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Understanding Medicare & What It Covers
Taking the first steps toward learning about Medicare can be overwhelming—there are many terms to understand and options to consider, so it’s completely understandable if the handbooks and pamphlets have left you dazed and confused. The good news is that we’re here to help you cut through the clutter of Medicare.
In just minutes, we can compare all the Medicare options available for you. Don’t wait to ensure you’re getting all the benefits you deserve.
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Prescription Drug Coverage.
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The Parts of Medicare Insurance
Medicare—a federal health insurance program—pays for a variety of health care expenses and services such as hospitalizations, physician visits, prescription drugs, preventive services, skilled nursing facility and home health care as well as hospice care. It was created in 1965 for people ages 65 and over, regardless of income, medical history or health status. In 1972, the program expanded to cover those under age 65 who have a long-term disability.
What is Medicare Part A coverage?
Medicare Part A helps cover most inpatient hospital, skilled nursing home, home health and hospice care. There is a monthly premium for Part A, but many people will qualify for premium-free Part A.***
Original Medicare Part A is the hospital insurance portion of Medicare and is the oldest product in the Medicare program. It is a benefit every U.S. citizen or permanent legal resident (residing for at least five continuous years) is entitled to if they meet eligibility requirements.
Services Medicare Part A Covers
- Care received while you’re in the hospital
- Inpatient care in a skilled nursing facility (but not custodial or long-term care)
- Hospice care
- Home health services (within approved limitations)
Services Medicare Part A Does Not Cover
- Private hospital rooms (or room TV, room phone, personal care items)
- Transfusions – first three units (unless donated by you or by donation)
- Private-duty nursing care
- Long-term care
What is Medicare Part B coverage?
Medicare Part B covers routine doctor visits, including specialists to treat your medical conditions. It also covers preventative services, which is meant to prevent illness (like the flu) or to detect at an early stage, when treatment is most likely to work best. There is a monthly premium for Part B.
Medicare Part B covers two key areas of healthcare:
Medically necessary services or supplies that are needed to diagnose or treat your medical condition within accepted standards of medical practice.
Preventive services, which is healthcare you receive to prevent illnesses, like getting a flu shot or having an x-ray to check for pneumonia. You need to receive preventive services from a healthcare provider who “accepts assignment,” so be sure to ask when you make your appointment.
Talk with your healthcare provider or contact Medicare directly to ensure the care you’re receiving is covered by Medicare Part B. SelectQuote, however, can help you see what other options you might have available when it comes to Medicare coverage. There’s no obligation to enroll.
Who is eligible to receive Medicare Part B coverage?
If you have Medicare Eligibility for premium-free Medicare Part A, then you are also eligible for Medicare Part B as long as you enroll and pay your monthly premium on time. If you are not eligible for premium-free Part A, you may still qualify for Part B if:
- You’re 65 or older and are a U.S. citizen or a permanent resident lawfully residing in the U.S. for at least five consecutive years.
- You are younger than 65 with a qualifying disability including end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS)—also known as Lou Gehrig’s disease—in which case you will be automatically enrolled in Medicare Part B.
- You are younger than 65 and receive Social Security or Railroad Retirement Board (RRB) disability benefits, in which case you will be automatically enrolled in Medicare Part A & Part B.
What is Medicare Part C coverage?
A Medicare Part C plan is an alternative developed by the government and sold through private insurers. It is widely known as “Medicare Advantage,” and by law, this plan offers—at a minimum—the same benefits as Original Medicare. The costs, rules and even the way coverage works can vary depending on the private insurer you purchase from. These plans often can include dental, vision, hearing coverage, extra benefits and in some areas, $0/mo. premiums.
Medicare Part C provides an alternative to Original Medicare (Medicare Part A and Medicare Part B). Offered by private health insurance companies that are approved by Medicare, Medicare Part C plans—also known as Medicare Advantage plans—are legally required to offer at least the same benefits that are provided from Original Medicare, but can include additional coverage, such as routine vision or dental benefits, prescription drugs or health wellness programs.
Services Medicare Part C Covers
- $0 premium plans and $0 deductible plans may be available in your area
- Prescription drug coverage may be included
- Additional benefits, such as vision, hearing and dental may be available
What is Medicare Part D coverage?
