About Medicare

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Medicare Part A

Medicare Part A is hospital insurance. Part A covers inpatient hospital care, limited time in a skilled nursing care facility, limited home health care services, and hospice care.

Most Medicare Part A beneficiaries don’t have to pay a monthly premium to receive coverage under this part of Original Medicare; this is called “premium-free Part A.” Generally, if you’ve worked at least 10 years (40 quarters) and paid Medicare taxes while you worked, you’re eligible for premium-free Part A. Otherwise, you pay a monthly premium.

Medicare Part A typically doesn’t cover the full amount of your hospital bill, so you will probably be responsible for a share in the cost. You will also have to pay a deductible before Medicare benefits begin. Medicare will then pay 100% of your costs for up to 60 days in a hospital or up to 20 days in a skilled nursing facility. After that, you pay a flat amount up to the maximum number of covered days. Your Medicare Part A benefits cover some of the costs for a total of 90 days in a hospital and 100 days in a skilled nursing facility. Medicare also covers up to 60 “lifetime reserve days.” These are days you stay in a hospital longer than 90 days in a row. You get a lifetime total of 60 reserve days.

Medicare Part B

Medicare Part B is medical insurance. Part B benefits cover certain non-hospital medical expenses like doctors’ office visits, blood tests, X-rays, diabetic screenings and supplies, and outpatient hospital care. You pay a monthly premium for this part of Original Medicare. The fee can be higher for people with high incomes. A different government program, Medicaid, can help cover Medicare Part B premiums for low-income beneficiaries.

Medicare Part B beneficiaries are usually responsible for a portion of their health care costs. You’ll have to pay a deductible each year before your Medicare Part B benefits kick in, and then you’ll generally pay 20% of the bill when you go to a participating Medicare doctor. Medicare pays the full cost of many lab tests and services requested by your doctor.

What is a Medicare Advantage plan?

If you currently are enrolled in Original Medicare, Part A and Part B, you can choose to enroll in Medicare Part C, more commonly known as Medicare Advantage. Medicare Advantage plans are offered by private health insurance companies to provide and coordinate Medicare Part A and Part B benefits (hospital and medical) for beneficiaries.

You might wonder why a beneficiary would choose to enroll in a Medicare Advantage plan. A Medicare Advantage plan is required to cover everything that Original Medicare covers (except for hospice care), including emergency and urgent care. Hospice care is covered by Original Medicare, and hospice benefits continue to be covered by Original Medicare even if you have a Medicare Advantage plan. But, there can be some differences between Original Medicare and a Medicare Advantage plan. Those differences can be in how much you pay out of your own pocket when you receive health care. For example, you might have lower copayments and coinsurance or a smaller deductible.

Medicare Advantage offers at least the same coverage as Original Medicare, and may offer additional benefits. It may be one way of adding coverage for routine vision, or dental services, dentures, and more. Some Medicare Advantage plans have a $0 premium. However, regardless of how much you pay for a Medicare Advantage plan, you must continue pay your Medicare Part B premium.

There can also be differences in the coverage you receive. Some Medicare Advantage plans include routine vision, routine dental, and/or wellness programs. Many plans also include prescription drug coverage; those plans are called Medicare Advantage Prescription Drug plans (MAPD).

Do be aware that you would remain enrolled in Original Medicare even if you enroll into a Medicare Advantage plan, and you must continue paying your Medicare Part B premiums. However, if you enroll into a Medicare Advantage plan, you will not be allowed to obtain a Medicare Supplement plan (Medigap).

About Medicare Advantage Part C Plans

It's important to understand the differences between the types of Medicare Advantage plans to see which works best for you. There are several different types of Medicare Advantage plans:

