Medicare & Medicare Advantage
What is Medicare?
Medicare is a federal health insurance program primarily for people aged 65 and older. It also covers some younger individuals with disabilities and those with End-Stage Renal Disease (ESRD).
What are the different parts of Medicare?
- Part A: Hospital insurance (covers inpatient care, hospital stays, skilled nursing facility care, hospice care, and some home health care).
- Part B: Medical insurance (covers doctor visits, outpatient care, preventive services, and some home health services).
- Part C: Medicare Advantage Plans (offered by private companies, these plans combine Parts A and B and often include additional benefits like prescription drug coverage).
- Part D: Prescription drug coverage (helps cover the cost of prescription medications).
What is the difference between Medicare and Medicaid?
Medicare is a federal program that provides health insurance primarily to individuals 65 and older, regardless of income. Medicaid is a joint federal and state program that provides health coverage to low-income individuals, regardless of age.
When can I enroll in Medicare?
You can enroll in Medicare during the following periods:
- Initial Enrollment Period (IEP): This is a 7-month period that starts 3 months before your 65th birthday, includes your birthday month, and ends 3 months after.
- General Enrollment Period (GEP): Runs from January 1 to March 31 each year, with coverage starting on July 1.
- Special Enrollment Period (SEP): If you delay enrollment due to having employer coverage, you can sign up within 8 months after losing that coverage.
Do I automatically get enrolled in Medicare?
If you're receiving Social Security benefits when you turn 65, you will be automatically enrolled in Medicare Parts A and B. If you're not receiving Social Security, you'll need to sign up during your Initial Enrollment Period.
How much does Medicare cost?
- Part A: Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes for at least 10 years.
- Part B: Premiums vary based on your income, but the standard premium in 2024 is $174.70 per month.
- Part D: The cost depends on the plan you choose and your income.
What is the Medicare Advantage Plan (Part C)?
Medicare Advantage Plans are an alternative to Original Medicare (Parts A and B). These plans are offered by private insurance companies and often include additional benefits like dental, vision, and prescription drug coverage.
Does Medicare cover prescription drugs?
Medicare Part D provides prescription drug coverage. You can join a stand-alone Medicare Prescription Drug Plan or enroll in a Medicare Advantage Plan that includes drug coverage.
Does Medicare cover dental, vision, and hearing services?
Original Medicare (Parts A and B) does not cover most dental, vision, or hearing services. Some Medicare Advantage Plans (Part C) may offer these benefits.
What is Medigap (Medicare Supplement Insurance)?
Medigap is private insurance that helps pay for some of the out-of-pocket costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles.
What happens if I don’t sign up for Medicare at age 65?
If you don’t enroll during your Initial Enrollment Period and don’t qualify for a Special Enrollment Period, you may face a late enrollment penalty for Part B and/or Part D, which could increase your premium.
Can I have both Medicare and employer coverage?
Yes, you can have both Medicare and employer-provided coverage. How Medicare works with your employer coverage depends on the size of your employer and your specific plan.
What is the Medicare Part B penalty?
If you don’t sign up for Part B when you’re first eligible and don’t qualify for a Special Enrollment Period, you may have to pay a 10% late enrollment penalty for each 12-month period you could have had Part B but didn’t.
Does Medicare cover long-term care?
Medicare generally does not cover long-term care, such as extended stays in a nursing home or assisted living facilities. It does cover short-term skilled nursing care or rehabilitation after a hospital stay.
How do I appeal a Medicare coverage decision?
If Medicare denies a claim or coverage, you can appeal the decision by submitting a request for redetermination. This must be done within 120 days of receiving the decision notice.
What is a Medicare Advantage Plan (Part C)?
A Medicare Advantage Plan is an alternative to Original Medicare. It’s offered by private insurance companies that contract with Medicare to provide all Part A (hospital insurance) and Part B (medical insurance) benefits. Most plans also include prescription drug coverage (Part D).
How is Medicare Advantage different from Original Medicare?
Medicare Advantage (Part C) combines Parts A and B into one plan, often with added benefits such as dental, vision, hearing, and prescription drug coverage. Original Medicare offers no additional benefits, and you typically need separate Part D and Medigap policies for drug and supplemental coverage.
What types of Medicare Advantage Plans are available?
- Health Maintenance Organization (HMO): Requires you to use doctors and hospitals within the plan’s network, except for emergencies.
- Preferred Provider Organization (PPO): Offers more flexibility by allowing you to see out-of-network providers at a higher cost.
- Private Fee-for-Service (PFFS): Allows you to see any doctor who accepts the plan's payment terms.
- Special Needs Plans (SNPs): Tailored for individuals with specific conditions or circumstances, such as chronic illnesses.
- Medical Savings Account (MSA): Combines a high-deductible health plan with a savings account to pay for medical expenses.
