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Health Care Reform: Better Medicare Benefits

Medicare can be confusing. With the changes coming with the Affordable Care Act, it’s a good idea to have a simple overview of the benefits coming your way. Above all, rest assured that your guaranteed benefits are protected. What’s more, there are new benefits designed to keep you healthier.

How You Get Your Medicare

Most people with Medicare get their health care through the Original Medicare Plan. Regardless of the Health Care law, it is a good idea to review how you receive your Medicare coverage each year during the fall annual enrollment period to make sure that your coverage is still right for you.

Most Everyone Will be Required to Have Health Insurance

Under the Health Care Law, as of January 1, 2014, most Americans will be required to have health insurance if they can afford coverage—people whose incomes fall below the guidelines set will not be penalized. Having Medicare fulfills this requirement. If you are entitled to Medicare, sign up for it, The penalty for not having insurance in 2014 is $95 per adult and $47.50 per child and the fee is capped at $285 or one percent of household income. Each year the penalty increases.

Free Preventive Care and Annual Checkups

If you are a Medicare beneficiary, you’ll no longer have to pay for preventive care services that are approved by Medicare. These include a yearly wellness visit, plus immunizations, screenings for diabetes and cholesterol, mammograms, colonoscopies and other preventive screenings. You’ll also be able to work with your doctor to create a plan to keep you healthy.

Closing the Doughnut Hole

If you have Medicare Part D, you’ll be happy to know that the doughnut hole will gradually disappear and will close by 2020. If you’re new to Medicare, the doughnut hole is a gap in your drug coverage under Medicare Part D. This plan covers up to $2,970 for prescription medications each year. Once you reach that limit, your prescription benefits are reduced. That’s when you are in the doughnut hole, otherwise known as the gap. While you’re in the doughnut hole, your copay for brand medications rises to 47.5% and 79% for generic medications. You pay this percentage on your prescription drugs until you have spent $4,750.

In 2014, you’ll get a 52.5% discount on brand name prescription medications and a 28% discount on generic medications while you’re in the doughnut hole or gap. By 2015, the discount percentages increase to 55% and 35%.

Each year the gap will get smaller until 2020 when you’ll pay 25% for all prescriptions, whether brand or generic.

Access to Your Doctor or Nurse

Your primary care physician or nurse will receive bonus payments for providing quality care. This motivates them to offer better quality care and to make it easier for you to get in to see them.

If you live in an area where there is a doctor shortage, your doctor or nurse will receive extra payments to provide care. This motivates them to make it easier for you to get an office appointment.

If you live in a rural area, there are special protections for the hospitals you might go to. Very small rural hospitals don’t treat many Medicare patients. They will receive bonuses to motivate them to treat more.

Changes to Income Related Medicare Premiums

There are two important changes in the premiums for people with higher incomes. If your income is above a certain level, you currently pay a higher premium for Medicare Part B The income level starts at $85,000 for individuals and $175,000 for married couples.

Higher income individuals will now have to pay higher premiums for Medicare Part D coverage, just like they do now for Part B.

The law also freezes 2010 income levels until 2020.

Changes to Medicare Advantage Plans

Medicare Advantage, otherwise known as Medicare Part C, is offered through private companies. You still can choose either Original Medicare or a Medicare Advantage plan.

The new law states that Medicare will be paying less to some Medicare Advantage Plans. What this means to you is that your Medicare Advantage Plan may cut some benefits such as dental care or gym memberships or your plan might increase what you pay for co-insurance or co-payments. Pay close attention to the information you receive from your Medicare Advantage plan as they will inform you of changes. If you have questions about your plan’s changes, you can call your plan directly or call Medicare (1-800-633-4227) and speak to a counselor about your options.

The good news is that the health care law rewards Medicare Advantage plans that provide high quality care. There is a new rating system for them. You can check your plan’s rating system on the Medicare website at

You will be notified about any changes to your Medicare Advantage plan during open enrollment. Go to to find out about any changes that apply to you and your situation.

Reduction of Payments to Medicare Providers

Most Medicare payments to providers change each year according to the growth in the economy. In 2010, a reduction in payments was implemented to certain providers, hospitals, home health agencies, skilled nursing facilities and hospices. This could mean that fewer providers will accept Medicare. Be sure to ask ahead of time if your provider still takes Medicare.

Health Insurance Exchanges: The Health Insurance Marketplace

Some seniors are confused about the Health Insurance Marketplace and wonder if they have to do something if they have Medicare. Medicare is not part of the Health Insurance Marketplace. If you have Medicare, you do not need to do anything. Your Medicare benefits are protected. The Health Insurance Marketplace is a way for people without Medicare and who need health insurance to find, compare and buy a health insurance plan. If you’re under 65 and need health insurance, you can learn about plans in your state beginning on October 1, 2013.


Every year Medicare beneficiaries are targets of scams during the open enrollment period that starts October 15. This year scammers are also making use of the changes in the health care reform. Here’s what to look out for:

  1. The scammer poses as a member of your health care plan or as an agent of the government. You might receive a phone call from one of these scammers asking for your Medicare information. He/she might ask you for your Medicare number, which is the same as your Social Security number. If anyone asks you for this do not give it to them!
  2. Another type of scam is where the scammer poses as an employee of the federal government and says that you will be receiving a new health insurance card under the Affordable Care Act. He/she will ask you for more information. Don’t give it to them!
  3. Another scam is fake online health exchanges. The fake websites have the word “exchange” in the heading.
  4. If anyone contacts you either by phone, email or mail claiming to be a marketplace “navigator” and you didn’t request the call, know that this is a scam. Beware. Do not give out any of your personal information. Note that there are true navigators—government representatives who can help answer your questions and guide you, but you will be the one to initiate the call through a marketplace.
For more information about Medicare scams and fraud, go to Senior Medicare Patrol or call Medicare at 1-800-MEDICARE.