  • HMO (Health Maintenance Organization plan): Lets you see doctors and other health professionals who participate in its provider network. If your doctor is already in network, it could be a good option because you tend to pay less out-of-pocket with in-network doctors.
  • PPO (Preferred Provider Organization plan): Covers both in- and out-of-network providers, giving you the freedom to choose any doctor that accepts Medicare assignment, which can work if you prefer that kind of flexibility.
  • PFFS (Private Fee-for-Service plan): The plan determines how much it will pay providers and how much you must pay when you get care. The treating doctor has to accept the plan’s payment terms and agree to treat you. If the doctor doesn’t agree to those terms, then the PFFS plan will not cover services through that doctor.
  • SNP (Special Needs Plans): Are especially for people who have certain special needs. The three different SNP plans cover Medicare beneficiaries living in institutions, those who are dual-eligible for Medicaid and Medicare, and those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS. This type of plan always includes prescription drug coverage.
  • HMO-POS (Health Maintenance Organization - Point of Service plan): Covers both in- and out-of-network health services, but at different rates. You pay less out-of-pocket when you go to in-network doctors, labs, hospitals, and other health care providers.
  • MSA (Medical Savings Account plan): Includes both a high deductible and a bank account to help you pay that deductible. The amount deposited into the account varies from plan to plan. The money is tax-free as long as you use it on IRS-qualified medical expenses, which include the health plan's deductible.

Eligibility for Medicare Advantage plans

Medicare Advantage plan eligibility is based on your eligibility for Original Medicare, Part A and Part B (except if you have ESRD). Generally, if you have Medicare Part A and Part B, you are eligible for Medicare Part C. However, you must live in the service area for the Medicare Advantage plan that you're considering.

If you have other health insurance coverage, for example through an employer or union, ask your plan administrator about that plan’s rules before you enroll in a Medicare Advantage plan. In some cases, you may lose your other coverage if you enroll in the Medicare Advantage plan and you may be unable to get it back if you change your mind later.

Enrollment in Medicare Advantage plans

You may only enroll in a Medicare Advantage plan during specified election periods:

Initial Coverage Election Period: You can enroll into a Medicare Advantage plan or Medicare Advantage Prescription Drug plan when you first become eligible for Medicare. Your Initial Coverage Election Period (ICEP), is a seven-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you are under age 65 and you receive Social Security disability, you qualify for Medicare in the 25th month after you begin receiving your Social Security benefits. If you fall into this category, you may enroll into a Medicare Advantage plan 3 months before your month of eligibility, during the month of eligibility, and 3 months after the month of eligibility. For example, if your Medicare Part A and Part B coverage begins in May, your Medicare Advantage plan ICEP is February through August.

Annual Election Period: The Annual Election Period (AEP) is October 15 through December 7 every year. The plan coverage you choose during the AEP begins on January 1 of the next year. It allows Medicare beneficiaries to add, change, or drop their current coverage. You can use this period to enroll into a Medicare Advantage or Medicare Prescription Drug Plan or switch plans. If you're already enrolled into a Medicare plan, you can use this period to disenroll from your plan.

Special Election Period: Generally, once you enroll into a Medicare Advantage plan, you stay enrolled in the plan until the next Annual Election Period (AEP) opens. However, there are some life events that might qualify you for a Special Election Period (SEP) during other times of the year, so you can make a change to your Medicare Advantage coverage. Some examples of these life events include (but aren’t limited to):

  • Moving outside your Medicare Advantage plan's service area
  • Qualifying for Extra Help (a program to help you pay for prescription drugs)
  • Moving into an institution (such as a nursing home)

To find out more information about Medicare Advantage plans and to see if this route may be a good idea for you, contact HealthPlan Freedom''s licensed insurance agents. We have the knowledge and expertise to answer your Medicare Advantage plan questions.

HealthPlan Freedom is a licensed insurance agency certified to sell Medicare products.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

Comparing Medicare Part D Coverage

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As a Medicare beneficiary, you have a few options when it comes to your Medicare prescription drug coverage (Medicare Part D) and how to get it.

If you're enrolled in Original Medicare, you can get prescription drug benefits through a stand-alone Medicare Prescription Drug Plan that works alongside your Medicare Part A and Part B coverage. If you have Medicare Part C, you can generally get prescription drug coverage through a Medicare Advantage Prescription Drug plan that covers your Part A, Part B, and Part D benefits. Both types of Medicare plans are available through private insurance companies that are approved by Medicare.

When comparing Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans, there are several factors to keep in mind while searching for a plan that fits your needs. Does the monthly premium provide a good value for your needs?

