最近加入了Medicare，发现申请过程中有些坑需要当心。
快到65岁时，就会接到许多要求代理Medicare的邮件和电话。比如有一天接到一个黑人小姑娘的电话，自称在一个大Medicare代理公司工作，她催促我们尽早申请Medigap，说65岁生日之前六个月就可以申请，而且月费每天都在变，越早申请越便宜。后来我们发现这都是忽悠。想把我们套牢，用她做代理。
Medicare的制度比较复杂，初到者很难搞清。联邦政府提供A部分和B部分：A部分承保住院费用，B部分承保医疗费用。这两部分被称为基本（Original） Medicare，不能通过代理人，要由申请人自己申请。如果本人或配偶在美国工作并交税10年以上，A部分的保费是零。但B部分仍有每月保费，保费根据收入而不同。基本Medicare提供的保险覆盖面有限，自己要付20%的共同保险。如果想要更好的保险，需要通过私营保险公司。
通过私营保险公司提供的品种有D部分和C部分。D部分提供处方药物的保险，要交月保费。C部分又叫Medicare Advantage（MA）。特点是牺牲广度换取深度，它提供比基本Medicare更好的福利，有基本Medicare没有的自付费用上限。牺牲资源的普遍性而得到一些基本Medicare不包括的服务：比如牙医，视力、处方药保险，健身俱乐部、免费非处方药等。MA有多种计划，HMO，PPO和MSA。HMO必须在指定的网络内看病，PPO可以到网络外看病，但要自付部分费用。MSA（Medical Saving Account）是医疗存款账户，很少人知道这种计划，我的代理就不很清楚。保险公司每年给被保险人账户里存一笔钱（2000到3000元），所有医疗费用都先从账户中出，如果费用超出，病人自付。当费用超过最高自付额后，超过的部分就全部由保险公司出。每个地区都有很多的MA计划选择（我所在的county有47种），月费从0到数百元不等。
Medigap又叫补充Medicare，有不同的计划，这些计划以字母命名，A,B,C,D, F, G,K,L,M,N，对应不同的自付额和自付比例。其中G计划是2020年以后最受欢迎的，每月除B部分的保费外，再交1百多元的保费，每年看病除了一个固定自付，不用再交钱。这个计划的优点是大部分医生都接受，资源多。可在所有的州看病, 也保部分国外医疗费用。同一计划中,有不同的公司,月费不一样，但由于标准化,提供的福利都是一样的。
Medigap的计划有三种月费模式: Community-rated :所有的人都付同样月费,与年纪无关；Issue-age-rated ：加入时年纪越低，月费越少，以后月费也不会因为年纪增加而改变；Attained-age-rated：加入时年纪越低，月费越少，但月费会因为年纪增加而增加。
常见的坑：代理一般推荐的计划是他们拿回扣高的计划。多向客户推荐Medigap的G计划。他们也常常夸大MA的坏处，比如高保费，高自付额，高自付百分比和最高自付费用限额。其实有很多MA计划是零保费（除B部分的保费外），大多数情形下零自付和合理的最高自付限额，适合比较健康的人。选择Medigap时，一般人只比较月费，不注意月费的种类。一般Attained-age-rated的计划的月费最便宜，但是随着年龄增长，可能变得并不便宜。
怎样申请：基本Medicare必须由当事人自己申请，可以通过medicare.gov网站上申请,一般一个多星期就会得到批准（对于在美国工作过的人）。得到基本Medicare号码后,就可以申请Medigap或者MA和Medicare D部分。可以通过代理，也可以在网上自己申请，通过medicare.gov的工具搜寻所在地区提供的计划并比较，到选择的公司网页上申请。自己申请的好处是针对自己的需要，比较不同公司的计划，选择一个适合自己的计划。
申请窗口和生效时间：基本Mediare和 MA，Medigap有不同的申请窗口和生效时间。基本Medicare的申请窗口是65岁生日前后3个月共7个月时间。生效时间是如果前三个月申请，生日当月1日生效；生日当月申请，30天后生效；生日的一个月后申请，申请之日起第二个月后生效；生日后两到三个月申请，申请之日起第三个月生效。如果生效日期没有正好落在一个月的首日，就会延到下一个月的第一日生效。MA和D部分的申请窗口和基本Medicare一样，也是生日前后7个月。但是生效时间不同，前三个月申请生日当月生效，生日当月及其之后申请，下个月生效。这里的坑是，如果在65岁生日后申请基本Medicare，其生效日期可能会滞后于MA或D部分的申请窗口，如果拖到基本Medicare生效的前一个月申请MA，就会错过MA的申请窗口。而Medigap的申请时间可以从得到Medicare号就开始，从B部分生效的半年内都是有效窗口。在这段窗口申请，申请人有受保障的权利（guaranteed-issue rights），任何保险公司都不能因其病史拒绝接纳或多收保费。
