Medicare 101: What is Medicare A, B, C, D?
Medicare is a federal health insurance program for people 65 years old and older, and for some younger people with disabilities or End Stage Renal Disease. The Initial Enrollment Period is from 3 months before you turn 65 until 3 months after. A late enrollment penalty may apply for those who join late. (In some cases the penalty may go up 10% for every year, or even 1% for every month in which you could have had coverage, but didn’t!) If you have any questions about Medicare, or would like to explore options that will allow you to go to doctors, hospitals, and other care providers of your choice, rather than only those who accept Medicare patients, please call a licensed, independent insurance agent at (951) 541-2684 or contact us online today.
QUESTION: Will I save money if I enroll in Medicare by myself and work directly with a private health insurance company, instead of using the services of a health insurance agency, such as Healthcare Plans West, LLC?
ANSWER: No, your monthly premium price will be the same; possibly even higher. We may be able to recommend a health insurance plan that fits your needs better and saves you money. We will also gladly review your coverage with you every year to see if there are any changes you would like to make.
Healthcare Plans West, LLC respects your right to choose a Medicare plan that works best for YOU. Our licensed, independent insurance agents are very familiar with what each policy does and does not cover. We can help you review all of your options for coverage and then help you narrow it down to the one that best fits your needs and your budget.
How do we get paid? Each policy has a small commission built into the price to compensate licensed and certified insurance agents for the time that it takes to learn all about their various insurance programs. This way, we can answer all of your questions and can help you make an educated decision. If you sign up for an insurance policy by yourself, the insurance company simply keeps that commission.
The following information is provided for general educational purposes only, to give you an overview of this complex federal insurance program. If you have any questions about this information or would like us to help you explore your Medicare options, please call a licensed, independent insurance agent at (951) 541-2684 or contact us online.
A Closer Look at Medicare: Part A, B, C, D
What does Medicare generally cover on tests, services, and other items?
Common Questions and Concerns
A Closer Look at Medicare: Part A, B, C, D
When you first enroll in Medicare, you are automatically placed in the Original Medicare program, which is Part A and/or Part B. There is generally no monthly premium for Part A, and most people are eligible for it, as long as you or your spouse paid Medicare taxes while working. (Some other qualifications include being 65 years of age or older, and a US citizen or permanent legal resident. Those under 65 with disabilities or End Stage Renal Disease may also be eligible.) There is, however, a monthly premium for Part B.
It’s important to know that you have a choice. You can choose to stay in the Original Medicare program, or you can choose to join a Medicare Advantage Plan, like a PPO or HMO. You may also have coverage through an employer, union, TRICARE, the VA, or Medicaid. You can also choose to have prescription drug coverage.
Original Medicare is Part A and/or Part B
If you are eligible for Part A, you are eligible for Part B. If you are not eligible for Part A, you may still qualify for Part B.
PART A: Hospital Insurance
This helps to cover costs associated with inpatient care in a hospital, skilled nursing facility (not long-term or custodial care), or religious, non-medical health care facility hospice care. It also covers home health care and hospice care.
Is there a monthly premium for Part A? Not usually. If you do not qualify to get Part A for free, you can buy it and pay a monthly premium.
Deductibles/coinsurance/copays: You must pay a set amount (deductible) for covered services and supplies. After Medicare pay its share you are responsible for whatever the coinsurance/copayment amount is.
Part A Late Enrollment Penalty: If you do not qualify for premium-free Part A, and you do not sign up for it as soon as you become eligible for Medicare, your monthly premium may go up 10% for every year that you did not have coverage. This penalty will be added to your premium for twice the number of years in which you could have had coverage, but didn’t.
Can I go to any hospital? No. You can only go to those that accept Medicare.
Important note: There is NO annual limit on out-of-pocket expenses.
PART B: Medical Insurance
This helps to cover costs associated with services that are medically necessary, such as visits to doctors and other health care providers, outpatient care, home health care, and durable medical equipment. In some cases, it also covers preventative services.
Medicare Part B does NOT cover: Acupuncture, cosmetic surgery, dental care, dentures, eye exams for glasses, hearing aids (or exams for fitting hearing aids), or long-term care.
Is there a monthly premium for Part B? Yes. Most people pay $104.90/month. If you get Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, your premium will be deducted from your benefit payment.
Deductibles/coinsurance/copays: Most preventative services are free, as long as your care was provided by a doctor or health care provider that accepts Medicare assignment.* (Some preventative services have a deductible and/or coinsurance amount.) For all other services in which the Part B deductible applies, you will have to pay out-of-pocket until the deductible has been met. In 2015, the annual deductible for Part B was $147.00. After that deductible has been met, you will typically pay 20% of the amount that Medicare has approved for that service or treatment, as long as your care was provided by a doctor or health care provider that accepts Medicare assignment. Then, Medicare will pay it’s share for services that are covered.
