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e.g., “Can I switch Medicare plans?” “Do I need a referral?” “Can I choose my own Doctors?”

Brief look at Medicare

We routinely speak to seniors who are either now or soon eligible for Medicare. Many are confused and sometimes overwhelmed by the multitude of coverage options available. At the Medicare Help Desk, we help make sense of all this confusion.

We are an independent insurance agency that provides help to those on Medicare and helps them choose the appropriate coverage, including Medicare Supplements, Medicare Advantage, and stand-alone Prescription Drug Plans from over 30 different insurance carriers. Let the Medicare Help Desk explain your options and help you find the best Medicare Plan for you.

Medicare Options Made Simple by Justin Colvin

The different parts of Medicare help cover specific services

Medicare Part A covers the following services:

  • Inpatient hospital care: This is care received after you are formally admitted into a hospital by a physician. You are covered for up to 90 days each benefit period in a general hospital, plus 60 lifetime reserve days. Medicare also covers up to 190 lifetime days in a Medicare-certified psychiatric hospital.
  • Skilled nursing facility (SNF) care: Medicare covers room, board, and a range of services provided in an SNF, including administration of medications, tube feedings, and wound care. You are covered for up to 100 days each benefit period if you qualify for coverage. To qualify, you must have spent at least three consecutive days as a hospital inpatient within 30 days of admission to the SNF and need skilled nursing or therapy services.
  • Home health care: Medicare covers services in your home if you are homebound and need skilled care. You are covered for up to 100 days of daily care or an unlimited amount of intermittent care. To qualify for Part A coverage, you must have spent at least three consecutive days as a hospital inpatient within 14 days of receiving home health care. (Note: You can get home health care through Medicare Part B if you do not meet all the requirements for Part A coverage.)
  • Hospice care: is the care you may elect to receive if a provider determines you are terminally ill. You are covered for as long as your provider certifies you need care.

 

Remember that Medicare does not usually pay the total cost of your care, and you will likely be responsible for some portion of the cost-sharing (deductibles, coinsurances, copayments) for Medicare-covered services.

Medicare Part B provides outpatient/medical coverage. The list below provides a summary of Part B-covered services and coverage rules:

  • Provider services: Medically necessary services you receive from a licensed health professional.
  • Durable medical equipment (DME): This equipment serves a medical purpose, can withstand repeated use, and is appropriate for use in the home. Examples include walkers, wheelchairs, and oxygen tanks. You may purchase or rent DME from a Medicare-approved supplier after your provider certifies you need it.
  • Home health services: Services covered if you are homebound and need skilled nursing or therapy care.
  • Ambulance services: This is emergency transportation, typically to and from hospitals. Coverage for non-emergency ambulance/ambulette transportation is limited to situations where no safe alternative vehicle is available and the ride is medically necessary.
  • Preventive services: These are screenings and counseling intended to prevent illness, detect conditions, and keep you healthy. In most cases, preventative care is covered by Medicare with no coinsurance.
  • Therapy services: Outpatient physical, speech, and occupational therapy services are provided by a Medicare-certified therapist.
  • Mental health services.
  • X-rays and lab tests.
  • Chiropractic care, when manipulation of the spine if medically necessary to fix subluxation of the spine (when one or more of the spine bones move out of position).
  • Select prescription drugs, including immunosuppressant, anti-cancer, anti-emetic, dialysis, and medications that a physician typically administers.

 

This list includes commonly covered services and items, but it is not complete. Remember that Medicare does not usually pay the total cost of your care, and you will likely be responsible for some portion of the cost-sharing (deductibles, coinsurances, copayments) for Medicare-covered services.

While the majority of people with Medicare get their health coverage from Original Medicare, some choose to get their benefits from a Medicare Advantage Plan, also known as a Medicare private health plan or Part C. MA Plans contract with the federal government and are paid a fixed amount per person to provide Medicare benefits.

