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Alabama Health Guidance is an independent insurance agency specializing in Medicare Education and Medicare Health Plans. We offer free Medicare classes and free individual counseling sessions to help you understand the basics of Medicare and your Medicare insurance options. We want to be your local resource for Medicare education and Medicare insurance plans.

 

If you need a basic education on Medicare or help comparing Local Medicare insurance plans, let us know. We offer a wide range of Local Medicare services to assist you.

 

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Facts About Medicare

Do you know the difference between the "Parts" of Medicare – Part A, Part B, Part C, and Part D? There are many important facts you need to understand about Medicare prior to enrolling to make sure you get the most out the available Medicare plans and benefits.

 

Background on Medicare
 

Medicare is a federal health insurance program that pays for a variety of health care expenses. It's administered by the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health & Human Services (HHS). Medicare beneficiaries are typically senior citizens aged 65 and older. Adults with certain approved medical conditions (such as Lou Gehrig's disease) or qualifying permanent disabilities may also be eligible for Medicare benefits.

 

Similar to Social Security, Medicare is an entitlement program. Most U.S. citizens earn the right to enroll in Medicare by working and paying their taxes for a minimum required period. Even if you didn't work long enough to be entitled to Medicare benefits, you may still be eligible to enroll, but you might have to pay more.

 

There are four different parts to the Medicare program. Parts A and B are often referred to as Original Medicare. Medicare Part C, or Medicare Advantage, is private health insurance, whileMedicare Part D offers coverage for prescription drugs. The details below tell you more about Medicare insurance plans, with an overview of the four parts.

 

The "Parts" of Medicare
 

The types of Medicare programs are often referred to as Part A, Part B, Part C, and Part D. Here's a rundown of what each "Part" is about.

 

Medicare Part A
 

Medicare Part A is hospital insurance. Part A covers inpatient hospital care, limited time in a skilled nursing care facility, limited home health care services, and hospice care.

Most Medicare Part A beneficiaries don't have to pay a monthly premium to receive coverage under this part of Original Medicare; this is called "premium-free Part A." Generally, if you've worked at least 10 years (40 quarters) and paid Medicare taxes while you worked, you're eligible for premium-free Part A. Otherwise, you pay a monthly premium.

 

Medicare Part A typically doesn't cover the full amount of your hospital bill, so you will probably be responsible for a share in the cost. You will also have to pay a deductible before Medicare benefits begin. Medicare will then pay 100% of your costs for up to 60 days in a hospital or up to 20 days in a skilled nursing facility. After that, you pay a flat amount up to the maximum number of covered days. Your Medicare Part A benefits cover some of the costs for a total of 90 days in a hospital and 100 days in a skilled nursing facility. Medicare also covers up to 60 "lifetime reserve days." These are days you stay in a hospital longer than 90 days in a row. You get a lifetime total of 60 reserve days.

 

Medicare Part B
 

Medicare Part B is medical insurance. Part B benefits cover certain non-hospital medical expenses like doctors' office visits, blood tests, X-rays, diabetic screenings and supplies, and outpatient hospital care. You pay a monthly premium for this part of Original Medicare. The fee can be higher for people with high incomes. A different government program, Medicaid, can help cover Medicare Part B premiums for low-income beneficiaries.

 

Medicare Part B beneficiaries are usually responsible for a portion of their health care costs. You'll have to pay a small deductible each year before your Medicare Part B benefits kick in, and then you’ll generally pay 20% of the bill when you go to a participating Medicare doctor. Medicare pays the full cost of many lab tests and services requested by your doctor.

 

Medicare Part C
 

Medicare Part C, or Medicare Advantage, insurance often includes every type of Medicare coverage in one health plan. It's offered by private insurance companies contracted through CMS to provide a Medicare benefits package as an alternative to Original Medicare. Medicare Advantage is optional, but to obtain this private insurance you must also have Original Medicare, Part A and Part B. You also continue to pay your Part B premium if you have a Medicare Advantage plan. 

