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Medicare Basics

Getting started with Medicare

Whether you’re new to Medicare, getting ready to turn 65, or preparing to retire, you’ll need to make several important decisions about your health coverage. If you wait to enroll at a later date, you may have to pay a penalty, and you may have a gap in coverage. Use these steps to gather information so you can make informed decisions about your Medicare:

Step 1: Learn about the different parts of Medicare

There are 4 basic parts of Medicare that help cover specific services. See “ABC’s of Medicare” below.

Step 2: Find out when you can get Medicare

There are only certain times when people can enroll in Medicare. Depending on the situation, some people get Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) automatically and other people have to sign up for it. In most cases, it depends on whether you’re getting Social Security benefits. The first time you can enroll is called your Initial Enrollment Period. Your 7-month Initial Enrollment Period usually:

  • Begins 3 months before the month you turn 65
  • Includes the month you turn 65
  • Ends 3 months after the month you turn 65

If you don’t enroll when you’re first eligible, you may have to pay a Part B late enrollment penalty, and you may have a gap in coverage if you decide you want Part B later.

Step 3: Decide if you want Part A & Part B

Most people should enroll in Part A when they turn 65, even if they have health insurance from an employer. This is because most people paid Medicare taxes while they worked so they don’t pay a monthly premium for Part A. Certain people may choose to delay Part B. In most cases, it depends on the type of health coverage you may have. Everyone pays a monthly premium for Part B. The premium varies depending on your income and when you enroll in Part B. Most people will pay the standard premium amount of $134 in 2017.

Step 4: Choose your coverage

If you decide you want Part A and Part B, there are 2 main ways to get your Medicare coverage— Original Medicare or a Medicare Advantage Plan (like an HMO or PPO). If you choose Original Medicare you will likely want additional coverage, like a Medicare Supplement Insurance (Medigap) and Medicare prescription drug coverage and Note, Medicare Supplements Plans do not include prescription drug coverage. If you choose a Medicare Advantage Plan it will likely include a prescription drug plan as part of the plan known as MAPD. Most people who are still working and have employer coverage don’t need additional coverage. Learn about these coverage choices.

Step 5: Sign up for Medicare (unless you’ll get it automatically)

Some people automatically get Part A and Part B. Find out if you’ll get Part A and B automatically. If you're automatically enrolled, you'll get your red, white, and blue Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability. If you don't get Medicare automatically, you’ll need to apply for Medicare online.

ABCs of Medicare

The four basic parts of Medicare labeled Part A; B; C; and D. Each part helps pay for certain health care services. Each one may also have certain costs that you may have to pay. Your costs will depend on which health services you choose to use.

Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

  • Monthly premium:
  • Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $413 each month in 2017. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $413. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $227.
  • Late enrollment penalty:
  • If you don't buy it when you're first eligible, your monthly premium may go up 10%. (You'll have to pay the higher premium for twice the number of years you could have had Part A, but didn't sign up.)
  • Part A costs if you have Original Medicare
  • All Medicare Advantage Plans must cover these services. If you're in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those in Original Medicare. Review the "Evidence of Coverage" from your plan.
  • Home health care
  • $0 for home health care services.
  • 20% of the Medicare-approved amount for durable medical equipment.
  • Hospice care
  • $0 for hospice care.
  • You may need to pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you're at home. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it's covered under Part D.
  • You may need to pay 5% of the Medicare-approved amount for inpatient respite care.
  • Medicare doesn't cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).
  • Hospital inpatient stay
  • $1,316 deductible for each benefit period.
  • Days 1–60: $0 coinsurance for each benefit period.
  • Days 61–90: $329 coinsurance per day of each benefit period.
  • Days 91 and beyond: $658 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).
  • Beyond lifetime reserve days: all costs.
  • Note: You pay for private-duty nursing, a television, or a phone in your room. You pay for a private room unless it's medically necessary.
  • Mental health inpatient stay
  • $1,316 deductible for each benefit period.
  • Days 1–60: $0 coinsurance per day of each benefit period.
  • Days 61–90: $329 coinsurance per day of each benefit period.
  • Days 91 and beyond: $658 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).
  • Beyond lifetime reserve days: all costs.
  • 20% of the Medicare-approved amount for mental health services you get from doctors and other providers while you're a hospital inpatient.
  • Note: There's no limit to the number of benefit periods you can have when you get mental health care in a general hospital. You can also have multiple benefit periods when you get care in a psychiatric hospital. Remember, there's a lifetime limit of 190 days.
  • Skilled nursing facility stay
  • Days 1–20: $0 for each benefit period.
  • Days 21–100: $164.50 coinsurance per day of each benefit period.
  • Days 101 and beyond: all costs.

