Medicare (CMS) & Medicare Supplements

The Medicare Program

Medicare is a health insurance program for:

  • People age 65 or older.
  • People under age 65 with certain disabilities.
  • People with End-Stage Renal Disease (i.e.-
  • (permanent kidney failure requiring dialysis or a kidney transplant).

The Original Medicare Has Two Parts

Part A - Hospital Insurance.

Most people pay for Part A through their payroll taxes when they are working.

Part B - Medical Insurance.

Most people pay monthly for Part B.

You can elect to participate in a Medicare Advantage Plan Part C and 

Medicare Prescription Drug Coverage Part D

Medicare Advantage Plans

 

You can choose different ways to get the services covered by Medicare.  Depending on where you live, 

you may have different choices. In most cases, when you first get Medicare,  you are in the Original

Medicare Plan. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that

provides all your Part A, Part B, and often Part D (Medicare Prescription Drug) coverage. You make a

choice when you are first eligible for Medicare. Each year you can review your health and prescription

needs and switch to a different plan in the fall.

 

Medicare Advantage Plans are health plan options that are approved by Medicare but run by private

companies. They are part of the Medicare  Program, and sometimes called "Part C." When you join a Medicare

Advantage Plan, you are still in Medicare. As long as you have both Part A and Part B, items covered by Part A and Part B are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO).

Part D - Prescription Drug Coverage

Medicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Medicare.

Medicare Health Plans

Today's Medicare is about choice. Your health plan choices include:

  • The Original Medicare Plan
  • Medicare + Choice Plans, including:
    • Medicare Managed Care Plans
    • Medicare Private Fee-for-Service Plans
    • Medicare Preferred Provider Organization Plans

Medicare + Choice Plans are available in many areas.

The Medicare health plan that you choose affects many things like cost, benefits (some have extra benefits like prescription drugs), doctor choice, convenience, and quality.

What is Medicare Part A?

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.

Cost 

Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.

  • The part A premium is $244.00 per month for people having 30-39 quarters of Medicare-covered employment.

  • The Part A premium is $443.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

  • Medicare Part A Helps Cover Your Medically Necessary:

Hospital Stays
Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes inpatient care you get in critical access hospitals and mental health care. This doesn't include private duty nursing, or a television or telephone in your room. It also doesn't include a private room, unless medically necessary. Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.

Skilled Nursing Facility Care
Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day inpatient hospital stay).

Home Health Care
Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Hospice Care
For people with a terminal illness, includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in your home. However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).

Blood
Pints of blood you get at a hospital or skilled nursing facility during a covered stay.
 

What is Medicare Part B?

Medicare Part B (Medical Insurance) helps cover your doctors' services and outpatient hospital care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Cost

The Medicare Premium for Part B is $96.40 per month. In some cases, this amount may be higher if you didn't sign up for Part B when you first became eligible. For additional details Click Here. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn't sign up for it, except in special cases. You will have to pay this extra amount as long as you have Part B.

Medicare Part B Helps Cover Your Medically Necessary:

Medical and Other Services
Doctors' services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Also covers second surgical opinions, outpatient mental health care, and outpatient occupational and physical therapy including speech-language therapy. (These services are also covered for long-term nursing home residents.).

Clinical Laboratory Services
Blood tests, urinalysis, some screening tests, and more.

Home Health Care
Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Outpatient Hospital Services
Hospital services and supplies received as an outpatient as part of a doctor's care.

Blood
Pints of blood you get as an outpatient or as part of a Part B covered service.
 

What is the Original Medicare Plan?

The Original Medicare Plan is a "fee-for-service" plan. This means you are usually charged a fee for each health care service or supply you get. This plan, managed by the Federal Government, is available nationwide. If you are in the Original Medicare Plan, you use your red, white, and blue Medicare card when you get health care. If you are happy getting your health care this way, you don't have to change. You will stay in the Original Medicare Plan unless you choose to join a Medicare + Choice Plan.

Your costs in the Original Medicare Plan

 What you pay out-of-pocket depends on:
  • Whether you have Part A and Part B
  • Whether your doctor or supplier agrees to accept "assignment"
  • How often you need health care
  • What type of health care you need
  • Whether you choose to get services or supplies not covered by Medicare. In this case, you would pay for these services yourself.
  • Whether you have other insurance

Medicare Part A (2010)

Part A is Hospital Insurance and covers cost associated with confinement in a hospital or skilled nursing facility.


When you are
hospitalized for:		 Medicare Covers You Pay
1-60 Days Most confinement costs after the required Medicare Deductible $1100 Part A Deductible
61-90 Days All eligible expenses, after the patient pays a per-day copayment.

$275/Day
 
91-150 Days All eligible expenses, after patient pays per-day copayment.
(These Are Liftetime Reserve Days Which may never be used again.)

$550/Day
 
151 days or more Nothing

You Pay All Cost
Skilled Nursing Confinement:
When you are hospitalized for at least 3 days and enter a Medicare Approved skilled nursing facility within 30 days after a hospital discharge and are receiving skilled nursing care.		 All eligible expenses for the first 20 days; then all eligible expenses, (if you qualify), for days 21-100, after patient pays a per day copayment.

After 20 days
$137.50/Day
 

Medicare Part B (2010)

Part B is Medical Insurance and covers physicians services, outpatient care, test, and supplies.


