Medicare Medical Savings Account (MSA) Plans

Jun 15th, 2017     Medicare

Medicare MSA plan is a consumer-directed Medicare Advantage plan, which combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible) can be used for your health care services during the year. This plan will only pay for Medicare-covered services once you have reached your deductible. Before you meet the deductible, you’re responsible for paying the bill for any Medicare-covered services. Once you meet the plan’s deductible, the plan pays for all of your Medicare-covered services. You won’t have to pay a monthly premium.

Parts Of Medicare MSA Plans

Medicare MSA plan is a combination of a high-deductible insurance plan and a medical savings account that you can use to pay for your health care costs. The high yearly deductible can vary by plan.

High-deductible Health Plan: The first part is a special type of Medicare Advantage plan (Part C). The plan will only begin to cover your costs once you meet a high yearly deductible, which varies by plan.

Medical Savings Account (MSA): The second part is a special type of savings account. The Medicare MSA plan deposits money into your account. You can choose to use money from this savings account to pay your health care costs before you meet the deductible.

Simple example: Medicare Medical Savings Account (MSA) Plans

Mr. Jones and Mrs. Martinez are interested in joining Medicare MSA plans. Plans ABC and XYZ are available in their area.

Terms Plan ABC Plan XYZ
Yearly deposit $2,500 $1,500
Yearly deductible $4,000 $3,000
What you pay after the deductible $0 $0
Out-of-pocket maximum $4,000 (same as deductible) $3,000 (same as deductible)

If Mr. Jones joins Plan ABC:

  • Plan ABC deposits $2,500 into his account at the beginning of the year.
  • If he uses the money in his account for Medicare-covered Part A and Part B services, he’ll have to spend $1,500 out-of-pocket before he meets his deductible and before the Medicare MSA Plan will begin paying for his health care.
  • Once Mr. Jones has met his deductible, Plan ABC pays all of his Medicare-covered Part A and Part B health care, and he pays nothing.
  • Mr. Jones must continue to pay the monthly Part B premium.

If Mrs. Martinez joins Plan XYZ:

  • Plan XYZ deposits $1,500 into her account at the beginning of the year.
  • If she uses the money in her account for Medicare-covered Part A and Part B services, she will have to spend $1,500 out-of-pocket before she meets her deductible and before the Medicare MSA plan will begin paying for her health care.
  • Once Mrs. Martinez has met her deductible, Plan XYZ pays all of her Medicare-covered Part A and Part B health care costs, and she pays nothing.
  • Mrs. Martinez must continue to pay the monthly Part B premium.

How To Choose A Medicare MSA Plan?

Once you decide which MSA plan you want, contact the plan for enrollment information and to join. The plan will tell you how to set up your account with the bank selected by the plan. You must set up an account before your enrollment can be processed. During the Open Enrollment Period you can join MSA plan. Here are some points that may help you to know more about Medicare MSA plans.

Who Can Join a Medicare MSA Plan?

People with both Part A and Part B can generally join a Medicare MSA Plan.

Can my Medicare MSA plan ever cancel my enrollment?

Your plan can cancel your enrollment if one of these events happen:

  • You get Medicaid.
  • You enroll in a Federal Employee Health Benefits Program (FEHBP) plan.
  • You get health care benefits from the Department of Defense (TRICARE) or the Department of Veterans Affairs (VA).
  • You get benefits (like an employer or union group health plan) that cover all or part of the yearly MSA deductible permanently.
  • You move outside of the service area of the plan, or are temporarily out of the service area for longer than 6 months.

What’s covered in Medicare MSA plan?

In addition to the Medicare services that all Medicare Advantage Plans must cover, some plans may cover extra benefits for an extra cost like dental, vision, long-term care not covered by Medicare and contact plans in your area for extra benefits they cover, if any.

Do MSA Plans cover Medicare Part D prescription drugs?

If you join a Medicare MSA plan and need drug coverage, you’ll have to join a Medicare Prescription Drug plan.