延迟申请罚款：基本Medicare和D部分如果在首次符合资格时未及时加入，则必须支付延迟罚款，除非申请人满足特定条件。基本Medicare的参加者必须同时有处方药保险，如果连续63天以内没有任何处方药保险（包括 Medicare D部分），则申请D部分时会有保费的延迟处罚。常见的坑是如果原来加入的MA包括处方药保险，当换到了不含处方药的Medigap时，必须在Medigap开始后的63天内参加一个D部分保险。
不同Medicare计划之间的转换：在每年年底的Open Enrollment Period（OEP）都可以选择新的Medicare计划。但选择是有限制的。首先如果你在MA计划，你可以在不同的保险公司的不同MA计划之间转换，也可以退出MA换到基本Medicare，也可以选择不同的D部分。每年1到3月，MA参加者也可以转换不同的计划。另外MA的参加者可以在前三个月内转换公司。如果MA参加者不满意当前的计划，可以在任何时间换到一个被评为5星级的计划。
从MA到medigap是一个两步过程，先退出MA，转为基本Medicare。再选择加入一个medigap计划。但是参加者如果没有guaranteed-issue rights，保险公司会审查你的以前病史，可能因为以前的病史拒绝，或者付更高的保费。下列情形有trial right，可以例外：
1. 在参加MA的第一年内，改变主意想换到Medigap；
2. 你从Medigap换到MA，在满一年之前，你想换回到Medigap。
3. 由于非自己可控的原因， 原有的MA保险覆盖丢失。
从Medigap换到MA很容易，一般在每年的OEP进行，而且转换容易，不会因以前的病史被拒绝。如果不满意，第一年可以转回去。
在Medigap不同计划之间的转换或在Medigap同一计划但不同公司之间的转换:这两种转换都可以在每年的OEP期间进行,但是除非你有guaranteed-issue权利,保险公司都可能拒绝你或者让你付更高的月费。所以第一次选择很重要。
最受欢迎的medicare计划是MA和Medigap G计划。从MA换到Medigap比从Medigap换到MA难一些，这是很多人一开始就选择Medigap的原因。很多身体好的人，担心年纪大了以后身体变差，怕以后不能进入medigap，所以在65岁一开始就选择一个Medigap G计划。用Meidigap G计划看病，除了一个初始的自付额，就不要再交钱，对常看病的人是经济的。但对于现在身体健康的人，相当于为以后生病预付长期的保费。实际上有很多MA是零保费（除B部分的保费外），零自付，大多场合下零自付百分比。最高自付限额也有限（二千多元）。即使生病也不会花很多钱。万一生一场大病，自掏腰包花费也和Medigap一年交的保费加自付额后相差不多。而不生病时，几乎是零费用。还另外有牙医、视力、听力、处方药、免费非处方药、健身俱乐部、交通和家庭看护等各种好处。如果身体好，没有病史，过几年转换到medigap也不是不可能的。另外MA还有一种MSA计划，一年不生病，账户里可存入2-3千元。万一生大病，最高自付额也就是3千元左右。如果累积数年，账户里存几万元，足以应付将来的医疗费用。 MSA的好处是可以选择任何接受Medicare的医院或医生，没有网络限制。MA计划的一个缺点的只在本州有效。所以在外州和出国旅游，都不能去看病。实际上，MA计划覆盖任何地区的急诊和紧急情况下的医药费用。而一般在外州和国外的就诊，都是急诊和紧急状况下的医疗。对这个限制不需要担心。所以如果身体比较健康，MA计划确实是一个好的选择。
没有对任何人都合适的医疗保险。不论是MA还是Medigap G，都只适应特定的人群。选择Medicare的计划，应该基于自己的身体状况，做自己的调查，不要盲目听从代理，掉到坑里。
来源: 思芦 [博客]
Medicare申请过程中需要注意的几个问题
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jacksonliam341
- 帖子： 1
- 注册时间： 周一 2月 28, 2022 11:12 am
Re: Medicare申请过程中需要注意的几个问题
As you approach 65, you get a lot of emails and calls asking for Medicare agents. For example, one day we received a call from a little black girl claiming to be working in a big Medicare agency.
