Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.

Part B helps cover:

• Services from doctors and other health care providers
• Outpatient care
• Home health care
• Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
• Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)

Part D helps cover the cost of prescription drugs (including many recommended shots or vaccines). You can join a Medicare drug plan in addition to Original Medicare, or you get it by joining a Medicare Advantage Plan with drug coverage. Plans that offer Medicare drug coverage are run by private insurance companies that follow rules set by Medicare. 

• Original Medicare includes Part A and Part B.
• Pays for 80% of your Medicare Coverage however there is NO CAP.
• You can also buy supplemental coverage that helps pay your out-of-pocket costs (like your 20% coinsurance).

When you first sign up for Medicare and during certain times of the year, you can choose which way to get your Medicare coverage. There are 2 main ways:

 Extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Policies are standardized, and in most states named by letters, like Plan G or Plan N. The benefits in each lettered plan are the same, no matter which insurance company sells it.

• Monthly Plan Cost $150 +/-
• Automatic Renewal (expect annual price increases).
• See any doctor, specialist, or hospital that accepts Medicare.
• Annual Deductible $257 (year 2025).
• Traveler: US Coverage
• Option to purchase seperately: Rx Coverage, Dental, and Vision.

• Monthly Plan Cost generally $0-100
• Annual Contracts (needs reviewing of doctors, hospitals, Rx, and benefits)
• These “bundled” plans include Part A, Part B, and usually Part D in most cases.
• Restrictions: You can only use doctors and hospitals who are in-network.
• Plans often have different out-of-pocket costs -You need to be aware of your deductibles and Max Out Of Pocket expenses.
• Plans may offer some extra benefits such as dental, vision, hearing, gym membmership, and grocery card. (plans vary year to year and by company)*Source: www.medicare.gov

How to sign up for Medicare Coverage and when not to.

When you first sign up for Medicare you have to contact Social Security Office.  You can elect Medicare coverage without requesting your Social Security retirement benefits.

• Sign Up for Medicare Part A and Part B
• Check with your employer to make sure they do not offer any retirment group benefits.

Qualified events can triger enrollment dates but will require a special code.  Qualifiing Event may include:

Move

Marriage/Divorce

Catastrophic Weather Event

Medicaid Level change

• Medicare Advantage (C) **make sure no Rx is provided
• Plans may offer some extra benefits that Original Medicare doesn’t.

• Original Medicare includes Part A and Part B.
• Pays for 80% of your Medicare Coverage however there is NO CAP.
• You can also buy supplemental coverage that helps pay your out-of-pocket costs (like your 20% coinsurance).

When you first sign up for Medicare and during certain times of the year, you can choose which way to get your Medicare coverage. There are 2 main ways:

 Extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Policies are standardized, and in most states named by letters, like Plan G or Plan N. The benefits in each lettered plan are the same, no matter which insurance company sells it.

• Monthly Plan Cost $150 +/-
• Automatic Renewal (expect annual price increases).
• See any doctor, specialist, or hospital that accepts Medicare.
• Annual Deductible $257 (year 2025).
• Traveler: US Coverage
• Option to purchase seperately: Rx Coverage, Dental, and Vision.

• Monthly Plan Cost generally $0-100
• Annual Contracts (needs reviewing of doctors, hospitals, Rx, and benefits)
• These “bundled” plans include Part A, Part B, and usually Part D in most cases.
• Restrictions: You can only use doctors and hospitals who are in-network.
• Plans often have different out-of-pocket costs -You need to be aware of your deductibles and Max Out Of Pocket expenses.
• Plans may offer some extra benefits such as dental, vision, hearing, gym membmership, and grocery card. (plans vary year to year and by company)

*Source: www.medicare.gov

Hospice care is always covered under Original Medicare, even if you have a Medicare AdvantagePlan. After electing hospice, care related to your terminal illness will follow Original Medicare’s costand coverage rules.

While you cannot receive curative care for symptoms related to your terminal illness, Medicare willcover treatment for unrelated conditions. For example, if you have elected hospice because you have terminal cancer and you fall and break your hip unrelated to the cancer and meet other requirements, Medicare would cover the physical therapy you need for the broken hip. If you have a Medicare Advantage Plan and need care unrelated to your terminal condition, you can choose to either see providers in your plan’s network or see Original Medicare providers.

• When seeing Medicare Advantage providers, you should follow your plan’s coverage rules, including seeing in-network providers. You should owe your usual Medicare Advantage costsharing.
• If you see Original Medicare providers, you will pay Original Medicare cost-sharing.

Your Medicare Advantage Plan or Part D plan should also cover prescription drugs unrelated to your terminal condition, and the plan’s cost and coverage rules will apply.

