MEDICARE BASICS Flashcards
What is Medicare?
Medicare is a health insurance program for:
people age 65 or older,
people under age 65 with certain disabilities, and
people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Medicare Part A - Hospital Insurance
Medicare has:
Part A Hospital Insurance - Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.
Medicare Part B - Medical Insurance
Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Medicare Prescription Drug Coverage
Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. In January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare. This coverage is to help you lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
Are You Eligible for Medicare?
Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States.
If you are not 65, you might also qualify for coverage if you have a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).
Here are some simple guidelines. You can get Part A at age 65 without having to pay premiums if:
You already get retirement benefits from Social Security or the Railroad Retirement Board.
You are eligible to get Social Security or Railroad benefits but have not yet filed for them.
You or your spouse had Medicare-covered government employment.
If you are under 65, you can get Part A without having to pay premiums if:
You have received Social Security or Railroad Retirement
Board disability benefit for 24 months. You are a kidney dialysis or kidney transplant patient.
While you don’t have to pay a premium for Part A if you meet one of those conditions, you must pay for Part B if you want it. It is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you don’t get any of the above payments, Medicare sends you a bill for your Part B premium every 3 months.
What is Medicare Supplement (Medigap) Insurance?
A Medicare Supplement (Medigap) insurance, sold by private companies, can help pay some of the health care costs that Original Medicare doesn’t cover, like co-payments, coinsurance, and deductibles.
If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. 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.
What you need to know about Medicare Supplement policies
You must have Medicare Part A and Part B.
If you have a Medicare Advantage Plan, you can switch to a Medicare Supplement insurance policy, but make sure you can leave the Medicare Advantage Plan before your Medicare Supplement insurance policy begins.
You pay the private insurance company a monthly premium for your Medicare Supplement insurance policy 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 Medicare Supplement insurance policy from any insurance company that’s licensed in your state to sell one.
Any standardized Medicare Supplement insurance policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medicare Supplement insurance policy as long as you pay the premium.
Medicare Supplement insurance 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 Advantage Plan, unless you’re switching back to Original Medicare.
Compare Medicare Supplement Plans Side by Side
Medicare Supplement policies (also known as Medigap policies) are standardized and must follow federal and state laws designed to protect you. Insurance companies can only sell you a “standardized” policy identified in most states by letters (see the chart below).
All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs. As you can see in the comparison chart there are many options from which to choose. As licensed insurance agents we can help you understand the differences between the plans so that you can decide on the right plan for you.
In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way.
Did you know that each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer? Insurance companies that sell Medigap policies:
Don’t have to offer every Medigap plan
Must offer Medigap Plan A if they offer any Medigap policy
Must also offer Plan C or Plan F if they offer any plan
Keep in mind, that the Medicare Supplement policy covers co-insurance after you’ve paid the deductible (unless the Medigap policy also pays the deductible).
What are the parts of Medicare?
Part A - Hospital Insurance
Helps cover:
- Inpatient care in hospitals
- Skilled nursing facility care
- Hospice care
- Home health care
PART B - MEDICAL INSURANCE
Help cover:
- Services from doctors and other health care providers
- Outpatient care
- Home health care
- Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
- Many preventive services (like screenings, shots or vaccines, and yearly
“Wellness” visits)
PART D - DRUG COVERAGE
helps cover the cost of prescription drugs (including many recommended shots or vaccines).
Plans that offer Medicare drug coverage (Part D) are run by private insurance companies that follow rules set by Medicare
What are the 2 main ways to get Medicare?
- Original Medicare
2.Medicare Advantage (also known as Part C)
What are the main points of Original Medicare?
Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).
- you can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
- You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
- To help pay you out-of-pocket costs in Original Medicare (like your 20% coinsurance_, you can also shop for and buy supplemental coverage (Medigap).
- In most cases, you don’t need a referral to use a specialist.
- For Part-B covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This amount is called your coinsurance.
- You pay a premium (monthly payment) for Part B. If you choose to join a Medicare drug plan, You’ll pay a separate premium for Medicare drug coverage (Part D)
- There’s no yearly limit on what you pay out of pocket, unless you have supplemental coverage – like Medicare Supplement Insurance (Medigap). You can
choose to buy Medigap to help pay your remaining out-of-pocket costs (like your 20% coinsurance). - Original Medicare generally doesn’t cover medical care outside the U.S. You may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care outside the U.S.
What are the main points of Medicare advantage (also known as Part C)
- Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for you health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D.
- In many cases, you can only use doctors who are in the plan’s network.
- In many cases, you may need to get approval from your plan before it covers certain drugs or services.
- Plans may have lower or higher out-of-pocket costs than Original Medicare. you may also have an additional premium.
- Plans may offer some extra benefits that Original Medicare doesn’t cover – like certain vision, hearing, and dental services.
- You may need to get a referral to use a specialist.
- Out-of-pocket costs vary – plans may have lower or higher out-of-pocket costs for certain services.
- You pay the monthly Part b premium and may also have to pay the plan’s premiun. Some planse may have a $0 premium and may help pay all or part of your Part B premium. Most Medicare Advantage plans include Medicare drug coverage (Part D).
Medicare Advantage plans have an early limit on what you pay out of pocket for services Medicare Part A and Part B cover. Once you reach your plan’s limit, you. pay nothing for services Part A and Part B cover for the rest of the year.
- With Medicare Advantage plans, you cannot buy and you don’t need Medigap.
- Medicare Advantage plans generally don’t cover medical care outside the U.S. Some plans may offer a supplement benefit that covers emergency and urgently needed services when traveling outside the U.S.
