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What is Medicare?

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities and any age with end-stage renal disease (ESRD) which is permanent kidney failure requiring dialysis or a kidney transplant.

The Four Parts of Medicare

Part A   Hospital Insurance
             There is a deductible. If you have a Medicare supplement it will cover the deductible.

Part B   Medical Insurance
             There is an 80/20 split.

Part C   Medicare Advantage

Part D   Prescription Drug Plan

Medicare Supplement Insurance covers extras and deductibles.

Medicare Coverage

PART A

·        Hospital stays: Inpatient room and board, general nursing, meals and other hospital services and supplies.

·        Skilled Nursing Facility Care: Inpatient skilled nursing or rehabilitation services (custodial care NOT covered).

·        Home Health Care: Part-time skilled nursing care, home health aides, physical and occupational therapy, speech and language pathology.

·        Hospice Care: For people with a terminal illness. This includes drugs for symptom control and pain relief.

·        All prescription medications you need during Medicare-covered INPATIENT care.


PART B

·        Medical Expenses: Physician’s services, some diagnostic testing, physical, speech therapy, ambulance, etc. Medicare usually pays 80% of approved amount, beneficiary pays the 20% balance.

·        Home Health Care: Part-time skilled nursing care, home health aides, physical and occupational therapy, speech and language pathology.

·        Outpatient Hospital Services: Observation hospital stays. Outpatient surgery, diagnostic procedures, emergency room, etc. Costs are a fixed amount, depending on the service.

·        Durable Medical Equipment: Walkers, wheelchairs, hospital beds, etc.

·        Drugs administered by a doctor’s office / ambulatory care. Only a few outpatient prescription medications.

PART C – Medicare Advantage Health Plans

·        Medicare Health Maintenance Organization (HMO)

·        Medicare Preferred Provider Organization (PPO)

·        Medicare Private Fee-for-Service (PFFS)

·        Medicare Special Needs Plan (SNP)

·        Medicare Medical Savings Account (MSA)

·        You still receive Part A and B. However, Medicare no longer pays your health care bills the insurance plan does.

·        May charge additional premium for plan, many do.

·        Premiums can range from $0 to $180/month.

·        Medications can be included in a Medicare Advantage plan.

May charge deductibles, then usually fixed copays such as a $20 fee for a visit to the physician or for the first several days of a hospital stay (instead of Medicare Part B or Part A inpatient deductible). Typically, very health seniors purchase these plans.

PART D – Prescription Coverage

·        At outpatient retail / mail order pharmacies.

·        Available to all people with Medicare.

·        Must be enrolled in a plan to get coverage.

·        Gets coverage through Medicare Prescription Drug Plans or Medicare Advantage Plans.

·        Choose the plan that meets your needs. Coverage, cost, convenience and customer service.

·        Under observation in a hospital as an outpatient, Part B will usually NOT cover the cost of the drugs at the hospital as the pharmacies are OUT OF NETWORK. If the hospital will not allow patients to bring in your own medications, if you receive a bill that includes medications you will need to pay the hospital and then send the bill to the Part D plan to get reimbursed.

You must obtain Medicare within 3 months before and 3 months after your 65th birthday or you will be penalized. Contact a broker who will help you choose your plans based on your personal health history and medication requirements.

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