MEDICARE
Medicare is the federal health insurance program for people who are 65 or older. It is also available for certain people younger than 65 with disabilities or people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). There are different parts of Medicare that cover specific services like inpatient hospital stays, doctors' services and the cost of prescription drugs. Learn more about Medicare Parts A, B, C and D below:
PART A
Hospital Insurance
Helps cover:
• Inpatient care in hospitals
• Skilled nursing facility care
• Hospice care
• Home health care
PART B
Medical Insurance
Helps cover:
• Services from doctors and other health care providers
• Outpatient care
• Home health care
• Durable medical equipment (like wheelchairs, walkers,
hospital beds, and other equipment)
• Many preventive services (like screenings, shots or vaccines,
and yearly "Wellness" visits)
PART C
Medicare Advantage
Helps cover:
• Medicare Advantage is an "all in one" alternative to Original Medicare.
These "bundled" plans include Part A, Part B and usually Part D.
• Plans may have lower out-of-pocket costs than Original Medicare.
• In most cases, you'll need to use doctors who are in the plan's network.
• Most plans offer extra benefits that Original Medicare doesn't cover -
like vision, hearing, dental, and more.
PART D
Prescription Drugs
Helps cover:
• Cost of prescription drugs (including many recommended shots or vaccines) Part D plans are run by private insurance companies that follow rules set by Medicare.
ELIGIBILITY
Age
You can qualify for Medicare by age once you are 65 years or older. You will become eligible to enroll three months before your 65th birthday until three months after turning 65. This window is called the Initial Enrollment Period. You can apply for Original Medicare during this period if you are eligible. If you decide to delay your enrollment, you may face a late enrollment penalty whenever you decide to enroll for Medicare at a later time. However, you can avoid these late enrollment penalties as long you qualify and enroll during a Special Enrollment Period.
Disability
People who receive Social Security Disability benefits can qualify for Medicare once they have received benefits for 24 months. Individuals in this category become automatically eligible on the 25th month.
Health Condition
People suffering from End-Stage Renal Disease and Amyotrophic Lateral Sclerosis may become eligible for Medicare even when under 65. Those with kidney failure who need a transplant or frequent dialysis qualify for Medicare automatically. Medicare will begin coverage after the first dialysis.
MEDICARE SUPPLEMENTS
Original Medicare, Part A and B, pays for many of your health-care services and supplies, but it doesn’t pay for everything. That’s why you may want to consider getting a Medicare Supplement plan, also called Medigap. Unlike Original Medicare, a Medicare Supplement plan is offered through private insurance companies. These Medigap plans help pay some of the hospital and medical costs that Original Medicare doesn’t cover, such as copayments, coinsurance, and yearly deductibles.
Some Medicare Supplement plans also help pay for a few services that Original Medicare doesn’t cover, such as emergency overseas travel coverage or Part B excess charges. Two out of ten Medigap plans include a yearly out-of-pocket limit, which Original Medicare doesn’t include. Basically, a Medigap policy fills the “gaps” in Original Medicare coverage.
Here’s an overview of how Medicare Supplement plans work, the types of benefits they cover, and how to enroll.
How do Medicare Supplement (Medigap) plans work with Medicare?
Medigap plans supplement your Original Medicare benefits, which is why these policies are also called Medicare Supplement plans. You’ll need to be enrolled in Original Medicare to be eligible for Medigap coverage, and you’ll need to stay enrolled in Original Medicare for your hospital and medical coverage. Medicare Supplement plans aren’t meant to provide stand-alone benefits.
Depending on the state that you live in, you may not be able to get Medicare Supplement coverage if you’re under 65 and have Medicare because of disability, end-stage renal disease, or amyotrophic lateral sclerosis. States aren’t required to offer Medigap coverage to beneficiaries under 65. If you’re under 65 and enrolled in Original Medicare, check with your state’s insurance department to find out if you’re eligible to enroll in a Medicare Supplement plan.
Keep in mind that Medigap plans don’t include prescription drug coverage (Part D), so if you want help with your medication costs, you’ll need to enroll in a stand-alone Medicare Prescription Drug Plan. In addition, you can’t use your Medicare Supplement plan to pay for costs you may have with a Medicare Advantage plan. Medigap insurance can only be used to cover costs in Original Medicare.
