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What Is Medicare? Everything You Need To Know.

What Is Medicare? Everything You Need To Know.

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Written by: Benavest

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Medicare

May 18, 2021

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Table Of Contents

9

What Is Medicare?

9

What Types Of Coverage Are There?

9

What Is Medicare Advantage?

9

Medicaid or Medicare?

9

What Is Medigap?

9

“What’s Covered?” App

9

Reporting Complaints

9

How To Get The Coverage You Need

9

How To Save On Medicare Costs

What Is Medicare?

Medicare is a federal insurance program made for people who are 65 years of age or older, certain younger people with disabilities, or people with permanent kidney failure who require dialysis or transplant.

 

Who Is Eligible For Medicare?

Although medicare caters to people that are 65 years or older medicare sometimes covers others. To be eligible for medicare the following must be true.

 

People 65 or older

  • You must be a U.S. citizen or permanent legal resident who has lived in the U.S. for at least 5 years
  • You are:
    • Receiving Social Security or
    • Railroad retirement benefits or
    • Have worked long enough to be eligible for those benefits but are not collecting them
  • You or your spouse is a government employee who has not paid into Social Security but has paid Medicare payroll taxes

 

People Under 65

  • You have been entitled to Social Security disability benefits for at least 24 consecutive months
  • You meet certain conditions and receive a disability pension from the Railroad Retirement Board
  • You have Lou Gehrig’s disease
  • You have permanent kidney failure requiring regular dialysis or a kidney transplant

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If you qualify for the Medicare Savings Program, Medicaid, or LIS, better plan options may open up so it is imperative to get a Medicare Plan Review done to make sure you are receiving the best healthcare benefits available.

New health plans may open up with better benefits including more coverage for things like dental & vision, better copay’s, lower deductibles, free meal delivery, and Much More!!

What Types Of Medicare Coverage Are There?

Medicare is divided into multiple parts that provide coverage. 

Part A: provides inpatient and hospital coverage

Part B: provides outpatient and medical coverage

Part C: Also known as Medicare Advantage. These plans are offered by private companies and provide the same coverage as Medicare parts A and B and sometimes offer more.

Part D: provides prescription drug coverage

 

Medicare Part A

Medicare part A covers the cost of inpatient and hospital care. Most of the time Medicare is free but there is a deductible in 2021. Medicare part A covers:

  • Surgeries
  • Inpatient care in hospitals
  • Skilled nursing facilities
  • Hospice care
  • Home healthcare services
  • Inpatient care in religious non-medical healthcare institutions

 

Medicare Part B

Medicare Part B is an optional addition that requires a monthly premium payment. Part B covers:

  • Doctor’s visits
  • Medical equipment
  • Outpatient care
  • Outpatient procedures
  • Purchase of blood
  • Mammograms
  • Cardiac rehabilitation
  • Cancer treatment

 

Medicare Part C

Medicare Part C, also known as Medicare Advantage are plans offered by private companies and approved by Medicare. These plans provide the same coverage as plans A and B and many provide extra benefits.

 

Medicare Part D

Medicare Part D covers the costs of prescription drugs. These plans are offered by private insurance companies and approved by Medicare. 

  • Many Part D plans divide their drugs into different tiers. Most of the time lower-tier drugs will cost you less than higher-tier drugs.
    • Tier 1 – copay: most generic prescription drugs
    • Tier 2 – medium copay: preferred, brand-name prescription drugs
    • Tier 3 – higher copay: non-preferred, brand-name prescription drugs
    • Specialty tier – highest copay: very high-cost prescription drugs
  • Generic Drugs are copies of brand name drugs and are the same as brand-name drugs in the following ways:
    • Dosage form
    • Safety
    • Strength
    • Route of administration
    • Quality
    • Performance
    • Intended use
  • Most Part D coverage plans will have their own drug formulary for the prescription drugs they cover

What Is Medicare Advantage?

Medicare Advantage plans, sometimes called Part C plans, are a great alternative to original medicare AKA Medicare Parts A and B. Medicare Advantage plans are plans sold by private insurers that are approved by Medicare.

 

What’s covered?

Medicare Advantage plans cover the same things that Medicare Part A and Part B cover. Most of them offer other things like:

  • Some vision programs
  • Hearing
  • Dental
  • Fitness programs

Some other services like transportation to doctor’s visits, over-the-counter drugs, and services that promote your wellness may be included as well.

 

How Much Does It Cost?

The price for Medicare Advantage plans depends on many factors. Most of the time you will need to use doctors that are in-network and within the service area for the lowest costs. Some plans may not even cover using doctors out-of-network.

The Factors that determine how much your Medicare Advantage Plan will cost are:

  • Monthly premium prices
  • Whether the plan pays any of your Part B premium
  • Some plans may have a yearly deductible
  • Copay and coinsurance that you pay for each visit
  • The type of health care you need and how often you need it
  • Whether you stay in-network or go out-of-network
  • You may possibly be eligible for savings on your plans

 

Drug Coverage

Most Medicare Advantage plans include drug prescription coverage but some do not. You can join a separate Part D plan with certain plans. Plans that do not offer drug coverage or choose not to.

