Medicare 101 - Gary Lavallee

Medicare Plans 101

Medicare Part A

It is offered by the federal government and overseen by the Centers for Medicare and Medicaid Services. Part A covers care from hospitals, skilled nursing facilities (not custodial or long-term care), hospice care, and some home healthcare-related services.

Who can get Medicare Part A?
If you are a U.S. citizen or a permanent, legal resident of the United States, and you are (or are turning) 65 years old, you are eligible for Medicare Part A. Additionally, people under the age of 65 with certain disabilities, and people with End-Stage Renal Disease are entitled to receive Medicare Part A.

When and how can I sign up for Medicare Part A?
Most people will get Medicare Part A automatically during their Initial Enrollment Period (IEP). If you are automatically enrolled, you will receive your red, white, and blue Medicare card in the mail 3 months before your 65th birthday (or the 25th month of your disability). Some people will need to sign up for Medicare Part A if you are not collecting Social Security or Railroad Retirement Board benefits.

If you did not sign up for Medicare Part A when you were first eligible, and you do not have a special circumstance to enroll midstream, you will need to sign up during the General Enrollment Period (GEP), which is January 1st- March 31st of each year. If you enroll during GEP, your coverage will start on July 1st of that year.

What does Medicare Part A cost?
For many, Medicare Part A is free, provided that you or your spouse has paid Medicare taxes while employed. if you or your spouse are not entitled to “premium-free” Part A, you may be able to purchase it Medicare Part A coverage includes Inpatient care in hospitals Hospice care Skilled nursing facility care Home health services and nursing home care may also be covered (if deemed medically necessary) Blood transfusions are also covered (after the individual has paid for the first 3 pints of blood).

Medicare Part A does not cover:
Hospitalization Deductibles & Copayments:
- For the first 60 days under hospitalization service, the individual will have a $1,216 deductible
- For days 61-90 days under hospitalization service, Medicare pays all but $341 per day of each benefit period
- For days 91 and beyond under hospitalization service, Medicare pays all but $682 per day of each benefit period

Skilled Nursing Care Deductibles & Copayments:
- Medicare pays all approved amounts for the first 20 days
- For days 21-100, Medicare pays all but $170.50 per day
- For days 101 and beyond, Medicare pays $0 (You pay all costs)

Additional Benefits:
- Care provided by a non-medically trained person at a nursing facility
- Most dental care
- Eye examinations related to prescribing glasses
- Dentures
- Cosmetic Surgery
- Hearing aids and exams for fitting them
- Routine foot care
- The cost of the first 3 pints of blood required during a blood transfusion

These limitations can, however, be covered by purchasing a Medicare Supplemental Plan.

If you have questions in regards to Medicare Plan A, or are interested in additional information about Supplemental Plan options please contact us at 413-224-2488

Medicare Part B

Offered by the government and overseen by the Centers for Medicare and Medicaid Services. Part B covers doctor services, outpatient care, medical supplies, and preventive services.

Who can get Medicare Part B?
If you are a U.S. citizen or a permanent, legal resident of the United States, and you are (or are turning) 65 years old, you are eligible for Medicare Part B. Additionally, people under the age of 65 with certain disabilities, and people with End-Stage Renal Disease are entitled to receive Medicare Part B.

When and how can I sign up for Medicare Part B?
Most people will get Medicare Part B automatically during their Initial Enrollment Period (IEP). If you are automatically enrolled, you will receive your red, white, and blue Medicare card in the mail 3 months before your 65th birthday (or the 25th month of your disability). Some people will need to sign up for Medicare Part B if you are not collecting Social Security or Railroad Retirement Board benefits.

If you did not sign up for Medicare Part B when you were first eligible, and you do not have a special circumstance to enroll midstream, you will need to sign up during the General Enrollment Period (GEP), which is January 1st- March 31st of each year. If you enroll during GEP, your coverage will start on July 1st of that year.

What does Medicare Part B cost?
Medicare Part B recipients pay a monthly Part B premium. The price of the Part B premium is dependent on your annual income (as indicated on your individual or joint tax return). The average American recipient pays a premium of $135 each month for Medicare Part B coverage, but it can cost as much as $429 a month per individual.

