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Intro to Medicare

The Medicare Program

Medicare is a health insurance program for:

  • People age 65 or older.
  • People under age 65 with certain disabilities.
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant.)

Medicare Health Plans

Today's Medicare is about choice. Your health plan choices include:

  • Original Medicare, or
  • Medicare Advantage Plans, which include:
    • Medicare Managed Care Plans
    • Medicare Health Maintanence Organizations (HMO)
    • Medicare Private Fee-for-Service Plans
    • Medicare Preferred Provider Organization Plans (PPO)

Most Medicare Advantage plans include Part D prescription coverage which are identified as MAPD plans.  However, some Medicare Advantage plans can be chosen without prescription benefits if desired, which are identified as MA (only) plans.

The Medicare health plan that you choose affects many things like; choice of doctor, premium, benefits (some have extra or optional benefits like, dental, vision, hearing aids, gym memberships, etc.), convenience, and quality.

Medicare Advantage plans are available in many, but not all, areas.

You can elect to participate in "Original Medicare" (Parts A and B) or a "Medicare Advantage Plan" (Part C,) with, or with out, Prescription Drug Coverage (Part D.)
 

What is the "Original Medicare" Plan?

The Original Medicare Plan is a "fee-for-service" plan. This means you are usually charged a fee for each health care service or supply you get. This plan, managed by the Federal Government, is available nationwide. If you are in the Original Medicare Plan, you use your red, white, and blue Medicare card when you get health care. If you are happy getting your health care this way, you don't have to change. You will stay in the Original Medicare Plan unless you choose to join a Medicare Advantage Plan.

Your costs in the Original Medicare Plan
What you pay out-of-pocket depends on:
  • Whether you have Part A and Part B
  • Whether your doctor or supplier agrees to accept "assignment"
  • How often you need health care
  • What type of health care you need
  • Whether you choose to get services or supplies not covered by Medicare. In this case, you would pay for these services yourself.
  • Whether you have other insurance
"Original Medicare" Has two Parts

What is Medicare Part A?

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.

Cost

  • Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.

  • The 2015 Part A premium is $407 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

  • Medicare Part A Helps Cover Your Medically Necessary:

Hospital Stays
Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes inpatient care you get in critical access hospitals and mental health care. This doesn't include private duty nursing, or a television or telephone in your room. It also doesn't include a private room, unless medically necessary. Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.

Skilled Nursing Facility Care
Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day inpatient hospital stay).

Home Health Care
Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Hospice Care
For people with a terminal illness, includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in your home. However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).

Blood
Pints of blood you get at a hospital or skilled nursing facility during a covered stay.


What is Medicare Part B?

Medicare Part B (Medical Insurance) helps cover your doctors' services and outpatient hospital care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Part B Cost

The 2015 premium for Part B is $104.90, which may be adjusted higher or lower depending on your income level.

You pay the Medicare Part B premium each month through a deduction in your Social Security check/deposit, (or quarterly billing if you don't qualify for Social Security.).

In some cases, this amount may also be higher if you didn't sign up for Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn't sign up for it, except in special cases. You will have to pay this extra amount as long as you have Part B.

Medicare Part B Helps Cover Your Medically Necessary:

Medical and Other Services
Doctors' services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Also covers second surgical opinions, outpatient mental health care, and outpatient occupational and physical therapy including speech-language therapy. (These services are also covered for long-term nursing home residents.).

Clinical Laboratory Services
Blood tests, urinalysis, some screening tests, and more.

Home Health Care
Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Outpatient Hospital Services
Hospital services and supplies received as an outpatient as part of a doctor's care.

Blood
Pints of blood you get as an outpatient or as part of a Part B covered service.

Part C - Medicare Advantage Plans

You can choose different ways to get the services covered by Medicare. Depending on where you live, you may have different choices. In most cases, when you first get Medicare, you are in the Original Medicare Plan. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that provides all your Part A, Part B, and often Part D (Medicare Prescription Drug) coverage. You make a choice when you are first eligible for Medicare. Each year you can review your health and prescription needs and switch to a different plan in the fall.

Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare. As long as you have both Part A and Part B, items covered by Part A and Part B are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO).

Medicare Health Plans

Today's Medicare is about choice. Your health plan choices include:

  • The "Original" Medicare Plan, or
  • Medicare Advantage Plans, which include:
    • Medicare Managed Care Plans
    • Medicare Health Maintanence Organizations (HMO)
    • Medicare Private Fee-for-Service Plans
    • Medicare Preferred Provider Organization Plans (PPO)

Most Medicare Advantage plans include Part D prescription coverage. However, some Part D plans can be chosen without prescription benefits if desired.

The Medicare health plan that you choose affects many things like; choice of doctor, premium, benefits (some have extra or optional benefits like, dental, vision, hearing aids, gym memberships, etc.), convenience, and quality.

Medicare Advantage plans are available in many, but not all, areas.

Part D - Prescription Drug Coverage

Medicare Prescription Drug Plans can be taken out as a "stand-alone" optional benefit that can be added on to Original Medicare or it can be included in a Medicare Advantage type plan.  They are offered by insurance companies and other private companies approved by Medicare.  In 2015, Californians have 30+ different Part D coverage options. 

You can choose the best plan to fit your current situation, and then change in the future if your list of medications changes.  Changes can be made during the Annual Election Period-AEP each year between October 15th and December 7th and coverage selected during the AEP will go into effect for the following calendar year on January 1st. 

There are several other "Special Election Periods" when you can make changes through out the year, such as; moving outside your current plan's service area, change in your Part B status when you come off of an employer based health plan, etc. 

Also, you may be able to get extra help to pay for your prescription drug premiums and costs.
To see if you qualify for extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;

• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or

• Your county Medi-Cal (Medicaid) office.


Medicare Frequently Asked Questions - FAQs

 

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