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Medicare is confusing. We can help.

Here's the 101 on Medicare

Medicare is federally managed healthcare for persons over 65, with certain disabilities or with End-Stage Renal Disease.  To qualify for Medicare you (or your spouse) must have worked 10 years in the United States.  There are four parts to Medicare:  parts A, B, C and D.

Medicare Part A is also known as Hospital Insurance

  • This coverage includes most inpatient care for hospitals as well as some coverage for skilled nursing, hospice and home health.

  • This coverage is an entitlement and costs you nothing as long as you meet the above mentioned requirements.

  • There is no network. You may utilize any hospital that accepts Medicare Part A as a payer source.

  • You can either stay with Original Medicare (A&B) OR enroll in a Medicare Advantage Plan (Part C – below), but not both simultaneously.

Medicare Part B is also known as Medical Insurance

  • This coverage includes virtually all other medical expenses except those covered by part A.

  • This includes visits to your primary physician (and doctors at the hospital), specialists or therapy services (such as physical, occupational or speech therapies), blood work, lab work, x-rays, durable medical equipment, surgeries and preventative services.

  • You pay a premium for part B monthly based on your income. This can be deducted from your social security check, or paid out of pocket.

  • For those in higher income brackets, the premiums are higher.

  • There is also a penalty for NOT enrolling in part B when you are first eligible for Medicare. This is important and many people inadvertently delay enrollment causing unnecessary penalties (in certain circumstances, however, these penalties can be avoided).

  • There is no network and you may visit any provider (doctor, urgent care, facility or otherwise) that accepts Medicare Part B as a payer source.

  • Parts A&B combined will cover 80% of all Medicare approved charges.

Medicare Part C is also known as Medicare Advantage

  • This is where its gets REALLY confusing as these plans are essentially a different option entirely than “traditional” Medicare.

  • These plans are either HMO’s or PPO’s and thus require you to use doctors and networks that are in-network.

  • These plans are sold by private insurance companies (not the government) and combine the benefits of A & B and often include drug coverage.

  • Costs of these plans very depending on the carrier, county of residence and plan selected.

  • You must have A & B to enroll in a Medicare Advantage plan, so you will still pay your Part B premium in addition to the premiums charged for these plans

  • You can either enroll in a Medicare Advantage plan OR stay with Original Medicare, but not both simultaneously.

Medicare Part D is Prescription Drug Coverage

  • These are offered through private insurance companies to assist in covering the cost of prescription drug plans

  • Plans are optional to enroll but you will pay a penalty if you do not enroll in a part D plan when you are first eligible to Medicare

  • Plan options and costs vary by county of residence – usually 20 to 30 plans exist.

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