Medicare as easy as A, B,C and D.
When should you start thinking about
Medicare? It’s a good idea to learn
the basics well before you become
eligible. That way you can be prepared
to make an informed decision when the
time comes.
4 Getting started with Medicare
Some of the elements
Original Medicare
(Parts A and B)
does not cover are:
Vision
Dental
Hearing
Prescription
drugs
Medicare Made Clear™ — an overview.
Medicare Parts A and B are considered Original Medicare.
Part A pays for hospital care and Part B pays for doctor visits
and other outpatient care.
Original Medicare doesn’t cover everything.
Original Medicare helps you get health care coverage, but you
should expect to pay some of the costs.
You can enroll in a Medicare supplement insurance plan to help
pay some of the costs and benefits that aren’t paid by Original
Medicare Parts A and B. You can also enroll in a stand‑alone
Medicare Part D plan for help with prescription drug costs.
OR
You can instead enroll in a Medicare Advantage Part C plan
offered by private insurance companies. Part C plans generally
give you all of the coverage provided by Parts A and B, as well
as additional benefits:
••Combines hospital costs and doctor and outpatient care
in one plan
••Often include Part D prescription drug coverage
••May include additional benefits such as dental, vision or
hearing services
Who is eligible for Medicare?
Someone who is a U.S. citizen or legal resident for at least
five consecutive years And is one of the following:
••Age 65 or older
••Younger than 65 with a qualifying disability
••Any age with a diagnosis of end-stage renal disease or ALS
Your plan choices don’t have to be permanent.
As your health care needs change, you can change plans to
best meet them. You’re not locked in to one plan permanently.
You’ll have an opportunity to change plans at least once a year
during the Medicare Open Enrollment Period (October 15 –
December 7). Keep in mind there may be limitations to rejoining
a Medicare employer-sponsored plan.
Original Medicare is a federal health
insurance program for people
65 and older and others with disabilities.
Your choices — illustrated.
Medicare Choices
Decide if you need additional coverage. You have two ways to get it.
step 2
Choose a Medicare Advantage plan:
Medicare Advantage (Part C)
Offered by private companies
Add one or both of the following
to Original Medicare:
Medicare Supplement Insurance
Offered by private companies
Covers some of the
costs not paid by Original
Medicare Parts A and B
Medicare Part D
Offered by private companies
Part D covers
prescription drugs
Part C combines
Part A (hospital) and
Part B (doctor)
Provides additional
benefits
Most plans cover
prescription drugs
Option 1 OR Option 2
Enroll in Original Medicare.
step 1
Original Medicare
Provided by the government
Part B covers doctor and
outpatient visits
Part A covers
hospital stays
6 Getting started with Medicare
1 There are two main ways to get Medicare coverage.
You can choose Original Medicare (Parts A and B), which is provided by the
federal government. Original Medicare includes Part A for hospital stays and Part B
for doctor visits.
OR
You can choose a Medicare Advantage (Part C) plan from a private insurance
company. Medicare Advantage plans combine Part A and Part B coverage, and
many also include prescription drug coverage as well as additional benefits, such as
routine hearing and vision care.
2 You will pay a share of your costs.
••Original Medicare doesn’t pay for everything, and there is no limit on your
out‑of‑pocket costs
••No matter what type of Medicare plan you choose, you will pay a share of your
costs through monthly premiums, deductibles, co‑pays and co-insurance
3 Medicare supplement insurance plans help pay some of
your out‑of‑pocket costs.
Medicare supplement insurance plans, which are sold by private insurance
companies, help pay for some of the expenses not covered by Original Medicare, like
deductibles and co-pays.
4 There are two ways you can get coverage for
prescription drugs.
You can enroll in a stand-alone Part D prescription drug plan to go with your
Original Medicare coverage. Part D plans are sold by private companies.
OR
You can enroll in a Medicare Advantage (Part C) plan that includes prescription
drug coverage. Part C plans are also sold by private companies.
Medicare basics.
5 Know the choices in your state.
••Original Medicare (Parts A and B) is the same across the U.S.
••Medicare Advantage (Part C) plans and prescription drug (Part D) plans may be
available in only certain counties, states or regions
••Medicare supplement insurance plans help pay some of your out-of-pocket costs.
They travel with you nationwide. Not all plans are available in all states
6 Enroll at the right time.
Your Initial Enrollment Period (IEP) is your first chance to enroll in Medicare.