  • Is the annual deductible amount something you are comfortable with?
  • Does the plan cover all of your prescription drugs? What are the copayment and coinsurance costs for your prescription drugs?
  • Do you want a stand-alone Medicare Prescription Drug Plan (PDP) that works alongside Original Medicare or a Medicare Advantage Prescription Drug Plan (MAPD) that includes all of your Medicare coverage under one plan?
  • What are the initial coverage and out-of-pocket limits?
  • Are you at risk for entering the Medicare Part D coverage gap (or "donut hole"), which is a temporary limit on what your Medicare plan will cover for prescription drugs? Read more about the coverage gap below.
  • Does the Medicare plan include a pharmacy network? (Please note that pharmacy networks are subject to change; you'll be notified by your Medicare plan if necessary.)

Comparing Medicare Part D costs and benefits

Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans are available through private insurance companies approved by Medicare. Because of this, however, the monthly premium amount is likely to vary by plan, insurance company, and location. Just as the monthly premium cost will fluctuate across insurance providers, the same is true of annual deductibles. It's a good idea to shop around in order to be fully aware of your prescription drug coverage options.

When choosing a Medicare plan that includes prescription drug coverage, start by deciding whether to enroll in a Medicare Advantage Prescription Drug plan (which covers medical and hospital benefits, along with prescription drug coverage) or a stand-alone Medicare Prescription Drug Plan that works with Original Medicare. Always check with the plan to confirm that your specific prescriptions are covered and make sure you understand what the cumulative out-of-pocket costs may be so that you can make an informed decision.

Keep in mind that just as costs can vary by plan, Medicare plans that include prescription drug coverage may also vary when it comes to the specific prescription drugs they cover. An easy way to make sure that your current medications are covered is to check the plan's formulary (list of covered medications) before enrolling in a Medicare plan that includes prescription drug coverage. Keep in mind that formularies are subject to change. Your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan will notify you if necessary.

Medicare Part D coverage gap ("donut hole")

One factor that could affect your out-of-pocket prescription drug costs is whether you're at risk for entering the coverage gap (also known as the "donut hole"). This is a temporary limit on how much your Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan will pay for covered prescription drugs. While you're in the coverage gap, you'll pay a higher percentage of the cost for covered generic and brand-name prescription drugs.

Most Medicare plans that include prescription drug coverage have a coverage gap, but not every beneficiary will reach it. Whether you enter the coverage gap will depend on the type of prescription medications you take, how much they cost, your cost-sharing expenses, and how much your Medicare plan pays for covered medications. People who take more expensive medications or have higher copayments and coinsurance costs may be at greater risk for entering the "donut hole."

You'll enter the Medicare coverage gap after you and your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan have spent a certain amount on covered medications; this amount includes your deductible and is known as the Initial Coverage Limit.

Costs that count towards reaching the Initial Coverage Limit include:

  • Your yearly plan deductible
  • Your copayment and coinsurance costs for covered medications

The Initial Coverage Limit may change from year to year, so visit Medicare.gov for the most up-to-date amount. Once you and your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan spends this combined amount in prescription drug costs, you enter the Medicare Part D "donut hole."

Once you're in the coverage gap, you assume a higher out-of-pocket responsibility for your prescription costs. The good news is that health-care reform provides government subsidies and manufacturer discounts to help lower what you pay for covered generic and brand-name medications in the coverage gap. Each year, people who enter the coverage gap will pay a smaller percentage of prescription drug costs until the Medicare "donut hole" is finally closed in 2020, and there's no longer a temporary increase in your prescription drug costs.

If you reach the coverage gap, you'll automatically get catastrophic coverage once your out-of-pocket costs for covered medications have reached a certain limit. This amount may change from year to year; for the most up-to-date amount, visit Medicare.gov. Once you have reached this limit, you're in the catastrophic coverage phase, and you'll only pay a small copayment or coinsurance amount for covered medications for the rest of the year.

Do you have any questions about how the coverage gap works? If you'd like help finding Medicare Part D coverage that may lower your out-of-pocket costs, contact HealthPlan Freedom to speak with a licensed insurance agent. We'd be happy to help you find Medicare plan options that cover your prescription drugs and fit your budget.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

HealthPlan Freedom is a licensed insurance agency certified to sell Medicare products.

Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.

Medicare Supplement Plans

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Medicare Supplement (also known as Medigap or MedSup) policies help cover certain out-of-pocket costs that Original Medicare, Part A and Part B, doesn't cover. There are 10 plan types available in most states, and each plan is labeled with a different letter that corresponds with a certain level of coverage.

