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A Quick Look at Medicare, Medicare Advantage (MA) and Medicare Supplemental Insurance Plans
What Is Medicare?
Medicare 101 – A Look At The BasicsOriginal Medicare started in 1965 and for several years was the only health insurance plan choice available through the Medicare program.
Medicare is health insurance designed for persons that are:
- Age 65 or older
- Under the of 65 with certain medical disabilities
- Of any age with ERSD – End Stage Renal Disease ( permanent kidney failure requiring dialysis or a kidney transplant)
- Medicare pays for many health care services and supplies, but doesn’t pay for all your health care costs that occur. As a medicare beneficiary, you still must pay for costs like coinsurance, copayment and deductibles, which are called “out-of-pocket” costs, or “cost sharing” if you have original medicare.
Medicare Coverage OptionsMedicare beneficiaries can choose the following options for their health care and prescription drugs coverage:
- Original medicare, is the governments owned federally managed program that provides Medicare Part A and Medicare Part B coverage.
- Medicare Part A (Hospital Coverage) – This helps pay for hospital charges, inpatient care, skilled nursing facilities, hospice care and home health care under certain conditions.
- Medicare Part B ( Medical Coverage) -Part B helps with medical charges like the cost for doctor services, lab tests and services received on an outpatient basis as well as other services that Part A doesn’t cover ( like physical and occupational therapy) including some home health and preventive services.
- Original Medicare Key Facts: You usually pay a monthly premium for Part You have access to any doctor or provider who accepts MedicareOut-of-pocket costs include hospital and medical deductible and coinsuranceYou may want to purchase separate Medicare supplement insurance and prescription drug plan coverage to avoid any gaps in your health insurance.
- Medicare Advantage Plans ( Part C) – Medicare Advantage plans are private insurers approved by Medicare and have a contract with the federal government to provide all the Medicare Part A and Part B benefits to those enrolled in their health plans.
What Might a Consumer Consider When Selecting a Medicare Advantage Plan?Cost – Monthly Plan Premiums- When compared to Medicare Supplement Insurance Plans and other health plan coverage Medicare Advantage Plans may offer lower monthly plan premiums. Some (MA) Medicare Advantage plans may have a $0 monthly plan premium. Predictable Costs – Medicare Advantage Plans have an annual out-of-pocket maximum that limits the amount of out-of-pocket costs a member must spend every year for covered services. In addition, some benefits may have a copayment (which is a set dollar amount) which provides a predictable member cost share. Coverage – Additional Coverage—Medicare Advantage Plans must provide all the benefits covered under Medicare Parts A & B, but most plans offer additional coverage beyond Original Medicare. In addition, many MA plans integrate medicare Part D prescription drug coverage, providing members with Medicare Parts A, B and D coverage all in one plan – all with one member ID card. Network-Network based plans (HMO, POS, PPO)
- Health Maintenance Organization (HMO)
- Point of Service (POS)
- Preferred Provider Organization / Regional Preferred Provider Organization (PPO/RPPO)
- Private Fee-for Service (PFFS)
- Must abide by the MA Plans’s coverage rules, which includes:
- Using contracted network providers if enrolled in a networked based plan. In some network-based plans like PPO/RPPO’s or some HMO-POS plans, the member can seek care from non-network providers, generally with high cost sharing
- Paying applicable plan premiums, deductibles, coinsurance, and/or copayments as their share of cost. MA Plans have an annual limit on what the member has to pay out-of pocket for Medicare-covered for Medicare-covered benefits called a Maximum Out-of Pocket (MOOP) amount.
- Are automatically disenrolled from any other MA plan or prescription drug plan PDP in which they are enrolled as of the new plans effective date. An exception exists for MA – only Private-Fee- for-Service PFFS plans as a member can also be enrolled in a standalone PDP.
- A Medicare Supplement insurance plan will not automatically terminate when enrolling in a medicare advantage plan. A Medicare beneficiary must cancel their supplement insurance policy in writing with the carrier after their request to enroll in the MA plan has been approved. This requirement applies even if MA plan and the supplemental plan are provided by the same insurance company.
- Medicare supplement policies do not work with any MA plan cannot be used in conjunction with a medicare advantage plan.
- Before enrolling in a MA plan, make sure you understand the benefits provided by the plan. You should carefully review the Benefits Coverage Information or Summary of Benefits to ensure you understand what medical coverage is provided by the plan before you enroll. For plans with drug coverage, make sure you know if your medications are covered by the new plan or if there are any utilization management restrictions that you would have to achieve prior to getting coverage for certain drugs.