What happens to the money in my account if I leave the plan before the end of the year?

No more money will be added to your account. You’ll need to pay part of the most recent yearly deposit (based on the number of months left in the current calendar year) back to Medicare.

If I die, will my spouse be able to use the money in my account?

Any funds in your account that were deposited before the current calendar year are part of your estate. Part of the most recent deposit (based on the number of months left in the current calendar year) will have to be paid back to Medicare.

What if my beneficiary isn’t my spouse?

If you name a beneficiary for your account who isn’t your spouse, the money in it after your death is counted toward that person’s gross income when he or she files that year’s income tax return. If your estate gets the money in your account, it’s counted as gross income on your final tax return.


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Medicare Zero-Dollar ($0) Premium Plans

Jun 15th, 2017     Medicare

Medicare Advantage Plans are offered by private companies which are approved by the Medicare. They offer, at minimum the same coverage of Original Medicare (Part A & Part B), however in MA plans, members can visit doctors in the plan’s network only (or pay higher co-pay) which help the insurance companies in saving some costs. These savings can be passed on to the members through lower (or $0) premiums and some additional benefits. These kind of plans which do not charge any additional premium (apart from the part-B premium) are called $0 premium medicare advantage plans. These plans could also include additional benefits such as foreign travel emergency care, preventive dental services, routine vision care and fitness benefits.

Who can enroll for $0 premium medicare advantage plan?

  • People who have Medicare Part A and Part B coverage.
  • People who come from the service area of the plan.
  • People who do not suffer form End-stage Renal disease.

How to enroll for $0 premium medicare advantage plan?

  • Visit the plan’s website for any online registration.
  • Contact the plan for offline mode of registration.
  • Search for the contact details of the plan to get enrolled.
  • Use Medicare’s plan finder from the official website Medicare.gov
  • Call at 1-800-MEDICARE (1-800-633-4227).

What is the cost of $0 premium medicare advantage plan?

As the name suggests, $0 premium plans comes without any additional cost (you just have to pay your Part B premium). Just like most medicare advantage plans, $0 premium plans also use a combination of deductibles, co‑insurance and co‑payments to share the costs of care with the member. Deductibles, co-pays and co-insurance, plus all costs for ‘services that aren’t covered’ are called “out-of-pocket costs”.

Other costs associated with $0 premium plans

$0 premium Medicare Advantage plans include out-of-pockets costs such as annual deductibles, co-payments, and coinsurance. For example, most of the Medicare Advantage plans have primary and specialist fee co-payments for the services offered. Apart from that, members can visit doctors within the plan’s network and may also need to get a referral for seeing the specialist (based on the plan’s terms of coverage).

Medicare Advantage plans include maximum out-of-pocket limit to control costs. This is a cap on the amount that the patient pays for the covered medical expenses in a calendar year. However, the patient must continue to pay his monthly Part B premium when enrolled in a Medicare Advantage plan.

  • Original Medicare contracts with Medicare Advantage plans to have private insurance companies cover a member’s Medicare bills. The beneficiary of this plan no longer associates with original medicare.
  • Medicare Advantage plans receive a monthly fee from the government to cover the members’ health-care bills. This amount can change based on age, sex, and health.
  • Medicare Advantage insurance companies associate with a network of doctors, hospitals, and other health providers with a smaller fee rate. This can produce savings, which can, in turn, be passed onto the beneficiary through extra benefits not covered by Original Medicare.
  • Medicare Advantage members must continue to pay for Part B premium.

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Medicare and Knee Replacement Surgery

Jun 10th, 2017     Medicare

Knee Replacement surgery is among the most common surgeries for people who are 65 and above. Medicare Part A and Part B cover different portions of this procedure and post-surgery care when it is medically necessary as suggested by the doctor.

To find out the list of orthopedic surgeons who are enrolled with medicare, refer to our website http://www.medicarelist.com/orthopedic-surgery/

Cost for Knee Replacement surgery

For surgeries or procedures, it’s difficult to estimate costs in advance because no one knows what kind of service is needed for the patient. If he/she is having surgery or a procedure, he/she can do some things in advance to figure out approximately how much he/she will have to pay.