Part B Late Enrollment Penalty: If you don’t sign up for part B as soon as you become eligible for Medicare, your monthly premium may go up 10% for every year that you could have had the coverage but didn’t (unless you or your spouse are still working and have health insurance coverage through your employer or union). This penalty amount will be added to your Part D premium for as long as you have coverage. (You may be exempt from paying this late enrollment penalty if you are allowed to sign up for Part B during a Special Enrollment Period.)
Can I go to any doctor or health care provider? No. You can only go to those who accept Medicare.
Important note: There is NO annual limit on out-of-pocket expenses.
*Assignment means that your doctor, provider, or supplier accepts the Medicare-approved amount as full payment for covered services. They are usually willing to wait for Medicare to pay its share before you pay your share. IF your doctor, provider, or supplier DOES NOT accept assignment you may have to pay the entire amount at the time of service, which may also be more than the Medicare-approved amount.
Medicare Advantage Plan is Part C
Those who wish to receive Medicare Part A and Part B benefits through a private insurance company instead of Original Medicare can enroll in Medicare Advantage during the following enrollment periods:
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Initial Enrollment Period: you have from 3 months before you turn 65 until 3 months after you turn 65
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General Enrollment Period: between January 1 and March 31 (IF you have Part A and are getting Part B for the first time)
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Open Enrollment Period: Between October 15 and December 7 (coverage begins January 7)
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Special Enrollment Period (SEP): when certain life events, such as if you move out of your plan’s service area, or lose other insurance coverage, you can make changes to your Medicare Advantage and Medicare Prescription Drug Coverage
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5-Star Special Enrollment Period (5-Star SEP): from December 8 through November 30 you can switch (only once) from your current Medicare Advantage Plan or a Medicare Cost Plan to one that has a 5-star overall rating. IF, however, you move from a Medicare Advantage Plan that has prescription drug coverage to a 5-star Medicare Advantage Plan that does not have prescription drug coverage, you will have to wait until the next Open Enrollment Period to get prescription drug coverage, and may be charged a late enrollment penalty.
In addition to covering everything that’s included in Medicare Part A and B, Medicare Advantage Plans generally offer additional coverage, including dental, hearing, vision, Medicare Prescription Drug coverage, and other health and wellness services through an HMO or PPO network of healthcare providers. (Those with End-Stage Renal Disease may only be able to join a Medicare Advantage Plan under certain circumstances.)
Is there a monthly premium? There may (or may not) be a monthly premium for your Medicare Advantage plan in addition to your Part B premium. Prices will vary depending on the type of plan you choose.
HMO (Health Maintenance Organization) Plan: for all health and wellness services (with the exception of emergency care, out-of-area urgent care, or out-of-area dialysis), you will generally select a primary care physician, and go to a doctor, hospital, or other health care provider that is in your plan’s network. (If you see someone outside of this network, you may be responsible for the full cost of service/treatment.)
HMOPOS (Health Maintenance Organization Point-Of-Service) Plan: with these plans, you will generally select a primary care physician, however, you may also be able to go to out-of-network doctors or health care providers, and get out-of-network services for a higher copayment or coinsurance.
Medical Savings Account (MSA) Plan: this is a high-deductible health plan. Once you meet the yearly deductible, which varies by plan, the plan deposits money into a special savings account. You can use this money to pay for your health care costs. This plan does NOT include prescription drug coverage, so you may need to purchase a Medicare Prescription Drug plan.
PPO (Preferred Provider Organization) Plan: although you will generally pay less if you go to a doctor, hospital, or other health care provider in your plan’s network, you have the option of going to an out-of-network provider. You do not need to choose a primary care physician, and, in most cases you do not need a referral to see a specialist.
PFFS (Private Fee-For-Service) Plans: you can generally go to any Medicare-approved doctor, hospital, or health care provider who accepts the plan’s payment terms and agrees to treat you. If your PFFS plan has a network, you can see any in-network provider or out-of-network provider who has agreed to treat plan members. Some PFFS Plans do NOT include prescription drug coverage. If not, you may need to purchase a Medicare Prescription Drug plan.
SNP (Special Needs) Plan: this is for people who require specialized health care, such as those who live in a nursing home, have chronic health conditions, or who are on both Medicare and Medicaid. You will generally need to select a primary care physician who can refer you to a specialist in the network, if/when one is needed. Medicare Prescription Drug coverage is included in this plan.
Important: If your Medicare Advantage plan includes prescription drug coverage and join a Medicare Prescription Drug Plan you will be disenrolled from Medicare Advantage and placed back in Original Medicare.
Original Medicare (Part A and/or Part B) does not include prescription drug coverage.
Prescription drug coverage is available to anyone who has Medicare Part A or Part B. There are two ways to get this coverage. One is through the Medicare Prescription Drug Plan that adds coverage to Original Medicare, some Medicare Cost Plans, some Medicare PFFS (Private Fee-For-Service) Plans, and Medicare Medical Savings Account (MSA) plans. The other way is through Medicare Advantage Plans or other health plans that offer prescription drug coverage.
