Medicare
Medicare is a government-sponsored health insurance program for people aged 65 and older, as well as those under 65 with certain disabilities or conditions such as Chronic Kidney or End State Renal disease, ALS or Lou Gehrig’s Disease, and under certain circumstances those receiving Social Security Disability Benefits. It is divided into several parts, each covering different types of medical expenses.
Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services. Medicare Part B covers doctor visits, outpatient care, and preventative services. Medicare Part C (also known as Medicare Advantage) is an alternative to Parts A and B, offered by private insurance companies, that often includes additional benefits such as dental and vision coverage. Finally, Medicare Part D covers prescription drugs.
Once you qualify for Medicare, you can apply for Original Medicare, Medicare Part A & Medicare Part B, at your local social security office or on their website. Medicare Parts C & D you must enroll in.
Here’s more details about each part
The 4 Parts Of Medicare
The Original Medicare plan consisted of two parts: A & B
1. Medicare Part A Is For Hospital Coverage
Inpatient Hospital Care
Part A covers hospital stays, including semi-private rooms, meals, and general nursing care. This includes all care you receive after being admitted into a hospital by a physician. Medicare covers up to 90 days each benefit period in a general hospital. In addition, you receive 60 lifetime reserve days. It also covers up to 190 lifetime days in a Medicare-certified psychiatric hospital.
Skilled Nursing Facility Care
Part A covers care in a skilled nursing facility, such as rehabilitation services, after a hospital stay, including your room, board, and certain services provided in a skilled nursing facility. This includes medications, tube feedings, and wound care. It covers up to 100 days each benefit period. To qualify, you must have spent at least three consecutive days in the hospital within 30 days of admission to a skilled nursing facility and must have needed skilled nursing or therapy services.
Home Health Care
Though it is normally covered by Part B, Part A coverage will kick in if you have spent at least three consecutive days as a hospital inpatient within 14 days of receiving home care. Up to 100 days of daily care are covered or an unlimited amount of intermittent care provided by a home health agency, such as physical therapy, skilled nursing care, and speech therapy.
Hospice Care
As long as your provider certifies it is necessary, Hospice care is covered under Part A for people with terminal illnesses, including pain management, counseling, and other support services.
No or Low Cost-Sharing
Most people do not have to pay a premium for Part A because they have paid into the Medicare system through payroll taxes during their working years. Additionally, for many services covered by Part A, there is little or no cost-sharing required, which can help provide financial security.
Nationwide Coverage
Medicare Part A provides coverage throughout the United States, giving beneficiaries access to quality healthcare services regardless of where they live or travel.
Overall, the benefits of Medicare Part A provide comprehensive coverage for hospital-related expenses, which can provide peace of mind and financial security for beneficiaries.
2. Medicare Part B Is For Outpatient Medical Coverage
Coverage for Doctor Visits
Medicare Part B covers visits to doctors and other healthcare providers, including specialists for services that are deemed medically necessary. This coverage includes consultations, diagnostic tests, and other outpatient services.
Coverage for Medical Equipment and Supplies
Medicare Part B covers medically necessary durable medical equipment (DME) that serves a medical purpose, able to withstand repeated use, and appropriate for home use, such as walkers, wheelchairs, and oxygen equipment, as well as some medical supplies, such as insulin.
Access to Preventive Care
Medicare Part B covers a wide range of preventive care services, including flu shots, screenings for cancer, diabetes, and heart disease, annual wellness visits, outpatient physical, speech, and occupational therapy services, as long as they are administered by a Medicare-certified therapist.
Coverage for Outpatient Surgeries
Part B covers a wide range of outpatient surgeries, including cataract surgery, hernia repair, and some types of plastic surgery.
Assistance for People with Chronic Conditions
Part B offers chronic care management services to help people manage chronic conditions such as diabetes, heart disease, and chronic obstructive pulmonary disease (COPD).
