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What is Medicare?Medicare is a health insurance plan that is owned and managed by the Federal Government. Medicare is found within the Department of Health and Human Services and managed by the Centers for Medicare and Medicaid Services.

Medicare is a government sponsored health program that most people automatically qualify for once they reach the age of 65. Medicare is also used to support medical insurance for people with qualifying disabilities and who are younger than 65 years of age.

Medicare is divided into four categories. Those are Medicare A, B, C, and D. Medicare A covers inpatient services like hospitalization. Medicare B works in conjunction with Medicare A to cover outpatient services such as doctors visits and therapy visits. Medicare A and B are often called “Original Medicare.”

Medicare C is Medicare A and B but managed by third party health systems such as Kaiser. Medicare D is the prescription drug coverage that goes along with Medicare A, B, and C. Most Medicare C plans come with a variation of Medicare D. Medicare C is also referred to as Medicare Advantage.

To qualify for Medicare you need to have worked and paid into the program for a certain amount of years. If you have not qualified by working, you may still be eligible for services, but the penalty is a higher cost each month.

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What is Medicare Advantage?Medicare Advantage is officially called Medicare C. Medicare C is Medicare A and B but managed by private insurance companies.

Medicare Advantage Plans vary from one private insurance company to the next, but they must cover all of the services covered in Medicare part A and B. Features to look for are lower deductibles and extra services that are not included in Medicare Part A or B.

Medicare C or Medicare Advantage is optional and you can sign up for either Medicare Part A and B or Medicare C. The Draw back to Medicare C is that Medigap plans to not apply to Medicare Advantage and you cannot buy a private insurance plan that will cover the gap between Medicare Advantage and out of pocket expenses.


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What is Medicare Part D?Medicare Part D is the Prescription Drug plan that works with both Medicare A and Medicare C (Medicare Advantage.) Though Medicare C plans almost always have a prescription drug plan associated with them. Medicare D is not issued by the government it is bought from private insurance companies.

Medicare D prescription drug plans all must meet a set of criteria in terms of what they offer, but the plans are not identical. They differ in price and what they offer.

Things to be aware of are deductibles, co-payments, and how each plan works with co-insurance. Another consideration is whether or not there is an Annual limit on how much your Medicare D plan will cover. IF you max out an annual limit you will have to pay full price for medications for the rest of the year.

Medicare D works like other insurance plans. You will pay full price for medications until your annual deductible is met. Once the deductible is met your cost for medications will be reduced to a co-pay. You will likely receive a monthly premium to pay to keep coverage in place.

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What is Medicare Supplemental Insurance?Medicare Supplemental insurance is also called a Medigap insurance policy. It is a secondary insurance that is only offered to those people who have “Original Medicare” Medicare part A and B. Medicare Supplemental Insurance helps to cover medical expenses that Medicare part A and part B do not cover.

Those would include things like co-payments, deductibles and other out of pocket expenses. Medicare Supplemental Insurance DOES NOT work with:

  • Medicare C
  • Medicare D
  • Veterans’ Administrative Benefits (VA Benefits)
  • TRICARE
  • Private Insurance
Medicare Supplement Insurance is sold by private insurance companies and it is highly regulated by both State and Federal laws. Plans are Labeled as A, B C, D, F, G, K, L, M and N. Each letter represents a different type of plan. Each lettered plan is always identical regardless of who is selling it. So every Medicare Supplement Insurance plan G is identical to every other Medicare Supplement Insurance plan G, but they are different from other lettered plans such as K, L, and F.

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Things to look for would be cost between plans that are the same, all the plan G’s. look for differences between plan types. For example how does plan F differ from plan D. Some states offer Medicare Select programs that are like an HMO. You only go to doctors and hospitals that are within the network. Those states are Wisconsin, Massachusetts, and Minnesota.


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Medicare.gov: What does it do?Medicare.gov is the official site for Medicare. It is hosted by the Federal Government and managed by the Centers for Medicare and Medicaid. Medicare.gov is the place to find the latest news about changes to Medicare and Medicaid. This is the place where you will find in depth information about all of the different Medicare and Medicaid programs that are offered.

