Medicare Basics
What is Medicare?
Medicare is a federal health insurance program primarily for people aged 65 and older, as well as some younger individuals with disabilities or certain medical conditions such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
What does Medicare Part A cover?
Medicare Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health services.
What is Medicare Advantage (Part C)?
Medicare Advantage plans are private insurance plans that provide Medicare Part A and Part B benefits, often including additional coverage such as vision, dental, hearing, and prescription drugs.
What is Medicare Part D?
While Part D is optional, those without other creditable prescription drug coverage may face a late enrollment penalty if they enroll later.
What are the key Medicare enrollment periods?
• Initial Enrollment Period (IEP): The 7-month window around a person’s 65th birthday.
• General Enrollment Period (GEP): January 1 – March 31 for those who missed their IEP.
• Annual Enrollment Period (AEP): October 15 – December 7, when beneficiaries can switch plans.
• Special Enrollment Periods (SEPs): Available for those with qualifying life events, such as losing employer coverage
Who is eligible for Medicare?
Individuals who are 65 or older, as well as certain younger individuals with disabilities or qualifying conditions such as ESRD or ALS.
Is Medicare Part A free?
Most people do not pay a premium for Part A if they or their spouse worked and paid Medicare taxes for at least 10 years (40 quarters). Otherwise, they may have to pay a monthly premium.
How is Medicare Advantage different from Original Medicare?
Medicare Advantage plans are offered by private insurers and often have network restrictions (HMOs or PPOs), whereas Original Medicare allows beneficiaries to see any provider that accepts Medicare. Medicare Advantage plans may also include extra benefits not covered by Original Medicare
Do all Medicare beneficiaries need Part D?
While Part D is optional, those without other creditable prescription drug coverage may face a late enrollment penalty if they enroll later.
What happens if someone misses their Medicare enrollment deadline?
Missing enrollment deadlines may result in late penalties. For example, late enrollment in Part B can result in a 10% penalty for each 12-month period without coverage.
How do people enroll in Medicare?
Enrollment can be done through the Social Security Administration (SSA) website, by visiting a local SSA office, or by calling SSA. Automatic enrollment may apply for those receiving Social Security benefits. Beneficiaries can also enroll through Agents/Brokers
What does Medicare Part B cover?
Part B covers outpatient services, such as doctor visits, preventive care, lab tests, medical supplies, and some home health services.
What are Medicare Supplement (Medigap) plans?
Medigap plans are private insurance policies designed to cover out-of-pocket costs associated with Original Medicare, such as copayments, coinsurance, and deductibles.
How do beneficiaries choose a Part D plan?
Beneficiaries should compare plans based on factors such as the formulary (list of covered drugs), monthly premium, copays, and pharmacy network.
Can someone change their Medicare Advantage or Part D plan after enrolling?
Yes, changes can be made during the Annual Enrollment Period (AEP) from October 15 – December 7. Medicare Advantage plans also have an Open Enrollment Period (January 1 – March 31), allowing beneficiaries to switch plans or return to Original Medicare.
What are Medicare Chronic Condition Special Needs Plans (C-SNPs)?
Medicare Chronic Condition Special Needs Plans (C-SNPs) are a type of Medicare Advantage plan designed for individuals with specific chronic conditions, such as diabetes, heart disease, or chronic lung disorders. These plans provide specialized care and services tailored to the needs of people living with these conditions. C-SNPs are part of Medicare Advantage, so they must provide all the benefits of Original Medicare (Part A and Part B), plus additional services like prescription drug coverage (Part D), care coordination, and access to specialists who understand their chronic condition.
How much does Medicare Part B Cost?
The standard monthly premium for Part B varies annually. Additionally, there is an income-related surcharge (IRMAA) for high-income beneficiaries. Part B also has an annual deductible and typically covers 80% of approved services, with the beneficiary responsible for the remaining 20%.
Can someone have both a Medicare Advantage plan and a Medigap plan?
No, Medigap plans cannot be used with Medicare Advantage. They are only available to those enrolled in Original Medicare (Parts A & B).
What is the Medicare Part D coverage gap (“donut hole”)?
The coverage gap is a temporary limit on what the drug plan will cover. After reaching a certain spending threshold, beneficiaries may pay a higher percentage of their medication costs until they qualify for catastrophic coverage.
What should someone do if they are still working at 65 and have employer coverage?
If they have creditable employer coverage, they can delay enrolling in Part B without penalty. Once they retire or lose employer coverage, they will have an 8-month Special Enrollment Period to sign up for Part B without a late penalty.
What is an HRA?
A Health Risk Assessment (HRA) is a tool used in the Medicare program to evaluate a beneficiary’s overall health status, identify potential risks, and understand their healthcare needs. It typically involves questions about medical history, lifestyle choices (e.g., smoking, physical activity), current health conditions, medications, and other factors that may affect the individual’s health.
When did Medicare begin, and what were 1 of the key factors that led to its establishment?
Medicare was established on July 30, 1965, when President Lyndon B. Johnson signed the Social Security Amendments of 1965 into law. The program was created to provide health insurance coverage to Americans aged 65 and older, regardless of their income or medical history, addressing the growing concern over the lack of affordable healthcare for senior citizens.
1. Aging Population
2. Rise in Health Care costs
3. Advocacy by Organizations
4. Legislative Foundations - like the New Deal and the success of Social Security
What is the Medicare Advantage Chronic Needs Special Election Period (C-SNP), and who is eligible to enroll during this period?
The Medicare Advantage Chronic Needs Special Election Period (C-SNP) is a special enrollment period that allows eligible beneficiaries with certain chronic conditions to enroll in a Medicare Advantage Special Needs Plan (SNP) tailored to their specific health needs. This period provides individuals with more flexibility in choosing a plan that offers specialized care for their chronic conditions.
Eligibility:
To be eligible for a Zing C-SNP, individuals must have one or more of the following chronic conditions:
Can a beneficiary have both a Part D plan and a Medicare Supplement Plan?
Yes, you can have both a Medicare Part D Prescription Drug Plan and a Medigap plan. In fact, if you are enrolled in Original Medicare, you will need a Part D plan for prescription coverage because Medigap does not cover prescriptions.
Who is eligible to enroll in a Medicare Chronic Condition Special Needs Plan (C-SNP)?
To be eligible for a Medicare Chronic Condition Special Needs Plan (C-SNP), you must meet the following criteria: