Medicare Basics

Medicare is a health insurance program provided by the government for those age 65 years or older, individuals with qualifying disabilities, and people with end-stage renal disease. Original Medicare is provided directly through Medicare and typically includes:

  • Part A: Hospital Insurance – most people don’t have to pay a Part A premium, which helps cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care
  • Part B: Medical Insurance – most people pay a monthly premium for Part B, which helps cover doctor’s services, outpatient care, medical supplies, and many preventative services

2020 Costs at a Glance

Part A Premium The majority of people don't pay a monthly premium for Part A (sometimes called "premium-free Part A")
  • If you buy Part A, you'll pay a maximum of $458 each month
  • If you have paid Medicare taxes for less than 30 quarters, the standard Part A premium is $458
  • If you have paid Medicare taxes for 30-39 quarters, the standard Part A premium is $252
Part A Hospital Inpatient Deductible and Coinsurance This is what you pay:
  • A deductible of $1,408 for each benefit period
  • $0 coinsurance for the first 60 days of each benefit period
  • $352 coinsurance per day for days 61-90 of each benefit period
  • $704 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
  • All costs beyond lifetime reserve days
Part B Premium $144.60 is the standard Part B premium amount for Part B, this could be higher depending on your income
Part B Deductible and Coinsurance Your cost is $198 per year. After your deductible is met, you typically pay 20% of the Medicare-approved amount for:
  • Most doctor services, including most doctor services while you're a hospital inpatient
  • Outpatient therapy
  • Durable Medical Equipment (DME)

You can choose to receive your Medicare benefits in various ways:

  • Original Medicare
  • Original Medicare + Supplement OR Cost Plan
  • Medicare Advantage Plan
    • An "all in one" alternative to Original Medicare is Medicare Advantage (Part C). These “bundled” plans include Part A, Part B, and usually Part D.
    • If you join a Medicare Advantage Plan, you’ll still have Medicare and still pay your Part B premium. However, you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan, not Original Medicare.
Watch this short video to learn more about Medicare basics.

Medicare Supplements (Medigap)

Medicare supplement insurance, also known as Medigap, is sold by private insurance companies and supplements Original Medicare Parts A and B. These policies cover gaps in Original Medicare Parts A and Part B such as co-payments, coinsurances, and deductibles you would otherwise pay yourself. Most Medicare Supplements do not have a network and you will continue to pay your Part B premium. Premiums are typically based on age and can increase as the insured gets older.

Medicare Select

Medicare Select supplements are typically low-cost versions of traditional Medigap/Medicare supplements, but they require subscribers to use in-network hospitals, clinics and/or doctors. By negotiating prices within the network, the Medicare Select plans are able to keep their costs down. For this reason, Medicare Select plans usually have lower premiums than comparable Medigap policies.

Medicare Advantage Plans

A Medicare Advantage Plan is another way to obtain your Medicare benefits. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private insurance companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you’ll still have Medicare, but you’ll get most of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) benefits from the plan, not Original Medicare. Many Medicare Advantage Plans offer additional benefits not available through Original Medicare such as dental, vision, hearing, gym memberships, and other items/services. Premiums are not based on the age of the insured. The two predominant plan types in our area are:

Health Maintenance Organization (HMO)
HMO Plans are an excellent option for cost conscious Medicare beneficiaries willing to diligently follow plan guidelines. Generally, you must get your care and services from the providers in your plan's network. If you utilize non-network providers you may have to pay the full cost of services yourself with these exceptions:

  • Emergency Care
  • Out-of-area Urgent Care
  • Out-of-area Dialysis

Preferred Provider Organization (PPO)
PPO Plans do have network doctors, other health care providers, and hospitals. Each Plan gives you the choice to go to doctors, specialists, or hospitals that are not on that list. However, it will usually cost less if you receive care from providers on your network's list.

Veterans

  • Medicare Advantage plans can be a great fit for Veterans. With Original Medicare Parts A & B, Veterans still have financial exposure when receiving services outside the VA system. Medicare Advantage Plans cap your out-of-pocket risk and add benefits Original Medicare or the VA may not offer such as dental, vision, and hearing services. Some plans also offer a Part B premium reduction.

Cost Plans

A Cost Plan is somewhat of a hybrid – a cross between a Medicare supplement and a Medicare Advantage Plan. Similar to an Advantage Plan, a Cost Plan has a network of doctors and hospitals the insured must use. There may be some cost sharing (a copay for example) when visiting a doctor, for a hospital stay, labs, or diagnostic tests, but this cost sharing all adds up to an out-of-pocket maximum to limit the annual risk for the insured.

Cost Plans may include additional benefits not covered under Original Medicare such as dental reimbursements, vision exams, eyewear coverage, hearing exams, gym memberships, and more. The rates do not vary based on age and generally are less expensive than a supplement, but more expensive than an Advantage Plan. Some Cost Plans may offer an optional prescription drug benefit to fulfill your creditable prescription drug needs as well. You will continue to pay your Part B premium.

As with a supplement, the client retains his or her original Medicare, ensuring the client has coverage if they receive services from outside the plan’s network. Medicare Cost Plans in our area do not have enrollment or dis-enrollment periods and they are not medically underwritten (with the exception of end-stage renal disease). When obtaining healthcare services you would show both your Original Medicare card and Cost Plan card.

Prescription Drug Plans (Part D)

Medicare prescription drug coverage, often referred to as Part D, is insurance that helps pay for prescriptions. Anyone with Medicare Part A and/or Part B is eligible for prescription drug coverage.

You can get Medicare prescription drug coverage through a stand-alone prescription drug plan (PDP), Medicare Advantage Prescription Drug plan (MA-PD), or Medicare Cost Plan if it is offered. You may have creditable Medicare prescription drug coverage through an employer or group plan. Knowing whether your coverage is creditable is important in order to avoid possible penalties. Watch this video for more information on Medicare Prescription Drug Coverage.

The Annual Enrollment Period (AEP) for Part D of Medicare currently runs from October 15-December 7 of each year, with Special Election Periods (SEP) available under limited circumstances. This is the time of year to select or change your insurance for the following year.

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