MEDICARE

Medicare is a national healthcare program funded by the U.S. Government, created in 1965 to give coverage to people of age 65 or older who didn`t have any health insurance. The program is administered by the Centers for Medicare and Medicaid Services (CMS), and coverage is extended to people with certain disabilities, those who have End-stage renal disease (ESRD) and those who have Lou Gehrigh`s disease and Amyotrophic Lateral Sclerosis (ALS).

There are four different parts to Medicare, all of which provide different types of services for the insured, named alphabetically: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage) and Part D (prescription drug coverage).

ELIGIBILITY

Anyone who has lived in the United States legally for at least five years and is age 65 or older qualifies for Medicare coverage. Enrollment in Parts A and B is automatic for anyone who receives Social Security benefits. Part C and Part D coverage is optional, and enrollment must be done by the individual.

MEDICARE PART A

Medicare Part A is basically hospital insurance which covers a variety of hospital services. Part A generally covers inpatient hospital stays, skilled nursing care, hospice care, and limited home health-care services. It covers the entire cost for covered home health care services. If durable medical equipment is needed and it is ordered by doctor – it is covered under Medicare Part B and you are responsible for 20% of the Medicare-approved amount.

To be able to enroll in Medicare Part A, you must meet one of the four criteria: 1.)You are 65 years old or older, 2.) You have dissability determined by doctor and you recieve Social Security benefits for at least 2 years (24 months) in a row, 3.)You have been diagnosed with End stage renal disease (ESRD) and 4.) You have been diagnosed with Amyotrophic Lateral Sclerosis (ALS), known as Lou Gehrig`s disease.

Most people who qualify for Medicare do not pay for Part A. This is the case if you or your spouse worked for at least 40 quarters (10 years) paying Medicare taxes. If you didn’t work for 40 quarters, you can still enroll and pay a monthly premium for Medicare Part A.

MEDICARE PART B

Medicare Part B is basically medical insurance. It provides insurance for outpatient medical care such as doctor visits, preventative services, ambulance services, mental health costs, and the cost of durable medical equipment. Under Part B insurance, in most cases you will pay 20% of the Medicare-approved amount for each item or service.

In general, Part B covers, but not limited to, next services: Visits to doctor`s office, preventive services, flu shots, pneumoccocal shots, outpatient mental health services, durable medical equipment, physical therapy, chemotherapy and alcoholism counseling.

For Medicare Part B eligibility applies the same rules as for Medicare Part A. Primary criteria is that you must be age 65 or older and a U.S. citizen. Legal and permanent residents of the United States for at least 5 years in a row can also qualify for Part B. Finally, you can apply for it if ypu have been diagnosed with End-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

MEDICARE ADVANTAGE (PART C)

Medicare Advantage is also known as Part C of Medicare. It is administered by private insurance companies certified by Medicare. If you choose to join a Medicare Advantage Plan, it will provide all of your Part A and Part B coverage. Part C may offer extra coverage, such as vision, hearing, dental, and health and wellness programs. Most Medicare Advantage plans include Medicare prescription drug coverage, known as Part D.

Part C coverage for inpatient care in general is covered by Medicare Part A. Regarding to Part C, it covers the same services as Medicare Part A, including inpatient hospital care and inpatient care in skilled nursed facility. Part C also covers Home health care, but hospice care benefits remains under Original Medicare (Part A and B). As for coverage for outpatinet care, which is covered by Part B in general, Part C covers the same benefits as Part B.

There are few extra benefits that Medicare Part C covers, but Original Medicare do not. Some of that services that Part C may include as extra benefits are: Routine dental, vision and hearing care (including x-rays, dentures, contacts and eyeglasses and hearing aids), Fitness benefits such as exercise class or something alike (SilverSneakers membership), Emergency medical assistance while outside the U.S. and allowance to buy health care products.

Main qualification for being eligible for Medicare Advantage plans is that you already have been enrolled in Original Medicare (Parts A and B) and that you live in the network area of Part C provider you are considering to apply to.

Medicare Part C costs are determined by several factors, such as premiums, deductibles, copayments, and coinsurance. These amounts can range from $0 to hundreds of dollars for monthly premiums and yearly deductibles. But most of your Part C costs will be determined by chosen plan.

There are two main types of Medicare Advantage plans offered: Health Maintenance Organization (HMO) plans and Preffered Provider Organization (PPO) plans. Beside tha two plans, there are Private Fee-for-Service Plans (PFFS) and Special Needs Plans (SNP).

MEDICARE PART D

Medicare Part D is a prescription drug benefit program that is offered as part of the wider Medicare federal health insurance program. Part D is an optional benefit that is administered by private insurance companies and available to anyone who has Medicare.

Medicare Part D is simply insurance for your medication needs. You pay a monthly premium to an insurance carrier for your Part D plan. In return, you use the insurance carrier’s network of pharmacies to purchase your prescription medications. Instead of paying full price, you will pay a copay or percentage of the drug’s cost. The insurance company will pay the rest.

There are 4 stages to a Part D drug plan, and they are: Annual Deductible ($480), Initial Coverage ($4,430), Coverage Gap ($7,050) and Catastrophic Coverage.

Medicare allows drug plan carriers to apply certain rules for safety reasons and also for cost containment. The most common utilization rules that you may run into are:

  • Quantity Limits – a restriction on how much medication you can purchase at one time or upon each refill. If your doctor prescribes more than the quantity limit, the insurance company will need him to file an exception form to explain why more is needed.
  • Prior Authorization – a requirement that you or your doctor must obtain plan approval before allowing a pharmacy to dispense your medication. The insurance company may ask for proof that the prescription is medically necessary before they allow it.
  • Step Therapy – the plan requires you to try less expensive alternative medications that treat the same condition before they will consider covering the prescribed medication. If the alternative medication works, both you and the insurance company save money. If it doesn’t, your doctor will need to help you file a drug exception with your carrier to request coverage for the original medication prescribed.

MEDICARE SUPPLEMENT PLANS

Medicare Supplement Insurance (also called “Medigap”) is insurance that helps fill “gaps” in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like Copayments, Coinsurance and Deductibles.
Medicare supplement plans are secondary payers to Original Medicare. Since Parts A and B do not cover 100% of healthcare expenses, Medicare supplement plans helps you pay the remaining costs. As long as the provider accepts Medicare assignment, they will also accept a one of the Medicare supplement plans. There are 10 Medicare supplement plans available in 2022, named alphabetically from A-N.

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