Medicare Premiums And Deductibles

May 26th, 2017     Medicare

Here is the snapshot of various costs associated with medicare insurance. We can divide the various costs in two broad categories. First is Premiums, which you pay at the time of taking the insurance and second is out-of-pocket expenses (deductibles, co-payments, co-insurance) which you pay while availing the medical services.

Medicare Part-A (Hospital Insurance)

This medicare insurance is for hospital stay and other inpatient services. Refer to Medicare Part-A for more information.

Part A Premium

You usually don’t pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes while working. This is sometimes called “premium-free Part A” and most people get premium-free Part A. If you are not eligible for premium-free Part-A then you’ll have to pay the premium for part-A coverage. The premiums will be as per the table below –

Duration for which medicare taxes are paid You pay (per month)
Equal or more than 40 quarters $0 (Premium-free)
30-39 quarters $227
Less than 30 quarters $413

Part-A Hospital Inpatient Deductibles And Coinsurance

 Deductibles (2017) You pay $1,316 for each benefit period
 Coinsurance (2017) Days 1-60  $0 for each benefit period
Days 61-90  $329 for each benefit period
Days 91 and beyond  $658 coinsurance per each “lifetime reserve day” after day 90 for each benefit period
 Beyond lifetime reserve days  All costs

Part-B (Medical Insurance)

This part of medicare is for paying doctor’s fees and other out-patient services. Refer to Medicare Part-B for more information.

Part-B Premiums

The standard Part B premium for 2017 is $134, however, it can be more for high income individuals. Also, most people who get Social Security benefits will pay less than this amount ($109 on average). You pay a premium each month for Part B. If you get Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, your Part B premium will be automatically deducted from your benefit payment.

Part-B Premium Based On Your Income

File individual tax return File joint tax return File married & separate tax return You pay each month (in 2017)
$85,000 or less $170,000 or less $85,000 or less $134
above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $187.50
above $107,000 up to $160,000 above $214,000 up to $320,000 Not applicable $267.90
above $160,000 up to $214,000 above $320,000 up to $428,000 above $85,000 and up to $129,000 $348.30
above $214,000 above $428,000 above $129,000 $428.60

Part B Deductible & Coinsurance

You pay $183 per year for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy and durable medical equipment.

Part-C (Medicare Advantage)

This insurance includes benefits of both part-A and part-B but offered by private insurance companies. Refer to Medicare Part-C for more information.

Monthly Premium Deductibles, Co-payments, & Coinsurance:

You will have to pay a monthly premium (in addition to your Part B premium, although many MA plans comes with $0 monthly premiums). Most medicare advantage plans use a combination of deductibles, co‑insurance and co‑payments to share the costs of care with you. Deductibles, co-pays and co-insurance, plus all costs for ‘services that aren’t covered’ are called “out-of-pocket costs”. Each plan sets its own premium and decides on cost sharing terms. Plans are required to limit the amount you may have to pay out-of-pocket each year. Co-insurance plans set their own co-insurance terms and percentages. The amount you pay for Part C deductibles, co-payments, and/or coinsurance varies by plan and you should check them prior to opting the plan.

Part-D (Medicare Prescription Drug Coverage)

This part includes coverage of prescription drugs costs. Refer to Medicare Part-D for more information.

Medicare Part D premiums

Most Medicare Prescription Drug Plans are provided by private insurance firms which charge a monthly fee that varies by plan. Also, there is a additional premium if you are in the higher income group as shown in the table below. You pay this in addition to the Medicare Part B premium. There will also be a late enrollment penalty which is calculated by multiplying 1% of the national base beneficiary premium ($35.63 per month) by the number of full months you didn’t have Medicare Part D or creditable coverage. That penalty is added to your monthly Medicare Part D premium. The national base beneficiary premium may increase each year, so your late enrollment penalty may likewise increase each year.

