We Have Answers.
Frequently Asked Questions about Medicare.
The U.S. government’s largest health insurance program serving more than 62 million people.
- A federal health insurance program
- For U.S. citizens and legal residents
- Individual health insurance
MEDICARE IS NOT:
- Social Security
- Family plans
- Medicare eligibles: either through being on Social Security Disability (SSDI) or age 65 and above.
- We serve and want to reach all that are Medicare eligible.
- We have expertise in serving Veterans (both retired and not), Veteran spouses, the Low Income population (those that are on Medicaid or with incomes below $2,000/mo), and the disabled (those that are on Social Security Disability).
You can qualify for Medicare if you meet one of the following requirements:
- Within three months of turning 65 or older,
even if you still work
- Younger than 65 with a qualifying disability
- Have end-stage renal disease (ESRD)
Note: you also may be eligible for Medicare Part A through your spouse, though you must meet the age or disability requirement
PART A: Hospital Insurance
- Hospital Room & Meals
- Skilled Nursing Facility Care
- Hospice Care
- Some Home Health Care
- Intensive Care
- Operating Room Services
- Rehabilitation Services
- Some drugs & medical supplies for inpatient stays
PART B: Medical Insurance
- Doctor visits
- Outpatient care
- Mental Health Care
- Durable Medical Equipment
- Annual Wellness Visits and Preventative Services
- Clinical Lab Services
- Ambulance Services
- Occupational/Physical Therapy
PART A: Hospital Insurance
DEDUCTIBLE: $1,556 per benefit period
OTHER COSTS: $389/Day (days 61-90) / $778/day (after 90)
PART B: Medical Insurance
PREMIUM: $170.10 per month**
DEDUCTIBLE: $233 per year
OTHER COSTS: 20% of costs, plus any excess charges
**but no out of pocket maximum**
*Premium free if you or your spouse worked and paid taxes for 10+ years. If you don’t get premium-free Part A, you pay up to$499 each month.
**If you are an above average income earner, you will have to pay a higher Part B premium.
Plans A and B Do Not Cover the Following:
- All of the costs of your care (on the prior slide)
- Prescription drugs
- Annual Physical*
- Dental, vision and hearing care
- Hearing aids
- Eyeglasses or contacts
- Long-term care
- Most care outside the US
*Original Medicare covers an annual “Wellness” visit 1x every 12 months, but that visit is not a physical exam. It includes a Health Risk Assessment questionnaire and a cognitive assessment.
PART C: Covers out-of-pocket costs and combines Part A (hospital insurance) and Part B (medical insurance) in one cohesive plan.
PART D: Helps pay for prescription drugs
+ may offer additional benefits, such as dental, vision, hearing
- All the benefits of Part A and Part B
- You’re still in the Medicare program, but plans are offered by private companies
- Most plans include prescription drugs
- Many plans offer additional benefits:
- Routine dental
- Routine eye exams and eyeglasses
- Hearing tests and Hearing aids
- Wellness programs
- Continue to pay the Part B Plan Premium
- Many plans are $0 premium
- But you have out-of-pocket co-pays and co-insurance when you use services
- Typically have annual out-of-pocket maximum
- You may need a referral to see a specialist
- Coordinated care support with provider network
- Most common medications
- Specific brand name & generic drugs according to the plan’s formulary (drug list)
- Vaccines not covered by Part B
HOW IT WORKS:
- You pay a monthly premium. The average premium is ~$33.
- You have a co-pay for each medication, based on its tier. There are 4 or 5 tiers, from lowest to highest priced.
- You may also have a deductible.
- You may have to use a specific pharmacy network.
You can get Part D via a stand-alone Part D plan OR via a Medicare Advantage plan that includes prescription drug coverage (MAPD)
- You pay a monthly fee in addition to the Part B premium, and the private plan cover
the costs in Original Medicare.
- There are 8 plans (each has its own letter) standardized by the Federal Government but offered by private insurance companies.*
- The monthly fee can generally range from $50 – 350, depending on the plan type and your home state.
- No drug coverage, or dental, hearing and vision benefits.
- No medical underwriting up to 6 months after enrolling in Part B at age 65 or older
- Guaranteed renewal
- Coverage nationwide; no provider network
*MA, MN, and WI have different plans from the standard
Medicare Supplement Insurance (Medigap): Helps pay some or all of the out-of-pocket costs not paid by Original Medicare
Depending on your income and assets, you may qualify for additional assistance through:
- Medicare Savings Programs to reduce Part A and B costs
- Extra Help (Low Income Subsidy) to reduce medication costs
- Additional local assistance programs
Initial enrollment period is 3 months before and after you turn 65
**If you miss it, you can enroll during the General Enrollment Period: (Jan – Mar for Parts A and B). Late enrollment premium penalties apply, so don’t miss it!
If you delayed enrollment, you can enroll the month after the last month of employment or health coverage. You may:
- Enroll in Part A and/or Part B
- Enroll in Part C or Part D stand-alone plan
- Enroll in a Medicare Supplement plan (within 6 months)
Medicare Annual Enrollment [October 15 – December 7]
- Switch from or into a Medicare Advantage plan
- Join, switch, or drop a Prescription Drug Plan
Medicare Advantage Open Enrollment [January 1 – March 31]
- Open only to Medicare Advantage Plan members to switch or drop plans
Special Enrollment Periods: Qualifying Events
- E.g. you move, lose coverage, qualify for a Special Needs Plan, start receiving State financial assistance, and other qualifying events
- Time frames vary depending on the Special Enrollment Period
*while you have opportunities to change plans, if you elect to start on a Medicare Advantage plan and then later decide to switch to a Medigap plan, you may be subject to underwriting requirements as you will be outside the guaranteed issue period.
Medicare Terminology 101
Benefit PeriodThe length of time Original Medicare uses to assess your use of hospital and skilled nursing facilities. It begins the day you're admitted as an inpatient to a hospital or skilled nursing facility and ends when you haven't gotten any care from these facilities for 6(5) consecutive days.
CoinsuranceThe amount of money (usually represented as a percentage of the total cost) that you may be required to pay for services once you hit your plan's deductible.
CopayThe amount of money you may be required to pay for medical services or supplies, like doctor’s appointments and medications.
DeductibleThe amount of money you will be required to pay out of pocket for healthcare services and supplies (including medications) before your insurance plan starts to cover any amount of the costs.
Lifetime Reserve DaysIf you have Original Medicare and require hospitalization for more than 90 days in a single benefit period, a portion of your costs for 60 additional reserve days will be covered. You'll pay coinsurance for each one of these reserve days, and Medicare will cover whatever is left over.
Out of Pocket LimitThe maximum amount of money you have to pay for covered health care services in a plan year. Medicare Advantage plans are required by law to set annual dollar limits on out-of-pocket expenses but there's no annual dollar limit on your out-of-pocket expenses if you have Original Medicare.
PremiumThe monthly payment you make to Medicare to receive the benefits of your healthcare plan.
Creditable CoverageCoverage and plan benefits that are up to the same standards as Medicare are considered "creditable coverage". Beneficiaries with other sources of creditable coverage - for example, through an employer - may stay on that plan and avoid late enrollment penalties.