how does medicare work?

Original Medicare is the federally administered health care program for adults over 65. You may also be eligible at any age if you qualify through disability or have certain conditions.

the four parts of medicare – a, b, c and d

Part A - Hospital stays and skilled nursing after a hospital stay. It also assists with some home-bound skilled care and hospice care.

You can choose any qualified provider in the USA who accepts new Medicare patients.
Some coverage limits apply – if you are hospitalized or are in a skilled nursing facility for more than 90 days, you may have to pay for part of the costs.
Doctor services in the hospital are not covered under Part A.
You will not pay a premium for Part A if you or your spouse have contributed to Social Security for at least 10 years.

Your share of the costs will include:

A deductible – that is determined each year.
A copay – after staying a certain number of days you are liable for copays. These increase for extended stays.
Coinsurance – applies to inpatient respite care for hospice patients.

Consider adding Medicare Supplement Insurance to cover Part A and B out-of-pocket expenses – Burdick Insurance Services can help you with these choices.

Part B - Covers the costs of medically necessary doctor visits and medical services such as outpatient care at hospitals and clinics, laboratory tests, certain diagnostic screenings, and some skilled nursing care.

You can choose any qualified provider in the USA who accepts new Medicare patients.
Some coverage limits apply – limits on occupational therapy, and limits on screenings are covered only for specific times.
Vision, dental and hearing is only covered under certain situations under Part B.
Part B does not cover care outside the USA.
Your Part B premium is dependent on your yearly income. Most people pay a monthly premium.
If you receive Social Security, premiums will be automatically deducted from your benefits.

Your share of the costs will include the deductible, copays and coinsurance.

Consider adding Medicare Supplement Insurance to cover Part A and B out-of-pocket expenses.

Part C - Medicare Advantage plans (Part C) are run by private insurance companies. These plans combine coverage for certain hospital costs, doctors visits and other medical services – they may also include prescription drug coverage.

All covered under one plan.
Depending on the plan, you can choose a primary care doctor or you can visit a provider who accepts the plan’s terms, conditions and rates.
Part C plans have appointed service areas and nationwide emergency coverage.
Coverage limits vary according to different plans.
Part C plans cover the same services as Part A and B except for hospice care under Part A.

Your share of the costs:

Plan premiums vary widely.
Plan details will tell you if they have deductibles or not. Many do charge copays or coinsurance.
For prescription drugs, you may be subject to a coverage gap.

Part D - Plans to help you pay for prescription drugs – these plans are optional. If you don’t sign up when you become eligible, you may be subject to a higher premium later when you do enroll.

These plans are sold by private companies.
The government set the guidelines and the plans offer different drug lists and costs.
The Part D plan details will inform you what pharmacies you can use and limitations which may apply. Check to see if your plan offers a mail order service?
Coverage limits in terms of cost and drugs offered vary widely dependent on the plan.
Most plans have a coverage gap (donut hole) where you will have to pay some of the costs.
Premiums for the following year are announced in October. Premiums may vary even though plans offer the same drug coverage.

with medicare you do have choices to fit your circumstances – it is not a one-size-fits-all process

Important Points You Need To Know

There are two ways to get Medicare;

Original Medicare (Parts A and B) provided by the government.
Medicare Advantage plans (Part C) offered by private insurance companies.

Original Medicare does not pay for everything;

Even though you have contributed to the costs of your Medicare by paying taxes, you will still have to pay a share of monthly premium costs and copays.

Medicare Supplement Insurance can help you cover out-of-pocket expenses;

This will will help you cover costs like deductibles and copays that are not covered by Part A and Part B.

As a Medicare member, you are entitled to get optional prescription drug coverage (Part D);

You can enroll in a stand alone Part D plan with your Original Medicare.
Or, you can enroll in a Medicare Advantage plan that includes prescription drug coverage.

The state you reside in may offer different choices;

Parts A and B (Original Medicare) is the same across the United States.
Medicare Advantage (Part C) and prescription drugs (Part D) may be available only in certain counties, states or regions as they are offered by private insurance companies.
Medicare supplement policies are available by state and offer nationwide coverage.

Be sure to enroll at the right time;

The Initial Enrollment Period (IEP) is your first chance to enroll in Medicare – this is three months before your 65th birthday month, the month of your birthday, and the three months after your birthday month.
Coverage starts on the first day of your birthday month if you enroll before the month you turn 65,
If you enroll during your birthday month or later, coverage starts on the first day of the following month.

Review your plan once a year;

You can change your plan each year during the Medicare Open Enrollment Period (OEP).
OEP runs from October 15 to December 7.

Special Election Period;

In certain cases you may be able to enroll or switch plans outside the IEP and OEP, for example, you retire and leave an employer or union health care plan; you move out of the service area of your current plan.

choosing medicare – a two step process

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Step 1

When eligible, enroll in Original Medicare.

Part A – Covers hospital stays

Part B – Covers doctor and outpatient visits

(If you need more coverage, you can choose Step 2 Option 1 OR option 2)

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Step 2

Keep Original Medicare (Step 1) and add:

Medicare Supplement Insurance (covers all or some costs not covered by Original Medicare)

and/or

Part D – covers prescription drugs (offered by private companies)

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Step 2 (Option 2)

Enroll in Medicare Advantage (Part C)

Combines Parts A and B

Most plans cover prescription drugs

Additional benefits available (usually at extra cost)

Important Questions About You

(Tip : it is a good idea to write these points down – they will help with understanding Medicare choices and serve to formulate the best plan for you)

Are you healthy or do you have chronic conditions?
How much do you spend on your prescription drugs and how often do you take them?
Who are your doctors? How do you feel about seeing new doctors?
Besides Medicare, are you eligible for any other health care coverage? If yes, will you keep that coverage when you retire?
How does health care impact your budget?
Will you need financial help to pay for your Medicare premiums?
How much did your health care cost in the last year?
Do you expect similar costs this year?
Do you like to travel – how often and where?