Medicare Insurance Eligibility and General Options
Medicare Insurance offers two main options for receiving your coverage. These are via Original Medicare or a Medicare Advantage plan. You must enroll for Medicare Part A and B for both options. There are several situations which prompt eligibility for Medicare but the most common are turning 65 years of age or a disability over two years. I will focus on Medicare options for those turning 65 years old in this post. There will be a future Blog post concentrating on Medicare for those on disability and under 65.
Usually deals with PLACES. Most people do not pay a premium for Medicare Part A if they have paid Medicare taxes while working. You usually don’t have to sign up for Part A if you have already enrolled in or are getting Social Security Benefits such as if you are retired or retiring. Each situation is different so it’s a good idea to contact Medicare for your specific situation. Part A covers Inpatient Hospital expenses, Skilled Nursing, Hospice and Home Healthcare-associated with a time- sensitive situation. In other words, you have a plan for treatment and recovery for a specific event. Medicare Does not cover custodial care. Custodial Care is non-skilled personal care ie. eating, bathing etc. In most of these situations, there is usually an overnight stay at a medical facility for treatment. This a simplified and general explanation but this is how PLACES are at the core of this coverage.
Usually deals with PEOPLE. You usually have to sign up for this by calling 1-800-MEDICARE or online at medicare.gov. You have 3 months before and until 3 months after your Medicare eligibility date (usually when you turn 65 yrs or eligible for disability and under 65) to enroll. It covers outpatient, medically necessary and Preventative Services. (ie. From your family Doctor or Specialist) but also clinical research, ambulance service, durable medical equipment, mental health- inpatient, outpatient and partial Hospitalization. It will also cover getting a second opinion before surgery and some limited outpatient drugs. There are many more specific services covered so you should check with your Doctor or on Medicare.gov to see if and how your services will be covered.
Part C (Medicare Advantage)
Medicare Part C or Medicare Advantage are health plan options approved by the federal government but offered by private health insurance companies. The plans must include at least the same coverage offered by Original Medicare. Some offer additional benefits and vary by plans. Some plans also include prescription plan coverage. Medicare Advantage is part of the Medicare program. The private companies must follow the rules set by the Center for Medicare & Medicaid Services who administers Medicare. Medicare pays a fixed amount( usually Part B premium) to the private company providing your coverage. There may or many not be an additional monthly premium charged which would be your responsibility. These plans are not the same as Medicare Supplements. The plans are usually network plans such as HMO(Health Maintenance Organization), PPO(Preferred Provider Organization), POS(Point of Service), RPPO(Regional Preferred Provider Organization), PFFS(Private Fee For Service), MSA(Medical Savings Account) and SNP(Special Needs Plans.) There will be out-of-pocket expenses such as co-pays, deductibles and co-insurance. Some plans will require you select a Primary Care Physician to as a Gatekeeper for your medical treatment which includes providing referrals to specific specialists when needed. In-network expenses may involve little to no out-of-pocket expenses. Some plans only offer in network coverage and won’t pay for out of network services while others will pay a portion of out of network costs. Please review Benefit Summaries carefully to determine what applies to your type of plan.
Medicare Part D (Stand Alone Prescription Plan)
Medicare Pard D is Medicare drug coverage approved by Medicare but offered by private insurance companies. A prescription plan for your medication is usually not included with a Medicare Supplement. It is often included in Medicare Advantage plan, however, there are some MA plans which do not include RX so review your coverage closely or consult your Insurance Agent. Each company or plan has a list of drugs which it will cover or a formulary so it’s important to make sure you select a plan that includes yours. Your out of pocket costs in these plans usually include all or some
- Yearly deductible- $360 in 2016
- Copayments or coinsurance
- Costs in the coverage gap- In 2016, generally once you and your plan have spent $3,310 you will be in the Gap or “doughnut-hole.” Then once you’ve spent $4,850 out-of-pocket in 2016, you’re out of the coverage gap and into the catastrophic level
- Costs if you get Extra Help
Another possible out of pocket expense might be a Penalty for Late Enrollment. If you do not enroll in a drug plan or have some type of credible coverage when you first become eligible for Medicare and then you enroll in a drug plan at a later time you may be assessed a Lifetime penalty fee which will be added on to your monthly premium.
It looks confusing but it really isn’t. Your first step to making it is easier is to CONTACT US. We’ll make sure you get the coverage that fits your specific needs and budget even if it’s something we don’t sell. We’ll, at least, tell you where to go to purchase it.
We are that committed to making sure you get the coverage that fits you!