MEDICARE 101

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WHAT IS ORIGINAL MEDICARE?

Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). There’s no limit to what you’ll pay out of pocket in a year. After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles). 

See pages 57 in Medicare & You handbook*

ORIGINAL MEDICARE PART A & PART B 

Part A (Hospital Insurance) Helps cover: 

-Inpatient care in hospitals 

-Skilled nursing facility care 

-Hospice care 

-Home health care 

See pages 26–29 in Medicare & You handbook*

Part B (Medical Insurance) Helps cover: 

-Services from doctors and other health care providers 

-Outpatient care 

-Home health care 

-Durable medical equipment (such as wheelchairs, walkers, hospital beds, and other equipment)

-Many preventive services (such as screenings, shots or vaccines, and yearly “Wellness” visits) 

See pages 30-55 in Medicare & You handbook* 

WHO QUALIFIES FOR MEDICARE?

-Individuals 65 years or older 

-Individuals under 65 and disabled (May take up to 24 months of disability in order to qualify) 

-Individuals diagnosed with ALS (Lou Gehrig's disease)  

-Individuals diagnosed with ERSD (End stage renal disease) *not automatic qualifier, must still apply 

See pages 15-16 in Medicare & You handbook*

*link to Medicare & You Handbook

MEDICARE SUPPLEMENTS (MEDI-GAP)

Medicare Supplement Insurance is a policy provided by Medicare approved private insurance companies.  These policies are designed to work along side with your Original Medicare (Parts A and B).  If you have Original Medicare and a "Medigap" policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs.  Then, your "Medigap" policy pays its share.  

See pages 75-78 in Medicare & You handbook*

MEDICARE ADVANTAGE PLANS (PART C)

Medicare Advantage is a bundled benefits plan provided by Medicare approved private companies which are paid by the government to administer your Medicare benefits.  These plans "look and feel" more like the traditional plan you may have had at work such as an HMO or PPO plan.  You must already be enrolled in Medicare Parts A & B to participate in a Medicare Advantage plan. 

See pages 61-72 in Medicare & You handbook*

MEDICARE COST PLANS 

Medicare Cost Plans are a type of hybrid Medicare health plan. Similar to a Medicare Advantage Plan, there are a network of providers and you maybe responsible for co-pays and/or coinsurance.  Medicare Cost Plans keep your Original Medicare - there for if you are outside of the service area, member will have coverage under their Original Medicare.  As a member of a Medicare Cost plan, you will need to choose a drug plan. 

See page 73 in Medicare & You handbook * 

PRESCRIPTION DRUG PLANS (PDP)

Prescription Drug Plans (PDP) are plans provided by Medicare approved private companies which are paid by the government to administer your PDP benefits.  Part D generally covers certain prescription drugs prescribed by your doctor.  

See pages 79-88 in Medicare & You handbook*

 *link to Medicare & You Handbook

ANNUAL OPEN ENROLLMENT || OCTOBER 15TH - DECEMBER 7TH 

During Annual Open Enrollment (AEP) - you can join, switch, or drop a Medicare Advantage Plan or Drug plan. Your coverage will begin on January 1 (as long as the plan gets your request by December 7).

See page 13, 71 in Medicare & You Handbook*

SPECIAL ELECTION PERIOD (SEP)

Generally, you must stay enrolled in your plan for the entire year. But when certain events happen in your life, like if you move or lose other insurance coverage, you may qualify for a Special Enrollment Period. You may be able make changes to your plan mid-year if you qualify. 

See page 17, 72 in Medicare & You handbook*

INITIAL ENROLLMENT PERIOD

You can first sign up for Part A and/or Part B during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you sign up for Part A and/or Part B during the first 3 months of your Initial Enrollment Period, in most cases, your coverage begins the first day of your birthday month. However, if your birthday is on the first day of the month, your coverage will start the first day of the prior month. If you enroll in and are paying for Part A and/or Part B the month you turn 65 or during the last 3 months of your Initial Enrollment Period - the start date for your Part B coverage will be delayed.

See page 17, 71 in Medicare & You handbook*

MA OPEN ENROLLMENT PERIOD || JANUARY 1ST - MARCH 31ST

During Medicare Advantage Open Enrollment Period, you can only make one change during this period. Any changes you make will be effective the first of the month after the plan gets your request. 

• If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage). 
• You can drop your Medicare Advantage Plan and return to Original Medicare. You’ll also be able to join a Medicare drug plan. 

During this period, you can’t

•  Switch from Original Medicare to a Medicare Advantage Plan. 
•  Join a Medicare drug plan if you’re in Original Medicare. 
• Switch from one Medicare drug plan to another if you’re in Original Medicare. 

See page 72 in Medicare & You handbook* 

 *link to Medicare & You Handbook