 

The Different Types Of Medicare Advantage Plans

Health Maintenance Organization (HMO) plans— Most of the time, HMO plans only allow you to stay in-network. The only time these plans do allow you to go out-of-network is in emergencies. Generally, you will need referrals from your doctors to see other doctors or specialists.

Preferred Provider Organization (PPO) plans— PPO plans allow you to go out-of-network however, if you prefer to keep expenses low there are fewer costs associated with any services done within their network.

Private Fee-for-Service (PFFS) plans— These plans generally allow you to go anywhere for your healthcare services as long as they accept the plan’s payment terms. 

Special Needs Plans (SNPs)— SNPs are specialized plans for specific groups of people.

  • People who have both Medicaid and Medicare
  • Live in a nursing home
  • Or have certain chronic conditions including
    • Chronic alcohol and other dependence
    • Dementia
    • HIV/AIDS
    • Stroke
    • And More

HMO Point-of-Service (HMOPOS) plans— These plans function like a regular HMO plan except they allow you to go out-of-network for a higher copay or coinsurance.

Should I Enroll In Medicare Or Medicaid?

The qualifying difference between these two programs is that Medicaid is based on income and Medicare is mainly based on age.

 

Medicaid

Medicaid covers different things varying by state. There are some mandatory benefits and some optional ones. Most Medicaid programs cover the minimum essential coverage benefits. Medicaid typically covers: 

  • Children 
  • Pregnant Women
  • Elderly adults and people with disabilities
  • Eligible low-income adults

The cost of Medicaid is dependent on how much income you make and state regulations. Costs may include premiums, deductibles, copay, and coinsurance. Some individuals do not need to pay any out-of-pocket costs.

Eligibility for Medicaid depends on the regulations set by your state. Contact your state’s Medical Assistance office to see if you qualify.

 

Medicare

As mentioned above in “What types of Medicare are there?”. Medicare is divided into 4 parts that all cover different types of medical costs. Medicare typically covers:

  • People that are 65 years of age and older
  • Some people under 65 who may qualify because of a disability or special exception

The cost of Medicare depends on the type of plan you select. Costs may include premiums, deductibles, copay, and coinsurance.

Many people have automatically enrolled in Medicare parts A and B automatically when they turn 65. You may contact your local social security office to check your eligibility.

What Is Supplemental Medicare Or Medigap?

Supplemental Medicare, or Medigap, is insurance that helps fill gaps in original medicare and is sold by private companies. Medigap plans help pay for additional things like copay, coinsurance, and deductibles.

 

Medigap Plans

Medigap plans are standardized and sold by plan letter. Different plans offer different benefits, here is a list of Medigap plans and what they include.

A
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
No
Part A deductible
No
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
No
Out-of-pocket limit**
N/A
B
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
No
Part A deductible
Yes
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
No
Out-of-pocket limit**
N/A
C
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
Yes
Part A deductible
Yes
Part B deductible
Yes
Part B excess charge
No
Foreign travel exchange (up to plan limits)
80%
Out-of-pocket limit**
N/A
D
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
Yes
Part A deductible
Yes
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
80%
Out-of-pocket limit**
N/A
F
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
Yes
Part A deductible
Yes
Part B deductible
Yes
Part B excess charge
Yes
Foreign travel exchange (up to plan limits)
80%
Out-of-pocket limit**
N/A
G
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
Yes
Part A deductible
Yes
Part B deductible
No
Part B excess charge
Yes
Foreign travel exchange (up to plan limits)
80%
Out-of-pocket limit**
N/A
K
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
50%
Blood (first 3 pints)
50%
Part A hospice care coinsurance or copayment
50%
Skilled nursing facility care coinsurance
50%
Part A deductible
50%
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
No
Out-of-pocket limit**
$5,880 in 2020 ($6,220 in 2021)
L
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
75%
Blood (first 3 pints)
75%
Part A hospice care coinsurance or copayment
75%
Skilled nursing facility care coinsurance
75%
Part A deductible
75%
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
No
Out-of-pocket limit**
$2,940 in 2020 ($3,110 in 2021)
M
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
Yes
Part A deductible
50%
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
80%
Out-of-pocket limit**
N/A
N
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Yes
Part B coinsurance or copayment
Yes
Blood (first 3 pints)
Yes
Part A hospice care coinsurance or copayment
Yes
Skilled nursing facility care coinsurance
Yes
Part A deductible
Yes
Part B deductible
No
Part B excess charge
No
Foreign travel exchange (up to plan limits)
80%
Out-of-pocket limit**
N/A

Medicare “What’s Covered?” App

If you are not sure whether your Medicare will cover a specific service then you should try Medicare’s mobile app, “What’s Covered”! 

This app allows you to see what your insurance plan covers and gives an estimated cost for the services. All you need is internet access and your phone to see everything you need to know about what your Medicare covers.

