Choosing Medicare coverage is important to both your health and your budget, but making the right choice can be difficult and overwhelming. When President Lyndon Johnson signed the Medicare Act into law in 1965, he likely never imagined the myriad of options, paperwork, forms, and deadlines we have today.
With the alphabet soup-like options available, it can be confusing or even frustrating to sign up for the right Medicare coverage plan. The good news is that you do not have to do it alone.
This guide will help you decipher all the Medicare coverage jargon and point you in the right direction of the perfect Medicare coverage for you.
The Medicare advisors at Braden Insurance Agency Inc. in Louisville, KY are here to provide free, unbiased expert advice to help you find the best Medicare coverage for your needs and budget.
WHO IS ELIGIBLE FOR MEDICARE?
You are eligible to join Medicare if…
- You are 65 years or older – regardless of whether you are already receiving Social Security, you are eligible for Medicare at 65, the age of your spouse at the time is irrelevant.
- You are under the age of 65 and qualify for disability.
- You are a U.S. citizen.
- A legal resident who currently lives in the United States or has lived in the U.S. for at least five consecutive years.
DIFFERENT MEDICARE SCENARIOS: WHICH ONE ARE YOU?
Each person and situation is unique. That’s why it is so important to understand all your options and devise a plan that is catered to you. Those who are eligible for Medicare coverage, typically fall into one of the following scenarios.
- You are about to turn 65 - If you fall into this category, you’ll likely be receiving a letter from the Social Security office in the mail. It may come several months, or even up to a year before your birthday. This is when it’s important to start thinking about your options.
- You are losing your health coverage from your employer - If you are retiring, and over 65 years old, you may be concerned about how to continue your medical coverage. This is the time that you want to look into your Medicare coverage options.
- You are over 65, but have not signed up for Medicare coverage yet - Some adults work well into their 70s and maintain their employer or independent insurance coverage. If you have not signed up for Medicare coverage, but are interested in the options available to you, we can help with that too.
Regardless of what scenario you are in, Medicare is very specific to the individual. Just because your neighbor has a Medicare plan, does not mean that that same plan will work for you.
DIFFERENT MEDICARE PLANS: HOW TO GET STARTED
Almost everyone, especially aging Americans, has heard of Medicare coverage. However, most do not understand what it provides and how it works. At the most fundamental level, there are three basic types of Medicare coverage: Part A, Part B, and Part C.
- Part A and Part B = Original Medicare
- Part C = Medicare Advantage
They cover the same basic services, but they work very differently. If you choose Medicare Advantage, you will have to pick a specific policy from a particular private insurance company. If you choose Original Medicare, it will come from the government.
Once you choose between Original Medicare vs Medicare Advantage, there are other coverage choices to make and supplemental policy options. As you can see, Medicare coverage can (and will) get very confusing very quickly.
We will break it down so it is easier to digest. Just hang in there and keep reading.
WHAT IS ORIGINAL MEDICARE?
Original Medicare (Part A and Part B) is operated by the government. It provides coverage for and access to doctors, hospitals, or other health care providers for Medicare participants over the age of 65. Part A is designed to cover the cost if you need to stay in the hospital while Part B is designed to cover ongoing health and wellness care and regular doctor’s visits care to keep you healthy.
WHAT IS MEDICARE PART A?
Description
- Medicare Part A insurance helps pay for “medically necessary” care. This is care for an illness or medical condition that involves an inpatient hospital stay. Part A also helps pay for a stay in a skilled nursing facility as a follow-up to a hospital stay. Part A may also cover hospice care for the terminally ill and some skilled home care for the homebound.
What Providers Can I See?
- With Part A Medicare coverage, you can choose any qualified provider in the United States who has been accepted by Medicare and who is accepting new patients. Since Part A offers the same benefits throughout the United States, you are not limited to a particular state or region for your care.
What Part A Does Not Cover
- While Part A helps you pay the costs of hospital care when you are sick, there are some things it will not cover.
- Personal Cost in a hospital - like additional food options, telephone calls, etc.
- Custodial Care - This is the care that helps with the activities of daily life, like eating, bathing, or dressing.
WHAT IS MEDICARE PART B?
Description:
- Medicare Part B insurance covers an annual wellness exam plus additional preventive screenings at no cost to you. Part B also helps pay for the ongoing and daily care of an illness or medical condition. This includes doctor’s visits, care in clinics and hospitals without being admitted, laboratory tests, diagnostic screenings, and some skilled nursing care at home if necessary. Part B covers most doctor services you receive as a hospital patient, while the services of the hospital and staff are covered by Part A. Part B is voluntary, but most people sign up when they first become eligible.
What Providers Can I See?
- You can choose any provider who is eligible to participate in Medicare, and who is accepting new patients.