Medicare Part B (Medical Insurance)

Part B helps pay for most doctors' services, outpatient care, medical supplies, and preventive services such as flu shots and vaccines. It also covers most routine medical care as well as emergency medical services.

Medicare Part C (Medicare Advantage Plans)

Part B helps pay for most doctors' services, outpatient care, medical supplies, and preventive services such as flu shots and vaccines. It also covers most routine medical care as well as emergency medical services.

Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. You must be enrolled in Part A and Part B to join a Medicare Advantage Plan. You are still in the Medicare program, but you will receive your benefits through the plan instead of through Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. Part C plans musty cover all of the benefits offered by Medicare Part A and Part B. Many plans also provide prescription drug coverage and additional benefits like routine dental, vision, hearing, and gym memberships.

Premiums: Vary by plan. You will still pay your Part B premium, and Part A if you have one.

Deductible: Vary by plans. Part A and B deductibles do not apply

Copayment: Vary by plan. Most plans charge copays for services and benefits.

Coinsurance: Plans set their own coinsurance terms and percentages.

Medicare Part D (prescription drug coverage)

Part B helps pay for most doctors' services, outpatient care, medical supplies, and preventive services such as flu shots and vaccines. It also covers most routine medical care as well as emergency medical services.

What does Medicare cover

Original Medicare is coverage managed by the federal government. Medicare is not free. Generally, there's a cost for each service. Here are the general rules for how it works:

Getting started with Medicare

Getting started with Medicare

Whether you’re new to Medicare, getting ready to turn 65, or preparing to retire, you’ll need to make several important decisions about your health coverage. If you wait to enroll at a later date, you may have to pay a penalty, and you may have a gap in coverage. Use these steps to gather information so you can make informed decisions about your Medicare:

Step 1: Learn about the different parts of Medicare

There are 4 basic parts of Medicare that help cover specific services. See “ABC’s of Medicare” below.

Step 2: Find out when you can get Medicare

There are only certain times when people can enroll in Medicare. Depending on the situation, some people get Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) automatically and other people have to sign up for it. In most cases, it depends on whether you’re getting Social Security benefits. The first time you can enroll is called your Initial Enrollment Period. Your 7-month Initial Enrollment Period usually:

  • Begins 3 months before the month you turn 65
  • Includes the month you turn 65
  • Ends 3 months after the month you turn 65

If you don’t enroll when you’re first eligible, you may have to pay a Part B late enrollment penalty, and you may have a gap in coverage if you decide you want Part B later.

Step 3: Decide if you want Part A & Part B

Most people should enroll in Part A when they turn 65, even if they have health insurance from an employer. This is because most people paid Medicare taxes while they worked so they don’t pay a monthly premium for Part A. Certain people may choose to delay Part B. In most cases, it depends on the type of health coverage you may have. Everyone pays a monthly premium for Part B. The premium varies depending on your income and when you enroll in Part B. Most people will pay the standard premium amount of $134 in 2017.

Step 4: Choose your coverage

If you decide you want Part A and Part B, there are 2 main ways to get your Medicare coverage— Original Medicare or a Medicare Advantage Plan (like an HMO or PPO). If you choose Original Medicare you will likely want additional coverage, like a Medicare Supplement Insurance (Medigap) and Medicare prescription drug coverage and Note, Medicare Supplements Plans do not include prescription drug coverage. If you choose a Medicare Advantage Plan it will likely include a prescription drug plan as part of the plan known as MAPD. Most people who are still working and have employer coverage don’t need additional coverage. Learn about these coverage choices.

Step 5: Sign up for Medicare (unless you’ll get it automatically)

Some people automatically get Part A and Part B. Find out if you’ll get Part A and B automatically. If you're automatically enrolled, you'll get your red, white, and blue Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability. If you don't get Medicare automatically, you’ll need to apply for Medicare online.

ABC’s of Medicare

ABCs of Medicare

The four basic parts of Medicare labeled Part A; B; C; and D. Each part helps pay for certain health care services. Each one may also have certain costs that you may have to pay. Your costs will depend on which health services you choose to use.

Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

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·         Monthly premium:

Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $413 each month in 2017. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $413. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $227.

·         Late enrollment penalty: 

·         If you don't buy it when you're first eligible, your monthly premium may go up 10%. (You'll have to pay the higher premium for twice the number of years you could have had Part A, but didn't sign up.) 

Part A costs if you have Original Medicare

All Medicare Advantage Plans must cover these services. If you're in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those in Original Medicare. Review the "Evidence of Coverage" from your plan.