Part-D Premiums By Income

File individual tax return File joint tax return File married & separate tax return You pay (in 2017)
 $85,000 or less  $170,000 or less $85,000 or less  your plan premium
 above $85,000 up to $107,000  above $170,000 up to $214,000  not applicable   $13.30 + your plan premium
 above $107,000 up to $160,000  above $214,000 up to $320,000  not applicable  $34.20 + your plan premium
 above $160,000 up to $214,000  above $320,000 up to $428,000  above $85,000 up to $129,000  $55.20 + your plan premium
 above $214,000  above $428,000  above $129,000  $76.20 + your plan premium

Part-D Deductibles, co-payments, & coinsurance:

The annual deductible for a standard Medicare Part D Prescription Drug Plan is a maximum of $400. Medicare Prescription Drug Plans may have a lower deductible than that or even have a $0 deductible. Premiums and deductibles may vary depending on the specific Medicare plan option you select. Most people only pay their Part D premium with no out-of-pocket expenses for medicines.


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Part B Preventive Services

May 25th, 2017     Medicare

Medicare Part B is the medical insurance offered by federal government to individuals who are 65 or above. Medicare Part B covers medical insurance i.e. outpatient services and preventive services. Below is the list of preventive services offered by Medicare. Each person should talk to his/her healthcare provider about which of these services is right for him/her.

  • Abdominal aortic aneurysm screening
  • Lung cancer screening
  • Alcohol misuse screenings & counseling
  • Mammograms (screening)
  • Bone mass measurements (bone density)
  • Nutrition therapy services
  • Cardiovascular disease screenings
  • Obesity screenings & counseling
  • Cardiovascular disease (behavioral therapy)
  • One-time “Welcome to Medicare” preventive visit
  • Cervical & vaginal cancer screening
  • Prostate cancer screenings
  • Colorectal cancer screenings
  • Sexually transmitted infections screening & counseling
  • Depression screenings
  • Shots:
    • Flu shots
    • Hepatitis B shots
    • Pneumococcal shots
  • Diabetes screenings
  • Tobacco use cessation counseling
  • Diabetes self-management training
  • Yearly “Wellness” visit
  • Glaucoma tests
  • Hepatitis C screening test
  • HIV screening

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Medicare Part B (Medical Insurance)

May 25th, 2017     Medicare

Medicare is a health insurance program offered by the federal government for people who are 65 and above. Within Medicare, Part-B includes two types of services. One is outpatient medical services and and the other one is preventative services. Lets have a look at each of the services in detail.

  • 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. The patient has to pay 20% of the Medicare-approved amount and Part B deductible also applies.
  • Outpatient Medical and Surgical Services and Supplies: Medicare covers for approved procedures like X-rays, casts, or stitches. The patient has to pay the doctor 20% of the Medicare-approved amount, pay the hospital a co-payment for each service and Part B deductible also applies.
  • 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. The patient has to pay 20% of the Medicare-approved amount and Part B deductible also applies.
  • 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. The patient has to pay nothing for covered services.
  • 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, diagnostic x-rays, MRIs, CT scans, and EKGs, transplants, and other services. The costs varies with each service.
  • Preventative Services: Medicare covers many preventative services to help the person stay healthy. Each person has to talk to his/her health care provider about the services which is right for him/her. Few services are listed below.
    • Alcohol misuse screening and counseling.
    • Bone mass measurement.
    • Diabetes screenings.
    • Lung cancer screenings and several other services.

Refer to our guide on Medicare Part B Covered Preventive Services for the complete list of preventive services.

Who are eligible for Medicare Part B?

People with the following criteria are eligible for Part B Medicare program.

  • People with the age 65 or above.
  • People who are disabled permanently.
  • People with the end stage renal disease.

Refer to our guide on Medicare Eligibility Requirement for in-depth eligibility requirments.

Premium and other costs associated with Part B

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).

Premium pricing chart for Part-B is based on the yearly income in 2015 (For what you pay in 2017)

File Individual Tax Return File Joint Tax Return File Married & Separate Tax Return In 2017 you pay
$85,000 or less $170,000 or less $85,000 or less $134
above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $187.50
above $107,000 up to $160,000 above $214,000 up to $320,000 Not applicable $267.90
above $160,000 up to $214,000 above $320,000 up to $428,000 above $85,000 and up to $129,000 $348.30
above $214,000 above $428,000 above $129,000 $428.60

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.

