Confused About Medicare? We can Help.
If you are confused about Medicare and how to get started or change your coverage, we can help. There are many different programs available and it can be difficult to navigate. Below is some information taken directly from Medicare.gov that may be helpful and we welcome the opportunity to discuss your particular situation and we can walk you through it step by step.
Original Medicare: Parts A and B
Medicare Coverage Options
Medicare Coverage Options
Medicare Coverage Options
When you first enroll in Medicare and during certain times of the year, you can choose how you get your Medicare coverage. There are 2 main ways to get your Medicare coverage—Original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C). Some people need to get additional coverage, like Medicare prescription drug coverag
When you first enroll in Medicare and during certain times of the year, you can choose how you get your Medicare coverage. There are 2 main ways to get your Medicare coverage—Original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C). Some people need to get additional coverage, like Medicare prescription drug coverage or Medicare Supplement Insurance (Medigap). Use these steps to help you decide what coverage you want:
Step 1: Decide if you want Original Medicare or a Medicare Advantage Plan (like an HMO or PPO)
Step 2: Decide if you want prescription drug coverage (Part D)
Step 3: Decide if you want supplemental coverage
Other options
- In addition to Original Medicare or an MA Plan, you may be able to join other types of Medicare health plans.
- You may be able to save money or have other choices if you have limited income and resources. Get help paying costs.
- You may also have other coverage, like employer or union, military, or veterans' benefits.
Medicare Part A
Medicare Coverage Options
Medicare Coverage Options
If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
In general, Part A covers:
If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
In general, Part A covers:
- Inpatient care in a hospital
- Skilled nursing facility care
- Inpatient care in a skilled nursing facility (not custodial or long-term care)
- Hospice care
- Home health care
2 ways to find out if Medicare covers what you need
- Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something that's usually covered but your provider thinks that Medicare won't cover it in your situation. If so, you'll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
- Find out if Medicare covers your item, service, or supply.
Medicare coverage is based on 3 main factors
- Federal and state laws.
- National coverage decisions made by Medicare about whether something is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
Medicare Part B
Medicare Coverage Options
Medicare Part B
Part B covers 2 types of services
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best
Part B covers 2 types of services
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care provider who accepts Assignment.
Part B covers things like:
Is a Medicare Advantage Plan a good option for you?
An option for your Medicare Coverage is a Medicare Advantage Plan. These plans turn your care over to a Medicare approved private insurance company. Medicare pays the insurance company a set amount each month to take care of your medical and prescription benefits. You also pay a premium, but this is usually lower than if your get your benefits directly from Medicare with separate Medicare supplement and prescription drug plans. In fact, some companies offer a $0 plan premium because the amount paid to that company from Medicare is enough to cover the plan’s benefits.
If you join a Medicare Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. This is different than a Medicare Supplement Insurance (Medigap) policy.
What do I need to know about Medicare Advantage Plans?
- Medicare Advantage Plans must cover all of the Part A and Part B benefits offered by Original Medicare.
- Medicare Advantage Plans must include an annual maximum out of pocket limit on cost sharing benefits (deductibles, copays or co-insurance) for Part A and Part B services.
- Medicare Advantage Plans may offer extra benefits not covered by Original Medicare.
- Open enrollment for Medicare Advantage plans is October 15 through December 7. You may also enroll when you first turn 65 or if you qualify for a special enrollment period.
These are the different types of Medicare Advantage Plans:
- Health Maintenance Organization (HMO) plans—In most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan’s network, except in an urgent or emergency situation. You may also need to get a referral from your primary care doctor for tests or to see other doctors or specialists.
- Preferred Provider Organization (PPO) plans—In a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You usually pay more if you use doctors, hospitals, and providers outside of the network.
- Private Fee-for-Service (PFFS) plans—PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.
- Special Needs Plans (SNPs)—SNPs provide focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.
- HMO Point-of-Service (HMOPOS) plans—These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.
- Medical Savings Account (MSA) plans—These plans combine a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA plans don’t offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan. For more information about MSAs, visit Medicare.gov/publications to view the booklet “Your Guide to Medicare Medical Savings Account Plans.”
Who can join a Medicare Advantage Plan?
You must have Medicare Parts A and B and live in the plan’s service area to be eligible to join. People with End-Stage Renal Disease (permanent kidney failure) generally can’t join a Medicare Advantage Plan.
How much do Medicare Advantage Plans cost?
In addition to your Part B premium, you usually pay one monthly premium for the services included in a Medicare Advantage Plan. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before you join.
What do Medicare Advantage Plans cover?
Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.
Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for the plan’s medical and prescription drug coverage.
Plan benefits can change from year to year. Make sure you understand how a plan works before you join.
What is Medicare Supplement Insurance (Medigap)?
A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn't cover, like:
- Copayments
- Coinsurance
- Deductibles
Medigap policies are sold by private companies. Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, here's what happens:
- Medicare will pay its share of the Medicare-approved amount for covered health care costs.
- Then, your Medigap policy pays its share.
A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
8 things to know about Medigap policies
- You must have Medicare Part A and Part B.
- If you have a Medicare Advantage Plan, you can apply for a Medigap policy. But, make sure you can leave the Medicare Advantage Plan
- You pay premium for your Medigap policy. You pay the private insurance company a monthly this monthly premium in addition to the monthly Part B premium that you pay to Medicare
- A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you'll each 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.
- Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren't 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 Medical Savings Account (MSA) Plan.
Medigap policies don't cover everything
Medigap policies generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.
Insurance plans that aren't Medigap
Some types of insurance aren't Medigap plans, they include:
- Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)
- Medicare Prescription Drug Plans
- Medicaid
- Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP)
- TRICARE
- Veterans' benefits
- Long-term care insurance policies
- Indian Health Service, Tribal, and Urban Indian Health plans
Dropping your entire Medigap policy (not just the drug coverage)
You may want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage). Or, you might decide to switch to a Medicare Advantage Plan that offers prescription drug coverage. If you decide to drop your entire Medigap policy, you need to be careful about the timing. When you join a new Medicare drug plan, you pay a late enrollment penalty if one of these applies:
- You drop your entire Medigap policy and the drug coverage wasn't creditable prescription drug coverage
- You go 63 days or more in a row before your new Medicare drug coverage begins
Still Have Questions?
Medicare Prescription Drug Plans
Do you have adequate prescription drug coverage?
There are over 30 prescriptions plans to choose from. Each has a different formulary (drug list).
Through the use of Medicare’s computerized search program, Allied Health Insurance Agency will help you determine the best prescription drug plan for you. There are several important factors to consider:
- Prescriptions taken
- Pharmacy preference
- Premium
Open enrollment for Medicare Prescription Drug Plans is October 15 through December 7. You may also enroll when you first turn 65 or if you qualify for a special enrollment period.
IMPORTANT NOTE: There is a permanent premium penalty if you do not enroll in Part D (prescription drug coverage) when you are first eligible, or have other creditable coverage. Medicare Part D coverage may be purchased through a Medicare Prescription Drug Plan (PDP) or a Medicare Advantage plan that includes prescription coverage (MAPD).