  • Ask the doctor, hospital, or facility how much the patient has to pay for the surgery and any care afterward.
  • Make sure the patient knows if he/she is an inpatient or outpatient because costs may vary accordingly.
  • Check with any other insurance the patient may have (like a Medicare Supplement Insurance (Medigap) policy, Medicaid, or coverage from his/her or spouse’s employer) to see what it will pay. If the patient belongs to a Medicare health plan, contact his/her plan for more information.
  • Check his/her Part A deductible if he/she expects to be admitted to the hospital.
  • Check his/her Part B deductible for a doctor’s visit and other outpatient care.
  • Patient needs to pay the deductible amounts before Medicare will start to pay. After Medicare starts to pay, he/she may have copayments for the care he/she gets.

Original Medicare Coverage for Knee Replacement surgery

Any inpatient stay associated with a knee replacement surgery is covered under Medicare Part A. Any outpatient care associated with a knee replacement surgery is covered under Medicare Part B. However, the patient has to pay the Medicare Part A and Part B deductibles and co-payments (if any).

Other costs associated with Knee Replacement Surgery

The other costs that might be included is that of any prescription medications that the doctor might prescribe such as painkillers, anticoagulants, or antibiotics. Medicare Part A covers the prescription drugs during the inpatient stay. Medicare Part B covers the prescription drugs associated when the patient is given outpatient services.

Medicare Part D Prescription Drug Plan may help cover the patient’s prescription drugs, although not every prescription drug is covered under every plan. Medicare prescription drug plans maintain their own lists of covered drugs.

How to limit expenses associated with Surgeries covered under Medicare

Medicare Supplement insurance (for limiting out-of-pocket expenses) and a stand-alone Medicare Part D Prescription Drug Plan (for prescription drugs) are the options to be considered for overall reduction in expenses if the person is enrolled in Original Medicare. The other option is to get a good Medicare Advantage plan which covers prescription drugs (sometimes called MA-PD) and also have limit on maximum out-of-pocket expenses.

If you have any questions, please post a comment below and we will be happy to answer.



Does Medicare Cover Hip Replacement?

Jun 10th, 2017     Medicare

Medicare covers many necessary medical surgeries and other related doctor’s services. This includes hip replacement surgery which is done by orthopedic surgeon. Before undergoing any surgery, it is a good option to research about the best surgical doctors who participate in medicare program.

To find out the list of orthopedic surgeons who accept patients with medicare insurance, refer to our website http://www.medicarelist.com/orthopedic-surgery/

To qualify for this surgery, the person’s doctor will have to provide detailed information and medical records to show hip replacement is medically required for the patient.

What is the cost for hip replacement surgery?

For surgeries or procedures, it’s difficult to estimate costs in advance because no one knows what kind of service is needed for the patient. If you or any member of your family is having surgery or a procedure, you can do some things in advance to figure out approximately how much it will cost for the complete procedure.

  • Ask the doctor, hospital, or facility how much the patient has to pay for the surgery and any care afterward.
  • Understand if the patient will be treated as an inpatient or outpatient because costs (and insurance) may vary accordingly.
  • Check with any other insurance the patient may have (like a Medicare Supplement Insurance (Medigap) policy, Medicaid, or coverage from his/her or spouse’s employer) to see what it will pay. If the patient belongs to a Medicare health plan (part C), contact his/her plan for more information.
  • Check the patient’s Part A deductible if he/she expects to be admitted to the hospital.
  • Check the patient’s Part B deductible for a doctor’s visit and other outpatient care.
  • Patient needs to pay the deductible amounts before Medicare will start to pay. After Medicare starts to pay, he/she may have have to pay co-payments for the care.

What does Medicare cover for Hip replacement surgery?

Medicare covers for the following services.