 

While Medicare Advantage plans are required to provide all Medicare Part A and Medicare Part B benefits (except hospice care), plans can also include different additional benefits, which vary among the individual private health insurers. Many Medicare Advantage plans include prescription drug coverage. Some plans might have a lower deductible, while also allowing you to pay a smaller share of the remaining costs. Medicare Advantage plans may even cover certain health care services that Original Medicare, Part A and Part B, does not cover, like eye exams, hearing aids, dental care, or health care received while traveling outside the United States.

 

Read more about Medicare Advantage Plans

 

Medicare Part D
 

Medicare Part D is optional prescription drug coverage. Medicare Part D is available as a stand-alone plan through private insurance companies, and the monthly fee varies among insurers. You will share in the costs of your prescription drugs according to the specific plan in which you’re enrolled. Those costs can include a deductible, a flat copayment amount, or a percentage of the full drug cost (called "coinsurance").

 

If you want prescription drug coverage, you can get it through a Medicare Advantage plan, if there's one in your area that offers this coverage. Alabama Health Guidance can help you review and compare a list of Medicare Advantage plans in your area.

 

If you have limited income and cannot afford your medications, even though you receive Medicare Part D benefits, you may qualify for the Extra Help program, which offers financial assistance for your monthly premium, deductible, copayment, or coinsurance.

 

Learn more about Covered and Excluded Drugs in Medicare Part D

 

 

 

Medicare has neither reviewed nor endorsed this information.

 

Sources: medicare.gov

 
 
 
 

More about Medicare Advantage Plans

What is a Medicare Advantage plan?

 

If you qualify for or are already enrolled in Original Medicare, you can choose to enroll in Medicare Part C, more commonly known as Medicare Advantage. Medicare Advantage plans are offered by private health insurance companies and provide Medicare Part A and Part B coverage (hospital and medical benefits).

 

You might wonder why a beneficiary would choose to enroll in Medicare Advantage. A Medicare Advantage plan generally covers everything that Original Medicare covers, including emergency and urgent care. But, there can be some differences between Original Medicare and Medicare Advantage. Those differences can be in how much you pay out of your own pocket when you receive health care. For example, you might have lower copayments and coinsurance or a smaller deductible.

 

Medicare Advantage offers at least the same coverage as Original Medicare, and may offer additional benefits. It’s one way of adding coverage for vision, dental, dentures, and more.

 

There can also be differences in the coverage you receive. Some Medicare Advantage plans include routine vision, routine dental, and/or wellness programs. Many plans also include prescription drug coverage; those plans are called Medicare Advantage Prescription Drug plans. (Hospice care is covered by Original Medicare, and hospice benefits continue to be covered by Original Medicare even if you have a Medicare Advantage plan.)

 

Do be aware that you would remain enrolled in Original Medicare even if you add a Medicare Advantage plan, and you must continue paying your Medicare Part B premiums. However, if you join a Medicare Advantage plan, you won't need and can't be sold a Medicare Supplement plan (Medigap). 

 

Types of Medicare Advantage (Part C) Plans

 

It's important to understand the differences between the types of Medicare Advantage plans to see which works best for you. There are several different types of Medicare Advantage plans:

  • HMO (Health Maintenance Organization Plan) : Lets you see doctors and other health professionals who participate in its network. If your doctor is already in that network, it could be a good option because you tend to pay less out-of-own pocket with network doctors.

  • PPO (Preferred Provider Organization Plan) : Covers both in- and out-of-network providers, giving you the freedom to choose any doctor, which can work if you prefer that kind of flexibility.

  • PFFS (Private Fee-for-Service Plan) : Pays a specific amount for health care services, and the treating doctor has to accept that amount--even if it is less than his or her usual charge. If the doctor doesn’t agree to those terms, then the Health Plan will not cover services through that doctor.

  • SNP (Special Needs Plans): Are especially for people who have certain special needs. The three SNP plans cover Medicare beneficiaries living in institutions, those who are dual-eligible for Medicaid and Medicare, and those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS. This type of plan always includes prescription drug coverage.

