General Medicare Info

Medicare 101

What is Medicare?

Medicare is a federal health insurance program for people age 65 or older, people of all ages with disabilities, and people with End-Stage Renal Disease (ESRD) or ALS — Lou Gehing’s Disease.

Medicare is made up of four parts:

  • Part A (Inpatient Hospital Insurance);
  • Part B (Outpatient/Physician Insurance);
  • Part C (Medicare Advantage Plans); and
  • Part D (Prescription Drug Coverage).

Who is Eligible?

People who are at least 65 years of age

  • Worked 10 or more years in Medicare-covered employment, and paid ( or spouse paid) Social Security for at least 40 quarters.
  • Are citizens or permanent residents of the United States.
  • Have been diagnosed with ESRD or ALS.

People who are not yet 65 years of age

  • After 24 months of Social Security Disability Insurance income.
  • Have been diagnosed with ESRD or ALS.

Original Medicare Plan

People with Original Medicare are called beneficiaries. Beneficiaries can go to any doctor, supplier, hospital, or other facility that accepts Medicare and is accepting new Medicare beneficiaries.

Beneficiaries with Original Medicare are responsible for a deductible and coinsurance for most covered services. The deductible is the amount a beneficiary must pay before Medicare begins to pay for services and supplies covered under the program. Coinsurance is the share of the cost for services that the beneficiary is responsible for after the deductible is met (normally a 20/80 percentage).

There are no maximum out-of-pocket limits for Original Medicare.

To help pay for some of the healthcare costs that Original Medicare doesn’t cover, beneficiaries may choose to purchase Medicare supplemental health insurance (Medigap policy). They may also choose to enroll in a Medicare Prescription Drug Plan (Medicare Part D) to receive prescription drug benefits.

Medicare beneficiaries are required to have Prescription Drug Coverage. If you don’t have coverage at least as good as Medicare Part D from an employer, union, or military, you will have to pay a penalty for each month you don’t have Part D coverage.

Services Typically Not Covered Under Original Medicare

  • Acupuncture
  • Long-term care (also called custodial care)
  • Most dental care
  • Eye examinations related to prescribing glasses
  • Dentures
  • Hearing aids and exams for fitting them
  • Routine foot care
  • Healthcare while traveling outside of the U.S.
  • Syringes or insulin, unless the insulin is used with an insulin pump
  • Cosmetic surgery

The Four Parts of Medicare

PART A

(Inpatient Hospital Insurance)

Eligible individuals are automatically enrolled in Part A with no premium. Others apply to the program when they are eligible or pay a monthly premium if they have worked less than 40 quarters (or 10 years) in their lifetime.

Covers

  • Helps cover inpatient care in hospitals (includes critical access hospitals, inpatient rehabilitation facilities and long-term care hospitals).
  • Helps cover skilled nursing facilities (not custodial or long-term care), hospice and home healthcare services.

Does Not Cover

  • Physician services in the hospital, personal care items, private rooms (unless medically necessary), phone, television, and custodial care, such as assistance with eating, bathing, and getting dressed.

Limitations

  • There are some limitations of the number of hospital days covered for inpatient hospital coverage. Days 1-90 in a hospital stay are covered, and days 90-150 are only covered once in your lifetime. These days are called “lifetime reserve days.” Deductible and copayments apply after 150 days. Providers must accept Medicare and be accepting new patients.

PART B

(Outpatient/Physician Insurance)

To obtain Part B, an eligible individual must enroll at their Social Security office during a specific period (usually the month of your birthday and the three months before or after your birthday month).

Covers

  • Part B is voluntary and is designed to supplement Part A coverage.
  • Helps cover doctor services, outpatient care, and durable medical equipment (DME).
  • Helps cover some preventive services to help maintain a person’s health, now including an annual wellness visit.

Does Not Cover

  • Routine vision, alternative healthcare, routine hearing screening exams, preventive or restorative dental services, routine chiropractic care, prescription drugs, and first three pints of blood.

Limitations

  • Part B only covers care for eyes, teeth, or hearing when medically necessary. No coverage for custodial care, such as assistance with eating, bathing, and getting dressed. No coverage outside the United States.

PART C

(Medicare Advantage Plans)

Sometimes called an “All in One” plan, Medicare Advantage plans are a way to get Medicare benefits through private companies approved by and under contract with Medicare.

Covers

  • Includes Part A, Part B, and usually additional benefits Medicare doesn’t cover (such as fitness benefits, chiropractic care, or vision and hearing benefits).
  • Often includes Part D Coverage.
  • Benefits that go beyond Original Medicare such as out-of-pocket maximums.

Does Not Cover

  • Hospice Care (still provided by Original Medicare).
  • It’s important to review each plan carefully tosee what it does and does not cover.

Limitations

  • Coverage options vary by plan and plan type. It’s important to review options carefully.
  • Medicare Advantage plans do not have the same network as Original Medicare.

PART D

(Prescription Drug Coverage)

These are plans that help cover prescription drug costs. Plans are available through private companies that contract with Medicare to provide coverage. Each plan can vary in monthly premium and drugs covered. If an individual does not have creditable coverage (coverage equal to Original Medicare) they are subject to a penalty for each month they are not enrolled.

Covers

  • Part D is voluntary and is designed to supplement Part A and B coverage because the beneficiary pays for the coverage, while Part A and Part B have government funding.
  • All drug classes mandated by Medicare.

Does Not Cover

  • Drugs not on the Medicare formulary.
  • Certain drugs that are covered under Part B.

Limitations

  • Coverage options vary by plan and plan type. It’s important to review options carefully.

Enrollment Periods

ICEP (aging into Medicare)

  • 7 month window
  • Effective date determined by receipt of application

Special Election Period (SEP)

  • Loss of coverage
  • Moved to new area or state

Annual Election Period (AEP)

  • October 15th - Dec 7st
  • Plan change opportunity
  • Add or drop a Part D coverage
  • Option to drop Medicare Advantage and go back to Original Medicare
  • Change goes into effective January 1st

After January 1, Medicare Advantage members will be locked into their Advantage plan for the year unless they decide to dis-enroll from their Advantage plan and go back to Medicare. From January 1st to February 15th, seniors enrolled in Medicare Advantage plans will be allowed to sign up for a stand-alone Part D plan if they drop out of their Advantage plan.

IMPORTANT MEDICARE CONTACTS

Social Security Department

  • To enroll or waive Medicare
  • To discuss income assistance programs
    1-800-772-1213 / TTY 1-800-325-0778
    Online at: http://www.ssa.gov

Medicare

  • Publications and Questions about Medicare
    1-800-Medicare (1-800-633-4227)
    TTY: 1-877-486-2048
    You can talk with a customer service representative 24 hours a day, 7 days a week.
    Online at: http://www.medicare.gov

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