  • An evaluation consultation with an orthopedic surgeon.
  • Pre-surgery consultation including diagnostic studies and lab tests.
  • The surgery including fees for the doctor, anesthesia, hip implant, and operation room.
  • Postoperative hospitalization.
  • Safety bars and other medical equipment setup at home after postoperative recovery.
  • Rehabilitation and physical therapy services.

If you have any questions, please post in the comments below and we will be happy to answer them.



What You Pay in a Medicare Advantage Plan?

May 31st, 2017     Medicare

Medicare Advantage Plans provide extra benefits in comparison to Original Medicare (Part A & Part B) and may also have lower out-of-pocket costs. The health insurance premium and out-of-pocket costs will be based on the chosen Medicare Advantage plan and are usually paid on montly basis. Other costs included are co-payments for doctors’ consultation and other healthcare services, and premiums for optional benefits, such as vision, hearing, dental and prescription drugs coverage .

Medicare Part B and Medicare Advantage Premiums

The person has to continue to pay for Medicare Part B premium even if he is enrolled in a Medicare Advantage plan. Medicare Part B premiums must be paid directly to Medicare. The monthly cost may increase based on the patient’s annual household income from two years prior.

In addition to the Medicare Part B premium, Medicare Advantage plans often charge a monthly premium for coverage. $0 premium medicare advantage plans are also available.

Annual deductibles in Medicare Advantage Plans

Health insurance premium depend on the plan’s annual deductible. Few Medicare Advantage plans should meet an annual deductible before coinsurance comes into play. These deductibles vary by plan, with higher annual deductibles often indicate lower monthly plan premiums.

The person should compare and choose wisely between plans with higher monthly premium and plans with higher annual deductible in order to save his Medicare costs. For Example, if the person is ill, a plan with a higher monthly premium and a lower annual deductible may save his most money in long run. He should also consider the plan’s Maximum Out-of-Pocket (MOOP) amount. Once he reaches this spending limit, the Medicare Advantage plan covers 100% of the cost. So choosing a plan with a low MOOP limit reduces his Medicare costs.

Co-payments in Medicare Advantage plans

Medicare Advantage co-payments vary extremely among plans. Few plans have co-payments for doctors’ visits, hospital stays, ambulance rides and emergency room visits. Co-payments are figured on a two or three tier system. For Example, a primary care physician’s visit may have lower co-payment (say $10 per visit) than a specialist’s visit (say $20 per visit). Emergency care co-payments are expensive.

Prescription drug costs in Medicare Advantage plan

Medicare Advantage plans with prescription drug coverage will have a formulary, which is a list of covered prescriptions. The formulary structures prescriptions into tiers, with generic ones located in the lowest tier. The lowest tiered ones are typically cheaper than the ones located in the highest tier.



Medicare Eligibility Requirements

May 31st, 2017     Medicare

Medicare is the health insurance program for people who are 65 and above. This coverage includes four parts namely Medicare Part A, Medicare Part B, Medicare Part C and Medicare Part D. Each part has different eligibility criteria. Lets have a look at each of them.

Medicare Part A Eligibility Requirement

Medicare Part A covers mainly inpatient and hospital services. Each person can avail Part A services for free of cost  who are 65 or above, if they meet any one of the following requirements-

  • Have eligibility to Social Security benefits.
  • Have eligibility to Railroad Retirement benefits.
  • Spouse (living or deceased, including divorced spouses) is eligible to receive Social Security or railroad retirement benefits.
  • If the person or his/her spouse has worked in a government job for a long time and through which he/she paid Medicare taxes.
  • If the person is dependent parent of a fully insured deceased child.

If the person does not meet the above requirements, he/she can avail Medicare Part A by paying a monthly premium.

Each Person is eligible for Medicare Part A before the age of 65, if they meet any one of the following requirements.