Your Medicare Advantage Plan will also continue to cover any additional benefits it provides, suchas vision or dental services.

© 2023 Medicare Rights Center. Used with permission

Generally, the different parts of Medicare help cover specific services. Most beneficiaries choose to receive their Parts A and B benefits through Original Medicare, the traditional fee-for-service program offered directly through the federal government. It is sometimes called Traditional Medicare

or Fee-for-Service (FFS) Medicare. Under Original Medicare, the government pays directly for the health care services you receive. You can see any doctor and hospital that takes Medicare (and most do) anywhere in the country.

In Original Medicare:

• You go directly to the doctor or hospital when you need care. You do not need to get prior permission/authorization from Medicare or your primary care doctor.
• You are responsible for a monthly premium for Part B. Some also pay a premium for Part A.
• You typically pay a coinsurance for each service you receive.
• There are limits on the amounts that doctors and hospitals can charge for your care.
• If you want prescription drug coverage with Original Medicare, in most cases you will need toactively choose and join a stand-alone Medicare private drug plan (PDP).

Note: There are a number of government programs that may help reduce your health care and prescription drug costs if you meet the eligibility requirements.

Unless you choose otherwise, you will have Original Medicare. Instead of Original Medicare, you can decide to get your Medicare benefits from a Medicare Advantage Plan, also called Part C or Medicare private health plan. Remember, you still have Medicare if you enroll in a Medicare

Advantage Plan. This means that you must still pay your monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but they can do so with different rules, costs, and restrictions that can affect how and when you receive care. 

It is important to understand your Medicare coverage choices and to pick your coverage carefully. How you choose to get your benefits and who you get them from can affect your out-of-pocket costs and where you can get your care. For instance, in Original Medicare, you are covered to go to nearly all doctors and hospitals in the country. On the other hand, Medicare Advantage Plans typically have network restrictions, meaning that you will likely be more limited in your choice of doctors and hospitals. However, Medicare Advantage Plans can also provide additional benefits that Original Medicare does not cover, such as routine vision or dental care.

© 2023 Medicare Rights Center. Used with permission.

Medicare is a massive program, and it can be difficult at first to know what

resources exist to help you navigate the whole thing. Medicare is both

complex and beneficial, and a variety of trusted sources can help you

navigate your rights and options. A few are listed here:

• 1-800-MEDICARE
• Social Security Administration (http://www.ssa.gov/)
• State Health Insurance Assistance Program (SHIP)
• (http://www.shiptacenter.org/
• Medicare Rights Center (http://www.medicarerights.org/)

Perhaps the greatest resource at your disposal is medicare.gov, which

represents a massive database of searchable information and topics about

your coverage.2

When you are under 65, you become eligible for Medicare if you have

received Social Security Disability Insurance (SSDI) checks for at least

24 months or if you have been diagnosed with end-stage renal disease

(ESRD).

In the first case, the two-year waiting period begins the first month you

receive an SSDI check. You will be automatically enrolled in Medicare at

the beginning of the 25th month in which you receive an SSDI check.

If you receive SSDI because you have amyotrophic lateral sclerosis

(ALS), Medicare automatically begins the first month that your SSDI

benefits start. You do not have the two-year waiting period.

If you are under 65 and have ESRD, when your Medicare benefits begin

depends on your specific circumstances, including when you apply for

Medicare, whether you receive dialysis at home or at a facility, and

whether you get a kidney transplant. If you are eligible for ESRD

Medicare, you can enroll in Parts A and B together at any time. Part A will

be retroactive for up to 12 months, but it cannot start earlier than the first

month you were eligible for ESRD Medicare.3

There is a great misconception by the public that Medicare will pay for long term care expenses. Medicare does pay for rehabilitative services at home or in a rehab type facility. At most, that coverage lasts for 100 days and there is a required a 3-day inpatient hospitalization prior to that. At home care is provided and paid for only if it medically necessary and a professional (like a nurse or therapist) makes intermittent visits to the home.

Paying for long term care services can be expensive in both the nursing home and home care setting. Like all insurance, you need to qualify and pay for LTCi well in advance of needing it. Basically, there are three different ways of insuring for this chronic care.