Which drugs are covered by the Medicare Prescription Drug (Part D) Plan?
Each plan has its own “formulary” (list of covered drugs). There are many different prescription drug formularies associated with stand-alone Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage.
If you currently have creditable prescription drug coverage through a current employer, former employer, union, etc., you may not need to pick up Medicare Prescription Drug Coverage (Part D).
If you do not currently have creditable coverage (it must meet Medicare’s standards for minimum coverage), and you do not enroll in a Medicare Prescription Drug Plan when you first become eligible for this coverage, you may incur a late enrollment penalty.
Part D Late Enrollment Penalty: If you ever go 63 or more days in a row without Part D or other creditable prescription drug coverage after your Initial Enrollment period, you will have to pay a penalty of approximately 1% (of the “national base beneficiary premium”) for each month that you could have had coverage, but didn’t. This penalty amount will be added to your Part D premium for as long as you have coverage.
Deductibles: Some prescription drug plans have a yearly deductible that you must meet before it will pay for covered prescription drugs; others do not.
Copayments/Coinsurance: this is the amount you pay for your prescription drugs after the deductible, if there is one. These amounts can vary by plan.
Coverage Gap: in some cases, if the cost of a covered prescription drug is high, there can be a gap in coverage after you and the insurance company have spent a certain amount of money. If this happens, you may have to pay a percentage of the plan’s cost for covered drugs until you reach the end of that coverage gap.
Catastrophic coverage: those who fell into a coverage gap, aka “donut hole,” will automatically receive “catastrophic coverage” when they get out of it.
How do other insurance and programs work with Part D?
Employer or union health coverage: If you currently have prescription drug coverage through an employer or union, contact them to find out if your coverage is creditable. If it is, you may be able to delay getting Medicare Prescription Drug Coverage. (Part D)
COBRA: in some cases you may be able to keep health coverage after your employment end with COBRA. Depending on the type of coverage you have, you may or may not want to take Part B, and may not need to pay a Late Enrollment Penalty for prescription drug coverage when your COBRA coverage ends.
Medicare Supplement Insurance (Medigap): you cannot have Medicare Prescription Drug Coverage plan and a Medigap policy that provides prescription drug coverage. So, if you have Medigap insurance and want to enroll in Part D, have your Medigap insurance company remove the prescription drug coverage from your policy (and adjust your premium accordingly).
Government insurance: these are creditable prescription drug coverage plans.
Federal Employee Health Benefits (FEHB) Program: this health coverage (for current and retired federal employees and covered family members) usually includes prescription drug coverage, so you most likely won’t need a Medicare drug plan.
Veterans’ benefits: veterans who have prescription drug coverage through the VA can also join a Medicare drug plan, however you cannot use both types of coverage for the same prescription at the same time.
TRICARE: this is a health care plan for active-duty service members, military retirees, and their families. Most people with TRICARE who are entitled to Part A must have Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you can also join a Medicare Prescription Drug Plan (the Medicare drug plan pays first; TRICARE pays second) or a Medicare Advantage Plan with prescription drug coverage. (If your Medicare Advantage Plan network pharmacy is also a TRICARE network pharmacy, they can coordinate benefits.)
Indian Health Service (IHS): this is the primary health care provider for American Indian/Alaska Native (AI/AN) who are on Medicare. Many Indian health facilities participate in the Medicare prescription drug program. If you get prescription drugs through an Indian health facility, you’ll continue to get drugs at no cost to you, and your coverage won’t be interrupted.
Medicare Prescription Drug Coverage is Part D
What does Medicare generally cover on tests, services, and other items?
Services covered by Part A
The following list gives you an overview of services covered under Part A. This list is to be used as a general guideline only. Some limitations may apply. If you’re in a Medicare Advantage Plan (like an HMO or PPO), some costs may be covered by Original Medicare and some may be covered by your Medicare Advantage Plan. For detailed information on specifically what is and isn’t covered under Part A, or what your out-of-pocket expenses may be, call a licensed, independent insurance agent at (951) 541-2684 or contact us online today. We will be happy to answer your questions. That said, Medicare will generally (but not always) cover:
Blood: this may depend on whether it came from a blood bank (at no charge), if it was donated, or if the hospital had to buy it.
Home health services: skilled nursing care, physical therapy, speech-language pathology services, occupational therapy, medical social services, some home health aide services, medical supplies for home, and durable medical equipment as long as they are all medically necessary.
Hospice care: all items for pain relief, symptom management, medical/nursing/social services, drugs, certain durable medical equipment, aide/homemaker services, spiritual counseling, and grief counseling.
Hospital care (inpatient care): semi-private rooms, meals, general nursing, drugs, hospital services, and hospital supplies in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, and mental health care.
Religious non-medical health care institution (inpatient care): non-religious, non-medical items, and non-medical services that do not require a doctor’s order or prescription.
