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What is Original Medicare?
Original Medicare consists of Medicare Part A (hospital coverage) and Medicare Part B (medical coverage). It’s a federal health insurance program for individuals 65 or older; under 65 who have a qualifying disability, and of any age with a diagnosis of End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease).
What is Original Medicare Part A?
Original Medicare Part A is hospital coverage. It helps pay for hospital stays and inpatient care in hospitals.
What is Original Medicare Part B?
Original Medicare Part B is medical coverage. It helps pay for doctor visits and outpatient care.
No. Medicare and Medicaid are both government programs that help people pay for health care, but they are not the same thing.
Medicare is a federal program that provides health care coverage for people who are 65 or older or have certain qualifying disabilities.
Medicaid is a joint state and federal program that provides health care coverage for individuals and families with limited incomes. “Dual eligibility” means you qualify for both Medicare and Medicaid.
Can I get my prescription drugs covered under Original Medicare?
No. Original Medicare doesn’t cover prescription drugs. Prescription drug coverage, also known as Medicare Part D, is available separately through private insurance companies approved by Medicare. You can get prescription drug coverage either through a standalone Part D plan (PDP) or a Medicare Advantage plan (MAPD) that includes prescription drug benefits.
Does Original Medicare cover vision, dental, or hearing care?
Generally, no. Original Medicare doesn’t cover routine vision or dental care, eyeglasses, or hearing aids. However, many Medicare Advantage (Part C) plans do. Be sure to compare the benefits of all plan options to find the coverage that best fits your needs.
Does Original Medicare pay for a nursing home stay?
Original Medicare Part A pays for some skilled nursing services, but doesn’t cover long-term or custodial care (daily life activities like eating and bathing). You’d also still be responsible for a portion of the costs, such as deductibles, copays and coinsurance.
What is a Medicare Advantage plan?
Medicare Advantage plans (Part C) can combine Parts A, B, and D in a single plan.
All Medicare Advantage plans include:
- All the coverage of Original Medicare hospital coverage (Original Medicare Part A)
- All the coverage of Original Medicare medical coverage (Original Medicare Part B)
Plus, Medicare Advantage plans can include:
- Prescription drug coverage (Part D)
- Routine vision, dental, and hearing coverage
- Fitness benefits and wellness programs
- And more
Not all plans are available in all locations. Find out which plans are available where you live.
What’s the difference between a Medicare Advantage plan and a Medicare Supplement plan?
You have coverage choices when it comes to Medicare. It’s important to understand the differences to find the plan that works for you. Medicare Advantage and Medicare Supplement are very different, and you can’t have both at the same time.
A Medicare Advantage (Part C) plan combines Part A, Part B, and often Part D (prescription drug) coverage into one plan. These plans may also include additional benefits, such as hearing, vision, dental, and fitness. Medicare Advantage plans also have an annual limit on out-of-pocket costs on covered services.
A Medicare Supplement (Medigap) plan helps with some of the out-of-pocket costs that Original Medicare doesn’t pay, like coinsurance and copayments. It doesn’t cover prescription drug costs.
Do Medicare Advantage plans have vision (eye care) benefits?
Most Medicare Advantage (Part C) plans offer routine vision care, such as eye exams, eyeglasses, and corrective lenses. Original Medicare (Parts A and B) alone doesn’t cover routine vision care.
Do Medicare Advantage plans have dental care benefits?
Most Medicare Advantage (Part C) plans offer routine dental care, such as dental exams. Original Medicare (Parts A and B) alone doesn’t cover routine dental care.
Do Medicare Advantage plans have hearing benefits?
Most Medicare Advantage (Part C) plans offer hearing care, such as hearing tests and hearing aids. Original Medicare (Parts A and B) alone doesn’t cover routine hearing care.
What is a Medicare Part D plan?
Medicare Part D is prescription drug coverage. Medicare Part D plans (PDP) help pay for medications prescribed by a doctor. Part D plans are offered by private insurance companies approved by Medicare. The types of drugs covered is decided by the U.S. government. Beyond that list, every Medicare Part D plan covers a different set of drugs. When choosing a Part D plan, you need to make sure it covers the drugs you take.
