Medicare: Common Situations

medicare medicaid

medicare medicaid

To help you get started thinking about Medicare drug coverage, find the situation that describes you and learn what you need to do.

“I have Original Medicare only, or Original Medicare and a Medigap (‘Supplement’) Policy without drug coverage.”If you use an average amount of prescription drugs, Medicare’s new prescription drug coverage could pay over half of your drug costs next year. If you have very high unexpected drug costs, Medicare will pay up to 95% of these costs after you spend $3,600 out-of- pocket in a year.

What you need to do:
To get this drug coverage, you can join a Medicare Prescription Drug Plan that covers prescription drugs only and keep your Original Medicare coverage the way it is. Or you can join a Medicare Advantage Plan or other Medicare Health Plan that covers doctor and hospital care as well as prescriptions.

Medicare Advantage Plans usually give you extra benefits and/or lower costs, but only if you use the doctors and hospitals that participate in the plan’s “network.” If you do not opt for prescription drug coverage by May 15, 2006, you will have to pay a late enrollment penalty to get drug coverage later.

“I have Original Medicare and a Medigap (‘Supplement’) Policy with drug coverage.”Medicare prescription drug coverage will generally provide significant savings compared to what you are paying in copayments for drugs under your Medigap plan, and will generally provide much better protection against unexpected drug expenses as well.

What you need to do:
Decide between keeping your Medigap policy with drug coverage or joining a Medicare plan that offers prescription coverage. You have probably received information in the mail for plans in your area offering coverage. Compare your current coverage to the new Medicare coverage.

Unlike Medigap, most of the cost of Medicare drug coverage is paid by Medicare, and will never run out if you have unexpected drug costs. Also, if you do not join a Medicare Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage by May 15, 2006, you will have to pay a late enrollment penalty to get drug coverage later. If you opt for Medicare prescription drug coverage, tell your insurer, and the drug portion of your Medigap policy will be removed.

“I am a retiree and I have drug coverage through my (or my spouse’s) former employer or union.”Medicare will help employers or unions continue to provide retiree drug coverage that meets Medicare’s standard. Your former employer or union has choices about how they will work with Medicare.

What you need to do:
Your former employer or union probably mailed you a letter already. This information will explain how they will work with Medicare on prescription drug coverage and what decisions you will have to make. If you do not hear from them, visit their website or call your benefits administrator.

“I have a Medicare Advantage Plan (like an HMO or PPO) or other Medicare Health Plan.”
Medicare is working with Medicare Advantage and other Medicare Health Plans to help them provide even more coverage and/or lower costs. Your plan will let you know about the prescription drug options they will offer. You can also choose to switch to another Medicare Advantage Plan or Medicare Health Plan. Or you could choose the Original Medicare Plan and join a Medicare Prescription Drug Plan.What you need to do:
Read the information you got in the mail explaining any additional prescription drug coverage your plan will offer.
“I have Medicare and Medicaid, and I get my drug coverage from Medicaid.”
Starting January 1, 2006, you will get your prescription drug coverage from Medicare instead of Medicaid. The prescription drug coverage from Medicare has no premiums, no deductibles, and no gaps, and you will pay very little or nothing for almost all prescriptions.What you need to do:
Starting in the fall, you will need to decide which Medicare plan that offers prescription drug coverage you would like. If you do not sign up for a plan, Medicare will sign you up for one to make sure you do not miss a day of coverage. Medicare will send you a letter to let you know which plan you are in. You can switch to a different plan if you choose.
“I have limited resources and live on limited income.”What you need to do:
If your resources are less than $11,500 (single) or $23,000 (married), you may qualify for extra help paying for Medicare Prescription Drug Coverage. If you haven’t received an application or information about the extra help, and you think you may be eligible, you should apply. Remember, as Department of Health and Human Services Secretary Leavitt says, “If in doubt, fill it out!” You can apply Online by visiting the Help With Medicare Prescription Drug Plan Costs section on the Social Security Administration website.


green apple wrapped in a tape measureAccording to current statistics, between 50 and 66% of African American women can be classified as being “overweight”. African American women suffer from obesity at an alarmingly disproportionate rate when compared to women of other races.