“What’s covered” is available for free on Android devices and IOS. Just search for “What’s covered” or “Medicare” and download the app. 

The app will give you a general cost of a service, coverage eligibility details for items and services covered by Medicare Part A and Part B. It also shows a list of covered preventive services.

 

IOS download link: https://itunes.apple.com/us/app/whats-covered/id1444143600?mt=8

Android download link: https://play.google.com/store/apps/details?id=gov.medicare.coverage

Reporting Complaints

When you are unhappy with the quality of your health care, make sure you speak with your health care provider first to let them know about how you feel. If you do not want to talk to your health care provider then it is your right to file a complaint.

Complaints are categorized as follows:

Depending on what your complaint is you will need to click on the corresponding link.

Every Medicare health or drug plan has its own regulations for dealing with complaints. If you need more assistance after your complaint has been filed, feel free to call 1-800-MEDICARE.

If you have filed your complaint, and called 1-800-MEDICARE and still need help. Ask the operator you talk with on 1-800-MEDICARE to send your complaint to the Medicare Beneficiary Ombudsman. The staff there will help make sure your problem is resolved. 

You can also file an appeal if you do not agree with a coverage or payment decision made by Medicare, a Medicare health plan, or a Prescription drug plan.

For other Medicare-related complaints, call SHIP or State Health Insurance Assistance Program for free personalized help.

How To Get Coverage On The Things You Need

Medicare advantage programs cover many different services, prescription drugs, diabetic test supplies, and many different screenings. But what should you do if your plan will not cover the cost of an item or service you need?

Filing an appeal can help you dispute whether a service or item should be included in your plan. You may also file an appeal for items or services that should be continued, provided, or covered. 

Here are some tips to get the ball rolling with appeals:

  • Get Help: If you are unsure how to move forward with the appeal process, simply appoint a representative. This representative can be a family member, attorney, doctor, friend, or advocate that acts on your behalf. Another option is to contact SHIP (State Health Insurance Assistance Program).
  • Gather Information: Ask your healthcare provider or doctor for any information to help your case.
  • Keep Copies: Make sure to keep a copy of all important documents that you send your plan as part of your appeal.
  • Start the process: You have 60 days from the day of your coverage determination to file an appeal. Follow the directions of your plan’s denial notice and plan materials. If you file after 60 days, You must provide a reason for filing late.

Once the appeals process is started, you can disagree with the decision made at any level of the process and go to the next level.

How To Save On Medicare Costs (LIS)

There are many different financial stresses in life and your health should not be one of them. Here are a few ways you can save money on Medicare.

 

Medicaid

One way to save money on health care expenses is with Medicaid. You may qualify for Medicaid if you have limited income and resources. Medicaid helps with medical costs, and offers benefits that are not normally offered by Medicare. 

Each state has different regulations about eligibility and the application process for Medicaid. So make sure to contact your state’s Medicaid program to make sure you qualify and what steps you need to take.

 

Medicare savings programs

Medicare has four savings programs that may help mitigate some of the costs of your coverage. 

  • (QMB) Qualified Medicare Beneficiary
  • (SLMB) Specified Low Income Medicare Beneficiary
  • (QI) Qualifying Individual
  • (QDWI) Qualified Disabled and Working Individuals

Call your state’s Medicare program for more information on these services and to see if you qualify.

Medicare LIS

Some people may be eligible for a Low-Income Subsidy (LIS) that helps pay for Medicare Part D prescription drug costs. The amount of subsidy is dependent on the individual’s income based on the Federal Poverty Level and limitations set by social security.

Extra Help Eligibility

Extra help is a Medicare program that helps people with limited income or resources pay Medicare prescription drug costs, like premiums, deductibles, or coinsurance. Extra help is included along with the four Medicare savings programs and Medicaid automatically.

To qualify for Extra Help

  • Your annual income and assets must be below the eligibility levels. These metrics change on a yearly basis so it’s best to check medicare.gov for the most recent levels.
  • If your annual income is above those levels but live in Alaska, Hawaii or support other family members who live in your household.

The assets that are considered in your eligibility are:

  • Cash and bank accounts
  • Investment property real estate
  • Stocks and bonds
  • Mutual funds and IRAs

 

Extra Help Benefits

You may or may not for full Extra Help or partial Extra Help. Depending on your assets and income. Either way you will receive some assistance with the cost of your prescription drugs. 

Extra Help:

  • Helps pay for your Part D premium
  • Lowers the cost of your prescription drugs
  • Eliminates Part D late enrollment penalties
  • Provides a Special Enrollment Period once per quarter during the first 9 months of the year.

Get A FREE Quote Now!

If you qualify for the Medicare Savings Program, Medicaid, or LIS, better plan options may open up so it is imperative to get a Medicare Plan Review done to make sure you are receiving the best healthcare benefits available.

New health plans may open up with better benefits including more coverage for things like dental & vision, better copay’s, lower deductibles, free meal delivery, and Much More!!

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