Standard Medicare Plan:
Are you already getting Social Security or Railroad Retirement benefits? Then you automatically get the standard (original) Medicare Plan at 65. You should get a packet of information on Medicare from the government, including your Medicare card.
If you are not getting Social Security or Railroad Retirement benefits and think you might qualify for those benefits, contact your local Social Security office. Ask them about whether you qualify for Medicare benefits. If you do, then they can give you further information about getting signed up for standard (original) Medicare.
What is Medicare Part A (Hospital) Coverage?
Medicare Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care. Most people don’t pay a Part A premium because they paid Medicare taxes while working. This is called “premium-free Part A.” In general, Part A covers:
- Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
- Inpatient care in a skilled nursing facility (not custodial or long term care)
- Hospice Care services
For more information – please refer to the Medicare Publication – Medicare Benefits.
What is Medicare Part B (Services) Coverage?
Part B helps cover medically-necessary services like doctors’ services, outpatient care, durable medical equipment, home health services, and other medical services. Part B also covers some preventive services, but it is wise to find out exactly what is covered before an appointment so you don’t end up paying more out of your pocket. The 2012 standard premium for Part B is $99.90 per month. Some people will pay more based on their income. If you don’t sign up for Part B when you’re first eligible, you may have to pay a late enrollment penalty of 10% for each 12 month period that you could have enrolled, but did not. Part B covers two 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.
For more information – please refer to the Medicare Publication – Medicare Benefits.
What is Medicare Part C?
A Medicare Advantage Plan (like an HMO, PPO, or PFFS) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Some plans also include Prescription Drug coverage. The benefts can vary between each plan, but each plan must provide, at a minimum, all of the coverage that standard (original) Medicare covers.
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services. The plans and rules can change each year, and not all plans are available in all areas. Additionally, Medicare Advantage plans are only available to people who enroll in both Medicare Part A and Part B. These plans may also have a monthly premium in addition to the Part B premium. The cost of the plans depend on the carrier and the type of plan chosen. Call us at (970) 255-8240 and we will help you find out what is available in your area and discuss the benefits of each plan.
Here are a few extra things you should know about Medicare Advantage Plans:
- You can only join a plan at certain times during the year. The Annual Election Period currently runs from October 15 – December 7 of each year.
- You should always check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
- You must follow plan rules, like getting a referralto see a specialist or getting prior approval for certain procedures to avoid higher costs.
- You can join a Medicare Advantage Plan even if you have a pre existing condition, except for End-Stage Renal Disease.
- If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
- If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare.
What is Medicare Part D (Prescription Drug) Coverage?
Medicare offers prescription drug coverage to everyone with Medicare. To get Medicare prescription drug coverage, you must join a plan run by a private insurance company approved by Medicare. Each plan can vary in cost and drugs covered. Please call us at (970) 255-8240 and we can show you what plans are available in your area and discuss the benefits of each plan.
If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty. The penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($31.08 in 2012) times the number of full, uncovered months you were eligible but didn’t join a Medicare drug plan and went without other creditable prescription drug coverage. The final amount is rounded to the nearest $.10 and added to your monthly premium.
What is the Prescription Drug “Coverage Gap” or “Donut Hole”
Medicare drug plans have a coverage gap (also called the “donut hole”). This means there’s a temporary limit on what the drug plan will cover for drugs. For 2012 the coverage gap begins when the retail costs of your prescription drugs reach $2930. Please note, this $2930 is the total retail cost of the covered medications, not what you spend personally at the pharmacy. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.
Once you enter the coverage gap, you get a 50% manufacturer-paid discount on covered brand-name drugs. Additionally, you’ll also pay only 86% of the plan’s cost for covered generic drugs until you reach the end of the coverage gap. These amounts are scheduled to change each year, until no coverage “gap” remains.
All part D plans are required by law to offer benefits equal to or better than the following benefits:
2012 Basic Benefits
100% of first $320
|Initial Coverage Limit||
25% of the next $2610
50% of brand name and 86% of generic until you reach $3727.50 in out-of-pocket cost
Medicare & Plan pay 95%
You pay the greater of $2.60 for generic, $6.50 for all other drugs, or 5% coinsurance
* There are plans available with no deductible.
Please keep in mind that this chart only represents the maximum cost to you for COVERED prescriptions. Some prescriptions are not covered, and therefore you may pay full cost, and it will not count towards your out of pocket maximums.
What if you Want to Change Medicare Advantage Plans?
Generally, you can choose to switch to a new Medicare Advantage plan from October 15 to December 7 of each year – during the Annual Election Period. If you qualify for a Special Election Period you can switch plans at other times. Some examples of Special Election Periods:
- You move out of the service area of your current plan.
- You no longer qualify for Medicaid
- You leave coverage from an employer plan – including COBRA plans.
- You qualify for extra help with Medicare Prescription Drug coverage
- You move into or out of a Skilled Nursing Facility
If you decide to switch plans, please contact us at (970) 255-8240 for help in choosing and enrolling in a new plan.
What if you Want to Change Medicare Supplement Plans?
Generally, you can switch to a different Medicare Supplement policy at any time. However, Medicare Supplement plans are only guarantee issue for 6 months following your Part B effective date. If you try to enroll in a new plan later on, you will have to answer several health questions, and the insurer may choose to deny you coverage. It is important that you do not cancel your current plan until you are sure that your new plan is active.
In any case, you might want to consider getting some help to navigate the Medicare Supplemental Health Insurance waters. We’re experienced and will be happy to help you. Just contact us by phone or email.
For more information, check out the AARP website page with a more detailed explanation: AARP Medicare Supplement Plans Information