How Does Health Insurance for Seniors Work in Michigan?

Michigan is home to over 10 million residents, out of which more than 18 percent are senior citizens aged over 65 years and over. Seniors tend to be more susceptible to health issues like heart disease, cancer, diabetes, hearing loss, cataracts and refractive errors, hypertension, depression, dementia, osteoarthritis, back and neck pain, and other chronic diseases. These health issues are typically expensive to manage without health insurance. Health insurance for seniors in Michigan typically covers the essential health benefits required by the Michigan Obamacare Act, such as medical care, preventative care, emergency services, hospitalization, mental health services, prescription drugs, pregnancy care, etc. Senior health insurance in Michigan typically comes in the form of:

• Medicare
• Medicare Supplement Insurance, also called Medigap coverage
• Medicare Advantage
• Long-term care insurance
  Health insurance for older adults is typically affordable. Individuals can contact health insurance agents in Michigan to enquire about affordable health insurance plans for seniors or go through the Michigan Senior Guide to Health Insurance. Individuals can also get additional information about Michigan health plans by dialing the Michigan enrolls customer service number, (800) 975-7630.

MEDICARE

Medicare in Michigan is administered by the federal government and the Michigan Health Department. It provides health coverage to older adults, aged 65 and older or persons receiving kidney dialysis treatments and qualified to get Medicare Part B. Residents can sign up for Medicare three months before they turn 65, except if they have a disability, like End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease). In such cases, Medicare can be obtained earlier. People younger than age 65 who are disabled and have been receiving Social Security benefits for two years can also get Medicare. Medicare has two main parts:

• Original Medicare
• Medicare Advantage

Original Medicare

Original Medicare provides health coverage in Michigan for most of the costs associated with approved health care services and supplies. After paying your deductible, you are required to pay your part of the costs of services and supplies as you get them. The amount you will pay out-of-pocket in a year does not have a limit unless you have other health insurance plans in Michigan (like Medicaid, Medigap, or employee or union coverage). Medicare only covers medically necessary services and many preventive services, like screenings and vaccines. Having original medicare enables you to seek treatment from any healthcare practitioner or hospital that accepts Medicare anywhere in the U.S., including Michigan. You are encouraged to only visit physicians or other healthcare providers that accept the Medicare-approved amount because, in such cases, you will not have to share a large part of the cost of treatment. Conversely, you will have to pay the full cost if you get a service that Medicare does not cover.
Original Medicare recipients can purchase a separate Medicare drug plan (Part D) for drug coverage and/or a Medicare Supplement Insurance (Medigap) policy to lower their share of costs for health care services. Note that Medicare only covers your claims when you are legally present in the U.S.
Medicare’s annual open enrollment period is typically between October 15 and December 7. The plans under Original Medicare are:
Medicare Part A (hospital coverage) - This covers inpatient hospital care, hospice care, home health care, and limited skilled nursing care. Medicare beneficiaries may be required to pay a deductible, copayment, or co-insurance for each service. The Part A deductible structure is as follows:
The insured is required to pay a deductible each time they are hospitalized, provided there are 60 days between each episode. The insured is charged:

• A deductible and zero coinsurance for days 1-60 per benefit period
• Co-insurance for days 61-90 per benefit period
• After the insured has paid their deductible, Medicare will pay a share of the covered healthcare expenses and the insured is required to pay a share of the covered services
  Medicare Part B (medical coverage): This covers doctors visits and outpatient services, home health care, outpatient care, preventive services, and durable medical equipment (like hospital beds, wheelchairs, walkers, and other equipment). Purchase is optional. It is financed through individual monthly premiums deducted from a person’s Social Security check. The insured is required to pay 20% of all covered healthcare costs, while Medicare pays 80%. However, some preventive services, such as an annual wellness visit, are covered free of charge. Insureds should expect modifications to their Medicare deductibles, and coinsurance amounts annually.
  In 2022, Michigan residents who qualified for premium-free Part A of Original Medicare, had to pay just for the cost of Part B and paid an average of $170.10 per month. In 2023 the average cost of Plan B went down to $164.90. Those who did not qualify for a premium-free Part A, could end up paying up to $506 per month in 2023, plus the $164.90 for the Plan B - for a total of up to $670.90.
  Note: Majority of Michigan Medicare recipients qualify for premium-free Part A.

Medicare Advantage (Part C)

Medicare Advantage is a Medicare-approved health plan provided by Federal government-approved private insurers that offers their plans as alternatives to Original Medicare for insureds’ health and drug coverage. The plan may also offer some additional benefits not covered under Original Medicare, such as vision, hearing, and dental services. Medicare Advantage plans are bundled plans that include Part A, Part B, and Part D. Insureds are mostly required to use doctors within the plan’s network. Plan C health coverage in Michigan sometimes has lower out-of-pocket costs than Original Medicare.
Speak with a state-licensed health insurance agent who is knowledgeable in Medicare health insurance and has access to multiple Medicare Advantage vendors - for comparison,

Medicare Prescription Drug Coverage (Part D)

Medicare Part D coverage is available to residents with Medicare and is offered by Federal government-approved private insurance companies. There are multiple Part D plan options, with various covered prescriptions and costs. Hence, it is important to verify with your health insurer the type of prescriptions your plan covers. Part D plans charge monthly premiums (based on the insured’s income) in addition to the Medicare Part B premium. Most Part D plans have annual deductibles that must be met before the plan pays its share of covered medications.
After the insured pays their deductible, they may be responsible for co-payments and co-insurance. Note that the DIFS does not regulate Medicare Part D plans, although it licenses most of the Michigan insurance companies that issue Medicare Part D plans in the state.
The cost of Michigan Medicare Part D Plans in 2023 ranged between less than $4 and over $100 per month, based on the:

