Navigating the Medicare Maze

Whether you are already receiving Medicare or about to enroll for the first time, we are here to help you or a loved one navigate the Medicare Maze.   Please don’t do it alone, we are here to help! Our goal is to assist you with finding the best plan to fit your health care needs.

Original Medicare

The original Medicare program was signed into law on July 30th, 1965.  Former President Harry Truman and his wife were the very first beneficiaries.  Today over 56 million Americans are enrolled in the Medicare program. That’s most Americans ages 65 and older, regardless of their income or health status.

Original Medicare has only two parts:  A and B. Part A is for hospital insurance and Part B is for medical insurance.   You can use any doctor or hospital that takes Medicare, anywhere in the U.S. If you want drug coverage, you can join a separate Part D plan. 

Parts A, B, C, and D

 

  • Part A – Hospital Care

    • Medicare Part A is for hospital care.  It covers things like your hospital room, meals, general nursing and hospital services and supplies.  It does not cover private duty nursing, comfort or convenience items.                       ​

    • Coverage is for up to 90 days per Benefit Period and the first 60 days are covered at 100% after the Medicare Part A Deductible is met.  You pay an out of pocket cost for any days after 60. There is an additional 60 days of coverage called lifetime reserve days, but it can only be used once. ​                                                                                   

    • It’s important to note that the deductible is $1,408 for 2020 and applies to any new Benefit Period.  So if you go into the hospital for a couple of days, get discharged and then return a week later – you are still in the same Benefit Period and will not be charged again for the $1,408 Part A Deductible that you incurred on the first confinement.                                                                                                                                                                                        ​
    • If you are out of the hospital and/or Skilled Nursing Facility for at least 60 days in a row, a return to the hospital would begin a new Benefit Period and you would owe the Part A Deductible.                                                                   

    • There are usually no premiums for Part A if you or your spouse paid Medicare taxes while working (a.k.a. ‘Premium-free Part A’).​






















       

 
 
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  • Part B – Medical Services

    • Medicare Part B is optional.  It covers things like doctors visits, lab work and x-rays outside a hospital stay.  It is an 80 – 20 plan meaning Medicare pays 80% of the approved expenses and you are responsible for the remaining 20%.  For 2020, the premium for Part B starts at $144.60 per month (or higher depending on your income). There is a $198 deductible but the deductible is for the whole calendar year, not per occurrence.  If you collect a Social Security check, your premium will most likely be deducted.   

  • Part C – Medicare Advantage Plans

    • Most Medicare Advantage plans also offer prescription drug coverage.  ​                                                                                                             
    • Medicare Advantage plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Services Plans (PFFS), Special Needs Plans (SNP), and Medicare Medical Savings Account Plans (MSA).                                                                                                                                                                                                          
  • Medicare Advantage Plans, sometimes called “Part C” or “MA Plans”, are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all of your Part A and Part B benefits. Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. Companies providing Medicare Advantage Plans must follow rules set by Medicare.​     

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  • ​Part D – Prescription Drug Coverage 
    • Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. 

    • There are two ways to get prescription drug coverage:                                                                                                             

      • 1. Medicare Prescription Drug Plan (Part D) - These plans (sometimes called "PDPs") add drug      coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.                                                                                                                                                                                                                                                                              

      • 2. Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that      offer Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance)  and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.     

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How does Part D work?

Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies. 

 

Some Part D plans have an upfront deductible. Once that has been met, the initial coverage phase begins. While in this phase, the member pays co-payments or co-insurances for the various tiers. Once the initial coverage limit has been met, the member falls into the donut hole and their Part D coverage ends. While in the donut hole, the member pays a predetermined percentage for generics and brand name drugs until the catastrophic coverage threshold is met. Once that is met, the member pays small co-payments or co-insurances for generic and brand name drugs for the remainder of the calendar year. Individuals identified as “dual eligible” (Medicare/Medicaid beneficiaries) by CMS are not subject to the donut hole, as their prescription coverage is fully subsidized. The donut hole will be phased out by the year 2020.

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Medicare Advantage Plans

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans”, are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all of your Part A and Part B benefits. Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. Companies providing Medicare Advantage Plans must follow rules set by Medicare.​                                                                                                             

Most Medicare Advantage plans also offer prescription drug coverage.  ​                                                                                                             

Medicare Advantage plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Services Plans (PFFS), Special Needs Plans (SNP), and Medicare Medical Savings Account Plans (MSA).   

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​Medicare Supplement Plans

A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn't cover like:

Copayments

Coinsurance

Deductibles

Medigap policies are sold by private companies.

Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, here's what happens:

Medicare will pay its share of the Medicare-approved amount for covered health care costs.

Then, your Medigap policy pays its share.

Drug Coverage

  • Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. 

  • There are two ways to get prescription drug coverage:                                                                                                             

    • 1. Medicare Prescription Drug Plan (Part D) - These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.                                                                                                                                                                                                                                                                              

    • 2. Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offer Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.