1. 1. Traditional Long-Term Care policies. You must medically qualify and pay a regular premium either monthly or yearly. To qualify for expenses to be paid, you must have documented evidence of not being able to perform at least 2 of the six activities of daily living (ADL). The six ADLS’s are bathing, continence, dressing, eating, toileting and transferring. The policy will also cover benefits for someone with a cognitive impairment such as Alzheimer’s who may need standby care. The benefits can be used in a variety of situations and the policy can have a menu of extra options. I explain, it is like pre-buying a pot of money. The cost is relative. It is based on your health at application, your age and location. The bigger the pot of money you buy, the more it will cost. Generally, licensed agencies must provide care. A family member or friend does not qualify.
2. Life insurance with a Long-Term Care rider. One of the reasons people do not buy LTCi is because you pay even though you might never need or use it. This is not any different than other types of insurance. However, there is a product available that guarantees that there is some benefit paid. If you do not utilize the long-term care benefits or only part of them, the full or reduced face value of the policy is paid to a beneficiary upon death. Some policies charge extra for the LTCi rider and others are competitive with life insurance policies without living benefits. Then the cost of the rider comes out when and if it is utilized.
3. At home care plans are available to help pay for in-home care only. This is not true insurance; it is a membership with benefits. The good news is that it is relatively easy to get a plan at any age or health condition. The only criteria are that you do not need assistance at the time of purchase. The cost is based on the amount of benefits pre-purchased. You can utilize a You are viewing a preview location. contracted certified home health care agency or friend, or neighbor can be used for care. Th

Original Medicare (Parts A & B) is NOT complete medical coverage. It is a good foundation, but there are gaps in the coverage. Part A has a deductible per benefit period. Part B has a deductible once a calendar year. Even when the deductibles are paid, most Medicare Part B services are only

covered at 80 percent. Also, there is no safety net for catastrophic coverage. It does not have a MOOP (maximum out of pocket) leaving a Medicare beneficiary to potentially have enormous medical bills.

There is a solution for that! One can purchase additional medical insurance from a private company to supplement what Medicare does not cover. It will fill in some or almost all the gaps. It pays secondary to Medicare. Medicare is the only decision maker about whether something is medically necessary or will be covered. If Medicare pays, by law, the Medicare Supplement must pay their portion. Medigap policies only cover what Medicare Part A and Part B cover. There is no addition drug or dental coverage. With one exception, if Medicare does not pay their portion, your

Supplement will NOT pay either. Medicare will not pay for medical care outside the United States. Some supplements have modest coverage for that.

If you want coverage, you need to buy a separate policy from a state- approved insurance company. There are a variety of levels of coverage. The good news is that all plans are standardized (Plans A-N) so making comparisons from one company to another is, in theory, easily accomplished. The level of benefits does not change from within a letter plan. For example, all Plans G’s have identical coverage. However, the premiums do vary by company. The premiums are NOT locked in. They can and do cost more every year because of the age of the policyholder

and the fast that healthcare costs increase. The big unknown is how much and how fast the premiums will rise. This is a gamble with any company, but I recommend going with a bigger, stable, highly rated insurance company.

Many mistakenly believe that if the premium price goes too high, you can switch to another plan or company. This may be a possibility, but it is not guaranteed. You can apply for a different supplemental plan anytime of the year, but you must disclose pre-existing medical conditions. If you have a history of a major medical condition you may likely be denied a new policy. Your existing policy can not cancel you because of health conditions, but they can and do raise the premiums. They can not single you out for a rate increase, but they can get approval to do a general rate increase.

There are significant reasons to consider a Medicare Supplement Plan. The only network is Medicare. If your doctor or hospital accepts payment from Medicare, it obligated to accept payment Y from your secondary insurance. They are not allowed to balance bill. You essentially can go to any ou are viewing a preview location. Medicare doctor without a referral or loss of benefits. Some Medicare supplements come with extra perks. Some have wellness benefits such as a free Silver Sneakers membership. Some have household discounts. Others may offer nurse helplines. It is important to know what extras you have available to you.

It is not mandatory to buy a Medicare Supplement. It is an option the same as getting a Medicare Advantage Plan is an option. You cannot mix and match a supplement with a Medicare Plan C. When you turn age 65 or get Medicare Part B for the first time, you have a guaranteed right to buy

a supplement regardless of your health for six months. If within the first year you want to do a trial Medicare Advantage plan, the guarantee option lasts up 12 months. Alternatively, you can move from a supplement to a Medicare Advantage plan during a valid enrollment period.

Original Medicare, nor Medicare Supplements, cover prescription medications. Because medications are more widely used and can be expensive, CMS (Centers for Medicare and Medicaid) made a new Part of Medicare in 2006 called Medicare Part D. However, you can not get a Part D plan directly from the government like you can for Part A and Part B. These plans are contracted out to private health insurance companies. Enrollment has to be directly with the company or through an authorized agent. CMS feels so strongly that every Medicare recipient should have one – even if you do not have any prescriptions -, that they impose a late enrollment penalty (LEP) if you do not have creditable prescription coverage or are not enrolled in an approved plan.

