Haris Ashley
Medicare is a federal insurance program for people aged 65 and over, as well as some individuals under 65 with certain disabilities or conditions. It is available in two main ways: Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), and Medicare Advantage, an alternative option offered by private companies. Those with Original Medicare can also opt for supplemental coverage, such as Medicare Supplement Insurance (Medigap), to help pay their share of costs. Additionally, Medicare enrollees can have dual coverage with private health insurance, providing extra benefits and potentially lowering out-of-pocket expenses. Medicaid, a joint federal and state program, is another option for specific groups, including low-income individuals, families, children, pregnant women, and people with disabilities.
| Characteristics | Values |
|---|---|
| Medicare Advantage Plans | Offered by Medicare-approved private companies; includes Part C and Part D (drug coverage) |
| Medicare Supplement Insurance (Medigap) | Extra insurance to cover costs not included in Original Medicare; generally requires Part A and Part B |
| Medicaid | Joint federal and state program for certain low-income people, families, children, pregnant women, elderly, and people with disabilities |
| Employer's Group Health Insurance | Provided by an employer or union |
| Military or Veterans' Benefits | Coverage for military personnel or veterans |
| Private Health Insurance | Available through the ACA marketplace, but not if already enrolled in Medicare |
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What You'll Learn
Medicaid
As of 2023, Medicaid provided health coverage for over 70 million low-income Americans, including nearly 4 in 10 children, over 8 in 10 children in poverty, and almost half of adults in poverty. It is a major payer in the U.S. healthcare system, accounting for about 18.5% of national healthcare spending in 2022. Medicaid is particularly important for people of colour, who made up 61% of non-elderly Medicaid enrollees in 2023, and for rural residents, with 21% of adults in rural areas covered by Medicaid compared to 16% in urban areas.
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Private health insurance
Medicare Advantage plans offer an alternative to Original Medicare for health and drug coverage. These plans are required to follow rules set by Medicare. Most Medicare Advantage Plans include Part D, which covers drug prescriptions. There are several types of Medicare Advantage Plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Medicare Medical Savings Accounts (MSAs), and Private Fee-for-Service Plans (PFFS).
In addition to Medicare Advantage and Medigap, individuals may also have access to employer-sponsored health insurance or other forms of private coverage. It is important to note that insurance companies can decide to offer plans in specific counties or states, and they may offer multiple plans in the same area with varying benefits and costs.
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Medicare Advantage Plans
It is important to note that Medicare Advantage Plans can disenroll individuals for various reasons, such as moving outside the plan's service area or losing Medicare eligibility. In such cases, there is a grace period during which individuals are eligible for a Special Enrollment Period to review their options and ensure they continue to have the desired coverage.
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Medicare Supplement Insurance (Medigap)
Medicare Supplement Insurance, also known as Medigap, is extra insurance that helps cover out-of-pocket costs associated with Original Medicare (Part A and Part B). Medigap policies are sold by private insurance companies and are generally only available to those who have Original Medicare. These policies help pay for costs that aren't fully covered by Original Medicare, such as copayments, coinsurance, and deductibles.
Medigap policies are standardized, meaning that each policy with the same letter (e.g., Plan G or Plan K) offers the same benefits regardless of the insurance company. The price is the only difference between policies with the same letter sold by different companies. It's important to note that Medigap policies do not cover long-term care, such as nursing home care, dental, vision, hearing aids, private-duty nursing, or prescription drugs. However, some Medigap policies offer coverage when travelling outside the US.
Generally, you need to have both Part A and Part B of Medicare to buy a Medigap policy. There is also a limited window to purchase a Medigap policy without incurring a late enrolment penalty. This window typically lasts for six months from when you first get Part A and Part B. If you miss this window, you may not be able to purchase a Medigap policy, or you may have to pay a higher price.
Medigap policies can provide valuable financial protection by helping to cover the gaps in Original Medicare. However, it's important to carefully review the policy details, as Medigap does not cover all potential expenses, and there may be alternative options, such as Medicare Advantage Plans, that could better suit your needs.
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State Health Insurance Assistance Program (SHIP)
The State Health Insurance Assistance Program (SHIP) provides free and unbiased insurance counselling and assistance to Medicare beneficiaries, their families, friends, and caregivers. SHIPs are not connected to any insurance company or health plan. They are highly trained volunteers who help thousands of people navigate Medicare each year. They provide information and assistance so that beneficiaries can make their own decisions regarding their insurance options. SHIP volunteer counsellors are trained in areas of health insurance coverage and benefits that affect Medicare beneficiaries. They do not provide legal advice or sell, recommend, or endorse any specific insurance product, agent, company, or plan.
SHIPs were created under the Omnibus Budget Reconciliation Act of 1990. This section of the law authorized the Centers for Medicare & Medicaid Services (CMS) to make grants to states to establish and maintain health insurance advisory service programs for Medicare beneficiaries. Grant funds support information, counselling, and assistance activities related to Medicare, Medicaid, and other health insurance options, such as Medicare Supplement Insurance, long-term care insurance, and managed care options. SHIP state funding is determined annually by a formula based on several factors, including the Medicare population.
SHIP also assists beneficiaries with limited incomes to apply for programs such as Medicaid, the Medicare Savings Program, and Extra Help/Low Income Subsidy, which help pay for or reduce healthcare costs. They conduct outreach by providing presentations, distributing information, conducting enrollment events, and participating in health fairs, senior fairs, and other community events. SHIP outreach helps to inform groups and individuals about Medicare benefits, coverage rules, written notices and forms, appeal rights and procedures, and more.
SHIP counselling appointments are held virtually, over the phone or with the assistance of other technology, or in person. To set up an appointment, individuals can contact the lead counselling agency in their area or call their County Office on Aging.
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Frequently asked questions
If you already have Medicare, you cannot use the ACA marketplace to buy a private insurance plan. However, you can buy Medicare Supplement Insurance (Medigap) from a private company to help pay your share of costs in Original Medicare.
You might be covered under your employer's group health insurance plan, or your spouse's plan.
Medigap is extra insurance that helps pay your share of costs in Original Medicare. Generally, you need Part A and Part B to buy a Medigap policy, and some policies offer coverage when you travel outside the U.S.
Medicare Advantage Plans (Part C) are offered by Medicare-approved private companies and serve as an alternative to Original Medicare for health and drug coverage.
Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Advantage is an alternative to Original Medicare, offered by private companies, that combines health and drug coverage.