In Summary Medicare Advantage Plans are:
- health plan options most notably (e.g., HMO – health maintenance organizations; PPO’s preferred provider organization and PFFS- private fee for service plans). If you enroll in a Medicare Advantage plan you are still part of the federal Medicare program and you must maintain your Part A & Part B eligibility.
- Private insurance companies approved by Medicare and have a contract with the Federal government to provide this coverage.
- Part C plans that provide Medicare beneficiaries a choice in how they receive their Medicare.
- Medicare Advantage plans are not Medicare Supplemental insurance plans.
- These are required to provide all the benefits of Original Medicare Part A & Part B and may include Part D prescription drug coverage.
- Medicare Advantage plans are designed to lower your costs and usually offer a maximum out-of-pocket limit. The maximum out- of pocket protects you and limits the amount you will be required to pay in copays, coinsurance and deductibles and other costs for medical services for the year.
- Medicare Prescription Drug Coverage (Part D)
MEDICARE SUPPLEMENT PLANSIf you are a Medicare beneficiary with Original Medicare you may want to purchase a Medicare Supplement plan to help cover the out-of-pocket costs including copays, coinsurance and deductibles that Medicare doesn’t cover. In order to purchase a Medicare Supplement or Medigap plan, a beneficiary must have both Medicare Part A and Part B.
WHAT IS A MEDICARE SUPPLEMENT?Medicare Supplemental plans (also commonly called Medigap plans) are health plans from private insurance companies that are specifically designed to work along with Original Medicare. Many private insurers sell Medicare supplement insurance plans. Medicare supplement insurance plans help pay for costs that Original Medicare doesn’t cover such as coinsurance, copayment and deductibles (also commonly called “gaps”). Medicare supplement plans may also cover certain medical services that Original Medicare doesn’t cover. For example people who are enrolled in Original Medicare and buy a Medicare supplement Plan F will generally have 100 percent of their Medicare-approved health care costs covered. (There are other medicare supplement plan choices, however Medicare supplement Plan F is the most comprehensive coverage available to individual medicare beneficiaries who are looking to purchase a Medigap insurance plan.). Our Medicare Coverage Helpline can explain the different Medicare supplement options available to you in your state. Medicare Supplemental insurance plans are not Original Medicare and are not Medicare Advantage plans because they’re not a way to get Medicare benefits. Original Medicare and Medicare Advantage plans are ways to get medicare benefits. Medicare supplement plans simply provide additional coverage to your Original medicare health insurance that you receive from the government as medicare beneficiary. To get more Medicare benefits information or information on how to apply for medicare please contact your local social security office at online at ssa gov or www.medicare.gov . Medicare supplement insurance plans are identified by letters (such as Medicare Supplement Plan F) except in the states of Massachusetts, Minnesota and Wisconsin. For example in Massachusetts medicare beneficiaries have a guaranteed issue right to purchase a medigap policy, but the polices are different. A Core Plan covers basic benefits, 60 days per calendar year of inpatient stay in a mental health hospital, state mandated benefits ( such as annual Pap tests and mammograms.). However in Massachusetts the Core Plan doesn’t cover: Part A inpatient hospital deductible, the skilled nursing facility coinsurance or Part B deductible or Foreign travel emergency. However the Supplement 1 Plan offered to residents of Massachusetts does provide this coverage. Both medicare supplement plans in Massachusetts are very different from the standardized medicare supplement insurance plans offered in many other states. Check your plan for details of other state mandated benefits. You may also compare those plans side by side by contacting Medicare.gov at www medicare gov online, or contact our Medicare Coverage Helpline for further information by calling 866-936-3831. Each of the standardized medicare supplement insurance plans must offer the same basic benefits, regardless of which insurance company sells it. Therefore a Mutual of Omaha Medicare supplement plan F is the same basic benefits as a Cigna medicare supplement plan F sold through Loyal American. A Medicare supplement plan G sold by Aetna medicare is the exact same basic benefits as a Mutual of Omaha Medicare Supplement Plan G. The main differences between Medigap or medicare supplement plans sold by different private insurance companies are the cost, the underwriting criteria used to qualify an applicant, the extra services offered by the insurance carrier (value-added) and the level of customer service. For example, although Mutual of Omaha medicare supplement plan f has the same basic benefits as other carriers, the monthly premium or what you pay differs from insurance carrier to insurance carrier. The insurance companies are private insurers and are allowed to establish their own pricing based on their revenue goals, expenses and obligations to their stockholders and members. You can therefore shop for a medicare supplement based on a true cost vs cost comparison, but be aware that some companies have more robust value added services and stellar customer service than others. Please feel free to contact our Medicare Coverage Helpline and speak to a licensed medicare supplement specialist to find a plan suited for you. Medicare supplement insurers are privately owned companies but they must follow all federal and state laws and regulating insurance carries. A Medicare supplement plan only covers one person. For example if a married couple wants to purchase medicare supplement coverage, they must buy separate individual policies. No family plan coverage is allowed, although some carriers may offer a “household discount” if more than one person has medicare supplement insurance coverage.