Your IEP is seven months long and includes the three months before the month you
turn 65, your birthday month and the three months after your birthday month.
••If you enroll before the month you turn 65, your coverage starts the first day of
your birthday month
••If you enroll during your birthday month or later, your coverage start date could
be delayed
••If you’re under 65 and have a qualifying disability, you are automatically enrolled
in Part A and Part B after you get Social Security or Railroad Retirement benefits
for 24 months
••If you’re under 65 and have ALS, you are automatically enrolled in Part A and
Part B the first month you get disability benefits from Social Security or the
Railroad Retirement Board
7 You can review your choices once a year.
After you choose your Medicare coverage, you can make changes each year during
Medicare Open Enrollment, which is from October 15 to December 7.
8 You may be eligible for a Special Enrollment Period.
You may be able to switch your Medicare coverage during a Special Enrollment
Period (SEP) if you have certain life changes, such as:
••You retire and leave a health care plan offered by your employer or union
••You move out of your current plan’s service area
8 Getting started with Medicare
Medicare Part A
(hospital coverage).
Medicare Part A helps with the cost of inpatient
hospital stays and skilled nursing after a hospital
stay. It also helps with hospice care and some
skilled care for the homebound.
What providers can I see?
You can choose any qualified provider in
the United States who is accepting new
Medicare patients.
Coverage limits.
There are some coverage limits with Part A.
For example, if you’re hospitalized or in a skilled
nursing facility for a long time (more than 90 days
at one time), you may have to pay part of the cost.
What isn’t covered.
Doctor services in the hospital are not covered
by Part A. Other services, such as personal
in‑hospital costs like telephone calls or services
related to “custodial care” — help with eating,
bathing or dressing — will also not be covered
under Part A unless medically necessary.
Costs.
Premium. If you or your spouse have made
payroll contributions to Social Security for
at least 10 years, you will not pay a premium for
Part A. Most people don’t pay Part A premiums.
If you haven’t made contributions, the premium
in 2016 is $411 a month. If you enroll late,
your monthly premium amount is higher.
Your share of the costs.
Deductible. You have to pay a deductible
before Part A starts paying a share of your costs.
In 2016, it’s $1,288 for each hospital stay, subject
to certain limits.
Co-pay. After staying a certain number of days,
you pay a co-pay. For hospital stays in 2016,
you’ll pay $322 per day (days 61 through 90) and
$644 per day (days 91 through 150). In a skilled
nursing facility, you’ll pay $161 per day (days 21
through 100). In 2016, you’ll also pay a co-pay of
up to $5 for each outpatient prescription drug
you receive in hospice care.
Co-insurance. You pay a small co-insurance
for inpatient respite care for hospice patients.
Part A Enrollment.
When can I join? As soon as you become eligible for Medicare.
How do I sign up? For most, if you’re already getting benefits from Social Security, enrollment
in Part A is automatic and there is no monthly premium. If you aren’t getting benefits from Social
Security, you can sign up at your local Social Security office.
Can they refuse to cover me or delay coverage? Not if you’re eligible for Medicare. You can’t be
refused Part A because of your medical history or a pre-existing illness.
Medicare Parts A and B
combined are often referred to as
Original Medicare.
Medicare Part B
(doctor visits).
How it works.
If you are receiving Social Security benefits
when you become eligible for Medicare you
will likely be automatically enrolled in Part B.
Medicare Part B helps with the cost of medically
necessary doctor visits and other medical
services, including outpatient care at hospitals
and clinics, laboratory tests, some diagnostic
screenings, and some skilled nursing care.
What providers can I see?
You can choose any qualified provider who
is eligible to participate in Medicare and
who is accepting new patients.
Coverage limits.
There are limits on a few services — for example,
the amount Part B will pay for occupational
therapy and some screenings.
What isn’t covered?
Keep in mind that Part B only covers vision,
dental or hearing in certain situations.
Additionally, it usually doesn’t cover care outside
the United States or help with things like bathing
or getting dressed.
Costs.
Premium. This depends on your yearly
income. Most people pay a monthly Part B
premium. If you receive Social Security, it will
be automatically deducted from your Social
Security benefits. For 2016, premiums range
from $104.90 to $389.80 a month.
Your share of the costs.
Deductible. Before Part B starts paying
a share of your costs, you first have to pay a
deductible. In 2016, it’s $166 for the year.
Co-pay. In 2016, outpatient hospital services
co‑pays range from a few dollars up to $1,288.