What Does Part B Not Cover?
- It does not cover any care for your eyes, teeth, or hearing. Only in very limited situations does it cover these. It also does not cover medical care you receive outside of the United States, except in a few very limited situations. Part B does not cover the cost of help with the activities of daily life, like eating, bathing, or getting dressed.
For free assistance on what is covered with Original Medicare (and what is not), set up a free, no-stress consultation with one of the independent agents at Braden Insurance.
WHAT IS A MEDICARE ADVANTAGE PLAN?
Medicare Advantage plans, or Medicare Part C plans, are run by private companies, not the government. They have different combinations of coverage for hospital stays with coverage for doctor visits and wellness exams as well. Many times coverage for Medicare Advantage can be coordinated with your current primary care physician in Louisville, KY.
Description
- Part C coverage provides a network of private companies that offer nationwide coverage for a variety of health and wellness services including emergency, urgent, dialysis and wellness care. Some policies include prescription drug coverage, some do not.
What Providers Can I See?
- The specific terms of these types of policies can vary. You may have to choose between specific doctors and hospitals in your area, but if your current doctor accepts Medicare, you can continue to see them. All Medicare Advantage plans offer nationwide coverage, but is assigned to a “service area”. Your service area is typically your county, state, or region. You need to live within this service area to join.
What Does Medicare Advantage Not Cover?
- A Medicare Advantage Plan covers the same services as Medicare Parts A and B, with the exception of hospice care, which is still covered by Original Medicare.
TYPES OF MEDICARE ADVANTAGE PLANS
Part C, Medicare Advantage Plans offer three main policies depending on your individual needs. Coordinated Care Plans, Private Fee for Service Plan (PFFS), and Medical Savings Account (MSA) plans. We will provide an overview of each of these with their options and services. Your medical needs will likely determine what plan is best for you.
Coordinated Care Plans: These plans offer one-stop shopping for all of your health care. They combine hospital care, doctor’s visits, and outpatient care in a single plan. Coordinated Care Plan options include:
- Health Maintenance Organization (HMO) Plans
This only includes doctors who belong to the plan, or hospitals in the network for your care. If you go outside the network for care, (other than emergency, urgent care, or out-of-area renal dialysis), you must pay for your own care.
- Point of Service (POS) Plans
This is a type of HMO plan that allows members the ability to visit doctors and hospitals outside their network for some covered services, usually for a higher copayment or coinsurance.
- Preferred Provider Organization (PPO) Plans
In this type of plan, you are more likely to have more freedom to choose your doctor. You can see doctors outside the network without having to pay the entire cost yourself, although you will usually pay a larger share of the cost of your care.
- Special Needs Plans (SNP)
These are care management plans designed for people with special needs. They combine hospital care and doctor’s visits and other outpatient care in a single plan.
Private Fee-For-Service (PFFS) Plans: The plans put a fixed out-of-pocket cost on doctors and hospitals. The cost you pay varies by plan and provider. The availability of these plans depends on the county and state in which you reside.
Medical Savings Account (MSA) Plans: This plan combines coverage for Medicare Part A and Part B services with the option to add funds to a tax-free savings account to pay for covered expenses tax-free. Once you have paid a deductible, the plan covers your Medicare-covered expenses. This is similar to a typical HSA insurance plan.
MEDICARE PART D: DO YOU NEED PRESCRIPTION DRUG COVERAGE?
Simply put, Medicare Part D provides help with the cost of prescription drugs. This coverage is supplemental and not an automatic part of Medicare coverage. Part D coverage is offered through private insurance companies. There are two ways to get Part D coverage. A Prescription Drug Plan (PDP) just covers prescriptions, or you can buy some types of Medicare Advantage policies that include drug coverage. You can decide whether or not to enroll in Medicare Part D when you enroll for Medicare coverage.
Description:
- Medicare Part D is designed to help with the high costs of prescription drugs. However, different policies cover different drugs, so it’s important to know which plan covers the medications you need.
For free assistance on picking the right Medicare Part D plan, set up a free, no-stress consultation with one of the independent agents at Braden Insurance.
What Pharmacies Can I Use?
- It depends on your plan. Each one specifies the pharmacies members may use. Some policies offer nationwide coverage or mail order services while others limit your choice of pharmacies in your local area.
What Does Medicare Part D Not Cover?
- The federal government does not cover certain types of drugs at all. Weight-loss drugs are one example. However, you can usually find a plan that works with the medications you take on a regular basis. Each policy varies in which specific drugs they cover and which ones they do not. If you are prescribed a drug that is not covered, you are responsible for the full cost.
In most Part D plans, there is a stage of cost sharing called the “donut hole.” We will cover this in the next section.
