Medicare 101

medicare education

Introduction to Medicare:

Medicare is a federal health insurance program serving people 65 or older, those with disabilities, and individuals with specific health conditions like ALS and End-Stage Renal Disease. It’s designed to provide comprehensive health coverage through different parts that address unique healthcare needs.

Parts of Medicare

Medicare Part A is also called “Hospital Insurance” and helps cover inpatient hospital care, skilled nursing facility services, and hospice care. This coverage is usually premium-free for those who paid Medicare taxes while working.

Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B is known as “Medical Insurance” and covers medically necessary outpatient services such as doctor visits, preventive screenings, lab tests, and durable medical equipment. It involves a monthly premium that varies based on income.

Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Part C Medicare Advantage Plans are an alternative to Original Medicare, provided by private companies that have agreements with Medicare to deliver your Part A and Part B benefits. These plans include various types such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans (PFFS), Special Needs Plans (SNPs), and Medicare Medical Savings Account Plans (MSA). When you choose a Medicare Advantage Plan, most of your Medicare services are covered through the plan, bypassing Original Medicare. Additionally, most Medicare Advantage Plans also include prescription drug coverage, offering a comprehensive solution for your healthcare needs.

Part D is a stand-alone prescription drug plan that helps cover the cost of prescription medications. It is available through private insurance companies and usually requires a monthly premium and a cost-sharing arrangement.

You can sign up for Part D Prescription Drug Plans, which helps cover prescription drug costs, along with other components of Medicare starting three months before your 65th birthday, or if you are under 65 and eligible for Medicare.

If you are already enrolled in a Part D “standalone” plan or a Medicare Advantage plan that incorporates drug coverage, you can switch plans during the open-enrollment period, which runs from Oct. 15 to Dec. 7 every year.

Medigap, or Medicare Supplement Insurance, fills the gaps in Original Medicare coverage. It is offered through private insurance companies and helps with costs like deductibles, copayments, and coinsurance.

Understanding Medicare Supplement Policies: What You Need to Know

Eligibility Requirements: You must be enrolled in both Medicare Part A and Part B to qualify for a Medicare Supplement (Medigap) policy.
Switching from Medicare Advantage: If you are currently on a Medicare Advantage Plan, you can switch to a Medigap policy during specific enrollment periods or under certain conditions (subject to underwriting). Ensure you can leave your Medicare Advantage Plan before your new Medigap policy starts.
Premium Payments: In addition to the monthly Part B premium you pay to Medicare, you’ll also pay a monthly premium to a private insurance company for your Medigap policy.
Individual Coverage: Medigap policies cover only one person. Couples must purchase separate policies if both need coverage.
Purchasing a Policy: You can buy a Medigap policy from any insurance company that is licensed in your state to sell one.
Guaranteed Renewability:Any standardized Medigap policy is guaranteed renewable, meaning the insurance company cannot cancel it as long as premiums are paid, even if you develop health problems.
Prescription Drug Coverage: Medigap policies sold after January 1, 2006, do not include prescription drug coverage. For drug coverage, you’ll need to join a Medicare Prescription Drug Plan (Part D).
Legal Restrictions: It is illegal for anyone to sell you a Medigap policy if you currently have a Medicare Advantage Plan, unless you are switching back to Original Medicare.

These guidelines ensure that you are fully informed about your health insurance options under Medicare.

Medicare costs include premiums, deductibles, and copayments. These vary based on income, eligibility for assistance programs, and the specific plan chosen. High-income earners might pay additional premiums, while low-income individuals may qualify for assistance.

Enrolling in Medicare involves understanding different enrollment periods like the Initial Enrollment Period, Special Enrollment Periods, and General Enrollment Period. Timely enrollment ensures access to appropriate coverage and may avoid penalties.

Medicare beneficiaries are entitled to rights and protections, including appeals, access to clear information, and protection against discrimination. Additionally, beneficiaries can work with Medicare to report fraud and resolve disputes.