What does Medicare Part B cover?
Medicare Part B coverage includes an expansive list of services, including (but not limited to):
- Doctor services
- Ambulance services Nursing services Chemotherapy
- Durable medical equipment
- Lab tests/ X-Rays/ Physical Therapy
- Preventive services to prevent illness
- Prescription drugs under limited conditions (doctor’s office or hospital outpatient setting)

What does Medicare Part B not cover?
- Part B Excess Charges
- Prescription Drugs not covered under Part B (Pharmacy)
- Eye examinations or eyeglasses
- Hearing aids or being fitted for one
- Most dental care

Also, it’s important to know that there is a $185 deductible that individuals are required to pay before Medicare begins to pay their share of all services covered by Medicare Part B. After the deductible is paid, recipients pay 20% of what Medicare deems to be a “reasonable charge” while Medicare pays the remaining 80%.

Supplemental Plans are available to cover the costs of these limitations associated with Medicare Part B.

If you have any questions in regards to Medicare Plan B or are interested in additional information about Supplemental Plans please contact us at 413-224-2488.

Medicare Part C

Medicare Advantage Plan (Also known as Medicare Part C)

Medicare Advantage plans are medical insurance plans offered by private companies, approved by Medicare, that offer the same benefits as Original Medicare and may provide additional benefits like vision, dental coverage, hearing benefits, health and wellness programs (Silver Sneakers), and some prescription drug coverage.

There are different types of Medicare Advantage plans to choose from. Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans (PFFS), Special Needs Plans (SNP), and Medicare Medical Savings Account Plans (MSA).

Medicare Advantage Plans differ from one another in a few ways such as:
- The network of doctors available.
- The amount of out-of-pocket costs that the individual will be responsible for paying.
- Referral requisition for certain specialists.

The basic components of Medicare Advantage (MA) plans are as follows:
- Medicare pays a fixed amount for an individual’s care each month to the private insurance company providing your Medicare Advantage plan.
- Individuals are responsible for paying your regular monthly Part B monthly premium in addition to the Medicare Advantage (Part C) – plan premium.
- Individuals who enroll in a Medicare Advantage Plan cannot have a Medicare Supplement Policy.
- These private insurance companies must follow rules set by Medicare, one of which is that a Medicare Advantage plan must provide enrollees with the same benefits they would receive under Original Medicare. (Medicare Part A including hospital stays, skilled nursing care, and home health care. Part B including doctor visits, outpatient care, screenings, shots, and tests).

The benefits of Medicare Advantage plans are as follows:
-The advantage plan combines Parts A, B, and D into one plan with one Medicare ID Card.
- The total cost of the deductibles, premiums, and co-pays that an individual will pay using an Advantage plan is often lower than the total cost for those same expenses under Original Medicare.

The Medicare Program rates all health and prescription drug plans each year, based on the plan’s quality and performance. A plan can get a rating between 1 and 5 stars (5 stars indicating the best possible service). These stars allow you to easily compare plans based on quality and performance, and they are updated every year (typically in the fall).

When deciding on which Medicare Advantage plan to choose, you should consider the following questions:
1. Are my doctors covered as In-Network providers?
2. Do I need a referral to see a specialist?
3. What happens if I want to go to a doctor outside the network? 4. What are the costs (copays, deductibles) associated with services provided in the summary of benefits by the plan?
5. Does the plan offer drug coverage? What tier do my drugs fall into and what are the copays associated with them?
6. What additional benefits are offered by this plan?

Call us today to discuss if a Medicare Advantage plan is right for you at 413-224-2488.

Medicare Part D

Medicare Part D is a drug program that helps pay for the costs of prescription drugs. It is offered by private insurance companies and approved by Medicare for eligible recipients. Individuals on Medicare are eligible for prescription drug coverage under a Part D Medicare plan if they are signed up for benefits under Medicare Part A and/or Part B.

How Do I Get Medicare Part D?
1. An individual can purchase it as a stand-alone Medicare Prescription Drug plan (also know as PDP). Most people who purchase a stand-alone drug plan typically purchase it with a Medicare Supplement Plan, which does not include the drug coverage. The two are purchased separately.
2. An Individual can get a Medicare Part D plan through purchasing a Medicare Advantage Plan Part C (also known as an MA-PD plan). The costs for Part D Medicare will vary among which private companies’ plan you choose and what kind of drug is covered.

How do I know if my drugs are covered?
Each Medicare Prescription Drug plan has its own list of covered drugs known as a formulary. The formulary is first organized by category or class of drug. The formulary is then divided up even further into tiers, for each prescription drug. The tier ultimately determines what an individual's co-pay or cost-sharing amount will be for that particular drug.