The most common types of MA plans are:

  • Health Maintenance Organizations (HMOs)
  • Preferred Provider Organizations (PPOs)
  • Private Fee-For-Service (PFFS)

 

You may also see:

  • Special Needs Plans (SNPs)
  • Provider Sponsored Organizations (PSOs)
  • Medical Savings Accounts (MSAs)

 

Remember, you still have Medicare if you enroll in an MA Plan. This means that you likely pay a monthly premium for Part B (and a Part A bonus, if you have one). If you are enrolled in an MA Plan, you should receive the same benefits Original Medicare offers. Keep in mind that your MA Plan may apply different rules, costs, and restrictions, which can affect how and when you receive care. They may also offer certain benefits that Medicare does not cover, such as dental and vision care, caregiver counseling and training, and specific in-home support like housekeeping. Not all MA Plans cover additional benefits, so check with a plan directly to learn what benefits it covers.

All Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and B services. For example, the maximum out-of-pocket cost for HMO plans in 2022 is $7,550. These limits tend to be high. In addition, while programs cannot charge higher copayments or coinsurances than Original Medicare for certain services, like chemotherapy and dialysis, they can charge higher cost-sharing for other services.

Remember: MA Plans may have different:

  • Networks of providers
  • Coverage rules
  • Premiums (in addition to the Part B premium)
  • Cost-sharing for covered services

 

Even plans of the same type offered by different companies may have different rules, so you should always check with a program directly to determine how its coverage works.

You can join an MA Plan if:

  1. You have Medicare Parts A and B
  2. And, you live in the plan’s service area

 

Many Medicare Advantage Plans also offer prescription drug coverage (Part D). You can enroll in a stand-alone Part D plan if you join an MSA plan or a PFFS plan without drug coverage. Remember that people with Original Medicare who want Part D coverage also enroll in a stand-alone Part D plan.

Suppose you have health coverage from your union or employer (current or former) when you become eligible for Medicare. In that case, you may automatically be enrolled in an MA Plan that they sponsor. You have the choice to stay with this plan, switch to Original Medicare, or enroll in a different MA Plan. Be aware that if you switch to Original Medicare or enroll in a different MA Plan, your employer or union could terminate or reduce your health benefits, the health benefits of your dependents, and any other benefits you get from your company. Talk to your employer/union and your plan before making changes to determine how your health and other benefits may be affected.

Medicare Part D, the prescription drug benefit, is the part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone plan for those enrolled in Original Medicare or as a set of benefits included with your Medicare Advantage Plan.

Unless you have creditable drug coverage and will have a Special Enrollment Period, you should enroll in Part D when you first get Medicare. If you delay enrollment, you may face gaps in coverage and enrollment penalties.

Part D coverage

Each Part D plan has a list of covered drugs, called its formulary. If your prescription is not on the form, you may have to request an exception, payout of pocket, or file an appeal.

A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. All Part D plans must include at least two medications from most categories and must cover all drugs available in the following categories:

  • HIV/AIDS treatments
  • Antidepressants
  • Antipsychotic medications
  • Anticonvulsive treatments for seizure disorders
  • Immunosuppressant drugs
  • Anticancer drugs (unless covered by Part B)

 

Part D plans must also cover most vaccines, except for vaccines covered by Part B.

Some drugs are explicitly excluded from Medicare coverage by law, including drugs used to treat weight loss or gain and over-the-counter medications.

Note: Your medications may be covered by Part A or Part B for certain drugs or under specific circumstances.

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Medicare FAQ's

It depends on each person’s situation. Today, many folks are working longer and are delaying their entry into Medicare since they have creditable employer health coverage. However, even if someone is working longer, it is still good to evaluate their Medicare options and compare its costs and benefits to their current coverage. In most cases, Medicare combined with a Supplement will offer more comprehensive coverage than the employer coverage. Give us a call and help determine the best solution for you.

Yes and No. According to Social Security, you must have worked at least 40 quarters (roughly ten years) to be eligible for FREE Part A hospital coverage. Part B is your medical coverage and has a modest monthly premium. Most folks have their Part B premium deducted from their monthly Social Security check.

Typically, Medicare does not provide benefits for these services, although various stand-alone plans cover these benefits for a low monthly premium.

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The Medicare Help Desk

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