  • Have eligibility to Social Security disability benefits for 24 months.
  • Have received a disability pension from the railroad retirement board and met certain conditions.
  • Have received Social Security disability benefits because the person has Lou Gehrig’s disease.
  • Have worked for a government job for a long time through which the person paid Medicare taxes and entitled to Social Security disability benefits for 24 months.
  • If the person is child or widow(er) age 50 or older, including a divorced widow(er), of someone who has worked for a long time in a government job through which he/she paid Medicare taxes and met Social Security disability program requirements.
  • If the person has permanent kidney failure and undergoes maintenance dialysis or a kidney transplant and
    • is eligible to Social Security benefits or railroad retirement benefits; or
    • worked for a Medicare-covered government job for a long time; or
    • is child or spouse (including divorced spouse) of a worker under Social Security or in a Medicare-covered government job.

Medicare Part B Eligibility Requirement

Medicare Part B covers outpatient services and preventive services. People who are eligible for Part A at no cost can avail Medicare Part B services by paying a monthly premium. People who are not eligible for Part A at no cost, can buy Part B without paying for Part A, if the person is 65 or above and he/she is:

  • A U.S. citizen; or
  • A lawfully admitted non-citizen who has lived in the United States for five years or above.

The late enrollment penalty is applicable, if the person did not sign up during designated enrollment period.

Medicare Part C Eligibility Requirement

Medicare Part C is also known as Medicare Advantage Plan which is managed by private companies that are approved by the Medicare. If the person has Medicare Part A and Part B, then he/she can join a Medicare Advantage Plan. Person with Medicare Advantage Plan is not eligible for Medigap policy.

Medicare Part D Eligibility Requirement

Part D is a prescription drug coverage of Medicare. Each person has to pay an extra premium on monthly basis for the coverage. Each person can join Medicare Part D if he/she meets the following requirements.

  • If the person is enrolled for Medicare Part A and/or Part B.
  • If the person permanently resides in the service area of the plan.
  • If the person is a U.S. citizen or lawfully present in the United States.

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Difference between Medicare Part A and Part B

May 30th, 2017     Medicare

Medicare is the federal health insurance program for people who are 65 or above, certain young people who have disabilities such as end stage renal disease. Medicare includes different parts that cover specific services like Part A covers hospital insurance, Part B covers medical insurance, Part C (issued by private insurers) covers services of both Part A and Part B (and sometimes Part-D), and Part D covers drug prescription services.

It is important to know the difference between Medicare Part A and Part B while enrolling for Medicare. Lets check them out.

Medicare Part A Medicare Part B
Coverage and Services Medicare Part A covers hospital insurance. Below are the services categorized as follows:

Hospital Care: This coverage includes benefits such as meals, semi-private room, general nursing, other hospital services and supplies, care in inpatient rehabilitation facilities and mental health care in a psychiatric hospital. To know the list of hospitals which are enrolled in Medicare and choose the best hospitals, you can refer to our website http://www.medicarelist.com/hospitals/

Skilled Nursing Facility Care: This coverage includes semi-private room, meals, skilled nursing care, medical social services, physical therapy, speech-language therapy, medical equipment, Ambulance transportation and Dietary counseling. To know the list of nursing-homes (along with quality ratings) which are enrolled in Medicare, you can refer to our website http://www.medicarelist.com/nursing-homes/

Hospice: This coverage provides services to people who are terminally ill and have less than 6 months to live. To get the services, doctor must certify that the patient is terminally ill. To know the list of hospice which are enrolled in Medicare, you can refer to our website http://www.medicarelist.com/hospice-care/

Home Health Services: Face to face interaction with the doctor is necessary to avail home health services. Patient must be home-bound. To know the list of home health agencies which are enrolled in Medicare, you can refer to our website http://www.medicarelist.com/home-healthcare/

Medicare Part B covers medical insurance. Below are the services categorized as follows:

Doctors’ Services: Medicare covers medically necessary doctor services. It also covers services given by other health care providers, like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists.

Outpatient Medical and Surgical Services and Supplies: Medicare covers for approved procedures like X-rays, casts, or stitches.

Durable Medical Equipment: Medicare covers costs for items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds for use in the home. Some items may be rented.