If you have Original Medicare and a Medicare Supplement plan, Original Medicare will pay first, and your Medigap policy will fill in the cost gaps. For example, suppose you have a $5,000 ambulance bill, and you have already met the yearly Medicare Part B deductible. Medicare Part B will pay 80% of your ambulance bill. If you have a Medicare Supplement plan that covers Part B copayments and coinsurance costs, then your Medigap policy would then pay the remaining 20% coinsurance of your $5,000 ambulance bill. Some Medicare Supplement plans may also cover the Part B deductible.
What types of coverage are not Medicare Supplement plans?
As a Medicare beneficiary, you may also be enrolled in other types of coverage, either through the Medicare program or other sources, such as an employer. When you first sign up for Original Medicare, you’ll fill out a form called the Initial Enrollment Questionnaire and be asked whether you have other types of insurance. It’s important to include all other types of coverage you have in this questionnaire. Medicare uses this information when deciding who pays first when you receive health-care services.
Below is a list of other types of insurance you may have. Please note that these types of coverage are different from Medicare Supplement plans:
Medicare Advantage plans (like an HMO or PPO)
Medicare Prescription Drug Plans (Part D)
Medicaid
Employer-or union-sponsored group coverage
TRICARE
Veterans' benefits
Long-term
Care insurance policies
What benefits do Medicare Supplement plans cover?
Currently, there are 10 standardized Medigap plans, each represented by a letter (A, B, C, D, F, G, K, L, M, N; there’s also a high-deductible version of Plan F). These plans are available in most states; Massachusetts, Minnesota, and Wisconsin each have their own different set of standardized Medicare Supplement plans.
Coverage levels and premiums vary, but the benefits of each plan within a lettered category remain the same despite the insurance company or location. For example, Plan A benefits are the same in New Jersey as they are in Oregon. If a Medicare Supplement plan includes a certain benefit, this benefit is covered 100% unless othe1 Columnrwise specified.
MEDICARE ADVANTAGE
Medicare Part C is also known as a Medicare Advantage plan. As with SIMs, Advantage plans come from private providers. These plans include and replace Medicare Part A, B, and D coverage, with the exception of hospice care. Medicare pays the premiums for participants. Plans have a structure of health maintenance organization (HMO), preferred provider organization (PPO) plans, private fee-for-service (PFFS) plans and special needs plans (SNPs). The federal government forbids private insurers from selling Medigap policies to individuals enrolled in Medicare Advantage. To be eligible the individual must live in the plan’s service area, have Medicare Parts A and B, and not have an end-stage renal disease. These plans come from private providers who have government approval.
TYPES OF MEDICARE ADVANTAGE PLANS
Health Maintenance Organization Plans
HMO plans typically limit their coverage to in-network healthcare providers. This means there is a list of health providers to choose from, but you may cover all the out-of-pocket costs for the services if you choose to receive care out-of-network. These plans may also require you to select a primary care physician from one of their networks and get referrals when a specialist is needed.
Preferred Provider Organization Plans
PPO plans offer more flexibility than HMO plans but at a higher cost. Though each PPO plan has a list of in-network providers, you will typically have the option to get healthcare services from out-of-network providers. However, you will pay more for these services but will still get more coverage than you would with an HMO plan. Also, you don’t need a referral to go to a specialist, nor are you required to choose a primary care physician.
Private Fee-For-Service Plans
This type of Medicare Advantage plan allows you to keep or choose any healthcare provider as long as they accept the terms of your Medicare Advantage plan. You won’t be required to choose a primary care physician or get referrals to visit a specialist. However, this plan will decide how much they will pay for your services, as well as how much you will pay.
Special Needs Plans
Medicare Advantage Special Needs Plans are available to individuals with chronic health conditions and specific healthcare needs. These plans will cover everything that Original Medicare does, and they are required to provide prescription drug coverage. The three types of Special Needs Plans are:
Chronic Condition Special Needs Plans.
Institutional Special Needs plans.
Dual Eligible Special Needs Plans.
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