Most Medicare Advantage (Part C) plans already include Part D prescription drug coverage, combined into a single plan with hospital and medical. Another option is to have a separate Part D plan in addition to Original Medicare, a Medicare Supplement Insurance plan, or a Private Fee-For-Service plan.
How do I know if my drugs are covered by the Medicare Part D plan?
All Part D plans have a drug list—also called a formulary—that gives you the information you need about which drugs are covered. The formulary can change, but your plan will let you know ahead of time if it does. The formulary will also tell you if your drug has any special rules or limits. Your plan will send you your formulary and/or give you a way to get all of your drug list information online.
What is Medicare Supplement insurance?
Medicare Supplement insurance plans, offered by private insurance companies, help pay some of the out-of-pocket costs that Original Medicare (which includes Part A and Part B) doesn’t pay. Medicare Supplement plans are also known as Medigap plans.
When can I apply for Medicare Supplement insurance?
Your acceptance into a Medicare Supplement insurance plan is guaranteed if you apply during the Medicare Supplement Open Enrollment Period. It starts on the first day of the month in which you’re both age 65 or older AND enrolled in Medicare Part B. You can apply for a Medicare Supplement insurance plan any time during the year, and some states have additional enrollment periods and guaranteed enrollment situations.
If you apply outside of this timeframe or another guaranteed issue period, you may be denied coverage or charged more based on your health history. This doesn’t apply if you live in Connecticut and New York, where guaranteed issue is ongoing and Medicare Supplement plans are guaranteed available.
When is the best time to enroll in a Medicare Supplement insurance plan?
It’s best to enroll in a Medicare Supplement insurance plan during your Medicare Supplement Open Enrollment Period. If you do, your acceptance is guaranteed. However, Medicare Supplement insurance companies may not cover your out-of-pocket costs for pre-existing conditions for up to 6 months.
How much Medicare Supplement insurance coverage do I need?
There are ten standardized Medicare Supplement insurance plans. All of them pay towards out-of-pockets costs for Medicare-approved services. Some plans pay most or all of your out-of-pocket costs, but have a higher monthly premium. Other plans pay fewer out-of-pocket costs, but have a lower monthly premium. Benefits and costs vary depending on the plan chosen.
Does a Medicare Supplement insurance plan replace Original Medicare Part A and Part B?
No. A Medicare Supplement insurance plan works with Original Medicare, which includes Part A and Part B. It helps cover some of the out-of-pocket health care costs that Original Medicare doesn’t pay for. For instance, Medicare Part B generally covers about 80% of Part B expenses. You’re responsible for paying the rest. A Medicare Supplement insurance plan could help pay your share.
How does MACRA affect Medicare Supplement insurance plans?
MACRA is the Medicare Access and CHIP Reauthorization Act. Based on projections from the Congressional Budget Office and others, MACRA will help to improve the sustainability of the Medicare program. Starting with individuals who become eligible for Medicare in 2020, insurers won’t be allowed to sell Medicare Supplement insurance Plan C or Plan F which cover the Medicare Part B deductible.
When am I eligible for Original Medicare?
You’re eligible for Original Medicare once you turn 65 and are a U.S. citizen or legal resident. If you’re a legal resident, you must have lived in the United States for at least five years in a row before you’re eligible for Original Medicare.
I’m not 65 yet. Could I still be eligible for Original Medicare?
Even if you haven’t turned 65, you may be eligible to get Original Medicare. You need to be a U.S. citizen or legal resident for at least 5 years in a row, and have one of the conditions below:
- Under 65 and have a qualifying disability
- Any age and have Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease) or End-Stage Renal Disease (ESRD).
Am I eligible for a Medicare Advantage or Medicare prescription drug plan?
Yes – but you have to enroll in Original Medicare first.
For a Medicare Advantage (Part C) plan, you must have both Original Medicare Part A AND Part B to apply. Medicare prescription drug coverage (Part D) is available for anyone who is enrolled in Original Medicare Part A and/or Part B. You cannot be denied enrollment in a Part D plan. There are several key Medicare Advantage enrollment periods you can use to apply, like the Medicare Annual Enrollment Period and Special Enrollment Periods.