Home Health Services: Medicare covers medically necessary part time nursing care, physical therapy, speech-language pathology services and services for people with a continuing need for occupational therapy.

Other (including, but not limited to): Medicare covers for clinical laboratory services, diabetes supplies, kidney dialysis services and supplies, mental health care, limited outpatient prescription drugs, and other services. The costs varies with each service.

Preventative Services: Medicare covers many preventative services to help the person stay healthy.

To know the list of doctors , therapists and nurses who accept medicare, you can refer to our website http://www.medicarelist.com/

Cost Part A Premiums.
Most people don’t pay any premium for Medicare Part A (individuals who paid medicare taxes for atleast 40 quarters). There is monthly premium for Medicare Part A for individuals who paid medicare taxes for less than 40 quarters. Check the premium prices at Medicare Part A Premium

Part A Deductibles.

  • Hospital care:
    Patient pays a $1,316 deductible and no coinsurance for days 1– 60 of each benefit period. For example, if the hospital bill for 7 days is $20,000, then the patient will pay $1,316 and the remaining amount will be paid by Medicare.

    Patient pays $329 per day for days 61– 90 of each benefit period. If the patient is hospitalized for 65 days, then he has to pay total of $2961 [$1,316 (deductible) + 5 x $329 ($1645 co-pay)]

    Patient pays $658 per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime).

  • Skilled Nursing Facility:

    Patient pays nothing for days 1-20 of each benefit period.

    Patient pays $164.50 per day for days 21-100 of each benefit period.

    patient pays all the costs after 100 days of benefit period.

    Home Health Care: Patient has to pay nothing for home health services in the original Medicare. For certain medical equipment like wheel chair or walker, he has to pay 20% of the amount and the rest 80% is covered by Medicare Part-B.

  • Hospice: Patient has to pay not more than $5 for each prescription drug and 5% for inpatient respite care. For example, if Medicare approved $150 per day for inpatient respite care, then he has to pay $7.50 per day.
Part B Premiums.

Each person pays a premium for Part B each month which depends on one’s income. The standard Part B premium amount in 2017 is $134.

If each person pays his/her Part B premium through his/her monthly Social Security benefit, he/she has to pay less ($109 on average).

Part B deductible and coinsurance.

A person has to pay $183 per year for his/her Part B deductible. After his/her deductible is met, he/she typically pays 20% of the approved amount of medicare for most doctor services, outpatient therapy and durable medical equipment.


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Medicare And Lasik Eye Surgery

May 30th, 2017     Medicare

Lasik eye surgery is a laser procedure, performed by an ophthalmologist in order to improve eye vision by reshaping the eye’s cornea which basically means a person can get rid off eye spectacles or contact lenses permanently after the surgery. The cost for the Lasik eye surgery include surgeon fee, the costs of the vision center and cost for the care before and after the eye surgery. Although, Lasik cost will vary for each person depending on his eye condition and requirement.

What is the cost of Lasik eye surgery

The cost of laser eye surgery can range from as low as $299 per eye to up to $4,000 or more per eye depending on various factors such as eye condition, quality, location etc. However, the average price of LASIK eye surgery is about $2,500 USD per eye.

The cost of the Lasik eye surgery depends on the following factors:

  • Surgeons picked by the patients.
  • The technology used by the surgeons.
  • The type of the Lasik surgery.
  • Geographical area of the patient. Places with higher cost of living may charge high.

Does Medicare cover for Lasik eye surgery?

Medicare Part A and Part B do cover the costs of certain medical eye conditions, if the person requires hospitalization or emergency care. Original Medicare also covers eye doctor consultation and treatments to improve or cure certain chronic eye conditions such as glaucoma and cataracts, if the person’s doctor considers the treatment is necessary. However, Lasik eye surgery is not considered medically mandatory and hence it is not covered.

Not just Medicare, most other healthcare insurance also do not cover Lasik eye surgery, unless the person’s job requires perfect vision. Athletes and combat fighters sometimes qualify for full coverage. Few insurance companies negotiate reduced rates from lasik surgery providers for their customers.