Medicare.gov is Useful if You Are

  • Receiving Medicare or Medicaid
  • A Medicare Beneficiary.
  • Approaching an open enrollment date and want to research options for changing plans.
  • Looking for information about Medicare or Medicaid.
  • Need information about Medicare C or Medicare D.
  • Need information about Medicare Supplemental Policies.
  • A family member or conservator of someone who is on Medicare or Medicaid.

Tools Available on Medicare.gov

  • Definitions about terms used and Medicare basic information.
  • Eligibility rules and explanations.
  • Management of your Medicare. Change of address, lost cards, and counseling near you.
  • Find Doctors, hospitals and health professionals near you.
  • Get information about help with costs.
  • Explore and examine Medicare health plans, such as comparison tools.
  • Find Prescription Drug Plans.
  • Find supplies such as Medical Equipment Suppliers.
  • Find nursing homes and Dialysis facilities.
  • The Medicare Blog, Videos, and News.
  • And a whole lot more.
If you have not yet been to Medicare.gov, then you should visit the site and get familiar with how it works and what is available. If you need additional help, Connect One Health can help.

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Accessing Medicare Benefits: What happens after I Enroll?The big change occurs about three months before your Medicare Eligibility Date. You should receive your official Medicare card in the mail. If you do not receive a Medicare card in the mail within 60 days of your Eligibility date, call Medicare at 1-800-Medicare and let them know you have not yet received your Medicare card.

Most people are enrolled in Medicare automatically when they begin to draw their social security or when if they have been disabled for 24 months. If you need to enroll in Medicare you can do so online at Medicare.gov. It is important that you enroll before you eligibility date. There are penalties and are applied and for Medicare Part B those additional costs are extend for your lifetime.

Once you receive your Medicare cards examine the cards and make sure that your name is spelled correctly. The cards will also indicate when your coverage starts. Once your eligibility date has occurred you may use your Medicare benefits.

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Am I Eligible for Medicare?If you are age 65 then you are probably eligible for Medicare. If you have a qualifying disability then you may also qualify for Medicare. For either case, you must be a U.S. citizen or a permanent resident of more than 5 years to qualify for Medicare once you are age 65.

If you do have a qualifying disability or illness and have been disabled for more than 24 months then you should also qualify for Medicare. The enrollment process is usually automatic, but in some cases you must enroll yourself. If you want to qualify for Medicare C or Medicare D you must first be qualified for, and enrolled in Medicare part A and B.


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Medicare Effective Dates: How do they work?There are two effective dates for the two types of qualified events. The first is the day you turn 65 years of age. This would be your effective date for Original Medicare part A and part B. The second effective date is for those who suffer from a qualifying disability.

The effective date for your Medicare benefits will be after your 24th month of receiving disability benefits. Once these dates have passed you may use your Medicare benefits and Medicare cards.


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Employer Prescription Coverage: Does it work with Medicare?Medicare requires that every Medicare beneficiary be enrolled in a qualifying Prescription Drug Program. Those would be:

  • Medicare part D (PDP)
  • Medicare Advantage Prescription Drug Program (MAPD)
  • A qualifying Employer or Union Prescription Drug Program.
A qualifying Employer or Union Prescription Drug Program must be as comprehensive in coverage as Medicare part D. If your employer, past employer or Union offer a qualifying Prescription Drug Plan, then you do not have to enroll in Medicare part D. You will not be assessed the late enrollment penalty so long as the plan is in place. You CANNOT go more than 63 days without a Prescription Drug Plan.

If you do you will be assessed the late enrollment penalty when you sign up for Medicare Part D. Once you qualify for Medicare part A you can sign up for Medicare part D during open enrollment periods, which are usually January 1 through February 15 of each year.


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 What if I have a Secondary Health Care Insurance?The answer to that question depends on the rules of Coordination of Benefits. Sometimes Medicare will pay first, and your secondary insurance will pay second. Sometimes it is the other way around. What happens is that each type of insurance that you have is listed as a payer. Then each payer is assigned a number Primary payer, Secondary payer, etc. Who pays first is determined through a range of rules.

Things you can do to Help the Process

Give all of your insurance cards to your healthcare provider to copy. This helps your healthcare provide sort out who to send bills to first. You can call the Benefits Coordination & Recovery Center at 1-855-798-2627 toll free. Have your Medicare card handy when you call. This is a company that acts on behalf of Medicare to help answer questions about pay order for Medicare.