  • In most states, Medigap plans have the same standardized benefits for each letter category. This means that the coverage for a Plan A, for example, is the same across every insurance company that sells Plan A, regardless of location. This makes it easy to compare Medicare Supplement plans because the main difference between plans of the same letter category will be the premium cost.
  • Medicare Supplement insurance works differently in Massachusetts, Minnesota, and Wisconsin, which standardize their plans differently from the rest of the country. Insurance companies that sell Medicare Supplement insurance aren't required to offer all plan types. However, any insurance company that sells Medigap insurance is required by law to offer Medigap Plan A. If an insurance company wants to offer other Medigap plans, it must sell either Plan C or Plan F in addition to any other plans it would like to sell.
  • * There is also a high-deductible version of Plan F where beneficiaries pay a deductible of before the Medigap plan begins to cover costs.

    ** After the out-of-pocket limit (including the Medicare Part B deductible) is reached for Plans K or L, the Medigap plan pays 100% of covered services for the remainder of the calendar year.

    ***Plan N pays 100% of the Medicare Part B coinsurance costs, with the exception of a copayment of up to $20 for some office visits and up to $50 for emergency room visits that don't result in the beneficiary being admitted as an inpatient.

    This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

    HealthPlan Freedom is a licensed insurance agency certified to sell Medicare products.

    The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

    Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.

    Medicare Supplement cost: plan premiums

    Like almost all insurance plans, Medicare Supplement policies do require premium payments. Because Medigap plans are offered through private insurance companies, the costs associated with each plan may differ. So, to follow up with the above example, a Medigap Plan F you buy in Boston may not cost the same as a Medigap Plan F you buy in Laredo, but the coverage would be the same.

    Each private insurance company offering Medicare Supplement plans can set its own plan premiums using one of these rating systems:

    • Community-rated: Each beneficiary is charged the same monthly premium, regardless of age. These premiums will not increase as you age, but may increase over time as a result of inflation.
    • Issue-age-rated: The premium cost of these plans is based on your age when you first buy the Medigap policy. In general, premiums are lower for younger buyers. These premiums will not increase as you get older, but may increase as a result of inflation.
    • Attained-age-rated: Premiums are set based on your current age and increase as you get older. Premiums are lower for younger buyers but increase over time.

    Note that besides your Medigap plan premium, you still need to pay your Original Medicare premium(s) as well; Medigap doesn't cover your Medicare Part A or Part B premium. Many people don't pay any Part A premium - if you worked at least 10 years (40 quarters) while paying Medicare taxes, Part A is premium-free. But most beneficiaries pay a monthly Part B premium.

    When to apply

    You can apply for a Medigap policy anytime you're enrolled in both Medicare Part A and Part B, but when you apply can make a big difference - both in terms of whether you're accepted into the Medigap plan, and in terms of other details, including cost.

    Your first opportunity to buy a Medicare Supplement plan is during your Medigap Open Enrollment Period. This six-month period begins the month you're both enrolled in Medicare Part B and 65 years old or greater. If you sign up for a Medigap plan during this period, you have a guaranteed issue right to buy the policy without undergoing medical underwriting or paying a higher premium because of a health problem. Once your Medigap Open Enrollment Period has ended, in most cases you don't have guaranteed issue rights. There are some other situations where you may have guaranteed issue rights.

    Factors that affect Medicare Supplement costs

    Besides buying a Medicare Supplement policy during a time when you may have guaranteed issue rights, the following factors might affect the cost of a Medigap plan.

    • Some insurance companies may offer discounts to women, people who are married, and non-smokers.
    • Insurance companies might give discounts to those who pay yearly, or who pay their premiums using electronic funds transfer.
    • You may be able to purchase a high-deductible option for Medigap Plan F, which might offer a lower premium, but requires you to pay a substantial deductible before the plan begins its coverage.
    • If you enroll in a Medicare SELECT plan (a type of Medigap policy that may limit you to using doctors in the plan's network), you might have a lower premium.

    Please note that not every type of Medigap plan or discount will be available in every state or from every insurance company that offers Medigap plans.

    HealthPlan Freedom is a licensed insurance agency certified to sell Medicare products.

    The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

    Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.