We know that we live in a culture that equates thinness with beauty, success, and happiness. Thus, the pressure for women to change their weight is enormous, and this is usually where the desire to diet comes in to play. It’s too bad that the first information these women usually run into is ‘magic’ diets and pills promoted by company’s whose major concern is their next dollar, not if someone actually loses weight or not. In fact, by using the typical calorie reduced diets, women are inevitably going to do these over and over again because in the process have trained their bodies to become better at storing fat. This of course leads to more profits for the diet companies.

Typical ‘crash diets’ fight your body’s natural reaction to starvation. Lipoprotein lipase is an enzyme in the body that promotes fat storage and it increases tremendously when someone is not taking in enough food. The lowest energy level that a female who is 90 years old, bedridden, and under 5 feet tall needs, is still approximately 1167 calories per day! Concentration camps during wars have shown us that humans need a minimum of 800-900 calories for sheer survival for any extended period of time. An average meal is around 500-600 calories so if someone skips breakfast, has a diet pop and salad for lunch, and a small dinner you can see how they could run dangerously close to these levels. A person’s metabolism is the complex of chemical and physical processes involved in the maintenance of life, and the rate at which your body uses substances (i.e. burns calories). When a human drastically reduces their food intake, their metabolism lowers, making it harder and harder to lose weight. This makes sense from a survival point of view, because if it continued at the same rate you would literally burn up! This is how people can end up ‘yo-yo’ dieting, because the body just gets better and better at storing energy. Cut calories, metabolism lowers; eat again (even if equal amount eaten before the dieting), and weight goes up. Usually higher than where they started. Of course the psychological damage diets can do is immense, and can take up another whole column, so for now we’ll just look at the physical.
When fuel is scarce, the body first uses up stored sugar in the liver and muscles. This stored sugar is called glycogen. Each glycogen is stored with a molecule of water, and this makes it relatively heavy. When they are metabolized, this is where one might see initial weight loss. During the first five to seven days of inadequate calorie intake, skeletal muscle protein is also broken down for energy. It is lost at approximately 360g (0.8 lb) lean tissue per day, and drops to a rate of 96g per day after those first five to seven days. This is not fat tissue. Adipose (fat) tissue will eventually be used for energy at a much lower rate of 18g per day. The body then shifts back and forth using muscle and fat tissue alternately. The last tissue to go would be the intercostal muscles (the muscle between the ribs) necessary for respiration. The body also adapts to starvation by reducing activity, increasing one’s need for sleep, and lowering body temperature.


If someone really needs to lose weight to reduce their risk of heart disease or diabetes, for example, then how should they do it? Well, the answer is not magic, but it works with the body not against it and involves commitment and education.

A breakfast that includes whole wheat toast with peanut butter, a glass of milk, and a piece of fruit will last a lot longer than a bowl of cereal with a glass of juice. (The first one has fiber and more protein). The second thing that raises one’s metabolic rate is the increase in muscle tissue. Good old exercise. Initially, someone may even gain a few pounds or stay at the same weight while doing this.

Physical exercise is not a regular part of the lifestyle of many African American women. Walking can help make your heart and lungs function more efficiently, help you lose weight, sleep better, and reduce stress. You should try to walk four times a week for at least thirty minutes each time.

The best way to do this is to decrease the fat intake in our diet (butter, oils, margarine, deep fried foods, pastries, chips, nuts, bologna, etc.). Notice, I said decrease, not eliminate. It is still okay to enjoy these foods once in awhile as long as one is eating a well-balanced, low-fat diet most of the time. The other improvement to make in one’s diet would be an increase in fiber. Fiber is a non-digestible plant component found in foods such as brown rice, whole grain breads, bran and oat cereals, fruits, and vegetables. Fiber helps with digestion and elimination and also helps to fill a person up without adding too many calories.

It is advisable that you to drink six to eight glasses of water daily (given that you have no other medical conditions). Water is important in body heat regulation, maintenance of blood volume, helps you eliminate wastes and acts as an appetite suppressant.