·         Home health care

·         $0 for home health care services.

·         20% of the Medicare-approved amount for durable medical equipment.

·         Hospice care

·         $0 for hospice care.

·         You may need to pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you're at home. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it's covered under Part D.

·         You may need to pay 5% of the Medicare-approved amount for inpatient respite care.

·         Medicare doesn't cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).

·         Hospital inpatient stay

·         $1,340 deductible for each benefit period.

·         Days 1–60: $0 coinsurance for each benefit period.

·         Days 61–90: $335 coinsurance per day of each benefit period.

·         Days 91 and beyond: $670 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).

·         Beyond lifetime reserve days: all costs.

Note: You pay for private-duty nursing, a television, or a phone in your room. You pay for a private room unless it's medically necessary.

·         Mental health inpatient stay

·         $1,340 deductible for each benefit period.

·         Days 1–60: $0 coinsurance per day of each benefit period.

·         Days 61–90: $335 coinsurance per day of each benefit period.

·         Days 91 and beyond: $670 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).

·         Beyond lifetime reserve days: all costs.

·         20% of the Medicare-approved amount for mental health services you get from doctors and other providers while you're a hospital inpatient.

 

Note: There's no limit to the number of benefit periods you can have when you get mental health care in a general hospital. You can also have multiple benefit periods when you get care in a psychiatric hospital. Remember, there's a lifetime limit of 190 days.

·         Skilled nursing facility stay

·         Days 1–20: $0 for each benefit period.

·         Days 21–100: $167.50 coinsurance per day of each benefit period.

·         Days 101 and beyond: all costs.

 

 

 

Medicare Part B (Medical Insurance) 

Part B helps pay for most doctors' services, outpatient care, medical supplies, and preventive services such as flu shots and vaccines. It also covers most routine medical care as well as emergency medical services.

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·         Monthly premium:

The standard Part B premium amount in 2018 is $134 (or higher depending on your income). However, most people who get Social Security benefits pay less than this amount. This is because the Part B premium increased more than the cost-of-living increase for 2018 Social Security benefits. If you pay your Part B premium through your monthly Social Security benefit, you’ll pay less ($109 on average). Social Security will tell you the exact amount you'll pay for Part B in 2018. You'll pay the standard premium amount (or higher) if:

·         You enroll in Part B for the first time in 2018.

·         You don't get Social Security benefits.

·         You're directly billed for your Part B premiums (meaning they aren't taken out of your Social Security benefits).

·         You have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard premium amount of $134.)

·         Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount. If so, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

If you're in 1 of these 5 groups, here's what you'll pay:

If your yearly income in 2016 (for what you pay in 2018) was

You pay each month (in 2018)

File individual tax return

File joint tax return

File married & separate tax return

$85,000 or less

$170,000 or less

$85,000 or less

$134

above $85,000 up to $107,000

above $170,000 up to $214,000

Not applicable

$187.50

above $107,000 up to $160,000

above $214,000 up to $320,000

Not applicable

$267.90

above $160,000 up to $214,000

above $320,000 up to $428,000

above $85,000 and up to $129,000

$348.30

above $214,000

above $428,000

above $129,000

$428.60

Get more information about your Part B premium from Social Security [PDF, 341 KB].

·         Late enrollment penalty:

In most cases, if you don't sign up for Part B when you're first eligible, you'll have to pay a late enrollment penalty. You'll have to pay this penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B. Coverage will start July 1 of that year.

Learn more about the Part B late enrollment penalty.

Part B costs if you have Original Medicare

Note

All Medicare Advantage Plans must cover these services. If you're in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those in Original Medicare. Review the "Evidence of Coverage" from your plan.

·         Part B annual deductible:

You pay $183 per year for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for these:

·         Most doctor services (including most doctor services while you're a hospital inpatient)

·         Outpatient therapy

·         Durable medical equipment

·         Clinical laboratory services:

 You pay $0 for Medicare-approved services.

·         Home health services:

·         $0 for home health care services.

·         20% of the Medicare-approved amount for durable medical equipment.

·         Medical and other services:

You pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy, and durable medical equipment.

Note: In 2018, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits. 

·         Outpatient mental health services:

·         You pay nothing for your yearly depression screening if your doctor or health care provider accepts assignment.

·         20% of the Medicare-approved amount for visits to a doctor or other health care provider to diagnose or treat your condition. The Part B deductible applies.

·         If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital.

·         Partial hospitalization mental health services:

You pay a percentage of the Medicare-approved amount for each service you get from a doctor or certain other qualified mental health professionals if your health care professional accepts assignment. You also pay coinsurance for each day of partial hospitalization services provided in a hospital outpatient setting or community mental health center, and the Part B deductible applies.