When to enroll for Medicare Part B?

A person can enroll for Part B only during

  • his/her Initial Enrollment Period (IEP).
  • The annual General Enrollment Period (GEP) that is January 1 – March 31 each year.
  • The Special Enrollment Period (SEP) in limited situations.

If a person does not enroll in Part B during IEP, then he/she has to pay lifetime penalty.

Late Enrollment Penalty of Part B (Lifetime Penalty)

If the person does not sign up for Medicare Part B coverage when he/she is first eligible, then he/she has to pay a premium penalty of 10% for each full 12-month period where he/she could have had Part B but didn’t sign up for it, except in special cases. This penalty will always be included in Part B premiums (lifetime penalty).

For example, John’s IEP ended on september, 2009. He waited to sign up during GEP in march 2012. The total time delayed was 30 months. So his late enrollment penalty is 20% as 30 months includes 2 full 12-month periods and John needs to pay 20% more premium (20% more than indicated in the chart above) as long as he is enrolled in Medicare Part-B.

How to apply for Medicare Part B?

  • Visit the social security website for online application.
  • Visit the nearest social security office for offline application.
  • Call Social Security at 1-800-772-1213
  • Call the R.R.B at 1-877-772-5772,  if you are a rail road employer.

When a person must have Medicare Part B?

  • When the person wants to buy a Medigap policy.
  • When the person wants to join a Medicare Advantage Plan.
  • When the person is eligible for TRICARE for Life (TFL) or Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
  • When the person’s employer coverage requires his/her spouse or family member to have it when you become eligible for Medicare.

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Medicare Advantage Vs Medicare Supplement

May 23rd, 2017     Medicare

There are multiple types of plans available in medicare and it can be difficult to understand the meaning of the plan from its name. Medicare Advantage Plan (also called Part C) and Medicare Supplement Plan (also called Medigap) are the most confusing of these plans. Although these two plan types differ greatly from each other but many people get confused due to similar names. In a nutshell, Advantage Plan (or Part C) is replacement of Original Medicare (Part A & B) while Supplement Plan (Medigap plan) helps you cover the out of pocket expenses under Original Medicare.

Medicare Advantage Plan

Medicare Advantage Plan (Part-C) includes all benefits and services covered under Part A and Part B. Sometimes it also includes Medicare prescription drug coverage (Part-D) as part of the plan. Medicare Advantage Plans may offer extra coverage, like vision, hearing, dental, and other health and wellness programs and are run by Medicare-approved private insurance companies that follow rules set by Medicare. Most Advantage Plans have a yearly limit on out-of-pocket expenses (deductibles, co-pays, co-insurance etc.) for medical services. In addition to your Part B premium, you may have to pay a monthly premium for the Medicare Advantage Plan.

Medicare Supplement

Medicare Supplement Insurance policies are also called Medigap policies. Medigap policies, sold by private companies, can help pay some of the health care costs that Original Medicare doesn’t cover, like co-payments, coinsurance, and deductibles (commonly referred to as out-of-pocket expenses). A person must be enrolled in part A and B of Medicare before they can enroll in a Medigap plan. Refer to our guide on medigap policies for complete information.

medigap vs medicare advantage

You may either choose Original Medicare (Part A & B) path or Medicare Advantage path.

How does Medigap work with Medicare Advantage Plans?

Simple Answer: Medigap doesn’t work with Medicare Advantage.

  • If you have a Medicare Advantage Plan (like an HMO or PPO), it’s illegal for anyone to sell you a Medigap policy unless you’re switching back to Original Medicare.
  • If you have a Medigap policy and join a Medicare Advantage Plan, you may want to drop your Medigap policy. Your Medigap policy can’t be used to pay your Medicare Advantage Plan copayments, deductibles, and premiums. Also, in most cases, if you drop your Medigap policy to join a Medicare Advantage Plan, you won’t be able to get it back.
  • If you join a Medicare Advantage Plan for the first time, and if you want to change the plan, you’ll have special rights to buy a Medigap policy if you return to Original Medicare within 12 months of joining.