Typically the private insurance companies will categorize the drugs offered into 5 different tiers. Tier 1 will most likely be a generic drug with the lowest copay while Tier 5 will be a brand name medication with the highest copay. Each company also has partnerships with in-network pharmacies that will offer you better copays than going to an out-of-network pharmacy. In addition, each private insurance company will utilize a mail order service that will always be considered an in-network pharmacy that will also sometimes gives you a 3 month supply of medication for 2 months copay.

The licensed agents at Plan Medicare use a proprietary set of tools that can quickly lookup a recipient’s prescription drug coverage and compare the copay amounts for each private insurance company. We can also determine what an individual’s annual out-of-pocket costs will be, including plan premiums, co-pays, and cost-sharing amounts.

We can help you by comparing all drug plans offered within a particular U.S. state side by side, to determine the most cost-effective option for each individual. So, it’s important for individuals to truly evaluate the landscape to find the most cost-effective Medicare Part D Plan.

Other important information about the Medicare Part D Program:
- You may be eligible for Extra Help or cost-sharing assistance from the government if you meet certain income requirements. - - - The Part D monthly premium varies by plan (higher-income consumers may pay more).
- It is possible to have your Part D premium automatically deducted from your monthly Social Security/Railroad Retirement Board benefit check.
- A late enrollment penalty can be added at any time after your initial enrollment period (IEP) unless you have creditable drug coverage (ie: an employer-sponsored plan).
- You can enroll in a Part D plan by calling 1-800 MEDICARE directly, go straight to a private insurance carrier or work with an agent who can help guide you to a plan that fits your specific needs.
- You cannot have a Medicare Advantage Plan (Part C) and a separate Part D prescription drug plan at the same time.
- Review your Medicare drug plan every year, as plan formularies can change.
- You are eligible to change, add or drop your Part D plan during the Open Enrollment Period every year (OEP)(AEP).

Some Medicare drug plans have a coverage gap also known as “the donut-hole” which means that after you and your drug plan have spent a certain amount of money for covered drugs, you may have to pay more for your prescription drugs, up to a certain limit.

Sure it's all confusing. That is why before entering into a Part D Prescription Drug Program for the year requires a little homework ahead of time as well as rechecking your current prescriptions against any plan changes every year. Let us help you with this task so you are assured to be signing up for the plan that makes the most sense for you. Call us at 413-224-2488.

Medicare Supplement Plans

A Medicare Supplement Plan, also known as a Medigap Policy, is designed to help pay for some of the costs that Original Medicare does not cover Medicare supplement plans are offered by private insurance companies and available to individuals who are eligible for Medicare. A Medicare supplement plan will help limit out-of-pocket medical expenses such as co-payments, coinsurance, and deductibles. Medicare supplement plans are secondary to Original Medicare while Medicare Advantage Plans are primary to Original Medicare.

For Medigap Policies sold on or after June 1, 2010, there are 11 standardized plans labeled Plan A through Plan N. Each one of these standardized Medigap policies provides the same benefits to the individual. Some of the Medigap plans can also offer additional benefits such as skilled nursing facility coinsurance and foreign travel emergency care.

Key Features of a Medicare Supplement Plan:
- Doctors Choice: Individuals can select their preferred doctors and hospitals, (so long as they accept Medicare patients).
- Convenience: Virtually no claim forms to file.
- Access to Specialists: Individuals can see specialists without needing a referral.
- Freedom: Coverage that travels with you anywhere in the U.S.
- Guaranteed Renewals: Medicare supplement plans are automatically renewed, so long as individuals continue to pay their premium on time, without misstating one or more material facts upon initial enrollment.

How do I get a Medicare Supplement Plan?
In order to get a Medicine Supplement Plan you must have Medicare A and B. you must continue to pay your monthly Part B premium in addition to your monthly Supplement plan premium. You can obtain this plan during your Medigap Open Enrollment Period, which is the six-month period starting in the first month you are 65 years or older. During this period, you cannot be denied coverage on account of a past or current health issue. In some states such as New York, the law requires that private insurance companies who underwrite these Medigap insurance policies must accept the enrollee's application for coverage at any time throughout the year.

What Does a Supplement Plan Not Cover?
Any plan sold in 2006 or later does not include prescription drug coverage. Individuals will need to purchase a stand-alone Part D plan in addition to their supplement plan to get prescription drug coverage. In addition, the core supplement plan will not cover things like long-term care, dental coverage, cosmetic surgery, vision care, eyeglasses, hearing aids, and acupuncture. However, some companies will offer optional supplemental benefits such as fitness programs, dental and vision plans.