·         Outpatient hospital services:

·         You generally pay 20% of the Medicare-approved amount for the doctor or other health care provider's services, and the Part B deductible applies.

·         For all other services, you also generally pay a copayment for each service you get in an outpatient hospital setting. You may pay more for services you get in a hospital outpatient setting than you would pay for the same care in a doctor's office.

·         For some screenings and preventive services, coinsurance, copayments, and the Part B deductible don't apply (so you pay nothing).

·         Medicare Approved Amount - Doctors who accept Medicare agree to take what Medicare pays as an Approved Amount for services paid in full.

·         Doctors who do not accept Medicare may charge more than the Medicare Approved rates (called excess charges) which you are responsible for.

 

Medicare Part C (Medicare Advantage Plans)

A type of Medicare health plan offered by a private health insurance companies that contracts with Medicare to provide you with all your Part A and Part B benefits.

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Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. You must be enrolled in Part A and Part B to join a Medicare Advantage Plan. You are still in the Medicare program, but you will receive your benefits through the plan instead of through Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Part C plans musty cover all of the benefits offered by Medicare Part A and Part B. Many plans also provide prescription drug coverage and additional benefits like routine dental, vision, hearing, and gym memberships.

 

Premiums:      Vary by plan. You will still pay your Part B premium, and Part A if you have one.

Deductible:    Vary by plans. Part A and B deductibles do not apply

Copayment:    Vary by plan. Most plans charge copays for services and benefits.

Coinsurance: Plans set their own coinsurance terms and percentages.

 

Medicare Part D (prescription drug coverage)

Part D is prescription drug coverage. It pays for the medications your doctors prescribe. Original Medicare does not cover prescription drugs. Most people who choose original Medicare add a Prescription Drug Plan ( Part D) or choose a Medicare Advantage plan that includes Part D.

·         Monthly premium:

The Part D monthly premium varies by plan (higher-income consumers may pay more).

The charts below show your estimated prescription drug plan monthly premium based on your income as reported on your IRS tax return from 2 years ago and last year. If your income is above a certain limit, you'll pay an income-related monthly adjustment amount in addition to your plan premium. 

If your filing status and yearly income in 2016 was

File individual tax return

File joint tax return

File married & separate tax return

You pay (in 2017)

$85,000 or less

$170,000 or less

$85,000 or less

your plan premium

above $85,000 up to $107,000

above $170,000 up to $214,000

not applicable

$13.30 + your plan premium

above $107,000 up to $160,000

above $214,000 up to $320,000

not applicable

$34.20 + your plan premium

above $160,000 up to $214,000

above $320,000 up to $428,000

above $85,000 up to $129,000

$55.20 + your plan premium

above $214,000

above $428,000

above $129,000

$76.20 + your plan premium

Late enrollment penalty: 

·         You may owe a late enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without one of these:

·         A Medicare Prescription Drug Plan (Part D)

·         A Medicare Advantage Plan (Part C) (like an HMO or PPO)

·         Another Medicare health plan that offers Medicare prescription drug coverage

·         Creditable prescription drug coverage

·         In general, you'll have to pay this penalty for as long as you have a Medicare drug plan. The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. Learn more about the Part D late enrollment penalty.

·         Deductibles, copayments, & coinsurance:

·         The amount you pay for Part D deductibles, copayments, and/or coinsurance varies by plan. Look for specific Medicare drug plan costs, and then call your Local County Case Manager with the plans you're interested in to get more details.

 

 

What Medicare covers

What Medicare covers

 

What does Medicare cover

Original Medicare is coverage managed by the federal government. Medicare is not free. Generally, there's a cost for each service. Here are the general rules for how it works:

Doctors and hospitals

In most cases, you can go to any doctor, or other health care provider, hospital, or other facility that's enrolled in Medicare and is accepting new Medicare patients.

·         In Original Medicare you don't need to choose a primary care doctor.

·         In Original Medicare, you don't need a referral to see a specialist, but the specialist must be enrolled in Medicare.

 

 

Prescription drugs

With a few exceptions, most prescriptions are not covered in Original Medicare.

You can add drug coverage by joining a Medicare Prescription Drug Plan (Part D) or by joining a Medicare Advantage Plan that Includes prescription drugs within the plan.

 Supplemental policies

You may already have employer or union coverage that may pay costs that Original Medicare doesn't. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy.

 

Other things you need to know about Original Medicare?

·         You generally pay a set amount for your health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (coinsurance / copayment) for covered services and supplies. There's no yearly limit for what you pay out-of-pocket.