Comparison of Medicare Advantage and Medicare Supplement

Factors Medicare Supplement Plan Medicare Advantage Plan
Networks There is no network restriction. You can have the choice of hospitals and doctors. You may have network restrictions, emergency care is covered for travel with-in United States and sometimes abroad.
Medical Care and Coverage Medigap policies don’t cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, or private-duty nursing. Medical Advantage Plan cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, or private-duty nursing.
Doctors and Referrals You can select Doctors and Hospitals as per the need. You can see specialists without Referrals. Selection of Doctors will be done according to plan network. You may need Referrals if required.
Costs Medigap plan has no Out-of-pocket costs and no need to pay co-payments, deductibles. MA Plans have an limited out-of-pocket annual maximum. You still need to pay your Medicare Part B premium.
Drug (Part-D) Part-D is not included in the plan. If you want this coverage, you need to enroll in a stand-alone Medicare Part D prescription drug plan. MA plan itself consists Part-D coverage. If your Medicare Advantage plan does not include drug coverage, you can enroll in a Medicare prescription drug plan.
Enrollment Must have Original Medicare, Part-A and Part-B. Benefits don’t generally change. You can enroll during Open Enrollment Period.
You cannot use Medicare Supplement plan if you are enrolled in MA plan. No Annual Election Period (AEP) for Medigap plans.
Must have Original Medicare, Part-A and Part-B. Benefits may change yearly. You may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period.
You usually remain in a plan unless you dis-enroll policies during the Annual Election Period.
Standardized Policies Medicare Supplement Plans are standardized. Medicare advantage Plans are not standardized.

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Medicare Part A (Hospital Insurance)

May 23rd, 2017     Medicare

Medicare is a health insurance program offered by the federal government for people who are 65 and above. Within Medicare, Part-A insurance covers the inpatient hospital care. Most people get Medicare Part A free of cost when they turn 65. Below are the services which come under Medicare Part A.

  • 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, you can refer to our website //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 which are enrolled in Medicare, you can refer to our website //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 //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 //www.medicarelist.com/home-healthcare/

Who are eligible for Medicare Part A?

People with the following criteria are eligible for Part A Medicare program.

  • People with the age 65 or above.
  • People who are disabled permanently.
  • People with the end stage renal disease.

Refer to our guide on Medicare Eligibility Requirement for in-depth eligibility requirments.

What is the cost of Medicare Part A?

Premium-Free

There is no monthly premium for Medicare Part A for individuals who paid their medicare taxes for atleast 40 quarters.

The eligibility for people at 65  is as follows:

  • People with retirement benefits from Social Security or Rail Road Retirement Board.
  • People who are eligible and yet to file for Social Security or Rail Road benefits.
  • People and their respective partners have medicare covered government employment.

The eligibility for people under 65 is as follows:

  • People who got disability benefits of Social Security or Rail Road Retirement Board  for 24 months.
  • People with end stage renal disease and meet certain requirements.

Premium

For the year 2017

  • People who paid taxes for less than 30 quarters have to pay $413 monthly.
  • People who paid taxes for 30-39 quarters have to pay $227 monthly.
  • People who paid taxes for 40 quarters or above avail free medicare coverage.

When to enroll for Medicare Part A?

  • Initial Enrollment Period (IEP): People can enroll 3 months before they turn 65 to get services from the day they turn 65. If they enroll during the month they turn 65, then they can avail services the next month. If they enroll in the last 3 months of this period, then they can avail services after 2 to 3  months they turn 65.
  • General Enrollment Period (GEP): People who did not sign up during Initial Enrollment Period can enroll during General Enrollment Period. It occurs every year from January 1 to March 31. If the person is not eligible for premium-free Part A and has not bought it in IEP, his/her monthly premium may go up 10%. He/She has to pay the higher premium for twice the number of years he/she did not signup for Part A.
  • Special Enrollment Period: Most of the people are not eligible for Special Enrollment Period. To be eligible, a person should have employer group health plan coverage based on his/her employment status. The SEP allows people to enroll for Medicare after IEP without needing to wait for GEP and there is no penalty as well.