Medicare Supplement Insurance Plan Features
Medicare supplement plans (also referred to as Medigap policy) offer beneficiaries:
- Help with managing costs Original Medicare doesn’t pay, like coinsurance and deductibles.
- Freedom to choose and visit any doctor who accepts Medicare patients.
- No claim forms to file, the medicare supplement simply pays its share of the medical cost after Original Medicare pays first.
- Nationwide coverage so medicare beneficiaries can use their supplement anywhere in the United States. Keep in mind that when a medicare beneficiary moves, you may or may not have to change insurance carriers or plans, depending on whether you select a national Carrier and/or if your plan is available in your new area.
- Foreign travel coverage for emergencies is generally available for most plans allowing you to have peace of mind when traveling outside of the United States.
- Guaranteed renewability, which means your plan automatically renews from year to year as long you continue to pay the insurance premiums when due. This means
- A 30 day “free look” period to evaluate your plan selection. If for any reason you choose not to accept the coverage, you may receive a full refund of the premiums ( minus claims paid during the free look period, if any) if policies are returned within 30 days of issuance.
- To get more information on selecting a Medicare supplement plan please see “Choosing a Medigap Policy: A Guide to Health insurance for People with Medicare. A copy can be found on the Medicare.gov www medicare gov or at https//medicare.gov/pubs/PDF/02110-medicare-medigap.guide.pdf
Medicare Supplement Benefits Comparison Chart
Whichever Medicare supplement plan you choose, these Basic Medicare Supplement Benefits are included:Hospitalization Costs : Pays Medicare Part A coinsurance plus provides coverage for up to 365 days in the hospital after Medicare benefits end. Medical Expense : Pays Medicare Part B coinsurance (which is generally 20% of Medicare approved charges) or copayment for hospital outpatient services. Supplement plans K, L and N required the insure beneficiary to pay a portion of the Part B coinsurance/copayment. Blood: Provide the first 3 pints of blood used by a patient each year. Hospice: Pays the Part A coinsurance and respite care expenses ( including the applicable prescription drug copayments) If you live in Massachusetts, Minnesota, or Wisconsin Medigap policies are standardized in a different way. Please contact medicare gov at www medicare gov website or call 1-800-Medicare. You may also contact a medicare insurance specialist on our medicare coverage helpline at 866-936-3831.
What You Should Know About Medicare Supplemental Insurance Plans
To have a medicare supplement PolicyYou must have Medicare Part A and Medicare Part B If you have a (MAPD) Medicare Advantage Plan (commonly referred to as Part C) you can apply for a medicare supplement, however make sure you have an enrollment or disenrollment period that allows you to do so before the supplemental policy begins. Medicare supplemental plans are through private insurance companies and you must pay a monthly, quarterly or annual premium in addition to you Medicare Part B premium A supplemental insurance plan only covers one person. If you and your spouse both want a supplement plan, then you must purchase them separately. However many companies like Mutual of Omaha offer household discounts. For example if you and your spouse both purchase Mutual of Omaha medicare supplemental insurance plan F coverage you’ll receive an added discount off your monthly premiums that you pay. You can purchase a medicare supplemental insurance plan from any insurance company that is licensed in your state to sell medigap coverage. Any standardized Medicare supplement is guaranteed renewable and cannot be cancelled regardless of your health condition as long as you pay the regular premiums when due. Medigap plans sold in the past included prescription drug coverage, however any supplement plans sold after January 1, 2006 aren’t allowed to include drug coverage. You must purchase a separate Part D prescription drug plan. It is illegal for anyone to sell you a Medigap policy if you have a Medicare Medical Savings Account (MSA) Plan.
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