·         You usually pay a monthly premium for Part B.  

·         You generally don't need to file Medicare claims. The law requires providers (like doctors, hospitals, skilled nursing facilities, and home health agencies) and suppliers to file your claims for the covered services and supplies you get.

Factors that affect Original Medicare out-of-pocket costs

·         Whether you have Part A and/or Part B. Most people have both.

·         Whether your doctor, other health care provider, or supplier accepts assignment.

·         The type of health care you need and how often you need it.

·         Whether you choose to get services or supplies Medicare doesn't cover. If you do, you pay all the costs unless you have other insurance that covers it.

·         Whether you have other health insurance that works with Medicare.

·         Whether you have Medicaid or get state help paying your Medicare costs.

·         Whether you have a Medicare Supplement Insurance (Medigap) policy.

·         Whether you and your doctor or other health care provider sign a private contract.

 

What Medicare does not cover

What Medicare does not cover

 

What Medicare does not cover

Medicare does not cover all services. Many people are surprised to learn that Prescription Medications are not covered by Original Medicare. The following list are some other items not covered by Original Medicare.

·         Dental - including dental exams, most dental care, and dentures,

·         Vision – Routine eye exams, eyeglasses or contacts

·         Hearing – hearing aids or related exams and services

·         Podiatry or routine foot care

·         Long Term Care

·         Custodial Care - Help with, bathing, dressing, eating

·         Cosmetic surgery

·         Chiropractic services

·         Acupuncture

·         Alternative treatments

·         Care while traveling outside of the USA

Many Medicare Advantage (Part C) plans offer help with certain services not covered by Original Medicare. We can check the plans in your county to see what is available in your area.

 

Medicare vs Medicaid

Medicare vs Medicaid

 

Medicare vs Medicaid

What’s the difference between Medicare and Medicaid? The words are so much alike that it’s easy to get them confused. Both are government programs and both help people pay for health care. But that’s where the similarities end. They are as different as apples and oranges.

 

Medicare is generally for people who are older or disabled. Medicaid is for people with limited income and resources. The table below provides more information about Medicare and Medicaid and how they compare.
 

.

Medicare 

Medicaid

What is it?
A federal health insurance program for people who are:

  • 65 or older
  • Under 65 with certain disabilities
  • Of any age and have End Stage Renal Disease (ESRD) or ALS

What is it?
A joint federal and state program that helps pay health care costs for certain people and families with limited income and resources. Different programs under the Medicaid umbrella are designed to help specific populations. 

Who governs it?
Federal government

Who governs it?
State governments

What does it cover?
Depends on the coverage you choose and may include:

  • Care and services received as an inpatient in a hospital or skilled nursing facility (Part A)
  • Doctor visits, care and services received as an outpatient, and some preventive care (Part B)
  • Prescription drugs (Part D)

Note: Medicare Advantage plans (Part C) combine Part A and Part B coverage, and often include drug coverage (Part D) as well - all in one plan.

What does it cover?
Each state creates its own Medicaid programs, following federal guidelines. There are mandatory benefits and optional benefits. Mandatory benefits include, in part:

  • Care and services received in a hospital or skilled nursing facility
  • Care and services received in a federally-qualified health center, rural health clinic or freestanding birth center (licensed or recognized by your state)
  • Doctor, nurse midwife, and certified pediatric and family nurse practitioner services
  • And more

What does it cost?
It depends on the coverage you choose. Costs may include premiums, deductibles, copays and coinsurance. 

What does it cost?
It depends on your income and the rules in your state. Costs may include premiums, deductibles, copays and coinsurance. Certain groups are exempt from most out-of-pocket costs. 

How do I get it?
Many people are enrolled in Parts A and B automatically when they turn 65. You can also contact your local Social Security office to see if you are eligible or speak to one of our enrollment specialists.. 

How do I get it?
Eligibility depends on the rules in your state. Call your State Medical Assistance (Medicaid) office to see if you qualify or speak to one of our enrollment specialists.

 

You can have both Medicare and Medicaid. If you have both, you are considered “dual eligible” Sometimes the two programs work together to cover most of your healthcare costs. Contact one our enrollment specialist to see if you qualify.  

 

Help with Medicare

Help with Medicare

 

Help paying for Medicare

If you have limited income and assets, you may qualify for help with medical costs for care you receive under Medicare. 

 

Here are a few of the programs you can look into if you need financial assistance.

