Medicare Coverage

If you’re one of the many people that are nearing 65 and are starting to think about Medicare, then you’ll want to know about the many different parts that are offered. The more you understand what each part offers, the more you’ll be able to get the best coverage for you or your family.

Part A – Hospital Expenses

You are automatically enrolled in Part A when you enroll in Medicare.

Most likely you won’t have a monthly premium for Part A because of the payroll taxes you or your spouse paid while you were both working. You’ll need to earn about 40 “credits” or “quarters” equal to about 10 years of work, so you can get Part A without paying any premiums. If you don’t have enough credits, that’s when you may be able to get premium-free Part A through your spouse, if you are 65 or older and your spouse is at least 62. If you don’t qualify for Part A, because you or your spouse didn’t contribute enough, you may also buy Part A coverage on your own.

For each benefit period Medicare pays all covered costs except the Medicare Part A deductible during the first 60 days for a hospital stay and coinsurance for longer than 60 days. You will also have deductible of $1,340 for your Medicare-approved hospital stays. This is why getting supplemental insurance is also important, because costs can add up quickly. Part A usually includes deductibles, coinsurance and copayments.

Things Part A covers:

• Long-term hospital care
• Many inpatient nursing homes
• Hospice care
• Home-health care
• Psychiatric hospitals
• Inpatient rehab facilities

Part B – Health Insurance Coverage

If you still have health insurance through an employer, union, or your spouse, you can opt out of Part B. It usually includes a premium, so this means it is optional. But if you turn it down and need it later, then you might have a late-enrollment penalty if you enroll later. You must have Part A and B if you want to enroll in a Medicare Advantage plan, so be sure it’s not something you need before turning it down.

Things that Part B covers:

• Doctor office visits
• Lab services
• Preventative care like flu shots
• Screenings
• Immunizations
• X-rays
• Ambulance services
• Mental health care and more
• Surgery and surgical supplies

Part B also covers any in-home health care, physical therapy and occupational therapy. These might seem like things you can’t imagine needing, but as you get older, you’d be surprised that having these kinds of coverage will be something you’re really glad you chose.

Part C – Private Insurance, also known as Medicare Advantage Plans

Part C is a combination of Part A and Part B, which means it covers hospital and medical coverage. If you sign up for Medicare Advantage, you still have the federal Medicare coverage, but many Medicare Advantage plans include extra benefits that the traditional plans don’t cover, such as wellness programs and routine vision care. Many of them also include prescription drug coverage.

Before you enroll in Medicare Advantage you have to enroll in Part A and Part B, original Medicare.

Plans available through Medicare Advantage:

Medicare Preferred Provider Organization (PPO) – You don’t have to choose a primary care doctor for your care but can see any doctor who accepts Medicare. When you go outside your PPO network, your out-of-pocket costs may increase.

Medicare Health Maintenance Organization (HMO) – This plan you do choose a primary care doctor who must refer you to other doctors if you need other care. Going outside your network could mean you pay the full amount for your visits and services.

Medicare Private Fee-for-Service (PFFS) – This plan sets the payment terms, not Medicare. Some plans allow you to see any doctor without dealing with network restrictions. Some PFFS have provide networks.

Medicare Special Needs Plans (SNPs) – This plan is for people with chronic diseases or special health needs.

Part D – Prescription drug plan coverage

Medicare Part D — Your Prescription Drug Plan

Just because you get Medicare, doesn’t mean you’re automatically covered for prescription drug coverage. That’s where Part D comes in. It is optional and available to people who are signed up for Part A and B and most Medicare Advantage plans.

They are offered by private insurance companies and approved by Medicare. Different plans have different medicines covered, which is called the formulary. So be sure to check to see which medications you need and what they will cost with different plans. If you don’t check before you sign up, you could end up paying a lot for one or more of your medications. Once you sign up, you pay a monthly premium, deductible and sometimes copays for the drugs you are taking.

If you don’t sign up when you’re eligible you could end up paying a late-enrollment penalty if you do decide to sign up at a later date.

Your drug costs could vary because of:

• The drugs you take
• The plan you sign up for
• If you choose medication in your plan’s network
• If you choose drugs in your plan’s formulary