Choose the best Surgeon

Lasik is a planned prodecure, so the person can do his research and choose a good surgeon to improve his eye sight and health. The quality of the eye surgeon is more important than the cost of the procedure. This kind of procedures generally have risks involved and a perfect result can never be guaranteed. So it is important to choose a well-qualified doctor.

You can refer to our website for the medicare list of ophthalmologists.
http://www.medicarelist.com/ophthalmology/


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Medicare Part D – Prescription Drug Plans

May 30th, 2017     Medicare

Medicare Part D (medicare prescription drug coverage) helps cover the cost of prescription drugs. It is run by medicare approved private insurance companies that follow rules set by Medicare. Part D may help lower your prescription drug costs and help protect against higher costs in the future. Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. A drug in a lower tier will generally cost you less than a drug in a higher tier.

There are 2 ways to get Medicare prescription drug coverage:

  1. Medicare Prescription Drug Plans (PDPs): These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) plans, and Medicare Medical Savings Account (MSA) plans. You must have Part A and/or Part B to join a Medicare Prescription Drug Plan i.e. Part D.
  2. Medicare Advantage Plans: MA plan (like HMOs or PPOs) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A, Part B, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs”.

When Can You Join Or Switch To A Medicare Drug Plan

  • When you first become eligible for Medicare, you can join during your Initial Enrollment Period.
  • If you get Part B for the first time during the General Enrollment Period, you can also join a Medicare drug plan.
  • During Open Enrollment, between October 15–December 7 each year. Your coverage begins on January 1 of the following year, as long as the plan gets your request during Open Enrollment.
  • If you want to drop your Medicare prescription drug coverage (Part D) and you don’t want to join a new plan, you can do so during the Open Enrollment Period. The Open Enrollment Period is between October 15–December 7 each year.
  • You can’t drop your Medicare drug plan outside the Open Enrollment Period unless you meet certain special circumstances (Special Enrollment Period).
  • During 5-Star Special Enrollment Period (December 8–November 30), you can switch to a medicare prescription drug plan that has 5 stars for its overall star rating. You can only use this special enrollment period once during this time-frame.

Medicare Drug Plans Coverage Rules

Medicare Drug Plans have certains coverage rules which you need to review before purchasing the plans.

  1. Prior Authorization: You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
  2. Quantity Limits: There are limits on how much medication you can get at a time.
  3. Step Therapy: Step therapy is process of trying lower-priced medications before taking a step up to one that costs more. (e.g. trying low-cost generic drugs before costly branded drugs)

Costs For Medicare Drug Plan Coverage

These are costs associated with medicare prescription drug plans:

  • Monthly premium
  • Yearly deductible
  • Co-payments or coinsurance
  • Costs due to the coverage gap
  • Costs if you pay a late enrollment penalty

Monthly premium 
Most drug plans charge a monthly premium that varies by plan. You pay this in addition to the Part B premium. If you’re in a Medicare Advantage Plan (like an HMO or PPO) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium may include an amount for prescription drug coverage. There may be additional premium for higher income consumers – read our guide to understand Part D premiums by income.

Yearly deductible
This is the amount you must pay before your drug plan begins to pay its share of your covered drugs. Many drug plans don’t have a deductible. The Part D monthly premium varies by plan and higher-income consumers may pay more. The annual deductible for a standard Medicare Part D Prescription Drug Plan is a maximum of $400.

Co-payments or coinsurance
These are the amounts you pay for your covered prescriptions after the deductible (if the plan has one). You pay your share and your drug plan pays its share for covered drugs.

Cost in the coverage gap
Most Medicare drug plans have a coverage gap (also called the “Donut Hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you enter the coverage gap, you pay 40% of the plan’s cost for covered brand-name drugs and 51% of the plan’s cost for covered generic drugs until you reach the end of the coverage gap. This means there’s a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. Once you and your plan have spent $3,700 on covered drugs, you’re in the coverage gap. This amount may change each year.

