Medicare is a healthcare system available to seniors over
the age of 65, and persons under age 65 who qualify on the basis of a disability
or other special situation. Beneficiaries of original Medicare (Parts A and B) must
be U.S. citizens or a legal resident who has lived in the U.S. for at least 5
consecutive years.
There are currently
four parts to Medicare – Part A, Part B, Part C and Part D.
Part A – Covers hospitalization
Part B – Covers doctor and outpatient care, lab test,
diagnostics, screenings and shots, and some medications.
Part C – is the Medicare Advantage Plan
Part D – is the Prescription Drug Plan.
Additional services and programs not covered under
Medicare include Dental, Vision Services, Podiatry Services, Hearing Services,
Hearing Aids, Transportation, Exercise Programs e.g. Silver Sneakers, and programs which enable beneficiaries to transfer
health benefits to geographical areas while on vacation or extended stay. These
additional benefits vary amongst carriers.
Beneficiaries have three options. In order to access
these options, beneficiaries must be enrolled in Part A and eligible for Part
B. All beneficiaries must continue to pay their part B premium in order to qualify
for Medicare Advantage or Supplement Plans.
The Center for Medicare and Medicaid commonly referred to as
“CMS” has contracted Medicare Advantage Plans
(Part C) to Private Insurance Companies. These insurers use a
network of providers to cover the same services available in Original Medicare
(Part A and B) and often prescription drug coverage (Part D) – all in a single
plan.
Medicare Advantage Plans offer additional benefits beyond doctor and
hospital visits. To qualify for a Medicare Advantage Plan, you must reside in
the service area of the plan, be enrolled in Original Medicare Parts A and B,
and not have end-stage renal disease (ESRD). Medicare Advantage is not a Medicare Supplement.
Premiums and plan options vary. Monthly premium
prices range from zero to over $200. Each plan must offer an annual out of
pocket maximum. After the annual maximum is reached, beneficiaries are
covered 100% by the plan without additional co-pays, coinsurance, and or
deductibles.
Medicare Advantage Plans are renewed annually, which means
that benefits and cost are subject to change annually. Once enrolled, the Plan
pays for covered services, not Medicare. Beneficiaries remain enrolled in
original Medicare. With the exception of end-stage renal disease, No medical
underwriting or pre-existing medical conditions will dis-qualify you to sign up
for an Advantage Plan.
A Medicare Supplement Plan
is an insurance policy that insures your original
Medicare. Medicare Part A and B require beneficiaries to pay deductibles, co-insurance and co-pays. The Supplement Plan
commonly referred to as a “Medi-gap” Plan will cover co-insurance, co-pays, and
deductibles that Medicare does not cover depending on the plan selected.
A Supplement Plan will not insure
services unavailable in original Medicare Parts A and B. A supplement Plan also
will not cover Part D. You will need to purchase a Part D Plan if you choose
this option.
The last option that some beneficiaries choose is to remain
enrolled in Original Medicare A and B. These beneficiaries can purchase a
Prescription Drug Plan (Plan D).
Beneficiaries who fail to
enroll, will be assessed a Late
Enrollment Penalty (LEP). This amount will be added to your Part D premium
if you go longer than 63 days in a row, after your Initial Enrollment Period
(IEP), without Part D or other credible Part D coverage. Think of the penalty
as a payment that will come out of your social security check each month. For
more information about the Late Enrollment penalty, visit www.medicare.gov or call 1-800-MEDICARE.
Hearing impaired users should call 1-877-486-2048.
There are three Enrollment
Periods: The Initial Enrollment Period (IEP) is a seventh month
period where you can enroll after you become eligible. The period consists of
your birthday month, three months prior and three months after. Some
individuals qualify for a Special Enrollment Period (SEP). If you move
outside of the service area, receive assistance from the state, have been
diagnosed with a qualifying chronic health condition, retire, or enter a
nursing home you qualify for a SEP. These are just some SEP's. Each year from October 15 to December 7,
there is an Annual Enrolment Period (AEP) where you can add, switch, or
drop your Medicare plan coverage.
Considerations when enrolling in any plan is the Cost, provider
network, and drug formulary. If the plan does not cover your doctors and or
medications that you need, it may not work for you. Medicare Advantage
enrollment may impact other existing coverage that you have such as employer
coverage. It is a good idea to consult with your employer prior to making a change.
You may also qualify
for the Low Income Subsidy (LIS) or
Extra Help program depending on your income. Please contact the Social Security
Administration at www.ssa.gov or call 1-800-772-1213, TTY 1-800-325-0778. Check with
your area hospital to see if they offer Charity Care. Charity Care will cover
co-pays for individuals who qualify.
Resources such as www.medicare.gov will assist you with comparing plans in your
service area. This site will help you view up to three plans side by side.
Please note: Medicare is a separate program from
Affordable Care Act (ACA). They are two distinct government health insurance
programs. Medicare beneficiaries are not subject to ACA rules and regulations.
Carmen Coleman is a licensed insurance agent and insurance consultant. Offering individual and small group session for Medicare beneficiaries, care providers, and anyone wishing to learn more about medicare. Carmen Coleman is not connected with the Federal Medicare Program.
© Carmen Coleman, President and CEO
Lifetime Financial Group, LLC
30 W. Broad Street, Suite 300
30 W. Broad Street, Suite 300
Rochester, NY 14614
(585)325-2525