Access to Mental Health Services
Medicare Part B covers mental health services, including psychiatric evaluations, individual and group therapy, and partial hospitalization for mental health conditions.
Home Health Services:
If you are homebound and need skilled nursing or therapy care, you’re covered under Part B.
Ambulance Services:
If you are homebound and need skilled nursing or therapy care, you’re covered under Part B.
X-Rays And Lab Tests:
All doctor ordered x-rays and lab tests are covered.
Chiropractic Care:
Only when medically necessary to fix subluxation of the spine. Certain prescription drugs: Certain drugs such as immunosuppressants, select anti-cancer, select antiemetic, select dialysis, and other typical drugs administered by a physician.
Access to Telehealth Services
Medicare Part B covers telehealth services, which can make it easier for people to access healthcare services from the comfort of their own homes.
Overall, Medicare Part B provides important coverage for a wide range of outpatient medical services and can help people manage their healthcare needs more effectively.
3. Medicare Parts C & D
In 1997, Congress passed a law to reduce the financial strain on Medicare funds and provide Medicare beneficiaries with a variety of new health plan options. The new options are available through Medicare Parts C & D.
Medicare Part C
Medicare Part C, also known as Medicare Advantage, is a type of health insurance plan offered by private insurance companies contracted with the federal government that can be added to your Original Medicare (Plan A & B), and offers additional benefits such as vision, dental, hearing and prescription drug coverage, caregiving & housekeeping.
Medicare Part C plans typically have lower out-of-pocket costs than Original Medicare and often include extra benefits such as wellness programs and gym memberships. These plans may also have provider networks that you will need to stay within to receive care.
One of the benefits of enrolling in a Medicare Part C plan is that it can simplify your healthcare coverage by combining all of your medical benefits into one plan. Additionally, some Medicare Advantage plans offer a $0 monthly premium, making it an affordable option for many seniors.
The Key benefits to Medicare Plan C (Medicare Advantage)
Comprehensive Coverage
Medicare Advantage plans offer coverage for all the benefits of Original Medicare, such as hospitalization, medical expenses, and prescription drug coverage. Some Medicare Advantage plans may also offer additional benefits such as dental, vision, and hearing coverage.
Cost savings
Medicare Advantage plans may offer lower out-of-pocket costs compared to Original Medicare. Many Medicare Advantage plans have a cap on out-of-pocket expenses, which can help protect you from high medical bills.
Coordination of care
Medicare Advantage plans often have a team of healthcare professionals who work together to coordinate your care. This can help ensure that you receive the right care at the right time.
Flexibility
Medicare Advantage plans may offer more flexibility in terms of choosing healthcare providers. Many plans have a network of healthcare providers, but some plans may allow you to see providers outside the network for a higher cost.
Additional benefits
Some Medicare Advantage plans may offer additional benefits such as gym memberships, transportation services, and home-delivered meals.
Simplified Administration
Medicare Advantage plans are administered by private insurance companies, which can simplify the process of enrolling in and managing your healthcare coverage.
Overall, Medicare Part C offers a range of benefits that can help you save money, receive comprehensive care, and enjoy additional perks and services.
Medicare Part D
Medicare Part D is an outpatient prescription drug coverage plan that is offered through private insurance companies as either a stand-alone plan or as a set of benefits included with a Medicare Advantage Plan. Medicare Part D helps to cover the costs of prescription drugs, including both brand-name and generic medications.
An individual can enroll in Part D if the individual has Parts A & B and lives in the plan’s service area. Part D plan has a list of covered drugs. If the drug you need is not on the list of covered drugs, you are allowed to request an exception, pay out of pocket, or file an appeal.
Each plan must cover all drugs in the following categories:
- HIV/AIDS treatment
- Antidepressants
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Immunosuppressants
- Anti-cancer drugs (unless they are being covered under Part B)
- Most vaccines are also covered under Part D unless they are already covered under Part B.