  • HMO-POS (Health Maintenance Organization - Point of Service Plan): Covers both in- and out-of-network health services, but at different rates. You pay less out of pocket when you go to in-network doctors, labs, hospitals, and other health care providers.

  • MSA (Medical Savings Account Plan) : Includes both a high deductible and a bank account to help you pay that deductible. The amount deposited into the account varies from plan to plan. The money is tax-free as long as you use it on IRS-qualified medical expenses, which include the health plan's deductible. 

 

Eligibility for Medicare Advantage

 

Medicare Part C eligibility is based on your membership in or eligibility for Original Medicare, Part A and Part B (except if you have ESRD). Generally, if you have Medicare Part A and Part B, you are eligible for Medicare Part C. However, you must live in the service area for the Medicare Advantage plan that you're considering.

 

If you have other health insurance coverage, for example through an employer or union, ask your plan administrator about that plan’s rules before you enroll in a Medicare Advantage plan. In some cases, you may lose your other coverage if you enroll in the Medicare Advantage plan, and you may be unable to get it back if you change your mind later.

 

Enrollment in Medicare Advantage

 

You may only enroll in a Medicare Advantage plan during specified election periods.

 

Initial Coverage Election Period:  You can enroll in Medicare Advantage or Medicare Advantage with prescription drug coverage when you first become eligible for Medicare. Your Initial Coverage Election Period (ICEP) is a seven-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you are under age 65 and you receive Social Security disability, you qualify for Medicare in the 25th month after you begin receiving your Social Security benefits. If you fall into this category, you may enroll in a Medicare Advantage plan 3 months before your month of eligibility, during the month of eligibility, and 3 months after the month of eligibility. For example, if your Medicare Part A and Part B coverage begins in May, your Medicare Advantage IEP is February through August.

 

Some Medicare Advantage plans have a $0 premium. However, regardless of how much you pay for Medicare Advantage, you must continue making your Medicare Part B premiums.

 

Annual Election Period:  If you are already enrolled in Original Medicare, then you must wait until the next enrollment period to sign up for Medicare Advantage. The Annual Election Period (AEP) is October 15th through December 7th every year. The plan coverage you choose during the AEP begins on January 1st of the following year.

 

Disenrollment:  If, after enrolling in a Medicare Advantage plan, you change your mind, you can switch back to Original Medicare from January 1st through February 14th each year. If you would be losing prescription coverage as a result of the switch, you can also sign up for a Medicare Part D stand-alone prescription drug plan during this time, if you wish.

 

Special Election Period:  Generally, once you enroll in Medicare Advantage, you stay enrolled until the next Annual Election Period (AEP) opens. However, there are some life events that might qualify you for a Special Election Period (SEP) during other times of the year, so you can make a change to your Medicare Advantage coverage. Some examples of these life events include (but aren’t limited to):

  • Moving outside your Medicare Advantage Plan's service area

  • Qualifying for Extra Help (a program to help you pay for prescription drugs)

  • Moving into an institution (such as a nursing home)

 

Medigap Supplemental Plans

 

If you're concerned about Medicare costs, a Medigap health insurance policy (also called Medigap supplemental insurance or a Medicare supplemental plan) helps pay the "gap" between what Original Medicare (Medicare Parts A and B) pays and what you pay out of your own pocket. You can get a Medicare Supplement policy through private insurance companies. Contact us to discuss specific Medicare Supplement Plans in detail.

 
What you should know about Medigap

 

The Medigap policy you purchase must be clearly identified as "Medicare Supplement Insurance." There are 10 different Medigap coverage options to choose from. Plans are labeled A, B, C, D, F, G, K, L, M, and N (Plans E, H, I, and J are no longer available).

 

All insurance companies selling a particular Medigap plan type in your area must offer the same coverage, but may offer it at different prices. So, you may want to shop for the best price.

 

You can get a Medicare Supplement Plan only if you already have Original Medicare. Medigap covers Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), but it does not cover Medicare Part C (Medicare Advantage plans), Medicare Part D (prescription drug plans), or any other private health insurance, Medicaid, Veterans' Administration benefits, or TRICARE.