Skilled nursing facility care: semi-private rooms, skilled nursing, rehabilitative services, meals, and other medically necessary services and supplies and inpatient hospital stay for a related illness or injury after a 3-day minimum stay, not including the day you’re discharged.
Important Note: Medicare will NOT cover Long-term care or custodial care.
Services that are generally covered by Part B
The following list gives you an overview of services covered under Part B. This list is to be used as a general guideline only.(Preventative services are labeled with an asterisk.*) Some limitations may apply. If you’re in a Medicare Advantage Plan (like an HMO or PPO), some costs may be covered by Original Medicare and some may be covered by your Medicare Advantage Plan. For detailed information on specifically what is and isn’t covered under Part B, and what your out-of-pocket expenses may be, call a licensed, independent insurance agent at (951) 541-2684 or contact us online today. We will be happy to answer your questions. That said, Medicare will generally (but not always) cover:
Abdominal aortic aneurysm screening*: one-time screening abdominal aortic aneurysm ultrasound for people at risk.
Alcohol misuse screening and counseling*: one alcohol misuse screening per year for adults who use alcohol, but don’t meet the medical criteria for alcohol dependency.
Ambulance services: ground ambulance transportation (and in some cases airplane or helicopter transportation) to the nearest hospital, critical access hospital, or skilled nursing facility for medically necessary services.
Ambulatory surgical centers: service fees related to approved surgical procedures provided in an ambulatory surgical center.
Blood: from a blood bank may be supplied at no charge. (There may be a blood processing and handling fee, and deductible.)
Bone mass measurement (bone density)*: once every 24 months (more often if medically necessary).
Breast cancer screening (mammograms)*: one baseline mammogram for women between 35–39, and once every 12 months for all women 40 and older. Also covers mammograms when medically necessary.
Cardiac rehabilitation: exercise, education, and counseling for patients who have had at least one of the following: heart attack in the last 12 months, coronary artery bypass surgery, current stable angina pectoris (chest pain), a heart valve repair or replacement, coronary angioplasty, or coronary stenting.
Cardiovascular disease (behavioral therapy)*: one visit per year with a primary care doctor in a primary care setting to help lower your risk for cardiovascular disease.
Cardiovascular disease screenings*: once every 5 years to test your cholesterol, lipid, lipoprotein, and triglyceride levels.
Cervical and vaginal cancer screening*: Pap tests and pelvic exams to check for cervical and vaginal cancers, and a clinical breast exam to check for breast cancer once every 24 months, or once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal Pap test in the past 36 months.
Chemotherapy for people with cancer: in a doctor’s office, freestanding clinic, or hospital outpatient setting. (Chemotherapy in a hospital inpatient setting is covered under Part A.)
Chiropractic services: limited coverage for manipulation of the spine to correct a subluxation, when medically necessary and provided by a chiropractor or other qualified provider.
Clinical research studies: office visits and tests in qualifying clinical research studies.
Colorectal cancer screenings*: one or more of these tests may be covered: multi-target stool DNA test once every 3 years (if you are between ages 50–85, show no symptoms of colorectal disease, and are at average risk for developing colorectal cancer), screening fecal occult blood test, screening flexible sigmoidoscopy, screening colonoscopy, and screening barium enema.
Concierge care: your concierge doctor must follow all Medicare rules. Medicare will NOT cover your membership fees.
Continuous Positive Airway Pressure (CPAP) therapy: if you’ve been diagnosed with obstructive sleep apnea, Medicare will cover a 3-month trial of CPAP therapy, and may cover it longer if the CPAP therapy is helping you.
Defibrillator (implantable automatic): devices for some people diagnosed with heart failure.
Depression screening*: one depression screening per year.
Diabetes screenings*: up to 2 diabetes screenings each year if your doctor determines you’re at risk for diabetes.
Diabetes self-management training*: outpatient self-management training and tips to help you cope with and manage your diabetes.
Diabetes supplies: blood sugar test strips/lancets/devices/monitors/control solutions, and in some cases, therapeutic shoes, and medically necessary insulin when administered with an external insulin pump.
Doctor and other health care provider services: medically necessary services and covered preventive services provided by doctors, physician assistants, nurse practitioners, social workers, physical therapists, psychologists, etc., are generally covered.
Durable medical equipment: oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare, for use in the home.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program: you generally must use Medicare contract suppliers if you want Medicare to help pay for these.
EKG or ECG (electrocardiogram) screening: EKG/ECG screening is covered once if you are referred by your doctor or other health care provider as part of your one-time “Welcome to Medicare” preventive visit.
Emergency department services: injuries, sudden illness, or an illness that quickly gets much worse.
Eyeglasses (limited): one pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. The contact lenses or eyeglasses must be provided by a supplier enrolled in Medicare.
Federally Qualified Health Center (FQHC) services: outpatient primary care and preventive health services
Flu shots*: one flu shot per flu season.