Medicare Part D is a stand-alone drug plan offered through private insurers that will cover most of your outpatient prescription medications. It’s good to know that if you choose a Medicare Advantage plan instead of Original Medicare, the benefits of Part D are often incorporated into your Medicare Advantage plan.
Medicare Part D—a federal program that began in 2006—provides Medicare beneficiaries access to retail prescription drugs at affordable copays. Prior to the introduction of Medicare Part D, Medicare beneficiaries mostly paid for their medications as an out-of-pocket expense as Original Medicare (Medicare Part A and Medicare Part B) doesn’t cover all prescription drug costs.
Also referred to as Medicare Prescription Drug Plans, Medicare Part D helps cover the cost of prescription medications, giving you broader healthcare coverage and potentially saving you money.
Some of the key things you need to know about the Medicare Part D include:
- Part D plans are operated by Medicare-approved private insurance companies
- Part D plans provide prescription drug coverage for both generic and brand name medications
- Medicare Part D has four phases of prescription drug coverage
- The cost varies based on the plan you choose, your medications and pharmacy
- Drugs covered and costs can change from year to year, so it’s important to compare plans
- Participation in Medicare Part D is purely voluntary
What are Medicare Supplement Insurance plans?
Because Original Medicare doesn’t cover every expense, many people add a Medicare Supplement Insurance plan (also called a Medigap plan) for extra coverage.
In most states, there are currently 8 Medicare Supplement Insurance plans available through private insurers. Each of the plans – which are standardized across all the states offering them – have a letter designation: A through N. Keep in mind that not all supplement plans are offered by every private insurer AND private insurers set their own premium rates, so it’s important to shop around.
Enrolling in Medicare
You can enroll in Medicare during the Initial Enrollment Period (IEP), which begins three months before and ends three months after your 65th birthday. Individuals on Social Security Disability Insurance (SSDI) become eligible for Medicare in the 25th month of SSDI benefits and are automatically enrolled in the program by Social Security. Some people may be eligible for special enrollment periods based on their employment history or other health insurance coverage they have.
What are the Medicare enrollment periods?
Each year, there are five set times you can enroll in Medicare or change existing Medicare plans. They include:
The first time an eligible person can enroll in Medicare Part A and Medicare Part B. This timeline begins three months before the month of a person’s 65th birthday and continues through the three months following a person’s 65th birthday.
Runs January 1-March 31 each year and provides an enrollment opportunity for individuals who didn’t sign up for Original Medicare (Part A and Part B) when they were first eligible. Individuals may have to pay a late enrollment penalty for not enrolling when first eligible and coverage will not start until July 1 of that year.
Current Medicare recipients can change or enroll in Medicare Advantage coverage during this period that runs October 15-December 7 each year. During AEP, you can:
- Switch from Medicare Parts A and B (Original Medicare) to a Medicare Advantage plan (Part C)
- Change from one Medicare Advantage plan to another
- Switch from one Medicare Prescription Drug plan (Part D) to another
- Add a Medicare Part D plan if you didn’t enroll when first eligible for Medicare
Certain life events can lead to an individual being eligible to enroll in Original Medicare or enrolling/changing Medicare Advantage coverage. You can utilize SEP if you’re:
- Moving to a new location where new plan options are available
- Losing employer coverage
- Being diagnosed with a qualifying chronic condition, such as diabetes or chronic heart failure
- Moving in or out of a skilled nursing facility or long-term care hospital
Runs from January 1-March 31 and was new in 2019, allowing Medicare Advantage participants to make a one-time plan. OEP allows beneficiaries enrolled in a Medicare Advantage plan or Medicare Advantage Prescription Drug plan to make a one-time change to:
- Switch to a different Medicare Advantage Plan
- Drop Medicare Advantage and return to Original Medicare (Part A and Part B)
- Sign up for a stand-alone Medicare Part D Prescription Drug plan, if an individual elects to return to an Original Medicare plan
The Medicare Advantage OEP is only accessible for current Medicare Advantage policyholders. During Medicare Advantage OEP, Original Medicare policyholders cannot:
- Switch from Original Medicare to a Medicare Advantage plan
- Join a Medicare Prescription Drug plan (Part D)
- Switch Medicare Prescription Drug plans