 

Because Medigap policies are regulated by state and Federal laws, the benefits for all the coverage options are the same regardless of insurer. The differences will be in the price, who administers the plan, and which of the 10 options the insurer chooses to offer. Choose a health insurer you trust, or let us help you shop for the best prices.

 

(Residents of Massachusetts, Minnesota, or Wisconsin also have the option to buy a Medicare SELECT policy. If you choose this type of Medicare Supplement Plan, then you will have to use a specific network of doctors and hospitals.)

 
Open enrollment for Medicare Supplement Plans

 

Your open enrollment for Medigap supplemental insurance begins the first day of the month in which you turn 65 and are covered under Medicare Part B. You have six months to enroll. If you are under 65, check with your state's Social Security Administration to see if it offers additional open enrollment periods.

 

Be aware that Medigap plans supplement Original Medicare to fill in cost gaps. If you are considering a Medicare Advantage plan, you won’t need, and can’t be sold, a Medigap plan.

 

As long as you enroll during this six-month open enrollment period, the insurance company cannot refuse to sell you a Medigap policy, charge you more because you have health problems, or make you wait for coverage to begin. However, you may have to wait up to six months for coverage of a pre-existing condition. Original Medicare will still cover that health problem, even if your Medicare Supplement Plan doesn't cover your out-of-pocket costs.

 

If you enroll in a Medicare Supplement Plan outside of your open enrollment period, the private insurance company may "underwrite" the plan. That means you may be subject to a physical, and the insurance company can refuse to sell you the plan, or they can adjust your premium based on your health status.

 

If you enroll in a Medicare Advantage plan, you are not allowed to use and can't be sold a Medigap policy. However, if you later return to Original Medicare, Parts A and B, you have a 12-month special enrollment period to sign up for a Medigap Supplement Plan. Contact us to discuss specific Medicare Supplement Plans in more detail.

 

How insurance companies set Medigap premiums

 

There are three ways an insurance company can set Medigap premium rates:

  • "Community-rated" (or "no-age-rated") premiums are the same for everyone, regardless of age.

  • "Issue-age-rated" (or "entry-age-rated") premiums are based on your age when you first buy the policy. The sooner you enroll, the less you will pay.

  • "Attained-age-rated" premiums are based on your current age, meaning it goes up as you grow older.

 

Other factors impacting the premium rates can include inflation, geography, medical underwriting (if you did not enroll when first eligible), and other discounts. Let us help you check each specific health insurer to see how it sets Medigap prices before you buy. Contact us today.

 

Medicare Part D Donut Hole - Medicare Coverage Gap

 

You may not know that under Medicare Part D, you will have a prescription drug coverage gap, often referred to as the "donut hole," during which you won't be able to receive prescription drug coverage. Find out exactly what this gap is, and learn how to bridge the prescription drug coverage gap.

 

What is the Medicare donut hole?

 

Most Medicare Part D plans have a coverage gap, sometimes called the Medicare donut hole. This means that after you and your Medicare drug plan have spent a certain amount of money for covered prescription drugs, you then have to pay all costs out-of-pocket for the drugs, up to a certain limit. The yearly deductible, co-insurance, or co-payments, and what you pay while in the coverage gap, all count toward this out-of-pocket limit. The limit doesn't include the drug plan's premium.

 

There are plans that offer some coverage while you're in the gap, for generic drugs for example. However, plans with gap coverage may charge a higher monthly premium. Check with the plan first to see if your drugs would be covered during the gap.

 

Once you reach the plan's out-of-pocket limit during the coverage gap, "catastrophic coverage" automatically kicks in. Catastrophic coverage means that when you've spent up to the plan's out-of-pocket limit for covered drugs, you will only pay a small co-insurance amount or a co-payment for the rest of the year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Extra Help with the coverage gap

 

People who get Medicare Extra Help to pay drug costs won't have a coverage gap and will pay a small or no co-payment once they reach catastrophic coverage. Extra Help is a special part of Medicare prescription drug coverage that gives more assistance to people with limited incomes than the regular program does.