On Expenses
incurred for:		 Medicare Covers You Pay $155 Annual Part B Deductible PLUS
Medical Expenses:
Physicians services, impatient, outpatient medical/surgical services, physical/speech therapy, diagnostic test.		 80% of approved amount 20% of approved amount
Clinical Laboratory Services
Blood Test, Urinalysis		 Generally 100% of approved amount Nothing for Services
Home Health Care
Part-time or intermittent skilled care, home health aide services, durable medical supplies and other services.		 100% of approved amount; 80% of approved amount for durable medical equipment Nothing for Services; 20% of approved amount for durable medical equipment
Outpatient Hospital Treatment
Services for the diagnosis or treatment of an illness or injury		 Medicare payment to hospital based on hospital cost 20% of Billed Amount
Blood After first 3 pints of blood, 80% of approved amount First 3 pints plus 20% of approved amount for additional pints

On all Medicare-covered expenses, a doctor or other health care provider may agree to accept Medicare "assignment." This means the patient will not be required to pay any expense in excess of Medicare's "approved" charge. The patient pays only 20% of the "approved" charge not paid by Medicare.

Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge for covered services.

Medigap Policies

     A Medigap policy is a health insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Medigap policies must follow federal and state laws. These laws protect you. The front of the Medigap policy must clearly identify it as "Medicare Supplement Insurance."

     In all states, except Massachusetts, Minnesota, and Wisconsin, a Medigap policy must be one of twelve standardized policies so you can compare them easily. Each policy has a different set of benefits. Two of the standardized policies may have a high deductible option. In addition, any standardized policy may be sold as a "Medicare SELECT" policy. Medicare SELECT policies usually cost less because you must use specific hospitals and, in some cases, specific doctors to get full insurance benefits from the policy. In an emergency, you may use any doctor or hospital.

Click image to view guide to Medigap Policies

 

Outline of Medicare
Supplement Coverage

(Benefit Plans A-N)
Medicare Supplement Insurance can be sold in only twelve standard plans. This chart shows the benefits included in each plan. Every company must make available Plan "A". Some plans may not be available in your state as indicated below.
  A B C D F* G K L M N
Medicare Part A Coinsurance and Medigap Coverage for Hospital Benefits
 

Y 

Y 

Y 

Y 

Y 

Y

Y

Y

 Y Y 
Medicare Part B Coinsurance or Copayment
 

Y 

Y 

Y 

Y 

Y 

Y 

 50% 75% Y Y***
Blood (First 3 pints)

Y 

Y 

Y 

Y 

Y 

Y 

 50% 75% Y Y
Hospice Care Coinsurance or Copayment
 		 Y  Y  Y  Y  Y  Y  50% 75% Y Y
Medicare Part A Deductible
 		  

Y 

Y 

Y 

Y 

Y 

 50% 75% 50% Y
Skilled Nursing Facility Care Coinsurance
 		    

Y 

Y 

Y 

Y 

 50% 75% Y Y
Medicare Part B Deductible
 		    

Y 

  

Y 

          
Medicare Part B Excess Charges
 		        

Y 

 100%        
Foreign Travel Emergency (Up to Plan Limits)
 		    

Y 

Y 

Y 

Y

     Y Y 
Preventive Care Coinsurance (Included in the Part B Coinsurance)
 

Y 

Y 

Y 

Y 

Y 

Y 

Y

Y

 Y  Y 
Out-of-Pocket Maximum (2010)
 		             $4,620** $2,310**    

Plans A-N are 2010 Modernized Plans by the federal government. Not all plans may be available in your area. Consider the benefits offered by each plan and look for one that best meets your individual needs.
*Medigap Plan F also offers a high-deductible option. You must pay the high-deductible ($2,000 in 2010) amount before your Medigap-covered costs before pays anything..
Foreign Travel: You must also pay a separate deductible for foreign travel emergency ($250 per year).
**After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($155 in 2010), the plan pays 100% of covered services for the rest of the calendar year.

***Plan N pays 100% of the Part B coinsurance except up to $20 copayment for office visits and up to $50 for emergency department visits.

Medicare Advantage

Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare. With Medicare Advantage Plans:
 

Some of the plans require referrals to see specialists.

  • In many cases, the premiums or the costs of services (co-pays and deductibles ) can be lower than they are in the Original Medicare Plan or the Original Medicare Plan with a Medigap policy. Medicare Health Plans charge different premiums and have different costs of services, so it is important to check with the plan before you join.
  • The plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services.
  • They often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.
  • They generally offer extra benefits, and many include prescription drug coverage.
  • In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans.
  • Some of the plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you.
  • You don’t need to buy a Medigap policy.

Medicare Health Plans include:

  • Health Maintenance Organization (HMO),
  • Preferred Provider Organization (PPO),
  • Private Fee-for-Service (PFFS) Plans,
  • Medicare Medical Savings Account (MSA) Plans,
  • Medicare Special Needs Plans.

 Important Contacts

Call: With your questions about:

1-800-MEDICARE
(1-800-633-4227)
www.medicare.gov
24 hours a day
TTY users should call
1-877-486-2048
  • Medicare (in general)
  • Medicare health plans
  • Ordering Medicare booklets
  • Medigap policies
  • Assistance Programs for Medicare Part B (limited income - ask about the Medicare Savings Programs)
  • Telephone numbers for local organizations who work with medicare, including TTY numbers
    		•

    Social Security Administration
    1-800-772-1213
    TTY users should call
    1-800-325-0778
  • Address/name changes
  • Death notification
  • Enrolling in Medicare
  • Medicare card (replacement)
  • Social Security benefits
  • Limited Income - you may be eligible for help paying for Prescription Drug Coverage under Medicare Part D
    		•

    CALL ME FOR A MEDICARE SUPPLEMENT QUOTE

    561-374-4476  or  954-600-3447

     

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