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Senior in hospital bed thinking about Medicare coverage

A Guide Through Medicare Coverage

Medicare is the national health insurance program to which all Social Security recipients who are either over 65 years of age or permanently disabled are eligible. Coverage under Medicare is similar to that provided by private insurance companies: it pays a portion of the cost of medical care. Often, deductibles and co-insurance (partial payment of initial and subsequent costs) are required of the beneficiary. Medicare have four parts (A, B, C and D) and they cover different types of healthcare services. In the text below we will breakdown what is covered and what is not covered under every Part of Medicare.

What is Covered under Original Medicare

Original Medicare consist of two parts: Medicare Part A and Medicare Part B. Each of them covers some parts of healthcare services provided by medical entity.

Medicare Part A, known as Hospital Insurance, is offered through Original Medicare and covers hospital stays, hospice, and care in a skilled nursing facility, home health care services, and short-term nursing home care. In addition, it includes inpatient care received through: Acute care hospitals, Critical access hospitals, Inpatient rehabilitation facilities, Long-term care hospitals, Mental Health care and Participation in qualifying clinical research study.

Medicare Part B, also known as Medical Insurance, is offered through Original Medicare and covers preventive exam visits, annual wellness checks, laboratory tests, medical equipment, mental health care, and ambulance services. Under Part B insurance, in most cases you will pay 20% of the Medicare-approved amount for each item or service.

What A/B Does Not Cover

Original Medicare – Part A and Part B, does not cover the following services: annual physicals, long-term nursing home care (if it is needed more than 100 days), hearing aids, dental care/dentures, or any healthcare outside of the U.S. It also does not cover cosmetic surgery, routine foot care, or acupuncture/naturopathy. All of the mentioned services could be covered under some Medicare Advantage (Part C) plans.

What Medicare Advantage Covers and what is not covered under Part C

Part C (Medicare Advantage) is offered through private companies. These plans are required to cover everything Parts A and B cover. That means it covers Inpatient care, Outpatient care and the great benefit is that many Part C plans also include prescription drug coverage, and some benefits/services mentioned in the paragraph before.

It is possible that in some states prescription drug coverage is not offered under Part C plans. If that is the case, you then must have other prescription drug coverage.

If you are in need of inpatient care, Medicare Part C may not cover the cost of a private room, unless it is deemed medically necessary. A private room is medically necessary if putting you in a semi-private room would endanger your health or the health of someone else.

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. But not all Medicare Part C plans covers these extra benefits, as well as they are not limited to only named possible benefits. It depends from the plan provider what they will be offering in their Part C plan coverage.

What Part D Covers

Part D (Prescription Drug Plans) is offered by Medicare separately from Original Medicare and covers 75% of prescription drug costs for covered drugs. Medicare sets a standard level of drug coverage, where drugs are grouped into tiers in a list called a formulary. Tiers are based on the copayment amount for that group of drugs, often based on the name-brand cost. Generic drugs will be in lower tiers, and name-brand non-preferred drugs will be in tiers with higher copayments.

For each of the most commonly prescribed categories and classes of drugs, Part D plans must cover at least two of the drugs. Most likely, a generic and name-brand will be covered.

What covers Medicare Supplement

Supplemental coverage, also known as Medigap, covers the deductibles, copayments, and coinsurance costs of Original Medicare. These plans cannot pay the Part B deductible. Premiums vary by plan because private companies offer these. Some Medigap policies also cover services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. These plans generally do not cover Long-term care, Vision, dental and hearing services, eyeglasses and private-duty nursing. There are 12 Medicare supplement plans available in 2022 with different types of coverage.

CT machine in hospital as a part of Medicare Coverage

How do I change my Medicare Coverage?

Medicare enrollment and change of Medicare plans could be done in some Medicare Enrollment Periods.

You can join Medicare during your Initial Enrollment Period, which begins three months before you turn 65 and last for seven months. If you want to drop or switch a health plan, you can do so in the Open Enrollment Period for Medicare Advantage from October 15 to December 7. You can switch from Part A and B to a Medicare Advantage (Part C) plan or switch back during this period. You can also switch from a Part C plan with drug coverage to one without, or vice versa. You can join, drop, or switch your Medicare prescription drug coverage (Part D) plan.

Medicare Advantage

If you joined a Medicare Advantage plan during your Initial Enrollment Period and want to switch to Original Medicare, you can do that within your first three months of Medicare.

Switching between Medicare Advantage plans regardless of drug coverage happens between January 1 and March 31 during the Medicare Advantage Open Enrollment Period. You can also switch during the previously mentioned Open Enrollment Period for Medicare Advantage.

If you want to enroll in a Medicare Advantage plan instead of Original Medicare, you can weigh your options and compare prices between different companies’ policies. This is the same service you would get through Medicare except through a private plan. There may be extra coverage for prescription drug costs or vision and hearing exams.

You cannot drop your Part B coverage if you join a Medicare Advantage plan. You will still be paying the Part B monthly premium on top of your Part C costs. If you have Medicare Advantage (Part C), you cannot also have a Medigap (Supplemental) policy.

Supplemental Coverage

When you buy Medigap coverage, you have 30 days of free trial coverage, beginning with the day the policy starts. After the 30 days, you pay the monthly premium. If you decide to switch within those 30 days, just cancel your coverage and there will be no fee.

If you drop your Medigap coverage or switch policies, be careful of the timing. To avoid a late enrollment penalty for drug coverage, you need to have creditable drug coverage within 63 days of your new prescription drug plan.

For all of your Medicare questions, speak with Turning 65 Solutions today.

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