  • Medicaid helps pay costs not covered by Original Medicare (Part A and Part B). It may also include some added benefits that Original Medicare doesn’t cover, such as coverage for prescription drugs, eye care or long-term care.
  • The Medicare Savings Program helps you pay your Original Medicare premiums such as your monthly Part B premium of $134, deductibles and co-insurance.
  • Programs of All-Inclusive Care for the Elderly (PACE) combines medical, social and long-term care services for people over the age of 55 who qualify. This program is not available in all states.
  • Federal Extra Help program helps qualified beneficiaries pay some or all Medicare Part D premiums, deductibles, co-payments and co-insurance. 
  • Other programs may be available in your state, such as State Pharmaceutical Assistance Programs. 

Eligibility for State and Federal assistance is based on your income and assets. Most state incomes count your social security, pensions, and any other taxable income. Your assets do not count your house or car but can count other properties that you may own. Income and asset eligibility levels vary by state. Contact one of our enrollment specialists for more details and to see which programs you may qualify for. 

 

Healthcare Glossary

Healthcare Glossary

Healthcare Glossary:

Making Sense of Medicare Terms and Phrases

 

The glossary below will define some commonly used terms related to Medicare.

 

ACTUAL CHARGE

 

The amount of money a physician or supplier charges for a specific medical service or supply. Because Medicare and insurance companies usually negotiate lower rates for members, the actual charge is often greater than the "approved amount" that you and Medicare actually pay.

ANNUAL ELECTION PERIOD (AEP)

 

AEP begins on October 15 and ends on December 7 of every year. During AEP, Medicare beneficiaries can enroll, disenroll, or change your Medicare Advantage (MA) plan, Prescription Drug plan (PDP) or also return to Original Medicare. Elections made during AEP are effective on January 1 of the following year.

ANNUAL NOTICE OF CHANGES (ANOC)

 

The Centers for Medicare & Medicaid Services (CMS) mandated notification of yearly plan benefit changes sent to enrolled members. This notification is mailed to enrolled members each year before the Annual Election Period begins. This notice is mailed with the Evidence of Coverage (EOC) and it explains any changes in plan benefits, services and costs for the next calendar year. It also provides instructions and important deadlines for changing plans as well as other helpful information.

BENEFICIARY

 

A person who is eligible to have health insurance through the Medicare or Medicaid program.

BENEFIT PERIOD

 

The time during which you are admitted and treated at a hospital or Skilled Nursing Facility (SNF). The benefit period begins the day you go to the facility and ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.

BENEFITS

 

The care, items, and services covered by an insurance plan.

CATASTROPHIC ILLNESS

 

A very serious and costly health condition that could be life threatening or cause life-long disability. The cost of medical services for this type of condition could cause you financial hardship if you are not properly insured.

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.

COINSURANCE

 

The percentage of billed charges that you may have to pay after you pay any plan deductibles. The coinsurance payment is a percentage of the cost of the service. For instance, your health plan might pay 70 percent of billed charges; this means, your coinsurance payment is the remaining 30 percent.

COPAYMENT

 

The flat amount you pay to a healthcare provider or pharmacy at the time of service. Copayments vary depending on your plan and the services you receive. Copayments do not reduce your annual deductible.

DEDUCTIBLE

 

The total amount you must pay for health care before your health plan begins to pay.

DUAL ELIGIBLES

 

Individuals who are entitled to Medicare and also qualify for Medicaid.

EFFECTIVE DATE

 

The date your coverage begins.

EMERGENCY CARE

 

Covered services that are 1) administered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.

END-STAGE RENAL DISEASE (ESRD)

 

Permanent kidney failure requiring dialysis or a kidney transplant.

EVIDENCE OF COVERAGE (EOC)

 

A document that details and explains a health plan’s benefits and services. Medicare Advantage and Prescription Drug plans are required to issue EOCs to new members upon enrollment and renewing members yearly.

EXCLUSIONS

 

Services or items not covered under your benefit plan.

FORMULARY

 

A list of prescription medications that are approved for coverage by a health plan, also known as Prescription Drug Guides.

FULL BENEFIT DUAL ELIGIBLE (FBDE OR MEDICAID ONLY)

 

An individual who does not meet the income or resource criteria for QMB or SLMB, but is eligible for Medicaid either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home and community-based waivers. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable. Medicaid payment of the Medicare Part A or Medicare Part B premiums may be a Medicaid benefit available to FBDE beneficiaries in certain states.

GENERIC DRUG

 

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

HEALTH MAINTENANCE ORGANIZATION (HMO)

 

With an HMO, you select a primary care physician (PCP) who is in the plan’s network and acts as a “gatekeeper” to direct access to medical services. Your PCP refers you to a specialist in the network when necessary.

INITIAL COVERAGE ELECTION PERIOD (ICEP)

 

This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B. The ICEP is the period during which and individual newly eligibile for Medicare Advantage (MA) may make an initial enrollment request to enroll in an MA plan.