Getting the right plan for you is super important. In 2020 there are 28 different plans available in Virginia. In a way, they are all the same because they have a government contract. However, they vary significantly because the contract has lots of moving parts. They vary by:

• Premium – the cost of the plan
• Deductible – the amount you have to pay before the plan kicks in.
• Formulary – Which specific medication is covered. The Plans only have to have two medications for the same condition. They may refuse to pay for a drug that is not on their list.
• Tiers – Some plans may charge a $30/mo co-pay for a month’s supply and another company may charge you a $40 co-pay for the exact same medication. Some may have free generic meds while others could be put on a Tier where you pay 44 percent of the cos
• Donut hole – too complicated to explain in a short synapsis
• Preferred Pharmacies - Insurance companies partner with specific pharmacies. You generally can use almost any pharmacy you want, but you may save significant co-pay amounts by using a specific pharmacy.

Because of all these variables, you could overpay by hundreds and thousands of dollars if you choose the wrong one

Prescription Drug Plans (PDP’s) do not pay for all the medication costs. On average, the Medicare beneficiary has to pay approximately 25 percent of the retail cost of the meds in the forms of co- You are viewing a preview location. payments when the prescription is picked up at the pharmacy or mail ordered.

One major problem is that the government and insurance companies renegotiate the contracts every year. That means the plan you have and like in 2020 can be not at all suitable for 2021. I recommend that they be “shopped” every year during Annual Election Period (AEP). The October

15th – December 7th of each year is time to decide which plan is best for starting the following January 1st

Medicare Advantage plans are also known as Medicare Part C. Sometimes, the doctors’ office staff refers to them as Medicare replacement plans. They really are NOT replacement plans, but an option available to all Medicare Insurance beneficiaries

These are the plans that are widely advertised on television. There really are no good plans and bad plans, only Medicare plans that suit your needs, that you understand and that you can afford. Usually, but not always, they come with a built- in prescription drug plan. The abbreviation is MAPD – Medicare Advantage prescription drug plans. They are plans that CMS (Centers for Medicare and Medicaid) has a contract with to provide their mutual clients Medicare health coverage. They are an alternative to having Original Medicare and a Medicare Supplement. Generally, by contract, these plans must be at least as good as Original Medicare (80/20) and can

be better in the fact that they offer a variety of things that Original Medicare does not offer. Examples of the Extras can be a bundled prescription plan, fitness membership, maybe dental, transportation and over the counter pharmacy items. Two of the main advantages is that they do have a MOOP (maximum out of pocket limit) and a low premium, sometimes zero $ a month.

Almost all the Medicare C plans are set up as managed care plans. CMS pays the insurance company a lot of money to take care of you. Some claim that you get better care because of care coordination. It generally means that they work in a network of providers who communicate with each other. Unless, it is an emergency or urgently need care, all medical care must to given by a participating provider to have it as a covered service. It is particularly important to make sure your doctor and hospital are “in network”. It is also important to make sure that the built- in prescription

plan covers your specific medications.

These plans can take many forms such as HMO’s, PPO’s, and private fee for service plans. Where you geographically live, determines which plans and companies are available for you to use. Generally, you sign a calendar year contract with the Medicare Advantage company. These plans have yearly contracts with CMS and the benefits can vary significantly from year to year

Also, if you become dissatisfied with your plan, after the first year, you may not have an option to buy a Medicare Supplement policy. Further information can be found at www.Medicare.org

Medicare is a US government health insurance plan for those 65 years or older or for people who have been disabled for at least 24 months. It is administered by CMS (Centers for Medicare and Medicaid).

Medicare Part A helps pay for inpatient hospital care, skilled nursing care and hospice. It has a benefit period deductible of $1408. Most people who have worked or had/have a spouse who contributed to Social Security, will pay NO premium for this portion.

Medicare Part B covers most everything else that is medically necessary (except prescription drugs). This includes doctor office visits, lab work, X-rays, Emergency Room, durable medical equipment, and outpatient surgery. The premium for this is on a sliding scale. However, the standard premium is $144.60 /mo. It has a once per calendar year deductible of $198. Once the

deductible has been met, Medicare Part B covers 80 percent of the costs.

By today’s standards, Original Medicare is good insurance. It has one major flaw. It does not have a MOOP (maximum out of pocket) protection. If a Medicare beneficiary becomes catastrophically ill, the deductibles and 20 percent co-pays can be financially significant. Most people avoid this by

purchasing either a Medicare Supplement or a Medicare Advantage Plan.

The US Government wants you to have health insurance. If you delay getting health insurance there is a late enrollment penalty. However, if you turn age 65 and you or your spouse is/are still actively working and are covered by employer health, you can delay getting Medicare and not be

subject to the penalty.

You can apply for Medicare online at www.SSA.gov or in person at a local Social Security office. Additional information can be found at www.Medicare.gov.