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The basics of medicare

Everything You Need To Know

What is Medicare?

a basic overview of medicare

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Medicare is a federal health insurance program that is offered by the federal government for those who are either turning 65 or older, under the age of 65 with certain qualifying health conditions or diagnosed with end stage disease (ERSD), which is permanent kidney failure requiring dialysis or a transplant.

The centers for Medicare and Medicaid Services (CMS) is the federal agency that oversees the federal health insurance program. Since they run the Medicare program, everything goes through CMS when someone is looking to choose their benefits

Medicare Part a

Covered
Not Covered
  • Inpatient hospitalization
  • Skilled nursing facility 
  • Home health care
  • Hospice care
  • some blood transfusion costs
  • Lab tests and other medically necessary procedures (X-Rays)
  • Other hospital services and supplies
  • doctor visits
  • long term home nursing care (100 < days)
  • Personal care items such as specific hygiene items
  • television inside your room
  • blood transfusion costs
  • inpatient hospitalization
  • Hospital expenses that are past your lifetime reserve days

Medicare Part A Deductible

  • Part A has a deductible, which for 2022 is $1,556. This $1,556 is not an annual deductible but rather a benefit period deductible.

  • This is one of the only insurances that uses a benefit period deductible and not an annual deductible.

  • If someone is admitted to the hospital, this deductible is good for 60 days starting from the day they were admitted.

  • Although unlikely, if someone were chronically ill and was admitted and discharged every 60 days, they could be responsible for this deductible up to six times during the calendar year.

Medicare Part B

Covered
Not Covered
  • Outpatient medical services 
  • Doctor visits (Primary/Specialist/Preventative care)
  • Outpatient surgeries
  • Durable medical equipment 
  • Expensive treatments like chemotherapy 
  • Ambulance services
  • doctor visits
  • long term home nursing care (100 < days)
  • Personal care items such as specific hygiene items
  • television inside your room
  • blood transfusion costs
  • inpatient hospitalization
  • Hospital expenses that are past your lifetime reserve days

Medicare Part B Deductible

  •  As of 2022, the Part B deductible is $233. This deductible is a calendar year deductible (January 1 – December 31) versus a benefit period deductible (60 days) like Part A.

  • Once this deductible has been satisfied, the good news is the individual has met Medicare’s Part B deductible for that entire calendar year. However, the individual is still responsible for a 20 percent coinsurance, which can be a big problem for someone with just Medicare Part A and B.

Medicare Part c

what is medicare advantage?

Part C is often referred to as a Medicare Advantage plan. These plans can be another way that someone can get their Medicare Part A and B coverage. Medicare Advantage plans are offered by private insurance companies that are approved by Medicare. Most of them will also include prescription drug coverage.

This option has become quite popular because it allows someone to get some additional benefits not offered by Original Medicare such as prescription, dental, vision, hearing, etc. The plans come with another big benefit because they are required to have a limit on out-of-pocket costs each year for health care services.

it is not a supplement!

These types of privatized plans are sometimes referred to as “all-in-one” plans because most will include prescription drug coverage, which is not provided under Medicare Part A and B. Someone must have both Part A and B and continue to pay their Medicare Part B premium in order to enroll in a Medicare Advantage plan.

When someone enrolls in a Medicare Advantage plan, they are no longer enrolled under Original Medicare Part A and B but will always be Medicare eligible. The individual will always be in Medicare’s system and have the right to take back their federal governments benefits. The Medicare Advantage plan is similar to group or individual health insurance.

it has it's own card

The individual will need to use the health insurance card that is sent to them by the Medicare Advantage plan to get their services covered since that will be their health insurance.  You will want to keep your red, white, and blue Medicare card somewhere safe if you decide to switch back to Original Medicare at some point in the future. 

Original Medicare has no provider networks so an individual can go to any doctor or hospital that they want to that accepts Medicare. With a Medicare Advantage plan, the individual may need to use the health care providers in that plan’s network or service area, so it’s important to refer to their card. Original Medicare Part A and B is offered by the federal government, and a Medicare Advantage Part C plan is offered by a private insurance company.

Medicare Part d

what is a prescription drug plan?

Part D covers prescription drug coverage.  These plans are provided by private insurance companies that are approved by Medicare to help with the cost of prescription drugs. Medicare never got involved in the prescription drug market but it oversees how the private insurance companies administer the prescription coverage.

the prescription drug plan (pdp)

The individual will only have two options to choose from for their prescription drug coverage when they are eligible for Medicare. The first option they have is a: Prescription drug plan (PDP), which is referred to as a stand-alone PDP. The PDP plan will not automatically be included with Original Medicare A and B as their insurance 

medicare advantage prescription drug plan (mapdp)

A Medication Advantage prescription drug (MAPD) plan is through Medicare Advantage, which includes prescription drug coverage that meets the requirements of Part D. If someone is not taking any prescription medication, they will still need to enroll in a standalone PDP or MAPD. There will be a penalty if someone does not have credible prescription coverage and does not enroll into a prescription plan when they are first eligible for Medicare.

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