Paul Sanchez
Medicare is a federal health insurance program for US citizens aged 65 and over, as well as some people under 65 with certain disabilities. There are two main ways to get Medicare coverage: Original Medicare and Medicare Advantage. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance), and covers inpatient hospital care, doctors' services and tests, and preventive services. Medicare Advantage is an alternative to Original Medicare, offered by private companies, and usually includes drug coverage (Part D). There are several types of Medicare Advantage Plans, including Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
| Characteristics | Values |
|---|---|
| Type of Insurance Program | Federal health insurance |
| Target Group | Anyone 65 and older, some people under 65 with certain disabilities or conditions |
| Coverage | Inpatient hospital care, doctors' services and tests, preventive services, prescription drugs, etc. |
| Cost | Monthly premium, monthly penalty for late enrollment |
| Choice of Doctors | Any doctor or hospital that takes Medicare, anywhere in the U.S. |
| Supplemental Coverage | Medicare Supplement Insurance (Medigap), coverage from a former employer or union, or Medicaid |
| Medicare Advantage Plans | Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Medicare Medical Savings Accounts (MSAs), Private Fee-for-Service Plans (PFFS) |
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What You'll Learn
Medicare Part A and Part B
Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions. Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) are two components of Original Medicare, which is one of the two main ways to get Medicare coverage. The other is Medicare Advantage, which is a Medicare-approved plan from a private company that offers an alternative to Original Medicare.
Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must meet certain requirements, such as having a specified number of quarters of coverage (QCs) or receiving monthly Social Security or Railroad Retirement Board (RRB) cash benefits.
Part B, on the other hand, is the medical insurance component of Medicare. When you have Part B, you can use any doctor or hospital that accepts Medicare anywhere in the US. You pay for services as you receive them, with Medicare covering a portion of the cost and you paying your share.
To enrol in Medicare Advantage or Part D prescription drug coverage, you must first enrol in Part A or Part B. Part D helps cover the cost of prescription medications, including several recommended injections or vaccines. Medicare Advantage Plans, also known as Part C, are bundled plans that include Parts A, B, and often D. These plans are offered by Medicare-approved private companies and may provide additional benefits not included in Original Medicare. However, they may have different out-of-pocket costs and network restrictions compared to Original Medicare.
Medigap policies are a type of supplemental coverage that can be purchased to help pay for out-of-pocket expenses like coinsurance. These policies are standardised, and in most states, they are named by letters like Plan G or Plan K. Generally, you need to have both Part A and Part B to purchase a Medigap policy, and you may pay more or be unable to buy a policy if you do not enrol within six months of getting Parts A and B.
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Medicare Advantage Plans
When enrolling in a Medicare Advantage Plan, it is important to be aware that your employer or union coverage may be affected. Joining a Medicare Advantage Plan might cause you to lose your existing coverage, which could also impact the coverage of your spouse and dependents. Therefore, it is recommended to consult with your employer, union, or benefits administrator before making any changes.
Additionally, Medicare Advantage Plans have specific service areas, and moving outside of these areas may result in disenrollment. Other reasons for disenrollment include losing Medicare or Medicaid eligibility or joining a separate drug plan in some cases. If disenrollment occurs, a grace period with a Special Enrollment Period is provided, allowing individuals to review their options and ensure they continue to have the desired Medicare health and drug coverage.
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Medigap policies
Medigap plans are standardized, which means that plans with the same letter, like Plan G or Plan K, offer the same benefits regardless of the insurance company. However, the price may vary between different companies. It is important to note that Medigap policies do not cover long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs. Additionally, Plan C and Plan F are not available for individuals who turned 65 on or after January 1, 2020, or for certain people under the age of 65.
To be eligible for a Medigap policy, individuals typically need to have both Part A and Part B of Medicare. It is recommended to purchase a Medigap policy within six months of enrolling in Part A and Part B to avoid paying higher premiums or facing limited policy options. Medigap plans offer flexibility in terms of network limitations, as they are generally accepted anywhere that accepts Medicare. Some Medigap plans even provide coverage for foreign travel emergency services.