IN-NETWORK PROVIDER

 

A healthcare provider – such as a physician, hospital, other medical facility, and/or pharmacy – that have contracts with the health plan to provide services at a set rate. Providers on the plan’s network listings are also called participating providers.

 

LIMITATIONS

 

A specific time period or number of visits a health plan covers, or items or services a health plan doesn't cover in some circumstances.

LOCK-IN PERIOD

 

Individuals with a Medicare Advantage plan are "locked-in", meaning they can only switch Medicare plans during certain times of the year unless they qualify for special circumstances or choose to switch to a plan with a Plan Performance Rating of 5 stars during the year in which that plan has the 5-star overall rating, provided the individual meets the other requirements to enroll in the plan (e.g., living within the plan’s service area as well as requirements regarding end-stage renal disease).

 

MAXIMUM OUT-OF-POCKET COSTS (MOOP)

 

The maximum dollar amount you would be required to pay out of your own pocket for health services during a specified period of time.

MAXIMUM PLAN BENEFIT COVERAGE

 

The maximum dollar amount that a plan will insure per benefit period. Medicare plans have a Maximum Plan Benefit Coverage expenditure limit only for service categories where the plan offers enhanced benefits.

MEDICAID

 

A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.

MEDICARE

 

The federal health insurance program available to people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD) – permanent kidney failure requiring dialysis or a transplant.

MEDICARE ADVANTAGE DISENROLLMENT PERIOD (MADP)

 

From January 1 – February 14, Medicare Advantage plan members can disenroll from their Medicare Advantage plan and return to Original Medicare and enroll in a stand-alone Prescription Drug Plan. MAPD does not provide an opportunity to join or switch Medicare Advantage plans.

MEDICARE ADVANTAGE PLAN

 

Medicare Advantage is a United States health insurance program of managed health care (preferred provider organization (PPO) or health maintenance organization (HMO)) that serves as an alternaive  for "Original Medicare" Parts A and B Medicare benefits. Medicare Advantage Organizations can offer one or more Medicare Advantage plans.

MEDICARE SAVINGS PROGRAMS

 

There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that help pay Medicare premiums. Some programs may also pay your Medicare deductibles and coinsurance.

MEDICARE-APPROVED AMOUNT

 

This is the payment amount that Medicare pays to a physician or supplier for a service or supply. It may be less than the actual amount charged by a physician or supplier. If a provider does not accept Medicare’s approved payment amount as full payment and you are not enrolled in a Medicare Advantage plan or do not follow the plan’s payment rules, you may have to pay the difference between what Medicare allows or the plan pays and what the provider charges.

MEDICARE PART A (HOSPITAL INSURANCE)

 

Medicare Part A provides payments for inpatient hospital, hospice and skilled nursing services, excluding those of physicians and surgeons.

MEDICARE PART B (MEDICAL INSURANCE)

 

Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, X-rays and diagnostic tests) and certain durable medical equipment and supplies.

MEDICARE PART C (MEDICARE ADVANTAGE PLANS)

 

Health benefits coverage offered by a Medicare Advantage Organization. You receive a specific set of health benefits at a set premium and predetermined cost-sharing level. Part C is available to all Medicare beneficiaries residing in a plan's service area.

MEDICARE PART D (PRESCRIPTION DRUG COVERAGE)

 

Coverage to help with the costs of prescription drugs offered through private companies and organizations. You can get Part D coverage through a Medicare-approved Stand-alone Prescription Drug plan or a Medicare Advantage HMO, PPO, or PFFS plan that includes drug coverage.

MEDICARE SUPPLEMENT INSURANCE

 

A Medicare Supplement insurance policy or Medigap plan is health insurance sold by private insurance companies to fill gaps in Medicare Parts A and B coverage. Medicare Supplement policies can help pay your share (like coinsurance, copayments, or deductibles) of the costs of Medicare-covered services. Some Medicare Supplement policies also cover certain benefits Medicare doesn’t cover like emergency foreign travel expenses. These policies don’t cover your share of the costs under other types of health coverage, including Medicare Advantage Plans, stand-alone Medicare Prescription Drug Plans, employer/union group health coverage, Medicaid, Department of Veterans Affairs (VA) benefits, or TRICARE. Insurance companies generally can’t sell you a Medicare Supplement policy if you have coverage through Medicaid or a Medicare Advantage Plan.

NETWORK

 

A group of healthcare providers, including pharmacies who have contracts with a health plan to provide care to the plan's members. Your network choices may vary, depending on your benefit plan and where you live. The provider network may change at any time. You will receive notice when necessary.

