Part A: “Hospital Insurance”, covers inpatient hospital, certain skilled nursing and skilled home health services. It does not cover long term or custodial care.

Part B: “Outpatient Services”, covers Medicare eligible physician’s services, outpatient hospital services, certain home health services or therapies, and durable medical equipment.

Part D: “Prescription Drug Coverage”, offered through stand alone plans via private insurers or as part of a Medicare Advantage Plan.

Medicare Advantage Plan (AKA Part C): Health Plans such as PPOs and HMOs that are approved by Medicare and run by private companies. They may include additional benefits not covered by regular Medicare and may require you to use networks of providers and follow other restrictions.

Medigap Plan (AKA Supplemental Policy): These policies help pay some of the costs not covered by regular Medicare (such as co-pays/deductibles).

*If your income is above $85,000 for a single individual and $170,000 for a married couple, the premium will be scaled higher, up to $238.40.

Aging Wisely can assist with Medicare and Medicaid questions, insurance claims, help apply for benefits, choose facilities, make appeals, and with many related concerns. We offer a personalized Medicare Analysis Package to help you through the Medicare maze. Contact us today (727-447-5845) or read more about our personalized Medicare Analysis.

Reference: www.medicare.gov or 1-800-MEDICARE

Initial eligibility: When you first become eligible for Medicare (age 65 or typically, 24 months after receiving Social Security Disability) your initial open enrollment for Parts B and D is a 7 month window (including the 3 months before and after month of eligibility). If you receive SS benefits, you will automatically receive a Medicare card and be signed up for Part B (follow instructions on your card if you wish to reject Part B). Part D requires active sign up. If you are covered by an employer or other plan, your benefits coordinator can provide information on how it works with Medicare. You should confirm the plan is “creditable” (the same or better than what Medicare offers) and save the letter of creditable coverage. If later, this coverage ends through no fault of the individual, you can enroll without penalty. During the first 6 months of Medicare eligibility you are also guaranteed issue for a Medigap/Supplemental policy.

Penalties: The penalty for not enrolling in a Part D plan is 1% of the national base premium multiplied by the number of months you did not enroll and were eligible (and went without creditable coverage for 63 continuous days or more), rounded to the nearest 10 cents. This amount is added to your monthly premium every month as long as you are enrolled. In most cases the only chance to enroll or switch plans after initial eligibility for Part D is the annual election period (11/15-12/31). Exceptions include moving out of a plan’s coverage area, losing creditable coverage, or being misled or not fully covered by a plan (or if a plan stops coverage). Late enrollment for Part B carries a 10%/year penalty and you can enroll annually from 1/1-3/31.

Plan Costs: Many Part D plans have what is known as a “donut hole” or coverage gap, meaning that once you received a certain amount of coverage each year, you pay all out of pocket costs until you reach “catastrophic coverage”. There are a number of plans that offer gap coverage, although it may only be for specified drugs. This, along with the varying premiums and co-pays for medications, dictates the importance of comparing plans individually and estimating which plan best fits your circumstances.

Medicaid/Financial Assistance: People who are “Dual Eligibles”, eligible for both Medicaid and Medicare, will be automatically enrolled by Medicare into a Part D plan, but can chose another plan if they would like (from amongst certain “low cost” plans). Individuals will have co-pays on their medications through Part D, unless they are “institutionalized”, i.e. in a nursing home. There are several different types of Medicaid programs available with varying levels of benefits, as well as additional help through Social Security for those with limited income and assets.

Analyzing Plans: Medicare offers a plan compare tool online. To use this tool, the individual should have available their Medicare #, effective date for Medicare (both are found on the Medicare card), last name, date of birth, and zip code, as well as a list of all medications including dosages and frequency. In addition to showing cost projections for the plan, you can review the plan’s performance and see details regarding customer service.

Medicare Advantage: The Medicare Advantage Plans (AKA Part C) are privately run plans approved by Medicare, and generally combine a number of the different benefits into one plan. These include HMOs, PPOs, and Fee for Service plans. They are often able to include extra benefits such as health club memberships or vision/dental coverage. These plans may be appropriate for certain individuals, especially those looking for extra benefits at lower cost. However, many individuals who sign up do not realize the potential restrictions. The HMO and PPO plans have networks of providers, meaning the potential doctors, specialists, and rehab./nursing facility choices may be limited. The Fee for Service plans do not have networks per se and are thus marketed as having full choice, but not all providers participate due to the negotiated fees and thus in reality, choices may be limited. Typically, you get your medication coverage through the Advantage plan and won’t be able to use a Medigap plan for costs while enrolled in Medicare Advantage (however, be aware if you drop a Medigap plan you will likely not be able to repurchase and will not be guaranteed issue). Clients should review all options carefully and weigh the pros and cons of each plan. If clients find themselves in a plan they do not like, there are options for disenrolling and returning to regular Medicare coverage.

It is also wise to reevaluate your Part D choices each year during open enrollment, as the plans make modifications, more options become available, and your health status changes. Review your “Medicare and You” handbook for information on all of the Medicare programs, rules, resource #s and procedures.

Medicare generally does not cover: long term care, routine dental care, dentures, cosmetic surgery, hearing aids (some Medicare Advantage plans add extra benefits such as dental or vision).