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Medicare Explained

Medicare is the United States 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. There are several parts to Medicare that contain different coverage.

Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance).  Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. Part B 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), and many preventive services (like screenings, shots or vaccines, and yearly “wellness” visits)

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Medicare Part A

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  • Introduction to Medicare Advantage Plans
    A Medicare Advantage Plan is a Medicare-approved insurance plan from a private company that you may join as an alternative way to get your Medicare benefits. When you do, Medicare pays the plan a fee every month to administer your benefits for Part A, Part B and often Part D. When enrolled in a Medicare Advantage Plan you will present your Advantage Plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare. Most Medicare Advantage plans have HMO or PPO Plan options. Medicare HMO Plans generally require that you only seek medical services with network providers, except in emergencies. You will usually need to select a primary care physician. That physician can coordinate a referral if you need to see a specialist. There are some HMO plans that no longer require referrals, and some offer a point-of-service (POS) feature where you can see out-of-network providers in certain circumstances. Medicare PPO Plans allow you to see doctors in network, and also doctors outside the network but you’ll have higher out-of-pocket spending to do so. In limited counties, there are Medicare Private-Fee-for-Service plans. These plans may or may not include Part D. How you access care is also different. While this plan type was very common in the past, it has been slowly phased out in most areas. Medicare Advantage Plans are different than the standardized Medicare Supplements. Insurance companies may have very different drug formularies, doctor networks, doctor copays, extra benefits, deductibles, etc. Your plan is required to offer, at a minimum, all the same services as Original Medicare, such as doctor visits, surgeries, lab work and so on. You might pay a small copay to see a primary care physician. Specialist copays will often cost a little more. Some higher copays, deductibles or a per day cost will be listed in detail for diagnostic imaging, hospital stays, and surgeries. Each Advantage plan has its own summary of benefits which explains exactly what the cost shares are for medical services. This summary will tell you what your copays and other out of pocket expenses will be for various healthcare services. One nice thing about Medicare Advantage plans is that some of them offer some extra benefits for routine dental, vision or hearing. Some plans include gym memberships.
  • Basic Medicare Advantage Rules
    You must be enrolled in both Medicare Part A & B and live in the plan service area. Present your Medicare Advantage Plan ID card for all medical services and medication purchases so that your providers bill your Medicare Advantage plan. Medicare Advantage Enrollment Periods Initial Enrollment Period - You may enroll 3 months prior, the month you first turn 65, and up to 3 months after your birthday month. After that, you may enroll or dis-enroll only during certain times of year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year unless you qualify for a special election period. The Annual Election Period - This period runs from October 15th – December 7th each fall. Medicare Advantage Plan changes are announced and members are allowed to change to another Medicare Advantage Plan or return to Original Medicare with an Individual Drug Plan. Changes made to your enrollment will take effect January 1. If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare unless you enroll in a stand alone part D. Medicare Advantage Open Enrollment Period - Some people may find themselves enrolled into a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan. For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st – March 31st each year. During this time, you have a one-time opportunity to disenroll from any Medicare Advantage plan to enroll in a different Advantage Plan or to return to Original Medicare. You will be allowed to add a standalone Part D drug plan. Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, you may have to answer health questions and go through medical underwriting to get re-approved for Medigap. This is something to consider before dropping any Medigap plan to go to Medicare Advantage.
  • Medigap vs Medicare Advantage
    When trying to decide whether you should stay with Original Medicare with a Medicare Supplement and a stand-alone Prescription Drug Plan OR enroll in a Medicare Advantage Plan, consider the following: Doctor networks – With Medicare Advantage Plans, there are doctor networks to adhere to. HMO’s require you to see doctors in the network and some still require a referral from your primary care doctor in order to see a specialist. PPO Plans allow you to see in-network providers without referrals, and out-of-network providers, for a higher out-of-pocket expense. With Medigap plans, you can see any doctor that accepts Medicare. You don’t have to ask your doctors if they take your specific Medigap insurance company. The network is Medicare, which has over 1 million contracted providers across the nation. Monthly Premium – Medigap and stand-alone Prescription Drug Plans have monthly premium costs typically higher than Medicare Advantage Plans, which can start at $0 premium. With Medigap plans you are sort of paying up front, even if you stay healthy and don’t require the use of many services. With Medicare Advantage Plans, you pay copays and deductibles when you use the services, but if you don’t, there is much less monthly cost to have the plan. Prescription Drug Coverage – Medigap plans do not include Part D coverage, so you will need to purchase a separate stand-alone Part D policy. Many Medicare Advantage Plans typically have the prescription Drug plan included. Extra benefits – Medigap plans do not offer any routine dental, vision or hearing while some Medicare Advantage plans may have some of these benefits included in the plan. Remember to check if your dentist or vision/eye glass provider is in the network. Skilled Nursing Facility Stay - Medicare Advantage Plans typically cover the first 20 days at $0 copay or a very small daily copay, but then require a higher daily copay for up to 80 additional days, about $200/day (2024). Some Medigap Plans will completely cover the first 100 days in the Skilled Nursing Facility, which can save Medicare Beneficiaries thousands of dollars, depending on the length of stay. The two types of coverage simply work differently. Go with the option that best meets your needs. Remember, there are some Election Periods each year when you can make a switch, as long as you have had continuous coverage. It's always a good idea to work with a knowledgeable advisor who can guide you through your options.