How to apply for Medicare Part A?

  • Visit the social security website for online application.
  • Visit the nearest social security office for offline application.
  • Call Social Security at 1-800-772-1213
  • Call the R.R.B at 1-877-772-5772,  if you are a rail road employer.

How much does Medicare Part A pay?

Inpatient care:

Benefit Period in 2017 Pay
Days 1-60 $1316 deductible
Days 61-90 $329 per day
Days 91-150 $654 per day
(60 lifetime reserve days)
All days after 150 All Costs

Cost Working Examples

  1. 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.
  2. 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)]
  3. Patient pays $658 per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime).

Skilled Nursing Facility:

Benefit Period in 2017 Pay
Days 1-20 $0
Days 21-100 $164.50 per day
All days after 100 All Costs

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.


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Medigap – Medicare Supplement Plan

May 22nd, 2017     Medicare

Medicare Supplement Insurance policies are also called Medigap policies. Medicare Supplement Insurance policies, sold by private companies, can help pay some of the health care costs that original medicare doesn’t cover, like co-payments, coinsurance, and deductibles. The Medigap policy can no longer have prescription drug coverage, but you may be able to join a Medicare Prescription Drug Plan (Part-D) separately. Generally, Medigap policies don’t cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

medigap policy

Medigap policies cover the difference or “gap” between the total expenses and amount reimbursed to providers by Medicare Parts A and B. Medigap policies are only available to people who already have both Medicare Part A and Medicare Part B. People who have a Medicare Advantage plan cannot get a Medigap plan. However, most medicare advantage plans have a upper limit on the out of pocket expenses.

Medicare Policies

Medicare policies are standardized and they must follow federal and state laws, and must be clearly identified as “Medicare Supplement Insurance”. Medigap “standardized” policies are identified in most states by letters A through D, F through G, and K through N. All policies offer the same basic benefits, but some offer additional benefits so you can choose which one meets your needs. In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way.

The chart below shows basic information about the different benefits that Medigap policies cover. If a percentage appears, the Medigap plan covers that percentage of the benefit, and you’re responsible for the rest.

Benefits A B C D F1 G K2 L2 M N3
Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Medicare Part B coinsurance or co-payment 100% 100% 100% 100% 100% 100% 50% 75% 100% 100%
Blood (first 3 pints) 100% 100% 100% 100% 100% 100% 50% 75% 100% 100%
Part A hospice care coinsurance and co-payment 100% 100% 100% 100% 100% 100% 50% 75% 100% 100%
Skilled nursing facility care coinsurance 100% 100% 100% 100% 50% 75% 100% 100%
Part A deductible 100% 100% 100% 100% 100% 50% 75% 50% 100%
Part B deductible  100%  100%
Part B excess charges 100% 100%
Foreign travel emergency(up to plan limits) 80% 80% 80% 80% 80% 80%

1 Plan F also offers a high-deductible plan in some states. If you choose this option, this means you must pay for Medicare-covered costs (coinsurance, co-payments, and deductibles) up to the deductible amount of $2,200 in 2017 before your policy pays anything.
2 In 2017, the Out-of-pocket limit for the plan K is $5,120 and for plan L is $2,560.
3 Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that don’t result in an inpatient admission.

Points To Be Considered before taking Medigap policies

  • You must have both Part A and Part B (Original Medicare).
  • You pay the private insurance company a monthly premium for your Medigap policy in addition to your monthly Part B premium that you pay to Medicare.
  • A Medigap policy only covers one person. Spouses must buy separate policies.
  • You can’t have prescription drug coverage in both your Medigap policy and a Medicare drug plan.
  • It’s important to compare Medigap policies since the costs can vary and may go up as you get older. Some states limit Medigap premium costs.