Co-insurance. After you pay your deductible,
Part B generally pays 80% and you pay 20%
as co-insurance.
Part B Enrollment.
When can I join? As soon as you become eligible for Medicare. You can also join later on, but only
at certain times of the year, and there may be a penalty.
How do I sign up? For most, if you’re already getting benefits from Social Security, enrollment in
Part B is automatic and most people pay a monthly premium. Otherwise, you can sign up at your
Social Security office.
Can they refuse to cover me or delay coverage? Not if you’re eligible for Medicare. You can’t be
refused Part B because of your medical history or a pre-existing illness.
Monthly premiums for Part B are
automatically taken out of your
Social Security check.
10 Getting started with Medicare
Medicare Part C
(Medicare Advantage).
How it works.
Medicare Advantage (Part C) plans are offered
by private insurance companies, and some
are offered through your plan sponsor. They
combine coverage for certain hospital costs,
doctor visits and other medical services in one
plan. They may also include prescription drug
(Part D) coverage, often with no added premium.
What providers can I see?
With some plans, you choose a primary care
doctor. In other plans, you can go to any
Medicare‑eligible provider who accepts the
plan’s terms, conditions and payment rates.
Medicare Advantage plans have service areas
and offer nationwide emergency coverage.
Coverage limits.
Plans vary. Check the limits and exclusions.
What isn’t covered?
Part C plans generally cover the same services
as Original Medicare (Parts A and B), except for
hospice care, which is provided under Part A.
Costs.
You’ll continue to pay your Part B premium.
And in many cases Part C plans may have their
own premiums too. Plan premiums vary widely.
Your share of the costs. Some plans have
deductibles. Some don’t. Many charge co-pays
or co-insurance. Look at the plan for details.
Out-of-pocket limits. All plans limit the
amount you have to spend, whereas Original
Medicare does not limit the amount that you may
spend out-of-pocket.
Coverage gap. If you have prescription
drug coverage, there’s a coverage gap when
your costs will likely go up.
Part C Enrollment.
When can I join? Once you have enrolled in Original Medicare (Parts A and B), you can enroll in a
Medicare Advantage plan. Unless you qualify for an exception, you may pay a penalty on your premium
if you don’t sign up for Medicare Part D coverage as soon as you are eligible. You must also join
Original Medicare (Parts A and B).
How do I sign up? Each insurance company handles its own enrollment process. These plans renew
automatically each year as long as you pay your premiums. To join, you can go online at Medicare.gov
or contact a plan provider (insurance company) directly.
Can they refuse to cover me or delay coverage? Not if you have joined Original Medicare
(Parts A and B), and the plan is accepting new members.
Can I change my coverage later? Yes, you have a chance to change your coverage each year during the
Open Enrollment Period, October 15 – December 7, or if you qualify due to a Special Enrollment Period
(SEP). Keep in mind there may be limitations to rejoining a Medicare employer‑sponsored plan.
Most Medicare Advantage
(Part C) plans include prescription
drug coverage.
How it works.
Medicare Part D plans help with the cost of
prescription drugs. They’re optional, although if
you don’t sign up when you become eligible, you
may pay a higher premium if you enroll later.
Part D is sold by private companies. Plans offer
different costs and different drug lists. The
federal government sets the guidelines. Some
Medicare Advantage plans include prescription
drug coverage.
What pharmacies can I use?
••Some plans limit your choice by area
••Others offer nationwide coverage
••Your plan may also offer mail order service
Coverage limits.
Enrolling in a Medicare
plan for the first time.
eligible for Extra Help.
Extra help is available.
If you have a lower income and fewer assets,
you may qualify for help.
Less than half of those who would qualify actually sign up,
so don’t hesitate to apply.
Medicaid
Helps pay for health care costs not covered by Medicare for
people and families with limited incomes. It may also offer extra
benefits that Medicare doesn’t cover, but each state creates its
own program, so contact your state office for more information.
See the resources on page 17 or call the Medicare Helpline at
1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048,
24 hours a day, 7 days a week for more information.
Medicare Savings Program
Helps you pay your Parts A and B premiums, deductibles
and co‑insurance.
Program of All-Inclusive Care for the Elderly (PACE)
Combines medical, social and long-term care services for frail
elderly people who live in the community, not a nursing home.
Only available in certain states.
Prescription drug premium assistance program
Helps pay for some or all of a person’s Medicare Part D
premiums, deductibles, and co-pays or co-insurance.
Other programs
May be available in your state.
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