What if I’m 65, but I’m still working? Do I still need to sign up for Medicare?
If you’re still working when you turn 65, you still need to make some decisions around Original Medicare – even if you’re covered by your employer’s health plan. When you turn 65, you may want to enroll in Medicare Part A, which is premium free. If you have qualified insurance from your employer, you may be able to delay enrolling in Part B and Part D without penalty. Talk to your employer’s benefit administrator to help you learn more about your choices.
What if I get health insurance under my working spouse?
If you’re 65 or older and covered by your spouse’s employer health insurance plan, you may be able to sign up for Original Medicare through a Medicare Special Enrollment Period when that coverage ends. No longer having coverage from an employer is a qualifying life event. That counts for spouses that are under that employer’s health insurance plan, too.
When do I need to enroll in Original Medicare?
If you’re turning 65 AND are already receiving Social Security or Railroad Retirement Board benefits, you’ll be automatically enrolled in Original Medicare Parts A and B. If you’re not already receiving Social Security benefits when you turn 65, you’ll need to sign up during your Initial Enrollment Period.
How do I enroll in Original Medicare?
If you’re not enrolled in Original Medicare automatically, visit the ssa.gov/benefits/medicare website, or call or stop into your local Social Security office. If you’re eligible for Medicare due to disability or End-Stage Renal Disease (ESRD), check www.medicare.gov for details on how to enroll.
What is the Original Medicare Initial Enrollment Period?
The Original Medicare Initial Enrollment Period (IEP) is a seven-month period that includes your 65th birthday month, the three months before and the three months after.
What is an Original Medicare Special Enrollment Period?
Original Medicare grants a Special Enrollment Period (SEP) for certain qualifying situations and life events. With an SEP, you can switch Medicare plans or sign up for Original Medicare outside of the standard Medicare enrollment periods.
There are many ways to qualify for a Special Enrollment Period. For example, if you’re working past the age of 65; move out of your plan’s service area; you have Medicaid; or you live in an institution, such as a nursing home.
What is the Medicare Advantage Open Enrollment Period?
The Medicare Advantage Open Enrollment Period (MA OEP) runs from January 1 to March 31 every year. During this period, you can make a one-time election to leave a Medicare Advantage plan, switch to a different Medicare Advantage plan, or leave a Medicare Advantage plan and go back to Original Medicare (Part A and Part B) with or without a Part D plan.
What if I want to change plans?
The Medicare Annual Enrollment period (AEP) happens at the same time every year. During this time you can join, switch or drop a Medicare plan – including Medicare Advantage (Part C) and Medicare prescription drug coverage (Part D). The Medicare Annual Enrollment Period runs from October 15 to December 7.
How much does Original Medicare Part A and Part B cost?
It’s important to understand the basics of Medicare costs. Most people pay no premium for Original Medicare Part A. The premium for Original Medicare Part B depends on your income. For both Part A and Part B, there are also deductibles and coinsurance. You may also qualify for help paying for Medicare costs.
What Medicare costs can I expect for 2020?
Depending on what coverage you choose, your costs can be different. To get an idea of 2020 costs directly from Medicare, go to Medicare costs at a glance on the Medicare.gov website.
How much do I have to pay for Medicare Part D plans?
There are some costs associated with Medicare Part D plans. Standalone Part D plans offered through a private insurance company, like UnitedHealthcare, charge a monthly premium. You could also consider Medicare Advantage (Part C) that includes Part D coverage under a single plan. Some plans also require you to pay an annual deductible and coinsurance or copayment amounts.
What is Extra Help?
Extra Help is a Medicare financial assistance program for people with low incomes and limited assets. It helps pay prescription drug costs. It is also called Low Income Subsidy or LIS.
What is the Donut Hole?
The Donut Hole is also known as the Coverage Gap. This is one of four drug payment stages in Medicare Part D plans. In the Coverage Gap, you pay a percentage of the drug cost – instead of copay or coinsurance – until you reach your out-of-pocket limit.
For 2020, it begins when your total drug costs have reached $4,020. In the Coverage Gap (Donut Hole), you pay 25% of the cost for brand name drugs and 25% of the cost of generic drugs, until you reach $6,350 in out-of-pocket costs.