Enrollment Of Medicare Supplement Plan

A person must be enrolled in part A and B of Medicare before they can enroll in a Medigap plan. When a person turns 65 or if they are older and new to Medicare Part B they become eligible for Medigap Open Enrollment. This period starts on the first day of the month you turn 65 and lasts for 6 months. During this period, a person can buy any Medigap plan regardless of their health. After this enrollment period, you may not be able to buy a Medigap policy or it may cost much more. If you delay enrolling in Part B, your Medigap Open Enrollment Period won’t start until you sign up for Part B. Medigap insurance is not compatible with a Medicare Advantage plan i.e. you cannot have both a Medicare supplement and a Medicare Advantage plan at the same time.



How Medicare Advantage Plans Differ from Original Medicare

May 19th, 2017     Medicare

Almost all people who want to enroll with medicare have to decide whether they want to keep original medicare or want to go with medicare advantage plans (Part C). Each of them have some tradeoffs against each other (in terms of cost, coverage and convenience) and it’s important to understand the difference between the two to select the best suitable plan for you.

Original Medicare (Part A and Part B)

Original Medicare is a coverage managed by the federal government. It includes Part-A (hospital insurance) and Part-B (medical insurance) coverage if you enroll in both. You pay a deductible and/or coinsurance when you receive healthcare services. Most people get Part A free of cost and pay a monthly premium for Part B. If you want prescription drug coverage, you must buy a separate prescription drug plan (part D) from a private insurance company. Also, separate medigap policies are available to cover the out-of-pocket expenses.

Medicare Advantage Plan (Part C)

Medicare Advantage Plan includes all benefits and services covered under Part A and Part B. Many times it also includes medicare prescription drug coverage (part D) as part of the plan and it is run by Medicare-approved private insurance companies that follow rules set by Medicare. You pay Part B premium and additional premium to private insurer. To understand how to choose the best MA plans, refer Choosing Best Medicare Advantage Plans.

Differences Between Original Medicare And Medicare Advantage Plan

Original Medicare Plan and Medicare Advantage Plan differ greatly and it is important to know these differences. Let us check out the comparison guide so you can decide which Medicare plan is better as per your needs.

Factors Original Medicare Medicare Advantage Plan
Costs? You pay medicare premiums, deductibles, and co-insurances. There’s no yearly limit for what you pay out-of-pocket. You usually pay a monthly premium for Part B, if you opted for medical insurance. You pay Medicare part B premiums and Part C premium (if any), deductibles, and co-insurances. However, most MA plans have max-limit on Out-of-pocket expenses.
Should I get a supplemental policy? You may already have employer or union coverage that may pay costs that Original Medicare doesn’t. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy if you’re eligible. You can’t buy a Medigap policy to pay your out-of-pocket costs in a Medicare Advantage plan. In most case, there is a max-limit on OOP expenses.
Do I have to get a referral to see a specialist? In most cases, no, but the specialist must be enrolled in Medicare. You often need to get a referral from your Primary Care Physician if you want to see a specialist.
Covers drugs? No, but if you want medicare prescription drug coverage, you can buy a separate Part D plan. Many MA plans include Part D drug coverage.
Out-of-pocket limit? There’s no max limit on the out-of-pocket expenses which you may need to incur. MA Plans have a max-limit on the out-of-pocket expenses which safeguard you in case of expensive medical care. The plan pays the full cost of your care after you reach the limit.
Covers extra services like vision and dental? Doesn’t cover certain services such as routine vision, hearing or dental care. MA plan cover services like routine vision, hearing and dental care.
Do the services are provided nation wide? Yes, you can go to any doctor or hospital in the U.S. that accepts Medicare. Usually not. Most people have HMOs or PPOs, which provide coverage through their network of healthcare providers. You may need to take additional coverage if you need to travel.