Costs if you pay a late enrollment penalty
The cost of the late enrollment penalty depends on how long you didn’t have creditable prescription drug coverage. Currently, the late enrollment penalty is calculated by multiplying 1% of the “national base beneficiary premium”. That penalty is added to your monthly Medicare Part D premium. If you disagree with your penalty, you can ask for a review or reconsideration.

Important Points For Medicare Drug Plan

  • If your Medicare Advantage Plan includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you’ll be dis-enrolled from your Medicare Advantage Plan and returned to Original Medicare.
  • Call your benefits administrator before you make any changes, or sign up for any other coverage. If you drop your employer or union coverage, you may not be able to get it back.
  • If you’re in a Medicare drug plan and take medications for different medical conditions, you may be eligible to get services, at no cost to you, through a MTM (Medication Therapy Management) program. This program helps you understand your medications and use them safely.
  • If you drop out of a Part D plan during Open enrollment, you need to notify the plan that you want your coverage to end on Dec. 31. Otherwise, it will carry over into the new year and you will continue to be responsible for paying its premiums.
  • Part D works with other insurance like Employer or union health coverage, COBRA, Medicare Supplement Insurance (Medigap) policy with prescription drug coverage, Medicaid, Supplemental Security Income Benefits, State Pharmaceutical Assistance Program, Long-term care facility, HUD housing assistance, Food stamps, Health Insurance Marketplace.

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Does Medicare Cover Emergency Room Visits?

May 26th, 2017     Medicare

Emergency room visit is covered by Medicare Part B. So, if a person has medicare part B, then it is covered, however, the patient has to pay a co-payment for these services just like any other part-B covered services. If the person is hospitalized after the ER visit, then he/she will be covered through Medicare Part-A and will have to borne the corresponding Part A deductible and coinsurance.

How often it is covered?

Medicare Part B covers benefits for emergency room visits. The services of emergency room department are offered when a person has an injury, sudden illness or an illness that gets much worse quickly.

Eligibility Criteria

All persons who are part of Medicare Part B are covered.

Costs For Emergency Room Visit

  • A person has to pay a co-payment for each visit to emergency department and a co-payment for each hospital service.
  • A person has to pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible is also included.
  • If a person is admitted to the same hospital for a related condition with 3 days of the emergency room visit, then he/she don’t pay the co-payment because the visit is considered as inpatient stay (and it comes under Medicare Part A).

Inpatient or outpatient hospital status during Emergency Visits affects costs.

Here are some common scenarios in an emergency case and a description of how Medicare will pay. Remember, the patient will be responsible for his/her deductible, co-insurance, and co-payment.

Situation Inpatient or Outpatient Part A pays Part B pays
If a person is in the Emergency Room (ER) and then he is hospitalized formally with a doctor’s order. Outpatient until admitted formally to the hospital (on doctor’s order). Inpatient following such admission. his Inpatient hospital stay. his doctor services and other outpatient services in ER.
If a patient visits the ER and is sent to the intensive care unit (ICU) for close monitoring. His doctor expects him to be sent home the next morning unless his condition worsens. His condition resolves and he is sent home the next day. Outpatient. Nothing. Your doctor services.
If a person comes to ER with chest pain, and the hospital keeps him for 2 nights. One night is spent in observation and the doctor writes an order for inpatient admission on the second day. Outpatient until admitted formally to hospital (on doctor’s order). Inpatient following such admission. his Inpatient hospital stay. Doctor services and hospital outpatient services (for example, ER visit, observation services, lab tests, or EKGs)

Emergency Hospital Transportation

A person can get emergency ambulance service when he had a sudden medical emergency, and his health is in serious danger because he can’t be safely transported by other means, like by car or taxi. The ambulance services are covered under Part-B.

Below are the examples of when Medicare might cover emergency ambulance transportation.

  • If a person is in shock, unconscious, or bleeding heavily.
  • If a person needs skilled medical treatment during transportation.


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