F A Q ' s

What Medicare?

Medicare, a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS), provides coverage for consumers who are:

• Age 65 and older

• Under 65 with certain disabilities

• Any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

• Any age with Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig's disease)

Individuals who meet eligibility requirements are generally automatically enrolled in the Medicare program by the Social Security Administration (SSA) or the Railroad Retirement Board (RRB).

What does Medicare consist of?

Medicare consists of four parts: A, B, C and D. Parts A and B are a federal health insurance program referred to as Original Medicare. All parts of Medicare include cost sharing, such as deductibles, co-payments or coinsurance, and specific eligibility qualifications.

What does Part A & Part B cover?

Medicare Part A: Hospital Insurance

• Helps with the cost of inpatient hospital stays and skilled nursing home costs

• Includes hospice care

• Provides limited home health benefits

Medicare Part B: Medical Insurance

• Helps with the cost of medically necessary doctor visits and other medical services including:

- Outpatient care at hospitals and clinics

- Laboratory tests

- Some diagnostic screenings

- Some skilled nursing care

What Original Medicare Doesn't Cover ?

Here are some things not covered by Original Medicare:

• Prescription Drugs

• Dental exams, most dental care or dentures

• Routine eye exams, eyeglasses or contacts

• Hearing aids or related exams or services

• Most care while traveling outside the United States

• Help with bathing, dressing, eating, etc. (custodial care)

• Comfort items such as a hospital phone, TV or private room

• Long-term care

• Cosmetic surgery

• Most chiropractic services

• Acupuncture or other alternative treatments

• Routine foot care

What is Medicare Advantage?

Medicare Advantage Plans (MA)

Part C

MA Plans are Medicare health plans offered by private insurance companies, that are contracted by the federal government and follow their rules. MA Plans provide Medicare Part A (hospital) and Part B (medical) coverage, and some plans include Medicare Part D (prescription drug) coverage.

MA Plans:

• Must provide the same coverage as Original Medicare (most plans also offer additional benefits, which may vary by plan).

• Are part of the Medicare program, where Medicare pays a fixed amount for care every month to the companies offering MA Plans and the companies must follow rules and regulations set by the Centers for Medicare & Medicaid Services (CMS) who administers the Medicare program.

• Are not Medicare Supplement Insurance Plans, and MA Plan cost sharing cannot be covered by a Medicare Supplement Insurance Plan.

• May have a monthly premium, payable to the plan, in addition to the Part B premium t he member must continue to pay.

• Do not administer hospice care, which is still administered under Medicare Part A.

What's Medicare Supplement Insurance (Medigap)?

Medigap is Medicare Supplement Insurance that helps fill "gaps" in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like:

• Co-payments

• Coinsurance

• Deductibles

Note

As of January 1, 2020, Medigap plans sold to new people with Medicare aren't allowed to cover the Part B deductible. Because of this, Plans C and F are not available to people new to Medicare starting on January 1, 2020. If you already have either of these 2 plans (or the high deductible version of Plan F) or are covered by one of these plans before January 1, 2020, you’ll be able to keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans.

Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, here's what happens:

• Medicare will pay its share of the Medicare-approved amount for covered health care costs.

• Then, your Medigap policy pays its share.

8 things to know about Medigap policies

1. You must have Medicare Part A and Part B.

2. A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.

3. You pay the private insurance company a monthly premium for your Medigap policy. You pay this monthly premium in addition to the monthly Part B premium that you pay to Medicare.

4. A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you'll each have to buy separate policies.

5. You can buy a Medigap policy from any insurance company that's licensed in your state to sell one.

6. Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium.

7. Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren't allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).

8. It's illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you're switching back to Original Medicare.

Medigap policies don't cover everything

Medigap policies generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Insurance plans that aren't Medigap

Some types of insurance aren't Medigap plans, they include:

• Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)

• Medicare Prescription Drug Plans

• Medicaid

• Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP)

• TRICARE

• Veterans' benefits

• Long-term care insurance policies

• Indian Health Service, Tribal, and Urban Indian Health plans

Dropping your entire Medigap policy (not just the drug coverage)

You may want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage). Or, you might decide to switch to a Medicare Advantage Plan that offers prescription drug coverage.

If you decide to drop your entire Medigap policy, you need to be careful about the timing. When you join a new Medicare drug plan, you pay a late enrollment penalty if one of these applies:

• You drop your entire Medigap policy and the drug coverage wasn't creditable prescription drug coverage

• You go 63 days or more in a row before your new Medicare drug coverage begins

• Find a Medigap policy.

• Call your State Health Insurance Assistance Program (SHIP).

• Call your State Insurance Department.