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Medicare Advantage Plans

May 19th, 2017     Medicare

Medicare Part C plans are also referred to as Medicare Advantage plans. These plans are offered by private insurance companies and allow you to get all the coverage Original Medicare (Parts A and B) offers, plus additional benefits and services all in a single plan. Many Medicare Advantage plans include prescription drug coverage (Part D), often for no additional premium or for small premium amount. Some plans also include extra benefits such as:

  • Routine vision, hearing and dental care
  • Wellness programs

Different Types Of Medicare Advantage Plans:

Most Medicare Advantage plans are built on the idea of a network of doctors and hospitals working together to provide care. Each MA plan creates its own network of doctors and other health service providers. In most cases, you will pay most or all costs if you see a provider outside of the network.

  1. Health Maintenance Organization (HMO) Plans: HMO plans require you to seek care from providers in your network. Many require you to get a referral from your primary care physician to see a specialist.
  2. Point Of Service (POS) Plans: A type of HMO plan that allows you to see doctors and hospitals outside the network for some covered services, usually for a higher co‑pay or co‑insurance.
  3. Preferred Provider Organization (PPO) Plans: PPO plans typically don’t require a referral to see a specialist and allow you to see providers outside the network without having to pay the entire cost yourself.
  4. Special Needs (SNP) Plans: SNPs are designed for people with a range of special needs, including those with chronic diseases, nursing home residents, and people who are eligible for both Medicare and Medicaid.
  5. Private Fee-For-Service (PFFs) Plans: PFFS plans allow enrollees to see any providers in the U.S. who accept Medicare’s payment terms and conditions.
  6. Medical Savings Account (MSA) Plans: MSA plans combine Medicare Advantage plan coverage with a special savings account you can use to pay for covered expenses tax‑free.

Premiums and other Costs:

Medicare Advantage plans can reduce the costs and the hassle for patients who need to buy three policies (Part A, Part B and Drug Plan) for comparable coverage in traditional Medicare, and a supplemental policy that covers out-of-pocket costs. Read our guide to understand differences between Original Medicare and Medicare Advantage Plans.

Only private insurance companies that are approved by Medicare can provide Part C coverage. Insurance companies decide what services the plan will cover, so monthly premiums vary from plan to plan (and state to state) and they are only allowed to make changes to the premium rate once a year. Part C premiums are billed through the private insurance company. You will have to pay a monthly premium (in addition to your Part B premium, although many MA plans comes with $0 monthly premiums). Most Medicare Advantage plans use a combination of deductibles, co‑insurance and co‑payments to share the costs of your care with you. Deductibles, co-pays and co-insurance, plus all costs for ‘services that aren’t covered’ are called “out-of-pocket costs”.

  • Co-insurance: The costs that you and the health insurance plan pay are split on a percentage basis.
  • Co-payments: The fixed amount you pay at the time you receive a covered service.
  • Deductible: A set amount you pay out of pocket for covered services each year before your plan begins to pay.

Out-of-pocket: The maximum amount you pay during a policy period (usually a year). This amount does not include your premium or the cost of any services that are not covered by your plan. After you reach your out‑of‑pocket maximum, your plan pays 100% of the allowed amount of covered services for the rest of the policy period.

When can You Join or Switch to a Medicare Advantage Plan:

  • If you have Part A coverage and Part B coverage during the General Enrollment Period, you can also join a Medicare Advantage Plan.
  • Between Oct 15 – Dec 7, anyone with Medicare can join, switch, or drop a Medicare Advantage Plan. Your coverage will begin on Jan 1, as long as the plan gets your request by Dec 7.
  • Between Jan 1–Feb 14, if you’re in a Medicare Advantage Plan, you can leave that plan and switch to Original Medicare.
  • You may lose your prescription drug coverage if you move from a Medicare Advantage Plan that has drug coverage to a Medicare Advantage Plan that doesn’t.
  • In certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period. You can only use this Special Enrollment Period once during this time-frame.

Renewal: Your plan renews automatically each year as long as you pay the premium and the plan is still available in your service area.

