The ABC's (and D) of Medicare

Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). You should add a Part D Drug Plan when first eligible to avoid future penalties. Medicare Advantage Plans, also known as Part C, bundle or include Part A, Part B and sometimes Part D all together.

Medicare Part A:

Medicare Part A (Hospital Insurance) covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care.

Medicare Part B:

Medicare Part B (Medical Insurance) covers doctor and other health care providers' services and outpatient care. Part B also covers durable medical equipment, home health care, and some preventive services. You can go to any doctor or hospital that takes Medicare, anywhere in the U.S. In most cases, you don't need a referral to see a specialist.

Medicare Advantage (Part C):

• Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” Part C plans include Part A, Part B, and usually Part D.
• In most cases, you’ll need to use doctors who are in the plan’s network.
• Plans may have lower out-of-pocket costs than Original Medicare.
• You pay the monthly Part B premium and may also have to pay the plan's premium. Plans may have a $0 premium or may help pay all or part of your Part B premium. Most plans include Medicare drug coverage (Part D).
• Plans may offer some extra benefits that Original Medicare doesn’t cover - like vision, hearing, and dental services.
• Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and Part B covers. Once you reach your plan’s limit, you’ll pay nothing for the services that Part A and Part B cover for the rest of the year.

Medicare Drug Coverage (Part D): 

You can join a separate Medicare drug plan to get Medicare drug coverage (Part D). Some Medicare Advantage plans include Part D.

All Part D plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Medicare drug coverage typically places drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.

· NOTE: If you don't get Medicare drug coverage or Medigap when you're first eligible, you may have to pay more to get this coverage later. This could mean you’ll have to pay a lifetime premium penalty for your Medicare drug coverage.

WHAT IS A MEDICARE ADVANTAGE PLAN?  

A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. 

Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. 

If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans also offer prescription drug coverage.

WHAT IS MEDICARE SUPPLEMENT INSURANCE?

 Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private insurance company to help pay your share of costs in Original Medicare.   Medicare supplement (Medigap) insurance can help pay some of the health care costs that original Medicare does not cover, like copayments, coinsurance, and deductibles.

Some Supplemental Plans also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a supplemental policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs, then your Medicare supplement insurance policy pays its share.
 

Medigap & Medicare Advantage Plans:

A Medigap policy is different from a Medicare Advantage Plan (Part C). A Medicare Advantage Plan is another way to get your Medicare coverage besides Original Medicare. A Medigap policy is a supplement to Original Medicare coverage. 

When you’re getting started with Medicare, you can either buy Medigap or enroll in a Medicare Advantage Plan, but you can’t have both!

• If you have a Medicare Advantage Plan, you can’t buy and don’t need a Medigap policy. It's illegal for anyone to sell you a Medigap policy unless you're switching back to Original Medicare. If you want to switch to Original Medicare and buy a Medigap policy, contact your Medicare Advantage Plan to see if you're able to disenroll.

• If you have a Medigap policy and join a Medicare Advantage Plan for the first time, you may want to drop your Medigap policy because you’ll be paying for coverage you can’t use. If you’re not happy with your Medicare Advantage Plan, you’ll have a single 12-month period (your trial right period) to get your Medigap policy back if the same insurance company still sells it once you return to Original Medicare. After that period, you might have to wait to drop your Medicare Advantage Plan, and you might not be able to buy a Medigap policy, or it may cost more.

How to get prescription drug coverage:

Medicare drug coverage helps pay for prescription drugs you need. It's optional and offered to everyone with Medicare. Even if you don’t take prescription drugs now, consider getting Medicare drug coverage. If you decide not to get it when you’re first eligible, and you don’t have other creditable prescription drug coverage (like drug coverage from an employer or union) or get Extra Help, you’ll likely pay a late enrollment penalty if you join a plan later. Generally, you’ll pay this penalty for as long as you have Medicare drug coverage.  

If you need prescription drugs in the future, all plans still must cover most drugs used by people with Medicare. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage. Each plan can vary in cost and specific drugs covered. 