Foot exams and treatment: for patients who have diabetes-related nerve damage and/or meet certain conditions.
Glaucoma tests*: once every 12 months for people at high risk for glaucoma eye disease.
Hearing and balance exams: if your doctor or other health care provider orders this to see if you need medical treatment. (Original Medicare doesn’t cover hearing aids or exams for fitting hearing aids.)
Hepatitis B shots*: for people at medium or high risk for Hepatitis B.
Hepatitis C screening test*: yearly repeat screenings for certain people at high risk (a current or past history of illicit injection drug use, you had a blood transfusion before 1992, you were born between 1945–1965). The screening test must be ordered by a primary care doctor or other primary care provider.
HIV (Human Immunodeficiency Virus) screening*: once every 12 months for people who are between the ages of 15–65, and people under 15 and older than 65 who are at increased risk, and up to 3 times during a pregnancy.
Home health services: medically necessary part-time or intermittent skilled nursing care, and/or physical therapy, speech-language pathology services, and/or services if you have a continuing need for occupational therapy. A doctor (or certain health care professionals who work with a doctor) who has seen you face-to-face must certify that you need home health services and order your care. Services must be provided by a Medicare-certified home health agency.
Kidney dialysis services and supplies: 3 dialysis treatments/week for those with End-Stage Renal Disease (ESRD).
Kidney disease education services: up to 6 sessions of kidney disease education services for those with Stage IV chronic kidney disease, when referred by a doctor or other health care provider.
Laboratory services: certain blood tests, urinalysis, certain tests on tissue specimens, and some screening tests.
Lung cancer screening* – Low Dose Computed Tomography (LDCT): once per year if you meet all of these conditions: you are 55–77, either a current smoker or have quit smoking within the last 15 years, you have a tobacco smoking history of an average of one pack of cigarettes a day for 30 years, and you get a written order from a physician or qualified non-physician practitioner.
Medical nutrition therapy services* and certain related services: if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and have been referred by a doctor or other health care provider.
Mental health care (outpatient): services to help with depression, anxiety or certain other conditions. Includes visits with a psychiatrist or other doctor, clinical psychologist, nurse practitioner, physician assistant, clinical nurse specialist, or clinical social worker, and laboratory tests. (Inpatient mental health care is covered under Part A.)
Obesity screening and counseling*: face-to-face individual behavioral therapy sessions (to help those with a body mass index (BMI) of 30 or more to lose weight) in a primary care setting where it can be coordinated with your other care and a personalized prevention plan.
Occupational therapy: evaluation and treatment to help you perform daily life activities, such as getting dressed or bathing. A doctor or other health care provider must certify that you need it.
Outpatient hospital services: diagnostic and treatment services; you will generally have a copayment for services (except for certain preventative care services)
Outpatient medical and surgical services and supplies: X-rays, casts, stitches, or outpatient surgeries; you will generally have a copayment for these services and supplies.
Physical therapy: evaluation and treatment for injuries and diseases that change your ability to function; a doctor or other health care provider must certify that you need it.
Pneumococcal shot*: a shot for the prevention of pneumococcal infections, such as certain types of pneumonia. Medicare also covers a different second shot if it’s given one year after the first shot, or later.
Prescription drugs (limited): a limited number of drugs are covered. Check your plan for specific coverage.
Prostate cancer screenings*: a Prostate Specific Antigen (PSA) test and a digital rectal exam once every 12 months for men over 50.
Prosthetic/orthotic items: arm/leg/back/neck braces, artificial eyes, artificial limbs/replacement parts, prosthetic devices, ostomy supplies, and parenteral/enteral nutrition therapies are generally covered when ordered by a doctor or other health care provider enrolled in Medicare, and provided by a supplier that’s enrolled in Medicare.
Pulmonary rehabilitation: comprehensive pulmonary rehabilitation program for those with moderate to very severe chronic obstructive pulmonary disease (COPD). Must have a referral from the doctor who is treating you for this disease.
Rural Health Clinic (RHC) services: outpatient primary care and preventive health services in non-urban areas that are medically underserved, or shortage areas.
Second surgical opinions: for non-emergency surgeries. In some cases, third surgical opinions are covered, as well.
Sexually transmitted infection (STI) screening and counseling*: STI (chlamydia, gonorrhea, syphilis, and Hepatitis B) screenings once every 12 months for those who at increased risk for an STI, or at certain times during pregnancy for people who are pregnant. Must be ordered by a primary care doctor or other primary care practitioner. Medicare also covers up to two individual, 20–30 minute, face-to-face, high-intensity behavioral counseling sessions per year for sexually active adults at increased risk for STIs.
Shots: Flu shots, Hepatitis B shots, and Pneumococcal shots. (The shingles shot is NOT covered by Part A or Part B.)
Smoking and tobacco-use cessation (counseling* to stop smoking or using tobacco products): tobacco users can have up to eight face-to-face visits in a 12-month period.