If you qualify, you can save a lot of money. If you qualify for "full" Extra Help, you receive coverage throughout the year (no coverage gap) and pay very little for your prescriptions. If you qualify for "partial" Extra Help, you receive coverage throughout the year and pay a reduced premium and deductible and up to 15% of the cost of your drugs.

 

Obamacare and the coverage gap

 

Federal health care reform legislation -- the Affordable Care Act, also called Obamacare -- has addressed the problem by steadily reducing the prescription drug coverage gap over several years. By 2020, the prescription drug coverage gap will be closed completely, meaning that the donut hole will cease to exist, and you will only have to pay 25% of the cost of your prescription drugs until you reach your annual out-of-pocket limit.

 

 

 

Medicare has neither reviewed nor endorsed this information.

 

 

 

Do you have more questions?  Connect with any of our Licensed Insurance Agents to answer your Medicare questions or discuss a Medicare plan that is right for you. Make an appointment to talk to a LOCAL Medicare Insurance Specialist.

 

 
 

Covered and Excluded Drugs in Medicare Part D Drug Formulary

 

Medicare Prescription Drug Plans are privately insured. This basically means that each Medicare Prescription Drug Plan will provide different types of prescription drug coverage. It's the insurance company that ultimately decides which drugs to cover under its prescription drug plan and at what benefit level.

 

The different levels of covered drugs under the prescription drug plan are called "tiers." The tiers represent how much you pay out of pocket for the Part D drugs listed in each particular tier. For example, the plan may have one tier for generic drugs, another for brand-name drugs, and even a third tier for preventive drugs used to control certain medical conditions.

 

This list of covered prescription drugs is called a "formulary," and it contains all the drugs that the Medicare Prescription Drug plan prefers you to buy. Generally, a plan covers drugs that cost less at a higher level, meaning you pay less out of pocket. Thus, it's always in your interest to ask your doctor to prescribe drugs that are on your Medicare Prescription Drug Plan's formulary. Usually, generic drugs are the least expensive.

 

Changes in a Part D formulary

 

Each Medicare Prescription Drug Plan is required to publish its formulary. You can usually find this list of covered drugs on the plan insurer's website. The plan must also tell you when it removes drugs from the Part D formulary.

 

Prescription drug plans are restricted from making changes to the listed drugs – or changing the tiered pricing – between the beginning of the plan's annual election period until 60 days after the plan coverage begins. The exception to this is if the FDA determines a drug is unsafe or a manufacturer removes a drug from the market.

 

Mid-year changes to formulary drugs are limited, and plan insurers must always notify you of such changes. The notification of change must include the name of the drugs, Part D change type (e.g., add/remove/tier change), the reason for the change, alternate drugs, new Part D cost sharing, and exceptions.

 

Drugs covered under Medicare Part D

 

Medicare Prescription Drug Plans cover all commercially available vaccine drugs when medically necessary to prevent illness. Otherwise, the insurer decides which drugs to cover, which drugs not to cover, and under which tier to cover them.

 

Before enrolling in a Medicare Prescription Drug Plan, you should review the plan's formulary to see which drugs it covers. You can contact us for assistance, if you like.

 

Drugs not covered under Medicare Part D

 

Since the Medicare Part D plan insurer decides which drugs not to cover, the list here is not complete. However, plans usually do not cover:

  • Barbiturates

  • Weight loss or weight gain drugs

  • Drugs for cosmetic purposes or hair growth

  • Fertility drugs

  • Drugs for sexual or erectile dysfunction

  • Nonprescription drugs

 

Medicare Part D also does not cover any drugs that are covered under Medicare Part A or Part B.

 

Your Medicare Part D rights

 

If you have a Medicare Prescription Drug Plan, you have the right to:

  • Receive "coverage determination" – a written explanation from your plan about your benefits, including how drugs are covered, your costs for drugs, any coverage requirements (such as drugs that require the plan's prior authorization), and requirements for making coverage exceptions.

  • Ask for exceptions to drugs not covered by your plan's formulary.