Enrolling in a Medicare Part D plan is optional, but it’s important to consider the costs of your prescription drugs and the potential savings that could be gained by having this coverage. Without this coverage, you could be responsible for paying the full cost of your medications, which can be quite expensive.
Most Medicare Part D plans have a monthly premium, a deductible, and co-payments or co-insurance for each prescription. However, some plans may offer lower costs based on the medications you take or by using preferred pharmacies.
When choosing a Medicare Part D plan, it’s important to compare different plans and their formularies, which is a list of medications covered by the plan. This will ensure that you find a plan that covers the medications you need at a cost that fits your budget.
Here are some of the key benefits of Medicare Part D
Access to Prescription Drugs
Medicare Part D provides coverage for a wide range of prescription drugs, including brand-name and generic drugs.
Cost Savings
Medicare Part D plans often negotiate lower prices with drug manufacturers, which can help you save money on your prescriptions. Many plans also have a cap on out-of-pocket expenses, which can help protect you from high drug costs.
Flexibility
Medicare Part D plans allow you to choose the pharmacy you prefer, including retail pharmacies, mail-order pharmacies, and specialty pharmacies.
Comprehensive Coverage
Medicare Part D plans are required to cover a wide range of drugs that are commonly used to treat medical conditions.
Simplified Administration
Medicare Part D plans are administered by private insurance companies, which can simplify the process of enrolling in and managing your prescription drug coverage.
Medication Therapy Management
Some Medicare Part D plans offer medication therapy management services, which can help you better understand your medications and ensure that you are taking them correctly.
Overall, Medicare Part D can help you save money on prescription drugs, receive comprehensive coverage, and enjoy greater flexibility and convenience when it comes to filling your prescriptions.
What if Medicare is Still Not Covering All of Your Needs?
4. Medicare Supplement Plans
Medicare Supplement Plans, also known as Medigap plans, are health insurance plans that are designed to supplement the coverage provided by Original Medicare. These plans are sold by private insurance companies and are designed to cover the out-of-pocket costs that Original Medicare does not cover.
When you have a Medigap policy, Medicare pays up to its limit on your medical expenses. Then, your Medicare Supplement plan will then kick in up to its limit. That limit usually is able to pay off the remainder. However, that will depend on which policy you select.
There are 10 standardized Medigap plans, which have a letter designation of A, B, C, D, F, G, K, L, M, or N.
Medigap policies are standardized
Every Medigap policy must follow federal and state laws designed to protect you, and it must be clearly identified as “Medicare Supplement Insurance.” Insurance companies can sell you only a standardized policy identified in most states by letters.
All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs.
Each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer. Insurance companies that sell Medigap policies:
- Don’t have to offer every Medigap plan
- Must offer Medigap Plan A if they offer any Medigap policy
- Must also offer Plan C or Plan F if they offer any plan
Note
As of January 1, 2020, Medigap plans sold to people new to Medicare can no longer cover the Part B deductible. Because of this, Plans C and F are no longer available to people new to Medicare on or after January 1, 2020. If you already have either of these 2 plans (or the high deductible version of Plan F) or are covered by one of these plans before January 1, 2020, you can keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans (Plan C or F).
Here are some of the benefits of Medigap plans
Covers Out-of-Pocket Costs
Medicare doesn’t cover all healthcare costs, and beneficiaries may have to pay copays, deductibles, and coinsurance. Medigap plans can help cover these out-of-pocket costs, making healthcare more affordable for beneficiaries.
Freedom to Choose Healthcare Providers
Medigap plans allow beneficiaries to visit any healthcare provider that accepts Medicare, giving them more freedom to choose the doctors and hospitals that best fit their needs.
Predictable Healthcare Costs
Medigap plans offer predictable healthcare costs, as beneficiaries pay a fixed premium each month. This can help seniors on a fixed income budget for their healthcare expenses.