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Medicare B: Do I need to enroll in it if I am still working?You do not need to enroll in Medicare part B if you or your spouse are still working and are covered by a health plan that is issued through your employer, your spouses’ employer, or a union. This only works though if the health plan that is offered by your employer, spouses’ employer, or union is the primary payer for healthcare expenses. You will still need to enroll in Medicare B if Medicare A is going to be the primary payer.

You can talk with the employer’s healthcare plan administrator to see if their healthcare coverage will be the primary payer or the secondary payer. Businesses with less than 20 employees are deemed small businesses and Medicare A is usually the primary payer. Clear up any questions about what you should do before your enrollment date. If you are not enrolled in Medicare part B and you need to be you will be penalized.


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Medicare vs Medicaid: What is the Difference?The Difference between Medicare and Medicaid is really about who is involved. Medicare is a Federally sponsored health plan while Medicaid is a Federal and State sponsored Health Plan. Medicare is available for qualifying people who are aged 65 or older or those people who have suffered a qualifying disability for more than 24 months. Medicaid is available to people who have limited income and limited resource.

Those people may be children, women who are pregnant, seniors with low incomes, parents, and people with disabilities. In some cases, an individual may be eligible for both Medicare and Medicaid. When that happens Medicare is the primary payer and Medicaid helps to cover medical expenses after Medicare has paid. Note: Rules differ from State to State about qualification for Medicaid and dual beneficiaries.

Learn more about the differences between Medicare and Medicaid here!


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Does Medicare Cover Eyeglass Care, Hearing Aids, or Routine Dental Care?Sadly, Medicare does not cover additional services such as eyeglass care, hearing aids or routine dental care. Those basic services were not included in the Medicare list of benefits. To change that, Congress would need to change the Medicare laws to include these services.

The Exceptions are when routine dental care is part of a Medicare covered treatment. An example of this would be a procedure that needed to extract teeth in preparation for the treatment of cancer via radiation therapy. This example shows that while tooth extraction is not a covered Medicare Benefit, it can be covered as part of a Medicare covered treatment.


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How to Apply for Medicare?You can apply for Medicare on the Medicare.gov website. This is normally part of the process when you apply for retirement or disability. By visiting medicare.gov, you can fill out a simple online form.

You are given choices to apply for Medicare only, Return to a saved application, or to check your application status. The entire process should take less than 10 minutes. Everything is submitted electronically so you do not have to sign forms or go to the nearest social security office. Medicare.gov have made the application process very easy.

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What happens if I did not enroll in Medicare Part B during my election period?The answer depends on why you did not sign up for Medicare Part B during your initial enrollment period. If you need to enroll in Medicare part B you will need to call Medicare at 1-800-722-1213.

Considerations

  • If you are just newly 65 you may still have time. Your enrollment time is 3 months prior to your 65th birthday and extends to 7 months past your 65 birthday.
  • If you have private coverage you can sign up Medicare part B anytime you are still covered by your Employer, Union or Spouses’ Employers health plan for up to 8 months after the health plan ends.
  • General Enrollment periods occur each year and run from January 1 through March 31. When you enroll in during a General Enrollment your coverage begins July 1 of the year you enrolled.
    Penalties for late enrollment are 10% of your premium for Medicare B for each year (12 month period) that you were eligible for Medicare B but did not enroll. So for two years your penalty will be 20%.

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Medicare Part A: What does it Cover?Medicare Part A covers hospital type medical expenses. These expenses would include part or all of the costs of inpatient medical stay, supplies for treatment while admitted, skilled nursing facility admissions, hospice care, and even home health care services.

Medicare part A is comprehensive, but it does not cover eyeglasses, routine dental care, or hearing aids. Medicare A can be paired with Supplement Medicare Insurance, which is sometimes referred to as Medi-gap insurance, as a means of providing complete financial coverage for most health issues. Medicare A is also paired with Medicare B to provide outpatient coverage.


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Medicare Part B: What does it Cover?Medicare B covers the outpatient type of services needed to manage a person’s health. This would include medical care needed to prevent illness, and to manage illness when the patient is not admitted to a medical facility, such as a hospital.

Medicare part B covers things like doctors visits, Durable Medical Equipment (DME,) mental health services, lab tests, etc. Medicare part B is paired with Medicare part A and is referred to as “Original Medicare.” The two plans work together to provide comprehensive medical coverage.

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