There are 2 ways to get Medicare drug coverage:

1. Medicare drug plans. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Private Fee‑for‑Service plans, and Medical Savings Account plans. You must have  

Medicare Part A (Hospital Insurance) and/or  Medicare Part B (Medical Insurance) to join a separate Medicare drug plan.

2. Medicare Advantage Plan (Part C) or other  Medicare Health Plan with drug coverage. You get all of your Part A, Part B, and drug coverage, through these plans. Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.

To join a Medicare drug plan, Medicare Advantage Plan, or other Medicare health plan with drug coverage, you must be a United States citizen or lawfully present in the United States.

If you're not currently taking prescriptions drugs, but want peace of mind and want to avoid future penalties, look at Medicare drug plans with a low or zero monthly  premium for drug coverage. 

Joining a Medicare drug plan may affect your Medicare Advantage Plan:  

If you join a Medicare Advantage Plan, you’ll usually get drug coverage through that plan. In certain types of plans that can’t offer drug coverage (like Medical Savings Account plans) or choose not to offer drug coverage (like certain Private Fee-for-Service plans), you can join a separate Medicare drug plan. If you’re in a Health Maintenance Organization, HMO Point-of-Service plan, or Preferred Provider Organization, and you join a separate drug plan, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

You can only join a separate Medicare drug plan without losing your current health coverage when you’re actively enrolled in a:

• Private Fee-for-Service Plan
• Medical Savings Account Plan
• Cost Plan
• Certain employer-sponsored Medicare health plans

Talk to your current plan if you have questions about what will happen to your current health coverage.

· NOTE: If you don't get Medicare drug coverage or Medigap when you're first eligible, you may have to pay more to get this coverage later. This could mean you’ll have to pay a lifetime premium penalty for your Medicare drug coverage.

What's an SNP?

A Special Needs Plan (SNP) provides benefits and services to people with specific diseases, certain health care needs, or who also have Medicaid. SNPs tailor their benefits, provider choices, and list of covered drugs (formularies) to best meet the specific needs of the groups they serve. All SNPs must provide Medicare drug coverage (Part D). 

SNPs are either HMO or PPO plan types, and cover the same Medicare Part A and Part B benefits that all Medicare Advantage Plans cover. However, SNPs might also cover extra services for the special groups they serve. For example, if you have a severe condition, like cancer or congestive heart failure, and you need a hospital stay, an SNP may cover extra days in the hospital. You can only stay enrolled in an SNP if you continue to meet the special conditions of the plan.

Who can join an SNP?

You can join an SNP if you meet these requirements:

• You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
• You live in the plan's service area. 
• You meet the eligibility requirements for one of the 3 types of SNPs:
  1. Dual Eligible SNP (D-SNP)
  2. Chronic Condition SNP (C-SNP)
  3. Institutional SNP (I-SNP)

What are the eligibility requirements for SNPs?

Dual Eligible SNP (D-SNP): You’re eligible for both Medicare and Medicaid. D-SNPs contract with your state Medicaid program to help coordinate your Medicare and Medicaid benefits, depending on the state and your eligibility.

Chronic Condition SNP (C-SNP): You have one or more of these severe or disabling chronic conditions:

• Chronic alcohol and other dependence
• Certain autoimmune disorders
• Cancer (excluding pre-cancer conditions)
• Certain cardiovascular disorders
• Chronic heart failure
• Dementia
• Diabetes mellitus
• End-stage liver disease
• End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
• Certain severe hematologic disorders
• HIV/AIDS
• Certain chronic lung disorders
• Certain chronic and disabling mental health conditions
• Certain neurologic disorders
• Stroke

Institutional SNP (I-SNP): You live in the community but need the level of care a facility offers, or you live (or are expected to live) for at least 90 days straight in a facility like a:

• Nursing home
• Intermediate care facility
• Skilled nursing facility
• Rehabilitation hospital
• Long-term care hospital  
• Swing-bed hospital
• Psychiatric hospital
• Other facility that offers similar long-term, health care services and whose residents have similar needs and health care status as residents of the facilities listed above