She urged us to apply for Medigap as soon as possible, saying that we could apply six months before our 65th birthday, and the monthly fee was changing every day, the sooner The cheaper the application. Later we found out that it was all gimmicks. Want to lock us up and use her as a proxy.
The Medicare system is complicated, and it is difficult for newcomers to understand.The federal government offers Parts A and B: Part A covers hospital expenses and Part B covers medical expenses.
These two parts are called Basic (Original) Medicare and cannot be applied through an agent, but must be applied for by the applicant.Part A premiums are zero if you or your spouse has worked and paid taxes in the U.S. for more than 10 years. But Part B still has monthly premiums, which vary based on income.
Basic Medicare provides limited coverage and pays 20% coinsurance yourself. If you want better insurance, you need to go through a private insurance company.
Varieties offered through private insurance companies have Part D and Part C. Part D provides coverage for prescription drugs for a monthly premium. Part C is also called Medicare Advantage (MA).
Characterized by sacrificing breadth for depth, it offers better benefits than Basic Medicare, with a cap on out-of-pocket costs that Basic Medicare does not. Sacrificing universality of resources to get some services that are not covered by basic Medicare: such as dentists, vision, prescription drug insurance, health clubs, free over-the-counter drugs, etc.
There are multiple plans for MA, HMO, PPO and MSA. HMOs must see a doctor within the designated network, and PPOs can see a doctor outside the network, but they have to pay part of the cost. MSA (Medical Saving Account) is a medical savings account, very few people know this kind of plan, my agent is not very clear.
The insurance company deposits a sum of money 2,000 to 3,000 yuan into the insured's account every year, and all medical expenses are first paid out of the account. If the cost exceeds, the patient will pay by himself.
When the cost exceeds the maximum deductible, the excess will be paid by the insurance company.There are many MA plans to choose from in each region (47 in my county), with monthly fees ranging from 0 to several hundred dollars.
She urged us to apply for Medigap as soon as possible, saying that we could apply six months before our 65th birthday, and the monthly fee was changing every day, the sooner The cheaper the application. Later we found out that it was all gimmicks. Want to lock us up and use her as a proxy.
The Medicare system is complicated, and it is difficult for newcomers to understand.The federal government offers Parts A and B: Part A covers hospital expenses and Part B covers medical expenses.
These two parts are called Basic (Original) Medicare and cannot be applied through an agent, but must be applied for by the applicant.Part A premiums are zero if you or your spouse has worked and paid taxes in the U.S. for more than 10 years. But Part B still has monthly premiums, which vary based on income.
Basic Medicare provides limited coverage and pays 20% coinsurance yourself. If you want better insurance, you need to go through a private insurance company.
Varieties offered through private insurance companies have Part D and Part C. Part D provides coverage for prescription drugs for a monthly premium. Part C is also called Medicare Advantage (MA).
Characterized by sacrificing breadth for depth, it offers better benefits than Basic Medicare, with a cap on out-of-pocket costs that Basic Medicare does not. Sacrificing universality of resources to get some services that are not covered by basic Medicare: such as dentists, vision, prescription drug insurance, health clubs, free over-the-counter drugs, etc.
There are multiple plans for MA, HMO, PPO and MSA. HMOs must see a doctor within the designated network, and PPOs can see a doctor outside the network, but they have to pay part of the cost. MSA (Medical Saving Account) is a medical savings account, very few people know this kind of plan, my agent is not very clear.
The insurance company deposits a sum of money 2,000 to 3,000 yuan into the insured's account every year, and all medical expenses are first paid out of the account. If the cost exceeds, the patient will pay by himself.
When the cost exceeds the maximum deductible, the excess will be paid by the insurance company.There are many MA plans to choose from in each region (47 in my county), with monthly fees ranging from 0 to several hundred dollars.