Speech-language pathology services: evaluation and treatment to regain and strengthen speech, language skills, cognitive skills, and swallowing skills. Your doctor or other health care provider must certify that you need it.
Surgical dressing services: treatment of a surgical or surgically treated wound when medically necessary.
Telehealth: limited medical or other health services like office visits and consultations via interactive, two-way telecommunications system (like real-time audio and video) by an eligible provider who isn’t at your location.
Tests (other than lab tests): X-rays, MRIs, CT scans, EKG/ECGs, and some other diagnostic tests.
Transplants and immunosuppressive drugs: doctor services for heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and only in Medicare-certified facilities. Medicare covers bone marrow and cornea transplants under certain conditions. (Medicare drug plans may cover immunosuppressive drugs if they aren’t covered by Original Medicare.)
Travel (health care needed when traveling outside the U.S.): Medicare generally does NOT cover health care while you are traveling outside the 50 states, District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. There are some exceptions, such as: if you are on board a ship within the territorial waters adjoining the land areas of the U.S., or if you are in the U.S. when an emergency occurs, and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition, or you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another U.S. state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency, or you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.
Urgently needed care: treatment for a sudden illness or injury that isn’t a medical emergency.
Welcome to Medicare preventive visit*: during the first 12 months of having Part B, you can get a preventive visit to review your medical and social history as it relates to your health, and education/counseling about preventive services. This preventative visit may also include certain screenings, shots, and referrals for other care, if needed.
Yearly Wellness visit*: for those who have had Part B for longer than 12 months, to develop/update a personalized plan to prevent disease or disability based on current health and risk factors.
Common Questions and Concerns
Do I need Medicare Supplement Insurance? (Medigap: Plans A~N)
Original Medicare covers many of your hospital and medical expenses, but it does not cover everything.
If you are enrolled in Original Medicare and have Part A and Part B, you may want to consider purchasing a Medicare Supplement Insurance policy to cover some of the “gaps” and help you pay for copayments, coinsurance, and deductibles. In some cases, it may also pay for services that Original Medicare does not cover all at.
Medigap policies are standardized by the state and federal government to protect you. These are identified by letters A, B, C, D, F, G, K, L, M, N. (Plans E, H, I, J are no longer sold but can be used if you already have them). They all offer the same basic benefits, but some policies offer additional benefits. Prices for these policies will vary.
Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount before your Medigap plan pays anything.
Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in inpatient admission.
Some states offer a (HMO/PPO) Medigap SELECT policy, in which participants can save money by receiving benefits through a network of providers.
Medicap Open Enrollment Period: there is a 6 months window of time in which you are eligible to buy a Medicare Supplement Insurance (Medigap) policy. It begins the first day of the month in which you are 65 or older and enrolled in part B. After this period, you may not be able to buy it, or it may cost more UNLESS your delay in enrolling is due to you or your spouse having group health insurance coverage through current employment. In that case, your Medigap Open Enrollment Period won’t start until you sign up for Part B.
IMPORTANT NOTE: If you already have a Medicare Advantage Plan (Part C), you can ONLY purchase a Medigap policy if you disenroll from Medicare Advantage Plan and return to Original Medicare.
Long-Term Care is not covered by Medicare
Long-term care for those with a chronic illness or disability who need non-medical care and non-skilled personal care assistance to help them with daily activities (such as dressing, bathing, and using the bathroom), is generally NOT covered by Medicare, Medicare Supplement Insurance (Medigap) policies, or most health insurance plans.
How will I pay for long-term care?
Long-Term care can be very expensive. If you have do not have long-term insurance coverage through an employer, union, life insurance policy, Medicaid, the VA, or the Federal Long-Term Care Insurance Program, and do not want to use your own personal (savings, trust, annuity) resources, you should seriously consider purchasing a long-term care insurance policy to avoid becoming a financial burden on your family. Call a licensed, independent insurance agent at 800-831-9876 (in Las Vegas: 702-449-8311) or click here to contact us online. We will be happy to help you explore your options for coverage.
What if I need help paying for my Medicare coverage?
If you have limited income and resources, you may qualify for help to pay for some health care and prescription drug costs.
Extra Help
Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs.
You will automatically qualify for Extra Help if you have Medicare and full Medicaid coverage, the state helps to pay for your Part B premiums through a Medicare Savings Program, or you get Supplemental Security Income benefits.
If you qualify, it will help you pay for your Medicare drug plan’s monthly premium, yearly deductible, coinsurance, and copayments. You will have no coverage gap or late enrollment penalty, and you can switch plans at any time.
Extra Help is not available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
Medicare Savings Programs
MSPs are available for those (with Medicare Part A) who have limited income and resources. To qualify for assistance you must be:
• Single person with a monthly income of less than $1,333 and resources less than $7,160 (2015)
• Married and living together with a monthly income of less than $1,790 and resources less than $10,750 (2015)
Resources include money in a checking or savings account, stocks, bonds, mutual funds, and Individual Retirement Accounts (IRAs). Resources do not include your home, car, burial plot, burial expenses up to your state’s limit, furniture, or other household items.