When considering a Medigap policy, it is important to compare the benefits offered by each plan, as they vary. For example, Plans K and L specify how much they will pay for approved services before the beneficiary meets their out-of-pocket yearly limit and Part B deductible. Individuals can consult their local State Health Insurance Assistance Program (SHIP) for free personalized health insurance counselling to make informed decisions about their Medigap options.
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Medicare drug plans
Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions. There are two main ways to get Medicare coverage: Original Medicare and Medicare Advantage. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). You can join a separate Medicare drug plan (Part D) to get Medicare drug coverage. Medicare Advantage Plans (Part C) are offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D).
If you chose Original Medicare and want to add drug coverage, you can join a separate Medicare drug plan. Medicare drug coverage is optional and available to everyone with Medicare. Each plan has a list of covered drugs, called a "formulary", which can vary in cost and specific drugs covered. Most plans have a monthly premium that you pay in addition to your Part B premium. You may pay a Part D late enrollment penalty if you don’t join a Medicare drug plan when you first get Medicare and go 63 days or more without creditable drug coverage. The penalty goes up the longer you wait to join a plan, and in most cases, you pay this monthly penalty for as long as you have Part D coverage, even if you switch plans.
Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Medicare Medical Savings Accounts (MSAs), and Private Fee-for-Service Plans (PFFS). Insurance companies can decide if a plan will be available to everyone with Medicare in a state or only in certain counties. They may also offer multiple plans in an area with different benefits and costs. Each year, insurance companies can decide to join or leave Medicare. If a plan decides to stop participating in Medicare, you will need to join another Medicare health plan or return to Original Medicare.
Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Medigap policies are standardized, and in most states, they are named by letters, like Plan G or Plan K. The benefits in each lettered plan are the same, no matter which insurance company sells it. Price is usually the only difference between policies with the same letter sold by different companies. Generally, you need Part A and Part B to buy a Medigap policy.
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Medicaid and Medicare
Medicare is a federal health insurance program for individuals aged 65 and older, as well as certain individuals under 65 with disabilities or specific conditions. There are two main ways to receive Medicare coverage: Original Medicare and Medicare Advantage. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Advantage, also known as Part C, is a Medicare-approved plan offered by private companies that provides an alternative to Original Medicare for health and drug coverage. Medicare Advantage Plans may include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Special Needs Plans (SNPs).
Medicare enrollees can also opt for supplemental coverage, such as Medicare Supplement Insurance (Medigap), to help pay for out-of-pocket expenses. Medigap policies are standardized and named by letters like Plan G or Plan K, with consistent benefits across insurance companies. However, prices may vary between companies. It is generally necessary to have Part A and Part B to purchase a Medigap policy.
Medicaid, on the other hand, is a joint federal and state program that provides health coverage for specific low-income individuals, families, children, pregnant women, the elderly, and people with disabilities. In some states, Medicaid also assists in covering medical costs for other adults. Eligibility requirements and benefits may vary across states, but it generally offers benefits not typically covered by Medicare, such as nursing home care and personal care services.
Individuals may be eligible for both Medicare and Medicaid, known as "dual eligibility." In such cases, Medicare is the primary payer, covering prescription drugs, while Medicaid may cover additional drugs and services that Medicare does not. Medicaid pays last, after Medicare and any other health insurance the individual may have.
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Frequently asked questions
Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions.
Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). It covers inpatient hospital care, doctors' services and tests, and preventive services. Medicare Advantage Plans (Part C) are offered by Medicare-approved private companies and include drug coverage (Part D).
Once you've signed up for Part A and Part B, you can choose between Original Medicare and Medicare Advantage Plans. You can also shop for supplemental coverage, like Medicare Supplement Insurance (Medigap), to help pay your share of costs.
Yes, if you qualify for both, you can have both Medicare and Medicaid. Medicaid is a joint federal and state program that provides health coverage for certain low-income individuals, families, and specific groups such as children, pregnant women, and people with disabilities.