How To Choose A Type Of Medical Advantage Plan:

  1. Convenience: Check the network of the MA Plan – Where are the doctors’ offices, which pharmacies can you use, whether your favorite doctor is part of the network, whether you’ll require a referral to visit a specialist etc.
  2. Costs: How much are your premiums, deductibles, and other costs? Is there a yearly limit on the out-of-pocket expenses?
  3. Costs: How well does the plan cover the services you need?
  4. Prescription Drugs: Do you need to join a Medicare drug plan? Are your drugs covered under the plan’s formulary?
  5. Travel: Will you have coverage in another state or outside the U.S.?

Important Points To Be Considered:

  • If you’re in a Medicare Advantage Plan, review the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC) your plan sends you each year. If you don’t get these important documents before the start of Open Enrollment, contact your plan.
  • If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your services may not be covered, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
  • Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
  • Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. This limit may be different between Medicare Advantage Plans and can change each year.
  • 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.
  • You can’t use (and can’t be sold) a Medicare Supplement Insurance (Medigap) policy while you’re in a Medicare Advantage Plan. You can’t use it to pay for any expenses (co-payments, deductibles, and premiums) you have under a Medicare Advantage Plan. If you already have a Medigap policy and join a Medicare Advantage Plan, you’ll probably want to drop your Medigap policy. If you drop your Medigap policy, you may not be able to get it back.

Resources:

  • Medicare.gov can show you the plans available in your area.
  • The Medicare Helpline can answer your Medicare questions. Call 1-800-MEDICARE (1-800-633-4227).

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Medicare Terminology and Jargons

Dec 25th, 2016     Medicare

Medicare terminology with the explanation of the terms and jargons you will come across when reading about Medicare.

Assignment

An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Benefit Period

The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Coinsurance

An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Copayment

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

Creditable Prescription Drug Coverage

Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.

Critical Access Hospital

A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas.

Custodial Care

Nonskilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

Deductible

The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

Demonstrations

Special projects, sometimes called “pilot programs” or “research studies,” that test improvements in Medicare coverage, payment, and quality of care. They usually only operate for a limited time, for a specific group of people, and in specific areas.

Extra Help

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

Formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This is also called a drug list.

Inpatient Rehabilitation Facility

A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.

Institution

For the purposes of this publication, an institution is a facility that provides short-term or long-term care, such as a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences, like an assisted living facility or group home, aren’t considered institutions for this purpose.

Lifetime Reserve Days

In Original Medicare, these are additional days that Medicare will pay for when you’re in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

Long-term Care

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, like dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living, or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

Long-term Care Hospital

Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

Medically Necessary

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

Medicare-approved Amount

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

Medicare Health Plan

Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans that can be offered by public or private entities and provide Part D and other benefits in addition to Part A and Part B benefits.

Medicare Plan

Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug Plans.

Premium

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Preventive Services

Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).

Primary Care Doctor

The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.

Primary Care Practitioner

A doctor who has a primary specialty in family medicine, internal medicine, geriatric medicine, or pediatric medicine; or a nurse practitioner, clinical nurse specialist, or physician assistant.

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Service Area

A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.

Skilled Nursing Facility (SNF) Care

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility.

TTY

A teletypewriter (TTY) is a communication device used by people who are deaf, hard-of-hearing, or have a severe speech impairment. People who don’t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.



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Medicare Program: Medicare is a federal government program which provides health insurance to people who are 65 or older. This program also covers certain younger people with disabilities (who receive Social Security Disability Insurance - SSDI), and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD.

Medicare Assignment: Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

NPI Number: The National Provider Identifier (NPI) is a unique identification number for covered health care providers. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA (Health Insurance Portability and Accountability Act).

Our Data: Information on www.medicarelist.com is built using data sources published by Centers for Medicare & Medicaid Services (CMS) under Freedom of Information Act (FOIA). The information disclosed on the NPI Registry are FOIA-disclosable and are required to be disclosed under the FOIA and the eFOIA amendments to the FOIA. There is no way to 'opt out' or 'suppress' the NPPES record data for health care providers with active NPIs.