MEDICARE EXPLAINED

If you’re new to Medicare you’re probably wondering what Medicare Parts A, B, C, & D are and what they do. Or you may have heard the term Medigap and were wondering what that is. I hope to clear it up for you.

Medicare Part A is the hospital insurance portion of the Medicare program. It covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care services. Here are some key details about Medicare Part A:

Hospital Care: Part A covers inpatient hospital care, which includes a semi-private room, meals, and general nursing care. It also covers hospital services and supplies, such as X-rays, lab tests, and medications administered during the hospital stay.

Skilled Nursing Facility Care: Part A also covers care in a skilled nursing facility, which provides medically necessary services and supplies to help people recover from an illness, injury, or surgery. Medicare covers up to 100 days of skilled nursing care per benefit period.

Hospice Care: Part A covers hospice care for people who are terminally ill and have a life expectancy of six months or less. Hospice care includes medical and support services to manage symptoms and improve quality of life.

Home Health Care: Part A covers some home health care services, such as skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services. The services must be medically necessary and provided by a Medicare-certified home health agency.

To be eligible for Medicare Part A, you must meet certain requirements, such as being 65 years or older, having a disability, or having end-stage renal disease. Most people do not have to pay a premium for Part A because they or their spouse paid Medicare taxes while working. However, there may be some out-of-pocket costs, such as deductibles and coinsurance, for certain services.

Medicare Part B is the medical insurance portion of the Medicare program. It covers medically necessary services and supplies to diagnose or treat a medical condition, prevent or detect an illness, or maintain your health. Here are some critical details about Medicare Part B:

Doctor Visits: Part B covers visits to doctors and other health care providers, including nurse practitioners and physician assistants. It also covers preventive services, such as screenings for cancer, diabetes, and cardiovascular disease.

Outpatient Care: Part B covers medically necessary outpatient care, such as lab tests, X-rays, and diagnostic imaging services. It also covers ambulance services, durable medical equipment, and mental health care services.

Preventive Services: Part B covers a range of preventive services, including flu shots, pneumococcal shots, and screenings for cancer, diabetes, and cardiovascular disease. Many preventive services are provided at no cost to you.

Part B Drugs: Part B covers certain drugs administered in a doctor’s office or other outpatient setting, such as chemotherapy or intravenous antibiotics.

To be eligible for Medicare Part B, you must be enrolled in Medicare Part A and pay a monthly premium. Most people spend the standard premium amount set by Medicare, although some may pay more or less depending on their income. There may also be out-of-pocket costs, such as deductibles, coinsurance, and copayments, for certain services.

Medicare Part C, also known as Medicare Advantage, is a type of Medicare plan offered by private insurance companies approved by Medicare.

Medicare Advantage plans provide all the benefits of Medicare Parts A and B, and often include additional benefits, such as prescription drug coverage, dental, vision, and hearing services, and fitness programs.

Here are some key details about Medicare Part C:

Benefits: Medicare Advantage plans must cover all the services that Original Medicare (Parts A and B) covers. They may also offer additional benefits, such as prescription drug coverage, dental, vision, hearing services, and fitness programs.

Network: Medicare Advantage plans typically have a network of doctors, hospitals, and other health care providers. You may be required to use providers in the plan’s network or pay more if you go out of network.

Cost: Medicare Advantage plans may have different costs than Original Medicare. They may charge a monthly premium, and you may also pay out-of-pocket expenses, such as deductibles, copayments, and coinsurance.

Enrollment: You must be enrolled in Medicare Parts A and B to join a Medicare Advantage plan. You can enroll in a Medicare Advantage plan during certain times of the year, such as the Annual Enrollment Period (October 15 – December 7) or a Special Enrollment Period if you have a qualifying life event.

Coverage: Medicare Advantage plans may have different coverage rules than Original Medicare. For example, they may require prior authorization for certain services or treatments.

Medicare Part D is the prescription drug coverage portion of the Medicare program. It helps pay for prescription drugs and can lower your out-of-pocket costs. Here are some key details about Medicare Part D:

Enrollment: Medicare Part D is optional, but you may face a late enrollment penalty if you do not enroll when you are first eligible. You can enroll in a Part D plan during certain times of the year, such as the

Annual Enrollment Period (October 15 – December 7) or during a Special Enrollment Period if you have a qualifying life event.