NON-FORMULARY DRUGS

 

Drugs not included on a plan-approved list.

ORIGINAL MEDICARE

 

A healthcare insurance provided through the federal government. It is sometimes called "traditional” Medicare or "fee-for-service" Medicare. It provides Medicare eligible individuals with coverage for and access to physicians, hospitals, or other health care providers who accepts Medicare. You are responsible for the annual deductible. Medicare pays its share of the Medicare-approved amount, and you pay your member cost-share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). The Centers for Medicare & Medicaid Services (CMS) is the federal agency that runs Medicare.

OUT-OF-NETWORK BENEFITS

 

Generally, out-of-network benefits give you the option to use a physician, specialist, or hospital that is not a part of the plan's contracted network. In some cases, your out-of-pocket costs may be higher for out-of-network benefits, or not covered at all.

OUT-OF-POCKET COSTS

 

Healthcare costs that you must pay on your own because they are not covered by Medicare or other insurance.

OUTPATIENT CARE

 

Medical or surgical care that does not include an overnight hospital stay.

PART B LATE ENROLLMENT PENALTY

 

 

In most cases, if you don't sign up for Part B when you're first eligible, you'll have to pay a late enrollment penalty. You'll have to pay this penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B. Coverage will start July 1 of that year.

Usually, you don't pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period.

If you have limited income and resources, your state may help you pay for Part A, and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.

 

PRIMARY CARE PHYSICIAN (PCP)

 

A healthcare professional that is trained to give you basic care. Your PCP is responsible for providing, authorizing, and coordinating covered services while you are a plan member.

PROVIDER

 

A person or facility that offers healthcare services. Examples include: a physician, hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, End-Stage Renal Disease facility, hospice, non-physician provider, laboratory, supplier, pharmacies, etc. A provider is licensed or certified and practices within the scope of his or her license or certification.

QUALIFYING INDIVIDUAL (QI)

 

An individual entitled to Medicare Part A, with an income at least 120% Federal Poverty Level (FPL) but less than 135% FPL, and resources that do not exceed three times the Supplemental Security Income (SSI) limit, and who is not otherwise eligible for Medicaid benefits. This individual is eligible for Medicaid payment of the Medicare Part B premium. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.

QUALIFIED MEDICARE BENEFICIARIES (QMB ONLY)

 

These individuals are entitled to Medicare Part A, have income of 100% Federal Poverty Level (FPL) or less and resources that do not exceed three times the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services provided by Medicare providers. These beneficiaries do not qualify for any additional Medicaid benefits. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.

QUALIFIED MEDICARE BENEFICIARIES PLUS (QMB PLUS)

 

These individuals are entitled to Medicare Part A, have income of 100% Federal Poverty Level (FPL) or less and resources that do not exceed three times the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for full Medicaid. Entitled to all benefits available to the QMB, as well as all benefits available under the State Medicaid plan. These individuals often qualify for full Medicaid benefits by meeting the Medically Necessary standards, or through spending down excess income to the Medically Needy level. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.

REFERRAL

 

A written request from your primary care physician for you to see a specialist or to receive certain services.

SERVICE PLAN COVERAGE AREA

 

The specific county/ZIP code/state that a member actually resides in, the service area is where you must live for a plan to accept you as its member. If a member moves out of the plan coverage service area, he or she needs to contact the plan using the number listed on the back of their CarePlus ID card to find out if the service area is affected.

SPECIAL ELECTION PERIOD (SEP)

 

A period, outside of the usual ICEP, AEP or MADP, when an individual may elect a plan or change his or her current plan election. Some examples of special election situations are

·         The organization does not renew its contract with CMS

·         You are turning or recently turned 65

·         You recently moved to the plan coverage area

·         You have Medicare and Medicaid

·         You are disenrolling from an Employer or Union health coverage

Other exceptional conditions may exist, as determined by CMS. These are only examples.

SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB ONLY)

 

These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for Medicaid. Eligible for payment of Medicare Part B premiums only. These beneficiaries do not qualify for any additional Medicaid benefits. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.

SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES PLUS (SLMB PLUS)

 

These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility, and are eligible for full Medicaid benefits. Entitled to all benefits available to an SLMB, as well as all benefits available under the State Medicaid plan. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.

SUMMARY OF BENEFITS (SB)

 

A brief description or outline of your coverage, including the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.

URGENTLY NEEDED CARE

 

Care you receive for a sudden illness or injury that needs medical attention right away, but is not life threatening. The care should generally be provided by your primary care physician or an Urgent Care Center, unless you are out of the service area.