What are the benefits of enrolling in a Medicare Advantage Plan?
Medicare Advantage Plans often include additional benefits not covered by Original Medicare, such as dental, vision, hearing, prescription drugs, and wellness programs. They also cap out-of-pocket expenses, which Original Medicare does not do.
Do Medicare Advantage Plans cover prescription drugs?
Most Medicare Advantage Plans include prescription drug coverage (Part D). Plans that don’t offer drug coverage allow you to enroll in a standalone Medicare Prescription Drug Plan.
How much do Medicare Advantage Plans cost?
The cost of Medicare Advantage Plans varies depending on the plan and location. Many plans have low or $0 premiums, but you must still pay your Part B premium. Plans may also have deductibles, copayments, and other out-of-pocket costs.
Can I keep my current doctors if I enroll in a Medicare Advantage Plan?
It depends on the plan. HMOs typically require you to use doctors within the network, while PPOs offer more flexibility to see out-of-network providers at a higher cost. Before enrolling, check if your doctors are in the plan's network.
Do Medicare Advantage Plans have a maximum out-of-pocket limit?
Yes, all Medicare Advantage Plans are required to have an annual maximum out-of-pocket limit. Once you reach this limit, the plan covers 100% of your healthcare costs for the rest of the year. This limit is not available with Original Medicare.
Can I switch from Original Medicare to a Medicare Advantage Plan?
Yes, you can switch to a Medicare Advantage Plan during specific enrollment periods:
- Initial Enrollment Period (IEP): When you first become eligible for Medicare.
- Annual Enrollment Period (AEP): From October 15 to December 7 each year.
- Medicare Advantage Open Enrollment Period: From January 1 to March 31, you can switch from one Medicare Advantage Plan to another or go back to Original Medicare.
What happens if I want to leave my Medicare Advantage Plan?
You can leave your Medicare Advantage Plan during the Annual Enrollment Period (October 15 to December 7) or the Medicare Advantage Open Enrollment Period (January 1 to March 31). If you leave, you’ll return to Original Medicare unless you choose another plan.
Are there any disadvantages to Medicare Advantage Plans?
Some possible drawbacks include:
- Restricted networks (for HMOs and some PPOs).
- Plan benefits and costs can change annually.
- You may need referrals to see specialists.
- Some services may require prior authorization.
Will I still have to pay my Part B premium if I have a Medicare Advantage Plan?
Yes, even if you enroll in a Medicare Advantage Plan, you are still required to pay your Medicare Part B premium. Some Medicare Advantage Plans may cover part or all of this premium, but it varies by plan.
Can I have both a Medicare Advantage Plan and a Medigap policy?
No, you cannot have both a Medicare Advantage Plan and a Medigap (Medicare Supplement) policy. Medigap is meant to supplement Original Medicare, while Medicare Advantage Plans provide an alternative to Original Medicare with different coverage structures.
What is the Medicare Star Rating System for Medicare Advantage Plans?
Medicare rates all Medicare Advantage Plans on a 1 to 5-star scale based on factors like customer satisfaction, quality of care, and plan performance. A 5-star rating indicates the highest quality. This system helps beneficiaries compare plans based on quality and service.
Can I be denied coverage or charged more for a Medicare Advantage Plan based on pre-existing conditions?
No, Medicare Advantage Plans must accept all eligible applicants during enrollment periods, regardless of pre-existing conditions, except for those enrolling in a Medical Savings Account (MSA) Plan.
What is a Special Needs Plan (SNP)?
Special Needs Plans (SNPs) are Medicare Advantage Plans designed for individuals with specific needs, such as chronic conditions, institutional care needs, or those who are eligible for both Medicare and Medicaid (dual eligibles). These plans offer tailored benefits, provider choices, and drug formularies to better meet the needs of the individual.
Can I switch Medicare Advantage Plans if I move to a new area?
Yes, moving to a new area that is outside your current plan’s service area qualifies you for a Special Enrollment Period, allowing you to switch to a different Medicare Advantage Plan that covers your new location.
What does "prior authorization" mean in a Medicare Advantage Plan?
Prior authorization is a requirement where your plan must approve certain services, treatments, or prescriptions before you receive them. This is common for expensive procedures or specialized treatments to ensure they are medically necessary.
How do I enroll in a Medicare Advantage Plan?
You can enroll in a Medicare Advantage Plan during your Initial Enrollment Period, the Annual Enrollment Period (October 15 to December 7), or during a Special Enrollment Period if you qualify. To enroll in a Medicare Advantage Plan, please send an email to sales@lanady.com. Our team will assist you with the enrollment process.
Are preventive services covered under Medicare Advantage Plans?
Yes, all Medicare Advantage Plans cover the same preventive services as Original Medicare, including screenings, vaccines, and wellness visits. Many plans may offer additional wellness programs, such as gym memberships or weight management services.