Coverage: Part D plans cover a wide range of prescription drugs, including brand-name and generic drugs. Each plan has a formulary or list of covered drugs, which can vary from plan to plan.

Costs: Part D plans have monthly premiums, deductibles, copayments, and coinsurance. The costs can vary depending on the plan you choose and the drugs you take. The Medicare Plan Finder tool can compare Part D plans and estimate your costs.

Donut Hole: Part D plans have a coverage gap, also known as the donut hole, where you pay a larger share of the cost of your drugs. Once you reach the donut hole, you will pay 25% of the cost of your brand-name drugs until you reach the catastrophic coverage threshold.

Extra Help: If you have limited income and resources, you may qualify for Extra Help, a program that helps pay for Part D costs. To qualify, you must meet certain income and asset limits.

Medicare Medigap, also known as Medicare Supplement, is a type of private insurance that can help pay for some of the costs that Original Medicare (Parts A and B) does not cover. Private insurance companies sell Medigap policies and can help fill the gaps in Medicare coverage. Here are some critical details about Medicare Medigap:

Benefits: Medigap policies are standardized and are labeled with letters A through N. Each plan provides a different set of benefits. All Medigap policies cover Part A coinsurance and hospital costs; some plans also cover Part B coinsurance and deductibles and other services.

Cost: Medigap policies have a monthly premium, which can vary depending on the plan you choose and where you live. You may also be required to pay deductibles, copayments, and coinsurance.

Enrollment: You can enroll in a Medigap policy during your Medigap Open Enrollment Period, which starts when you are 65 or older and enrolled in Medicare Part B. During this time, you have a guaranteed right to buy any Medigap policy sold in your state.

Coverage: Medigap policies only work with Original Medicare (Parts A and B). They do not work with Medicare Advantage plans.

Underwriting: When applying for a Medigap policy, the insurance company may review your health history and charge you more or deny coverage based on your health status.

Medicare DSNP stands for Dual Eligible Special Needs Plan. This is a type of Medicare Advantage plan that is designed specifically for people who are eligible for both Medicare and Medicaid. Here are some key details about Medicare DSNP:

Eligibility: You must be enrolled in both Medicare and Medicaid to be eligible for a DSNP. These plans are designed to provide extra benefits and services to people with low incomes and limited resources.

Benefits: DSNPs provide all the benefits of Original Medicare (Parts A and B) and often include additional benefits, such as prescription drug coverage, dental, vision, and hearing services, and transportation to medical appointments.

Cost: DSNPs may have lower or no premiums, deductibles, copayments, and coinsurance than other Medicare Advantage plans. They also may have a lower maximum out-of-pocket limit.

Network: DSNPs typically have a network of doctors, hospitals, and other health care providers. You may be required to use providers in the plan’s network, or you may pay more if you go out of network.
Enrollment: You can enroll in a DSNP during certain times of the year, such as the Annual Enrollment Period (October 15 – December 7) or during a Special Enrollment Period if you have a qualifying life event.

Well, I hope that clears it up for you. It’s essential to review the details of Medicare plans carefully before enrolling to ensure that they meet your healthcare needs and fit your budget. If you have more questions, please call me at +1.813.388.8373. I’d love to be a resource for you, and I’ll do a thorough needs analysis to help ensure you pick the plan that is best for you.

About Steve Turner

Steve Turner is a longstanding member of the National Association of Benefits and Insurance Professionals® and holds the prestigious designation of Registered Employee Benefits Consultant^® NABIP^® is the preeminent organization for health insurance and employee benefits professionals and works diligently to ensure all Americans have access to high-quality affordable Healthcare and related services.

Steve Turner is a licensed Agent appointed with Florida Blue.

Medicare Annual Enrollment Period is Oct. 15th – Dec. 7th. Steve Turner is not connected with or endorsed by the United States Government or the Federal Medicare Program. Florida Blue does not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.