  • Ask for exceptions to waive plan coverage rules (like prior authorization).

  • Ask for a lower copayment for higher-cost drugs, if you or your prescriber believe you cannot take any of the lower-cost drugs for the same condition.

 

 

 

Medicare has neither reviewed nor endorsed this information.

 

 

 

Do you have more questions?  Connect with any of our Licensed Insurance Agents to answer your Medicare questions or discuss a Medicare plan that is right for you. Make an appointment to talk to a LOCAL Medicare Insurance Specialist.

 

 

Original Medicare, Part A & Part B

 

Medicare Part A and Medicare Part B are often referred to as Original Medicare. Original Medicare is managed by the federal government and provides Medicare eligible individuals with coverage for and access to doctors, hospitals, or other health care providers who accepts Medicare. It is a fee-for-service plan, meaning that the person with Medicare usually pays a fee for each service. Medicare pays its share of an approved amount up to certain limits, and the person with Medicare pays the rest.

 

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that runs Medicare. CMS is part of the U.S. Department of Health and Human Services. Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.

 

 

What is not covered by Original Medicare?

 

Original Medicare, Part A and Part B, doesn't cover everything. For example, it doesn't cover cosmetic surgery, health care you get while traveling outside of the United States (except in limited cases), hearing aids, most hearing exams, long-term care (like care in a nursing home), most eyeglasses, most dental care and dentures, and more. Generally, Original Medicare, Parts A and B, does not cover prescription drugs, although it does cover some drugs in limited cases such as immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs. Some of the services that are not available through Original Medicare may be covered by a Medicare Advantage plan.

 

How much does Original Medicare cost?

 

People usually don't pay a monthly premium for Medicare Part A coverage if they or their spouse paid Medicare taxes while working. For Medicare Part B, most people pay a standard monthly premium. Some people may pay a higher Medicare Part B premium based on their income.

 
Original Medicare assignment

 

Original Medicare pays for health care services through a process called assignment. Assignment means your doctor, health-care provider, or medical product supplier will accept the Medicare-approved amount as full payment for services. Getting services and supplies from a doctor, provider, or supplier who accepts assignment can reduce your out-of-pocket costs.

 

To fully benefit from Original Medicare assignment, you must be aware that:

 

  • Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. In some cases, they must accept assignment, for example when they have a participation agreement with Medicare and give you Medicare-covered services.

  • If a doctor, provider, or supplier accepts assignment, they agree to only charge you the Medicare deductible or coinsurance amount and will wait for Medicare to pay its share.

  • All doctors, providers, and suppliers that give you Medicare-covered services have to submit your claim to Medicare directly. They can't charge you for submitting the claim.

 

To find doctors and suppliers who accept assignment, visit Medicare.gov and select "Find a Doctor" or "Find Suppliers of Medical Equipment in Your Area." You can also call 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048), 24 hours a day, seven days a week.

 

If your doctor, provider, or supplier does not accept Original Medicare assignment, be aware that:

 

  • They still must submit a claim to Medicare when they give you Medicare-covered services. If they don't submit the claim for these services, you should contact the company that handles Medicare claims for your state to file a complaint. You can call 1-800-MEDICARE (1-800-663-4227) (TTY users 1-877-486-2048) for their telephone number. In the meantime, you might have to pay the entire charge at the time of service, and then submit your claim to Medicare to get paid back.

  • They may charge you more than the Medicare-approved amount, but there is a limit called "the limiting charge." They can only charge you 15% over the Medicare-approved amount. (This amount could be lower in your state.) The limiting charge applies only to certain services and doesn't apply to some supplies and durable medical equipment.

 

 

 

Medicare has neither reviewed nor endorsed this information.

 

 

 

Do you have more questions?  Connect with any of our Licensed Insurance Agents to answer your Medicare questions or discuss a Medicare plan that is right for you. Make an appointment to talk to a LOCAL Medicare Insurance Specialist.

 

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Alabama Health Guidance is an independent insurance agency and does not represent Medicare or any other government agency.