• Amount of deductible
• Type of benefit offered
• Availability of subsidized rates
  The usage of Medicare plans in Michigan is as follows:

For detailed information on how to enroll or disenroll from these medicare programs, consult with a Michigan-licensed health insurance agent or call Michigan ENROLLS at toll-free 1 (800) 975-7630. The MI enrolls phone number can only be contacted Monday-Friday from 8:00 am to 7:00 pm. Questions about Medicare can be directed to 1-(800) MEDICARE (1-800-633-4227)

Do You Need a Primary Care Doctor With Medicare in Michigan?

Original Medicare in Michigan does not require a primary care doctor. The insured can go to any medical professional at will. For Medicare Advantage, the requirements depend:

• Medicare Advantage Health Maintenance Organizations (HMO) and Special Needs Plans (SNP) usually require an assignment of a primary care doctor.
• Medicare Advantage Preferred Provider Organizations (PPO) and Private Fee-for-Service Plans (PFFS) do not require primary care physicians.

Does Medicare Require Referrals in Michigan?

No, most Michigan Medicare plans do not need referrals, especially if you need to see a specialist. Recipients of Original Medicare can go to any medical professional who accepts Medicare patients. For Medicare Advantage (MA), it depends on the network:

• MA Health Maintenance Organizations (HMOs) require referrals to specialists, but not for annual services.
• MA Preferred Provider Organizations (PPOs) typically do not require referrals, but the use of an in-network provider is usually more affordable.
• MA Private Fee for Service (PFFS) do not require referrals
• MA Special Needs Plans (SNPs), similarly to HMOs - require referrals to specialists but some annual services and screenings are exempt.
  If you are looking for a Medicare decision guide, speak with a Michigan-licensed health insurance agent who specializes in senior health plans.

MEDIGAP

Also known as Medicare Supplement in Michigan, Medigap, is designed to cover medical expenses not covered by Original Medicare, including deductibles and coinsurance. It is sold by private Michigan insurance companies and can be sold only to those who already have existing Original Medicare (Plan A + Plan B) coverage. Medigap only covers the insured and not their spouses or other family members; such persons are responsible for obtaining their own coverage. The insured is required to pay a monthly premium.
Eligible persons can purchase a Medicare Supplement policy during the open enrollment period. The open enrollment period begins on the first day of the month in which an applicant turns 65 or older and is enrolled in Medicare Part B. The open enrollment period lasts six months, during which an applicant can purchase any Medicare Supplement plan, even if they have a pre-existing health condition. Applying after the six-month open enrollment period, makes the applicant subject to the insurer’s medical underwriting criteria. This means they may be denied and/or rated based on their health conditions.
NOTE: Starting from January 2023, Michigan Medigap subsidy program is no longer available. Michigan Medigap Subsidy program, operated by the Michigan Health Endowment Fund, offered qualifying Michigan residents lower premiums through some of the participating Medigap insurers. The fund had set aside $120 million to help the residents who are most in need and the funds have run out.
Medicaid policies are guaranteed renewable. However, the insured can lose coverage for not paying premiums or for material misrepresentation. Material misrepresentation refers to a situation where an insured intentionally provides a wrong answer during their application that misleads the insurer into providing them coverage, when they normally should have been ineligible for the insurance plan or be charged a different premium.
Every Michigan Medicare Supplement plan (Medigap) includes the following:

• Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end
• Medicare Part A hospice co-insurance
• Medicare Part A and B blood coverage: first three pints of blood for every calendar year
• Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) for hospital outpatient services

In 2023, Michigan Medigap added an average of $60-$500 to the cost of Original Medicare.
Note that Medigap policies generally do not cover:

• Long-term care (like non-skilled care you get in a nursing home)
• Vision or dental services
• Eyeglasses
• Hearing aids
• Private-duty nursing
  Speak with a licensed Michigan health insurance agent to discuss your medigap questions.

LONG TERM CARE INSURANCE Michigan

In Michigan, Long-Term Care is designed to provide nursing-home care, home-health care, and personal daycare for persons aged 65 or older or persons sick with a chronic or debilitating condition that requires constant supervision by caregivers. LTC costs are steadily going up and in 2023, the average monthly cost of long term care in Michigan was $4,500 - $10,500 (depending on the type of facility and type of care needed). That is $54,000 - $126,000 per year.
Many senior citizens require LTC when they can not perform activities of daily living (ADL) like bathing, feeding, dressing, and using the toilet due to long-term illnesses or injuries. For instance, there is a 70% chance that a person turning 65 today will need long-term care services and support for the rest of their lifetime. Generally, women need care longer (3.7 years) than men (2.2 years). One-third of persons aged 65 years and over may never need long-term care support, but 20% will need it for longer than five years.
Typical long term care insurance in Michigan costs $1,000 - $2,500 per year, depending on:

• Gender
• Age
• Location
• Health
• Marital status
• Coverage options
  Michigan residents can get Long Term Care through private Michigan insurance companies, state-sponsored plans, Medicare, Medicaid, and through the use of a Long term Care rider to a life insurance policy or annuity. A knowledgeable life and health insurance agent can help you find long term care insurance for parents and for yourself.