Orlando Harmon
Medicare is a federal health insurance program in the United States for people aged 65 or older and younger people with disabilities. It is divided into four parts: A, B, C, and D. Medicare Supplement Insurance (Medigap) is extra insurance that helps pay your share of costs in Original Medicare (Parts A and B). This insurance is provided by private companies, and the benefits are standardized across companies. This article will explore which insurers administer Medicare by region.
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What You'll Learn
Medicare Part A
Original Medicare (Parts A and B) does not include drug coverage. To add drug coverage, individuals can join a separate Medicare drug plan (Part D) or choose a Medicare Advantage plan that includes drug coverage (MAPD). Part D plans are run by private insurance companies and help cover the cost of prescription drugs, including many recommended shots or vaccines. Each private insurance company offering Part D sets its formulary or list of covered drugs, so it is important to ensure that your specific medications are included.
Medicare Supplement Insurance (Medigap) is another option for individuals with Original Medicare who want additional coverage. Medigap is extra insurance that can be purchased from a private company to help pay for the individual's share of costs in Original Medicare. Medigap policies generally do not cover prescription drugs, and individuals typically need Part A and Part B to buy a Medigap policy.
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Medicare Part B
Medicare is a federal health insurance program in the United States for people aged 65 or older, as well as younger people with disabilities, including end-stage renal disease and amyotrophic lateral sclerosis (ALS). It is divided into four parts: Part A, B, C, and D.
If you are enrolled in Part B and have Medicare Supplement Insurance (Medigap) that pays your Part B coinsurance, your Medigap plan should cover the cost of insulin (up to $35). Similarly, if you use an insulin pump that is covered under Part B's durable medical equipment benefit, your cost for a month's supply of insulin for your pump cannot be more than $35.
The rates paid for Part B services are advised by the Specialty Society Relative Value Scale Update Committee (RUC), composed of physicians associated with the American Medical Association.
If you already have Part A, you can add Part B during specific enrollment periods. If you have been covered by an active employer group health plan since turning 65 and it ended within the last 8 months, you can enroll in Part B without any penalty. This is considered a "Special Enrollment Period."
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Medicare Part C
Public Part C Medicare Advantage health plan members typically pay a monthly premium in addition to the Medicare Part B premium to cover items not included in Original Medicare. These can include out-of-pocket (OOP) limits, self-administered prescription drugs, dental care, vision care, annual physicals, coverage outside the United States, and even gym or health club memberships. Part C can also help reduce the 20% co-pays and high deductibles associated with Original Medicare.
The rates paid for Part C services are agreed upon between the sponsor and the provider. In some cases, the sponsor may even rebate part or all of the Part B premium, although these types of Part C plans are becoming less common.
It is important to note that if an individual with a Medicare Advantage Plan moves outside the plan's service area, loses Medicare or Medicaid eligibility, joins a drug plan, or if the plan's contract with Medicare ends, they will be disenrolled from the plan. In such situations, there is a grace period during which they will be eligible for a Special Enrollment Period, allowing them to review their options and ensure they continue to have the desired Medicare health and drug coverage.
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Medicare Part D
To enroll in Part D, beneficiaries must also be enrolled in either Medicare Part A or Part B. They can participate in Part D through a stand-alone prescription drug plan or through a Medicare Advantage plan that includes prescription drug benefits. Enrollees can sign up directly through the plan's sponsor or through an intermediary. However, delaying enrollment may result in a late-enrollment penalty.
The number of Part D plans available varies by region, but enrollees typically have dozens of options to choose from. When selecting a plan, beneficiaries often compare premiums, covered drugs, and cost-sharing policies. Medicare provides an interactive online tool that allows users to compare coverage and costs for all plans in their geographic area. This tool uses personalized medication input to calculate projected annual costs under each plan option.
In 2019, about three-quarters of Medicare enrollees obtained drug coverage through Part D, with program expenditures totaling $102 billion. That year, the average monthly premium across all plans was $27, with stand-alone PDP premiums being three times higher than MA-PDs. Part D includes a "'standard benefit" that is updated annually. For 2022, the monthly costs for stand-alone Part D plans ranged from $6.90 (Dallas and Houston) to $160.20 (San Francisco).
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Medicare Supplement Insurance (Medigap)
Medicare is a federal health insurance program in the United States for people aged 65 or older and younger people with disabilities. It is divided into four parts: Part A covers hospital, skilled nursing, and hospice services; Part B covers outpatient services; Part D covers self-administered prescription drugs; and Part C allows patients to choose private plans with different benefit structures that provide the same services as Parts A and B, usually with additional benefits.
Medicare Supplement Insurance, also known as Medigap, is extra insurance that individuals can purchase from a private health insurance company to help pay their share of out-of-pocket costs in Original Medicare (Parts A and B). Generally, to buy a Medigap policy, one must already have Original Medicare. Medigap policies are standardized, and the benefits offered are the same regardless of which insurance company sells them.
Medigap policies help cover the costs of services such as hospital and skilled nursing care under Part A, as well as outpatient services under Part B. They can also assist with the costs of self-administered prescription drugs, which are covered under Part D of Medicare. Additionally, Medigap may provide coverage for certain benefits not included in Original Medicare, such as dental and vision care, annual physicals, and even gym or health club memberships.
It is important to note that Medigap policies do not cover all out-of-pocket expenses. For example, they do not typically cover the monthly premiums associated with Medicare Parts B and C. Medigap policies also do not cover costs related to self-administered prescription drugs if an individual has chosen to receive their Medicare benefits through a Medicare Advantage Plan (Part C) that includes drug coverage. In such cases, the drug coverage provided by the Medicare Advantage Plan would be the primary source of payment for prescription drugs.
Medigap policies can be purchased from a variety of private insurance companies, and the specific plans available may vary by region. It is always a good idea to research the different options and compare the benefits and costs of each plan before purchasing a Medigap policy. Additionally, individuals should ensure they understand what is covered by their Original Medicare plan to make an informed decision about whether a Medigap policy is necessary for their specific needs.
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Frequently asked questions
Medicare is a federal health insurance program in the United States for people aged 65 or older and younger people with disabilities.
Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). The Social Security Administration determines Medicare eligibility and collects premium payments.
There are two main ways to get Medicare coverage: Original Medicare (Parts A and B) and Medicare Advantage (Part C). You can also add drug coverage (Part D) to either option.