There are 4 types of MSP programs:
1. Qualified Medicare Beneficiary (QMB) Program: helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments.
2. Specified Low-Income Medicare Beneficiary (SLMB) Program: helps you pay for Part B premiums (only).
3. Qualifying Individual (QI) Program: helps you pay for your Part B premiums (only). You must apply for this each year. The benefits and the applications are granted on a first-come first-served basis.
4. Qualified Disabled and Working Individuals (QDWI) Program: helps you pay Part A premiums (only). You may qualify for this program if you have a disability and you are working.
Medicaid
Medicaid is a joint federal and state program that may help you pay medical costs if you have limited income and resources and meet other requirements. Some people are “dual eligibles,” which means they qualify for both Medicare and Medicaid.
If you have Medicare and full Medicaid coverage, most of your health care costs are covered. Medicare covers your Part D prescription drugs. Medicaid may cover some drugs plus other care that Medicare doesn’t cover.
People with Medicaid may get coverage for services that Medicare may not cover or only partially cover, like nursing home care, personal care, as well as home and community-based services.
State Pharmacy Assistance Programs
Many states have SPAPs that help certain people pay for prescription drugs based on financial need, age, or medical condition. Each SPAP makes its own rules on how to provide drug coverage to its members.
Pharmaceutical Assistance Programs/Patient Assistance Programs
Many major drug manufacturers offer assistance programs for people with Medicare drug coverage who meet certain requirements.
Supplemental Security Income (SSI)
People with limited income and resources who are disabled, blind, or 65 or older may be entitled to receive a cash benefit that is paid by Social Security. (SSI benefits are different from Social Security benefits.) This program helps people meet basic needs for food, clothing, and shelter.
Note: People who live in Puerto Rico, the U.S. Virgin Islands, Guam, or American Samoa cannot receive SSI.
Medicare is a very complex program. Understanding the difference between the different plans and keeping track of important dates can be quite daunting. Healthcare Plans West, LLC respects your right to choose. Our licensed, independent health insurance agents can guide you through the Medicare enrollment process with ease, answer all of your questions, review your policy, advise when a provider makes changes that may affect you, and remind you about important upcoming dates. If you have any questions, please call us at (951) 541-2684 or contact us online.
Definitions/Glossary of Terms
The following definitions are provided for general educational purposes only. If you have any questions about a specific term or definition as it relates to your care, please call us at (951) 541-2684 or contact us online.
Assignment
When a doctor, health care providers, or supplier “accepts Assignment” it means:
• They agree to be paid directly by Medicare
• They will accept the Medicare-approved amount for services
• They will only bill you for the Medicare deductible and coinsurance
Benefit period
Your benefit period begins on the day that you are admitted in a hospital or skilled nursing facility as an inpatient. It end when you have gone 60 days in a row without receiving any inpatient hospital care, or skilled care in a skilled nursing facility. You must pay the inpatient hospital deductible for each benefit period. (No limit.)
Coinsurance
After your deductible, your coinsurance is the amount that you must pay for your share of the cost of services.
Your coinsurance amount is usually a percentage, such as 20%.
Copayment
This is the amount you must pay as your share of the cost for medical services or supplies.
Your copayment is usually a set dollar amount, such as $15 per every office visit.
Creditable prescription drug coverage
If you have a prescription drug plan that covers at least as much as Medicare’s standard prescription drug plan, Medicare will generally allow you to keep that coverage without paying a penalty if your decide to enroll in Medicare prescription drug plan later.
Critical access hospital
This is a small facility in a rural area that provides outpatient services, as well as inpatient services on a limited basis.
Custodial care
With this type of care, a non-skilled person helps you with daily living activities, such as eating, dressing, and bathing. It may also include help with some health-related activities, such as using eye drops. Medicare generally does not pay for custodial care.
Deductible
This is the amount that you must pay for your health care and prescriptions before Original Medicare, your prescription drug plan, or other insurance will pays for services or supplies.
Demonstrations
These special, short-term projects are usually conducted with a special group of people in a specific area, to test Medicare’s quality of care, coverage, and payments
Extra Help
This Medicare program helps people with limited income and resources pay for Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Formulary
A list of covered prescription drugs.
Inpatient rehabilitation facility
A hospital, or section of a hospital, that can provide inpatients with an intensive rehabilitation program.
Institution
A facility that provides short-term or long-term care, such as a rehabilitation hospital, nursing home, or skilled nursing facility. (Does not include private residences or group homes.)
Lifetime reserve days
Original Medicare gives you 60 “reserve” days that can used during your lifetime to pay all covered costs (except for your daily coinsurance) when you are hospitalized for more than 90 days.