Guaranteed Renewable
Medigap plans are guaranteed renewable, which means insurance companies cannot cancel the plan as long as the beneficiary pays the premium on time.
Nationwide Coverage
Medigap plans provide coverage throughout the United States, which is especially beneficial for seniors who travel frequently or who live in multiple states throughout the year.
No Network Restrictions
Unlike Medicare Advantage plans, Medigap plans do not have network restrictions, allowing beneficiaries to see any healthcare provider that accepts Medicare.
Overall, Medigap plans provide important coverage that can help beneficiaries afford healthcare costs and access the healthcare providers they need.
Compare Medigap plans side-by-side
The chart below shows basic information about the different benefits Medigap policies cover in most state.
✔︎ = the plan covers 100% of this benefit
❌ = the policy doesn’t cover that benefit
% = the plan covers that percentage of this benefit
N/A = not applicable
| Medigap Benefits | Plan A | Plan B | Plan C | Plan D | Plan F* | Plan G* | Plan K | Plan L | Plan M | Plan N |
| Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ |
| Part B coinsurance or copayment | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | 50% | 75% | ✔︎ | ✔︎*** |
| Blood (first 3 pints) | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | 50% | 75% | ✔︎ | ✔︎ |
| Part A hospice care coinsurance or copayment | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | 50% | 75% | ✔︎ | ✔︎ |
| Skilled nursing facility care coinsurance | ❌ | ❌ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | 50% | 75% | ✔︎ | ✔︎ |
| Part A deductible | ❌ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | ✔︎ | 50% | 75% | 50% | ✔︎ |
| Part B deductible | ❌ | ❌ | ✔︎ | ❌ | ✔︎ | ❌ | ❌ | ❌ | ❌ | ❌ |
| Part B excess charge: If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge. | ❌ | ❌ | ❌ | ❌ | ✔︎ | ✔︎ | ❌ | ❌ | ❌ | ❌ |
| Foreign travel exchange (up to plan limits) | ❌ | ❌ | 80% | 80% | 80% | 80% | ❌ | ❌ | 80% | 80% |
| Out-of-pocket limit** | N/A | N/A | N/A | N/A | N/A | N/A | $6,940 in 2023 | $3,470 in 2023 | N/A | N/A |
* Plans F and G also offer a high-deductible plan in some states. With this option, you must pay for Medicare-covered costs (coinsurance, copayments, and deductibles) up to the deductible amount of $2,700 in 2023 before your policy pays anything. (Plans C and F aren’t available to people who were newly eligible for Medicare on or after January 1, 2020.)
** For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered services for the rest of the calendar year.
*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in inpatient admission.
You live in Massachusetts, Minnesota, or Wisconsin
If you live in one of these 3 states, Medigap policies are standardized in a different way.
- You live in Massachusetts
- You live in Minnesota
- You live in Wisconsin
Medicare Enrollment Periods
Initial Enrollment = 7 Months In Total
It includes the three months before your 65th birthday, the month of your 65th birthday, and the three months after your 65th birthday. If your birthday is on the first of the month your enrollment period will begin one month early. For example: if your birthday is October 1, your enrollment period will begin June 1 and your Medicare will begin one month early as well — September 1. During your initial enrollment period, you can enroll in Original Medicare (Part A and B), Medicare Advantage plan, or Medicare Part D.
Open Enrollment
Once you are enrolled in Medicare Part A and B, there is a six-month open enrollment period for Medigap (Medicare Supplement) plans. This window begins with your Part B effective date and is a one-time election period.
How We Can Help
Medicare can be confusing. The best thing you can do is have a licensed Medicare Agent help you determine the coverage you need and find the best policy for you. We work directly with health insurance companies so our advisors can help you compare and enroll in coverage—at no additional cost to you. You pay only for the coverage you choose.
Click on the “Get Me The Best Price” link or give us a call/text (206-550-0737) or contact us & give yourself and your loved ones peace of mind by getting covered today.