • Network: the comprehensive list of facilities and individual medical professionals who have contracted to receive negotiated payments from your insurance company; if providers are out-of-network you could be completely responsible for the cost of care

How to Buy Medicare Health Insurance: Online or Through an Insurance Agent If you’re turning 65 and looking to sign up for Medicare for the first time, you’ll have questions. And more often than not, help lines can only go so far. Working with a dedicated agent builds on the trust and confidence you already share, and can clue you in to factors unique to your situation that could affect premiums or your overall insurance needs. That’s what comes with a shared history. Agents can also accurately translate jargon and terminology so you can be sure that you understand precisely what a Medicare plan is offering you. But the most important reason to use an agent when searching for a new insurance plan, is that you have a built-in advocate going forward. Insurance agents have experience evaluating health insurance plans and can help to find the best plan for you. We’re here, ready to help you find the plan that meets your needs and fits your life, right now. All that’s left to do is get in touch to start the process. Reach out to us today––we’re happy to be of service!



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This blog post does not provide insurance advice and is intended for information purposes only. It is not a substitute for professional insurance advice from a licensed representative. Never ignore professional insurance advice because of something you have read in this blog post. Contact your licensed representative if you have any questions about your insurance policy.

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