Up to this point, we have talked about Medicare Part A, Part B, Part C, and Part D. But did you know that there are more parts, (and letters), to Medicare coverage? Stay tuned, we will talk about them in just a second.
WHAT IS THE MEDICARE DONUT HOLE?
The Medicare Donut Hole refers to the coverage gap, or donut hole, in Medicare Part D prescription benefits. In other words, it means there is a temporary limit on what the drug plan will cover for the drugs you need. If you don’t spend more than $3000 on prescription drugs each year, this probably won’t affect you. However, if you’re prescriptions are a major expense, this can drastically affect your healthcare spending.
How It Works: Once you have reached a certain total dollar amount for your drugs (different plans have different dollar amounts) then you will enter the “coverage gap.” While in the “coverage gap” you continue to pay your regular premiums, but the price of your prescriptions goes up. Once you hit the next threshold amount, you exit the coverage gap and return to paying the same amount for your drugs as you did before.
Let’s look at an example.
- In January, you are paying just 5% of your drug costs at the pharmacy.
- By September, you have paid $3,750 total for prescription drugs. (Note: $3,750 is just an example figure and can vary)
- Because you’ve paid $3,750 (threshold #1) – you are now in the coverage gap.
- Instead of paying 5% for your drug costs, you’ll now pay 25% for name-brand drugs and 37% for generic.
- By November, you’ve paid $5,000 in prescription costs, and have reached your threshold #2.
- Now you are out of the coverage gap and you’re back to paying no more than 5% of your drug costs for the rest of the year.
- In January, the process starts again.
Congress has been working to close this coverage gap and provide more consistent coverage to those on Medicare. By 2020, you will pay 25% for both brand-name and generic drugs during the gap.
HOW MUCH DOES MEDICARE COST?
Medicare coverage is one of the most important resources for aging Americans. While the benefits are wonderful, it is not a free program. Recipients must pay for their Medicare coverage via premiums, copays, deductibles, and coinsurance.
Let’s define the difference between each of these types of payments:
- Premium: A fixed amount you have to pay to participate. Most Medicare premiums are charged monthly.
- Deductible: A preset amount that you have to pay your doctor or hospital before Medicare begins to help with your costs.
- Copayment (Copay): A fixed amount that you pay for office visits or services. These are often low, (i.e. $25 for a doctor visit) and they contribute to your deductible.
- Coinsurance: Once you meet your deductible amount, you enter coinsurance where you split your health care costs with the plan on a percentage basis. As in, you would pay 20% and your plan would pay the remaining 80%.
How Much Does Medicare Part A, B, C, and D Cost?
| 2019 Costs At a Glance | |
|---|---|
| Part A Premium | $437 |
| Part A Hospital Inpatient Deductible | $1,364 for each benefit period |
| Part B Premium | $135.50 |
| Part B Deductible | $185 |
| Part C Premium | Monthly premium varies by plan. |
| Part D Premium | Monthly premium varies by plan (higher-income consumers may pay more). |
Because Medicare Part C is provided through private companies, the exact price cannot be listed. It is determined based on the plan coverage and company you choose.
MEDICARE SUPPLEMENT INSURANCE POLICIES
Medicare Supplement Insurance is provided by private companies. These supplemental plans are designed to help patients pay for medical expenses that are not covered by Original Medicare Part A and Part B. Supplement insurance plans are also called Medigap policies.
There are a few things Medicare eligible recipients need to know about Medicare Supplemental Insurance plans and how to use them best.
- To be eligible for Medicare Supplement Policy you must first have Original Medicare Part A and Part B, not a Medicare Advantage Plan.
- A Medigap policy only supplements your Original Medicare benefits and is not considered an independent insurance plan.
- Medigap policies are offered through a private insurance company and require a monthly premium payment. This is in addition to your Medicare monthly premium.
- A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you'll have to buy separate policies.
- You can buy a Medigap policy from any insurance company that's licensed in your state to sell one.
- Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium.
- Medigap policies are no longer allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
- It's illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you're switching back to Original Medicare.
- Medigap policies generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.
There are ten different Medicare Supplement plans: A, B, C, D, F, G, K, L, M, and N. Not all ten are offered in every state, but fortunately all ten are available in Louisville, KY and throughout the state. For a comparison of what each one covers and does not cover, take a look at our Medicare Supplement Plans guide.
If deciphering ten different Medigap policies sounds overwhelming, you’re not alone. That’s why the experts at Braden Insurance break it down for you so you can choose the supplemental plan that will work best for you.
HOW MUCH DOES MEDIGAP COST?
Since all Medigap policies are offered through private insurance companies, the price of each policy will differ based on the specific plan and individual company. For the most accurate costs associated with each plan, your best option is to talk to a licensed Medicare agent.
