MEDICARE EXPLAINED
If you’re looking for the most affordable Medicare Advantage Plan with the best coverage it’s time to speak with us. We are the specialists in Medicare Advantage Plans.
What is Medicare?
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.
What Are the Parts of Medicare?
There are several “parts” to Medicare that contain different coverage. Most people are familiar with “Part A” and “Part B”, which are a part of Original Medicare. Medicare also includes “Part C” and “Part D”.
What is Medicare Part A?
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Most of the time Part A does not cost a penny.
- Inpatient hospital 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: Medicare covers 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.
- Hospice care: Hospice care is covered for as long as your provider certifies it is necessary.
What is Medicare Part B?
Surgeries, lab work, and preventative services are all covered under Part B.
- Provider services: Services deemed medically necessary are covered under Part B.
- Durable medical equipment: Equipment that serves a medical purpose, able to withstand repeated use, and appropriate for home use, is covered. For example, diabetic supplies.
- Home health services: If you are home-bound and need skilled nursing or therapy care, you’re covered under Part B.
- Ambulance services: Emergency transportation by ambulance. Limited coverage for non-emergency transportation is available in which there is no safe alternative as long as it is medically necessary.
Preventative services: Outpatient physical, speech, and occupational therapy services are covered as long as they are administered by a Medicare-certified therapist. - 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.
What is Medicare Part C?
Medicare Part C is also called Medicare Advantage (MA). It’s an alternative benefit form to Original Medicare. Medicare Advantage may include prescription drug coverage, along with other extra benefits.
It is offered through private insurance companies, so you don’t enroll in it at the Social Security office or website. There are many different options to choose from in most states. Plans vary greatly by location this is why you see the television Commercials talking about checking your zip code to see if it has certain benefits. You must be enrolled in Medicare part A & B to be eligible.
What is Medicare Part D?
Medicare Part D is also known as prescription drug coverage. Part D coverage is available two ways as a stand alone Prescription Drug Plan (PDP) or as part of a Medicare Advantage plan (Part C).
Part D plans are offered by private insurance companies contracted and approved by Medicare. Typically there are 20 plus part D options in most states and it is very important to choose wisely or things could get quite costly at the pharmacy.
Each Part D plan has a list of covered drugs called a formulary. If the drug you need is not on the formulary, you are allowed to request an exception, pay out of pocket, or file an appeal.
These formularies differ from plan to plan so be sure to request a copy.
However, each plan must cover all drugs in the following categories:
- HIV/AIDS treatment
- Antidepressants
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Immunosuppressants
- Anticancer 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.
Frequently Asked Questions
Is Medicare automatic?
I hear this question a lot, Medicare used to be timed with receiving 100% of social security benefits at age 65. Now to collect 100% of your entitled social security benefits you will need to be older than 65, so many people are opting to wait past 65 to collect. If you decide to collect social security benefits before or on your 65th birthday Medicare is automatic. For those who opt to receive social security after 65 Medicare is not automatic and you have to enroll yourself.
Do I have to pay for Medicare?
Yes, most people will have to pay for Medicare part B the base premium for 2022 is $170.10. Some people may pay more based on their income. Medicare has established a sliding scale. Click here to learn more.
Why do I need to get extra coverage?
Original Medicare can leave you with a lot of out-of-pocket costs. Part A covers your hospital and inpatient stays after $1556 deductible that gets paid per occurrence. Part B of Medicare has a smaller deductible $233 and then covers up to 80% of doctors and outpatient bills. Original Medicare does not have a maximum out of pocket, which means there is no cap or limit to your out-of-pocket cost with original Medicare. Plus, original Medicare does not cover prescription drugs.
Are Medicare advantage plans free?
Medicare advantage plans are federally funded, and they may set up their premiums and fees the way they want to. Many carriers offer zero premium plans across the country and many times the plans have just as good or even better benefits than plans with a monthly premium.
When do I enroll in Medicare?
For most people Medicare enrollment should happen during your initial enrollment period, which begins three months before you turn 65 and runs three months after the month you turn 65. There are several different special election periods as well depending on your circumstances. Click here to learn more
When do I enroll in Medicare?
For most people Medicare enrollment should happen during your initial enrollment period, which begins three months before you turn 65 and runs three months after the month you turn 65. There are several different special election periods as well depending on your circumstances. Click here to learn more
What is a Medicare broker?
A Medicare insurance broker is an independent agent who represents multiple carriers so that they can work to give you an unbiased opinion on your Medicare plan options. They are appointed by many different insurance companies so that they can find the right fit for you rather than having to push one carrier. Your Medicare broker will be able to review all the options available and search for a plan that most closely fits your individual needs and budget.
How does a Medicare broker get paid?
The good news is that Medicare brokers get paid by the insurance companies they represent. And you pay the same rate for your insurance if you use a Medicare consultant (broker). There is no extra fee or cost for enrolling through a broker. This means you pay ABSOLUTELY NOTHING for our help.
I am still working and have insurance. Do I have to enroll in Medicare?
That depends on how many employees are on the group health insurance. If 20 or more employees are covered on the group plan you can delay your Medicare enrollment without any penalties. If the group is smaller than 20 you will need to enroll to avoid pHow does a Medicare broker get paid?
Does Medicare cover long term care?
NO, it does not. Neither Medicare nor Medicare advantage plans will cover long term care. Long term care insurance is a completely different insurance policy.
Does Medicare cover dental?
In general Medicare does not cover dental unless it is considered medically necessary. Ex, oral cancer, or infection. Medicare does not cover routine dental, or anything cosmetic.