Medicare

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 We believe that the better educated you are about Medicare, the easier it will be for you to make the right decisions about your Medicare health insurance choices.

This Medicare information section is here to educate you about your insurance options and provide you with the resources you need to help you select the right plan for your unique needs.

Medicare is a health insurance program for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has:

Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. On January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare. This coverage is to help you lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. If a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

This information comes from www.cms.gov

Medicare Advantage Plans, sometimes called Part C, are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through the Medicare Advantage Plan. This coverage can include prescription drug coverage. Medicare Advantage Plans include:

• Medicare Health Maintenance Organization (HMOs)
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service Plans
• Medicare Special Needs Plans

When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most of these plans, there generally are extra benefits and lower co-payments than in the Original Medicare Plan. Most Medicare Advantage Plans are managed care plans, usually a health maintenance organization (HMO) or a preferred provider organization (PPO) and you may have to see doctors that belong to the plan or go to certain hospitals to get services.

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you may have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer. In 2024, the standard Part B premium amount is $174.70 (or higher depending on your income). However, some people who get Social Security benefits pay less than this amount.

When can I enroll?

Keep in mind that Medicare limits when you can join, switch, or drop a Medicare Advantage Plan. You can join a plan when you first become eligible for Medicare. This is anytime beginning three months before the month you turn 65 and ends three months after the month you turned 65.

• For example, if you turn 65 on May 5, your eligibility period starts on February 1 and ends on August 31.
• If you are disabled and have Social Security Disability Insurance, you can join an advantage plan three months before to three months after month 25 of your disability.
• You can switch or drop your Medicare Advantage during an enrollment period between October 15 and December 7 of each year.

This information obtained from www.medicare.gov

A Medicare Supplement (Medigap) insurance, sold by private companies, can help pay some of the health care costs that Original Medicare doesn't cover, like co-payments, coinsurance, and deductibles.

If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Your Medigap policy pays its share.

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.

What you need to know about Medicare Supplement policies

1. You must have Medicare Part A and Part B.
2. If you have a Medicare Advantage Plan, you can switch to a Medicare Supplement insurance policy during certain enrollment periods or if you meet certain criteria (underwriting may apply), but make sure you can leave the Medicare Advantage Plan before your Medicare Supplement insurance policy begins.
3. You pay the private insurance company a monthly premium for your Medicare Supplement insurance policy 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 Medicare Supplement insurance policy from any insurance company that's licensed in your state to sell one.
6. Any standardized Medicare Supplement insurance policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medicare Supplement insurance policy as long as you pay the premium.
7. Medicare Supplement insurance 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.

Information obtained from www.medicare.gov

You can sign up for Part D Prescription Drug Plans, which helps cover prescription drug costs, along with other components of Medicare starting three months before your 65th birthday, or if you are under 65 and eligible for Medicare.

It's important to do this on time because there' may be a permanent premium surcharge for enrolling after your initial enrollment period if you don't have equivalent drug coverage from another source, such as a retiree plan.

If you are already enrolled in a Part D "standalone" plan or a Medicare Advantage plan that incorporates drug coverage, you can switch plans during the open-enrollment period, which runs from Oct. 15 to Dec. 7 every year.

In 2025, several significant updates will affect Medicare Part D enrollees, including a substantial improvement with the implementation of a $2,000 out-of-pocket cap. This means that once you reach $2,000 in prescription expenses, you will not have additional out-of-pocket costs for the remainder of the year. This change represents a notable reduction from previous thresholds, aimed at helping individuals manage high prescription costs throughout the year.

Additional changes include the elimination of the “coverage gap” phase, sometimes referred to as the “donut hole,” where beneficiaries previously faced a change in cost-sharing. Starting in 2025, you will continue to pay consistent cost-sharing percentages in the initial phase, removing the complex transition to higher out-of-pocket costs that had occurred mid-year. The deductible is also rising slightly to $590 for many plans, although this may vary depending on individual plan details.

Part D drug benefits in 2025 are structured into three phases:

1. Annual deductible. If your plan has a deductible, you will pay 100% of your gross covered prescription drug costs until the annual deductible is met. 
2. Initial coverage. Once the annual deductible is met, you will pay 25% coinsurance for covered Part D drugs. This phase ends when you have reached the annual out-of-pocket cap of $2,000 for 2025. 
3. Catastrophic. Once you meet the $2000 out-of-pocket cap, you will pay no cost sharing for covered Part D drugs. 

These updates aim to make Part D costs more predictable and manageable, especially for those with high-cost medications. The changes are part of the broader Inflation Reduction Act adjustments, which bring greater financial relief to Medicare enrollees in need of costly prescriptions.

It pays to review your Part D coverage every year, especially if you have started taking new drugs.