Long-term care
Services (medical and non-medical) to assist someone who needs help with basic daily living activities. Medicare and most health insurance plans will generally not cover long-term care.
Long-term care hospital
An acute care hospital can that provides treatment and services, such as comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management to patients. Many of these patients are transferred from an intensive or critical care unit, and stay for at least 25 days.
Medically necessary
Health care services/supplies that meet accepted standards of medicine, and are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms.
Medicare-approved amount
In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.
Medicare health plan
This is generally a plan that people can enroll in (through a private company that contracts with Medicare) to receive Medicare Part A and Part B benefits, such as Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs, and others.
Medicare plan
All Medicare health plans and Medicare prescription drug plans, except Original Medicare.
Premium
The payment that you must make to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
Preventive services
Health care services that are provided to help prevent illness, or to detect illness at an early stage.
Primary care doctor
The doctor that you go to first for most of your health care problems or concerns.
Primary care practitioner
A doctor who has a primary specialty in family medicine, internal medicine, geriatric medicine, or pediatric medicine; or a nurse practitioner, clinical nurse specialist, or physician assistant.
Referral
This is when your primary care doctor gives you a written order to a specialist or place to get medical services.
Service area
Some plans limit which doctors and hospitals you may use for routine (non-emergency) services, based on the geographical (service) area that you live in.
Skilled nursing facility (SNF) care
Skilled nursing care and rehabilitation services provided in a skilled nursing facility on a continuous, daily basis.
Medicare Enrollment Periods & Dates to Remember
Initial Enrollment Period (IEP): 7 months
The 7-month period in which you are eligible to enroll in Medicare Part A (Hospital insurance) and/or Medicare Part B (Medical insurance) begins three months prior to your 65th birthday, includes your birth month, and extends until three months after you turn 65. Prescription drug coverage is not included in this Original Medicare program.
If you do not have “creditable” prescription drug coverage through an employer plan, union, or other provider whose coverage is equivalent to or better than a Medicare Part D Prescription Drug plan, you can purchase a Part D plan through a private insurer. You can also choose to receive your Medicare Part A and Part B benefits through a Medicare Advantage Plan (Part C) that is purchased through a private insurer. Some Medicare Advantage plans include prescription drug coverage, as well as some other benefits, such as dental, vision, and hearing coverage. Medicare Prescription Drug Plans and Medicare Advantage Plan benefits vary by plan.
You may be charged a Part B or Part D Late Enrollment Penalty if you do not sign up for these during your Initial Enrollment period and choose to enroll in them later.
Medicare OPEN Enrollment Period (OEP): October 15 – December 7
During this time, all people with Medicare can change their Medicare health plans and prescription drug coverage for the following year. You may:
• Change from Original Medicare to an Medicare Advantage plan
• Change from a Medicare Advantage plan back to Original Medicare
• Switch from a Medicare Advantage plan to another Medicare Advantage Plan
• Switch from a Medicare Advantage plan that does not offer prescription drug coverage to a Medicare Advantage plan that offers prescription drug coverage
• Switch from a Medicare Advantage plan that offers prescription drug coverage to a Medicare Advantage plan that does not offer prescription drug coverage
• Join a Medicare Prescription Drug plan
• Drop your Medicare Prescription Drug coverage
• Switch from a Medicare Prescription Drug plan to another Medicare Prescription Drug plan.
Medicare Advantage Disenrollment Period: January 1 – February 14
During this time, those who are enrolled in a Medicare Advantage Plan can switch back to Original Medicare. You may also join a Medicare Prescription Drug Plan. (Coverage begins the first day of the month after the plan gets your enrollment form.)
Medicare General Enrollment Period (GEP): January 1 – March 31
During this time, those who did not sign up for Medicare Part A or Medicare Part B during their Initial Enrollment Period (IEP) can sign up for it now. (Coverage begins July 1.) Enrollees in Medicare Part B during GEP are eligible for a Special Enrollment Period for Medicare Part D Prescription Drug coverage. (See SEP: April 1-June 30, below)
Medicare Special Enrollment Period (SEP) for Part B General Enrollment Period enrollees: April 1 – June 30
During this time, those who enrolled in Medicare Part B during GEP may make one election to join a Part D Medicare Prescription Drug plan. These beneficiaries (who were previously not eligible to enroll in a Part C Medicare Advantage plan because they did not have the required Part B coverage) may also use this SEP to enroll in a Medicare Advantage plan with drug coverage. (MA-PD)
Other Special Enrollment Periods (SEPs)
If you did not sign up for Medicare during the Initial Enrollment Period – or if you’ve recently moved out of your plan’s coverage area, lost insurance coverage through an employer plan, have a severe or disabling condition, qualify for Extra Help, or numerous other “special” circumstances – you may qualify for a Special Enrollment Period. This would allow you to make a change in your Medicare coverage. Rules about when you can make a change, and the type of changes you can make, are different for each SEP.