WHEN IS OPEN ENROLLMENT FOR MEDICARE?
Once you are eligible for Medicare coverage, you must enroll during the “Open Enrollment Period”, also referred to as OEP. This happens during the beginning of the year. Prior to Open Enrollment, you’ll receive notice of plan details, policy changes, etc. It’s important to review this information so you know whether or not you’re going to enroll, renew, or make changes during the Open Enrollment Period.
Take this time to prepare yourself and, if you choose to use a Medicare consultant in Louisville, KY, to help you make important decisions about your health coverage. Before Open Enrollment begins, ask yourself the following questions:
- Has your health changed?
- Has your financial situation changed?
- Will you be needing any procedures/surgeries in the upcoming year?
- Are changes being made to your current plan?
If you answered yes to any of those questions, you may want to make changes to your Medicare coverage options. The better prepared you are, the better your needs will be met.
Medicare Open Enrollment begins around January 1st and ends around March 31st. This gives you 6 weeks to make a decision about your Medicare coverage and complete the enrollment process. All new policies and changes take effect the month following any changes.
Possible changes you may consider include:
- Add, drop or change your Medicare Part D prescription drug coverage
- You may add, drop or change Medicare Advantage plans
- Switch from Original Medicare to Medicare Advantage
- Switch from Medicare Advantage to Original Medicare (This must be done during Disenrollment Period, explained below).
Disenrollment Period
If you want to disenroll from your Medicare coverage, you can do that after Open Enrollment is over. This is referred to as the Medicare Disenrollment Period, or MADP. It is between January 1 and February 14. This is also the time where a Medicare eligible individual can disenroll from Medicare Advantage and return to Original Medicare. This change will take effect the first of the month after you make the request. For example, if you disenroll from your plan in February, it won’t go into effect until March 1.
Recap – Don’t forget to write down these important dates and details:
- Early October: Policy details are released for the following year. Time to talk to a Medicare consultant to review your healthcare needs and financial situation.
- January 1: Open Enrollment begins. At this time you may add, change, or drop coverage.
- March 31: Last day to enroll or change plans for Medicare coverage.
- Month following changes: Your new plan or changes take effect.
- January 1st: MADP begins where you may disenroll from Medicare Advantage and return to Original Medicare.
- October 15 - Demeber 7: Medicare Annual Enrollment Period
MEDICARE PLANS: THINGS TO KEEP IN MIND
Once you have signed up for your Medicare coverage plan, there are some important helpful tips to keep in mind so you use your Medicare coverage wisely.
- Keep your Medicare coverage card handy - You will need to present your card when you go to the doctor so keep it in a place where you will remember where it is.
- Keep your card safe - Remember that your Medicare card has valuable, private information on it. Keep careful track of it to prevent fraud.
Be sure you do your research - Do a bit of research before selecting a new doctor. Different doctors and hospitals may offer different levels of care quality and may charge you differently. Be sure to select the one you trust.- Understand how your Medicare coverage works - This is when it’s helpful to have a Medicare Consultant on hand to answer questions about services, supplies, treatment, providers, and limits.
- If you have questions, ASK! - You have the right to information about your Medicare coverage benefits. If something doesn’t make sense or are told your policy doesn’t cover something that you thought it did, ask.
- Pay attention to the paperwork - When you receive a health service that Medicare covers, you will get a Medicare Summary Notice (MSN). It will show the services or supplies that have been billed to Medicare. Make sure the listed items are correct.
- Know your rights - As a person with Medicare coverage, you have the formal right to complain, or appeal, about our treatment in certain situations. If your prescription drug coverage does not cover the cost of a drug both you and your doctor think you should have, speak up and voice your questions.
FREE MEDICARE ADVICE FROM AN INDEPENDENT AGENT
Medicare coverage is a wonderful benefit to aging Americans, but the cost and multiple plan options make it difficult to navigate. To ensure you get the right plan for both your needs and budget, it is extremely beneficial to discuss your options with a licensed Medicare consultant.
Braden Insurance Agency Inc. is an independent agency that offers plans from multiple companies so you get exactly what you need with 100% free, unbiased Medicare advice. Our goal is to make sure every Medicare eligible individual in Louisville, KY and Southern Indiana gets the Medicare coverage that best fits their needs and budget.
We offer plans from the following Medicare companies...
- Humana
- Aetna
- Mutual of Omaha
- Anthem
- Cigna
- Medico Insurance Company
- WellCare
- United Healthcare
- Silver Script
- Bankers Fidelity
The post Guide To Medicare Coverage: How To Find The Right Medicare Insurance Plan For You appeared first on Bradeninsurance.com
Braden Insurance Agency Inc.
3069 Breckenridge Ln
Louisville, KY 40220
502-454-9191
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