• Start at Medicare.gov, where you can find the basics about the benefit and Part D plans. There's a link to the Medicare Part D Plan Finder, which allows you to compare offerings and coverage options in your area and includes a helpful formulary finder that allows you to compare plans based on their coverage of your personalized list of drugs. It will even show you your monthly out-of-pocket drug cost for the year

Call us to help you understand your options.

Individuals with 2024 annual incomes of less than $22,590 and financial resources of up to  $17,220 or married couples with incomes of less than r $30,660 and financial resources of up to  $34,360 might qualify for Extra Help from Medicare to pay their Part D premiums and out-of-pocket drug costs.

See Medicare's instructions on applying for the Extra Help program.

Additionally, read about the ways to lower your drug costs on Medicare.gov.

This information was obtained from www.medicare.gov

Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States.

If you are not 65, you might also qualify for coverage if you have a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).

Here are some simple guidelines. You can get Part A at age 65 without having to pay premiums if:

• You already get retirement benefits from Social Security or the Railroad Retirement Board.
• You are eligible to get Social Security or Railroad benefits but have not yet filed for them.
• You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay premiums if:

• You have received Social Security or Railroad Retirement
• Board disability benefit for 24 months. You are a kidney dialysis or kidney transplant patient.

While you don’t have to pay a premium for Part A if you meet one of those conditions, you must pay for Part B if you want it. It is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you don’t get any of the above payments, Medicare sends you a bill for your Part B premium every 3 months.

Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.

Health Maintenance Organization (HMO) Plan

In most HMO Plans, you can only go to doctors, other health care providers, or hospitals on the plan's list except in an emergency, for out-of-area urgent care or for temporary out-of-area dialysis. You may also need to get a referral from your primary care doctor to see other doctors or specialists. Find and compare HMO Plans in your area.

Preferred Provider Organization (PPO) Plans

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) Plans

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medicare supplement. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Medicare Special Needs (SNP) Plans

Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. 

Find out who can join a Medicare SNP

These definitions are directly from www.medicare.gov

Medicare Supplement policies (also known as Medigap policies) are standardized and must follow federal and state laws designed to protect you. Insurance companies can only sell you a "standardized" policy identified in most states by letters (see the chart below).

All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs. As you can see in the comparison chart there are many options from which to choose. As licensed insurance agents we can help you understand the differences between the plans so that you can decide on the right plan for you. 

In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way.

Did you know that each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer? Insurance companies that sell Medigap policies:

• Don't have to offer every Medigap plan
• Must offer Medigap Plan A if they offer any Medigap policy
• Must also offer Plan C or Plan F to people who were eligible for Medicare before January 1, 2020, but haven’t yet enrolled.
• People new to Medicare on or after January 1, 2020 have the right to to buy Plan D or G instead of Plan C or F. 

Keep in mind, that the Medigap policy covers co-insurance after you've paid the deductible (unless the Medigap policy also pays the deductible).

The chart below shows basic information about the different benefits Medigap policies cover.

Crossed Out = the policy doesn't cover that benefit
% = the plan covers that percentage of this benefit
N/A = not applicable

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits)
• Out-of-pocket limit**: N/A

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits)
• Out-of-pocket limit**: N/A

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits): 80%
• Out-of-pocket limit**: N/A

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits): 80%
• Out-of-pocket limit**: N/A

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits): 80%
• Out-of-pocket limit: $2,870

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits): 80%
• Out-of-pocket limit: $2,870

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment: 50%
• Blood (first 3 pints): 50%
• Part A hospice care coinsurance or copayment: 50%
• Skilled nursing facility care coinsurance: 50%
• Part A deductible: 50%
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits)
• Out-of-pocket limit**: $7,220 in 2025

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment: 75%
• Blood (first 3 pints): 75%
• Part A hospice care coinsurance or copayment: 75%
• Skilled nursing facility care coinsurance: 75%
• Part A deductible: 75%
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits)
• Out-of-pocket limit**: $3,610 in 2025

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility care coinsurance
• Part A deductible: 50%
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits): 80%
• Out-of-pocket limit**: N/A

• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
• Part B coinsurance or copayment ***
• Blood (first 3 pints)
• Part A hospice care coinsurance or copayment ***
• Skilled nursing facility care coinsurance
• Part A deductible
• Part B deductible
• Part B Excess charge
• Foreign travel exchange (up to plan limits): 80%
• Out-of-pocket limit**: N/A

* Plans F and G also offer a high-deductible plan in some states. With this option, you must pay for Medicare-covered costs (coinsurance, copayments, and deductibles) up to the deductible amount of $2,870 starting in 2025 before your policy pays anything. (Plans C and F aren't available to people who were newly eligible for Medicare on or after January 1, 2020, or were eligible for Medicare before January 1, 2020, but not yet enrolled.)

** For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered services for the rest of the calendar year.

*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don't result in inpatient admission.

Source: www.medicare.gov