Medicare Part B

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  • Introduction to Medicare Advantage Plans
    A Medicare Advantage Plan is a Medicare-approved insurance plan from a private company that you may join as an alternative way to get your Medicare benefits. When you do, Medicare pays the plan a fee every month to administer your benefits for Part A, Part B and often Part D. When enrolled in a Medicare Advantage Plan you will present your Advantage Plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare. Most Medicare Advantage plans have HMO or PPO Plan options. Medicare HMO Plans generally require that you only seek medical services with network providers, except in emergencies. You will usually need to select a primary care physician. That physician can coordinate a referral if you need to see a specialist. There are some HMO plans that no longer require referrals, and some offer a point-of-service (POS) feature where you can see out-of-network providers in certain circumstances. Medicare PPO Plans allow you to see doctors in network, and also doctors outside the network but you’ll have higher out-of-pocket spending to do so. In limited counties, there are Medicare Private-Fee-for-Service plans. These plans may or may not include Part D. How you access care is also different. While this plan type was very common in the past, it has been slowly phased out in most areas. Medicare Advantage Plans are different than the standardized Medicare Supplements. Insurance companies may have very different drug formularies, doctor networks, doctor copays, extra benefits, deductibles, etc. Your plan is required to offer, at a minimum, all the same services as Original Medicare, such as doctor visits, surgeries, lab work and so on. You might pay a small copay to see a primary care physician. Specialist copays will often cost a little more. Some higher copays, deductibles or a per day cost will be listed in detail for diagnostic imaging, hospital stays, and surgeries. Each Advantage plan has its own summary of benefits which explains exactly what the cost shares are for medical services. This summary will tell you what your copays and other out of pocket expenses will be for various healthcare services. One nice thing about Medicare Advantage plans is that some of them offer some extra benefits for routine dental, vision or hearing. Some plans include gym memberships.
  • Basic Medicare Advantage Rules
    You must be enrolled in both Medicare Part A & B and live in the plan service area. Present your Medicare Advantage Plan ID card for all medical services and medication purchases so that your providers bill your Medicare Advantage plan. Medicare Advantage Enrollment Periods Initial Enrollment Period - You may enroll 3 months prior, the month you first turn 65, and up to 3 months after your birthday month. After that, you may enroll or dis-enroll only during certain times of year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year unless you qualify for a special election period. The Annual Election Period - This period runs from October 15th – December 7th each fall. Medicare Advantage Plan changes are announced and members are allowed to change to another Medicare Advantage Plan or return to Original Medicare with an Individual Drug Plan. Changes made to your enrollment will take effect January 1. If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare unless you enroll in a stand alone part D. Medicare Advantage Open Enrollment Period - Some people may find themselves enrolled into a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan. For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st – March 31st each year. During this time, you have a one-time opportunity to disenroll from any Medicare Advantage plan to enroll in a different Advantage Plan or to return to Original Medicare. You will be allowed to add a standalone Part D drug plan. Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, you may have to answer health questions and go through medical underwriting to get re-approved for Medigap. This is something to consider before dropping any Medigap plan to go to Medicare Advantage.
  • Medigap vs Medicare Advantage
    When trying to decide whether you should stay with Original Medicare with a Medicare Supplement and a stand-alone Prescription Drug Plan OR enroll in a Medicare Advantage Plan, consider the following: Doctor networks – With Medicare Advantage Plans, there are doctor networks to adhere to. HMO’s require you to see doctors in the network and some still require a referral from your primary care doctor in order to see a specialist. PPO Plans allow you to see in-network providers without referrals, and out-of-network providers, for a higher out-of-pocket expense. With Medigap plans, you can see any doctor that accepts Medicare. You don’t have to ask your doctors if they take your specific Medigap insurance company. The network is Medicare, which has over 1 million contracted providers across the nation. Monthly Premium – Medigap and stand-alone Prescription Drug Plans have monthly premium costs typically higher than Medicare Advantage Plans, which can start at $0 premium. With Medigap plans you are sort of paying up front, even if you stay healthy and don’t require the use of many services. With Medicare Advantage Plans, you pay copays and deductibles when you use the services, but if you don’t, there is much less monthly cost to have the plan. Prescription Drug Coverage – Medigap plans do not include Part D coverage, so you will need to purchase a separate stand-alone Part D policy. Many Medicare Advantage Plans typically have the prescription Drug plan included. Extra benefits – Medigap plans do not offer any routine dental, vision or hearing while some Medicare Advantage plans may have some of these benefits included in the plan. Remember to check if your dentist or vision/eye glass provider is in the network. Skilled Nursing Facility Stay - Medicare Advantage Plans typically cover the first 20 days at $0 copay or a very small daily copay, but then require a higher daily copay for up to 80 additional days, about $200/day (2024). Some Medigap Plans will completely cover the first 100 days in the Skilled Nursing Facility, which can save Medicare Beneficiaries thousands of dollars, depending on the length of stay. The two types of coverage simply work differently. Go with the option that best meets your needs. Remember, there are some Election Periods each year when you can make a switch, as long as you have had continuous coverage. It's always a good idea to work with a knowledgeable advisor who can guide you through your options.
Medicare Options
Original Medicare has gaps in coverage in the form of deductibles and coinsurance that you must pay.
Here are your options to help cover those costs.
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