FEDERAL HEALTH INSURANCE
Medicare is not easy to understand, and the rules change every year. Health care and health insurance mean different things to different people. What’s right for one person may not be suitable for another, and there is no one-size-fits-all solution. Each person, each case, and each situation needs a knowledgeable licensed insurance agent who knows the plans and programs to guide them around the slippery slopes and the pitfalls in the system today. Our mission is to help you make sense of it all, and determine your needs for this stage of life as your circumstances change.
Medicare is a federal health insurance program for individuals 65 or older, under 65 who have a qualifying disability, and of any age with a diagnosis of End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease).
There are four parts to Medicare: A, B, C, and D. Each part covers different aspects of healthcare. You can enroll in one or more parts of Medicare, but commonly people begin by enrolling in Parts A and/or B, as these cover the majority of services. If you plan to continue working after age 65, ask your agent about when to enroll. You do not usually have to pay a monthly premium for part A, but this can vary based on income. With Medicare alone you will have to pay copayments or a deductible. You can apply for assistance or help if you can’t pay.
Medicare Part A generally speaking, covers hospital “inpatient” costs. You are considered “inpatient” when you are formally admitted to a hospital with a doctor’s order. You are considered outpatient if you receive any type of in or outpatient hospital services without being formally admitted to a hospital with a doctor’s order. Part A also covers approved stays in skilled nursing facilities, hospice care at home and, in some situations, Hospice care in approved facilities.
Medicare Part B covers “outpatient care”. This may include your doctor services and preventive healthcare, emergency services, overnight “observation” stays, outpatient surgery, lab tests, and X-ray and a wide range of tests and services. There is a premium for part B coverage.
People often have Parts A and B together to get basic coverage. For example, if you stay in a hospital, the stay would be covered under Medicare Part A and the doctor’s services would be covered under Part B.
Approved services are covered under Medicare Parts A and B if you see a doctor that accepts Medicare. If you need a service outside of what is covered by Medicare, you will have to pay for that service. Services from doctors who do not accept Medicare may cost more and you might have to pay the full amount up-front. If some of the cost is covered, you will get paid back through a claims process.
Medicare Part D is prescription drug coverage and is available separately through private insurance companies approved by Medicare. You get prescription drug coverage either through a stand alone Part D prescription drug plan (PDP) or a Medicare Advantage plan (MAPD) that includes prescription drug benefits.
Medicare Advantage plans (Part C) can combine Parts A, B, and D in a single plan. All Medicare Advantage plans require enrollment in Medicare Part A and Medicare Part B. Medicare Advantage plans have an annual limit on out-of-pocket costs on covered services.
MSA is a type of Medicare Advantage plan that is different from the traditional plans. It provides a way to use your Medicare dollars to fund your own healthcare choices and allows for an open network.
A Medicare Supplement (Medigap), depending on the plan you choose, helps with some, most or all of the out-of-pocket costs that Medicare approves, but doesn’t necessarily pay in full, like coinsurance and copayments. Medicare Supplement plans don’t cover prescription drug costs. That is usually added separately through a part D plan.
Not all plans are available in all locations. We find out which plans are available in our area, and then compare the benefits to determine the best fit for your specific needs.