Medicare & Long Term Care

Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. Medicare Supplement Insurance policies, sold by private companies, can help pay some of the remaining health care costs for covered services and supplies, like copayments, coinsurance, and deductibles. Medicare Supplement Insurance policies are also called Medigap policies.

Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. Generally, Medigap policies do not cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Medigap policies are standardized

Every Medigap policy must follow federal and state laws and is standardized by the government. They are designed to protect you, and they must be clearly identified as “Medicare Supplemental Insurance.”

Most states offer Medicare supplemental insurance lettered A through D, F through G, and K through N. Each plan having different coverage levels, so you can choose which one meets your needs. In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way.

What else should I know about Medicare Supplement Insurance (Medigap)?

Important facts

• You must have Part A and Part B.
• You pay the private insurance company a monthly premium for your Medigap policy in addition to your monthly Part B premium that you pay to Medicare.
• A Medigap policy only covers one person. Spouses must buy separate policies.
• You will need a stand-alone prescription drug plan for coverage of your medications
• It’s important to compare Medigap policies since the costs can vary between insurance companies for exactly the same coverage, and may go up as you get older. Some states limit Medigap premium costs.
• In some states, you may be able to buy another type of Medigap policy called Medicare SELECT. If you buy a Medicare SELECT policy, you have rights to change your mind within 12 months and switch to a standard Medigap policy.

When to buy

The best time to buy a Medigap policy is during your Medigap Open Enrollment Period. This 6-month period begins on the first day of the month in which you’re 65 or older and enrolled in Part B. (Some states have additional Open Enrollment Periods.) After this enrollment period, you may not be able to buy a Medigap policy. If you’re able to buy one, it may cost more.

If you delay enrolling in Part B because you have group health coverage based on your (or your spouse’s) current employment, your Medigap Open Enrollment Period won’t start until you sign up for Part B.

Federal law generally doesn’t require insurance companies to sell Medigap policies to people under 65. If you’re under 65, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. However, some states require Medigap insurance companies to sell Medigap policies to people under 65. If you’re able to buy one, it may cost more. Ask us for details.

A Medicare Advantage Plan (like an HMO or PPO) is another way to get your Medicare coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan,  you’ll get your Medicare Part A (Hospital) and Medicare Part B (Medical) coverage from the Advantage Plan, not Original Medicare. In most cases, you’ll need to use health care providers who participate in the plan’s network and only within the plan’s coverage area. Some plans offer out-of-network coverage. You must use the card from your Medicare Advantage Plan for services. Keep your Original Medicare card in a safe place because you’ll need it if you ever decide to switch back to Original Medicare.

What are the different types of Medicare Advantage Plans?

• Health Maintenance Organization (HMO) plans
• Preferred Provider Organization (PPO) plans
• Private Fee-for-Service (PFFS) plans
• Special Needs Plans (SNPs)
• HMO Point-of-Service (HMO-POS) plans: These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.

Some Medicare Advantage Plans offer coverage for things that aren’t covered by Original Medicare, like vision, hearing, dental, gym memberships, over-the-counter benefits, and other health and wellness programs. Most include Medicare prescription drug coverage (Part D). Most Medicare Advantage plans do not have a monthly premium but there are some that do.

What do I pay?

• Your out-of-pocket costs in a Medicare Advantage Plan depend on:
• Whether the plan charges a monthly premium. You pay this in addition to the Part B premium.
• Whether the plan pays any of your monthly Medicare premiums. Some Medicare Advantage Plans will help pay all or part of your Part B premium. This benefit is sometimes called a “Medicare Part B premium reduction.”
• Whether the plan has a yearly deductible or any additional deductibles for certain services.
• How much you pay for each visit or service (copayments or coinsurance).
• The type of health care services you need and how often you get them.
• Whether you get services from a network provider or a provider that doesn’t contract with the plan.
• Whether you go to a doctor or supplier who accepts assignment (if you’re in a Preferred Provider Organization, Private Fee-for-Service Plan, or Medical Savings Account Plan and you go out-of-network).
• Whether the plan offers extra benefits (in addition to Original Medicare benefits) and if you need to pay an extra premium for them.
• The plan’s yearly limit on your out-of-pocket costs for all medical services. Once you reach this limit, you’ll pay nothing for covered services.
• Whether you have Medicaid or get help from your state.

How does Medicare prescription drug coverage (Part D) work?

Medicare prescription drug coverage is an optional benefit. Medicare offers drug coverage to everyone with Medicare. Even if you don’t take prescriptions now, you should consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage or get Extra Help, you’ll likely pay a late enrollment penalty if you join a plan later. Generally, you’ll pay this penalty for as long as you have Medicare prescription drug coverage.

To get Medicare prescription drug coverage, you must join a plan approved by Medicare that offers Medicare drug coverage. Each plan can varies in costs and coverages.

There are 2 ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans (sometimes called “PDPs”) You must have Original Medicare Part A and/or Part B to join a Medicare Prescription Drug Plan.
2. Medicare Advantage Plans (MAPD Plans) These ‘All inclusive plans’ incorporate your Medicare Part A & Part B services along with prescription drug coverage (Part D)

In either case, you must live in the service area of the Medicare drug plan you want to join.

How much do I pay?

Below are descriptions of what you pay in your Medicare drug plan. Your actual drug plan costs will vary depending on:

• Your prescriptions and whether they’re on your plan’s formulary (list of covered drugs) and depending on what “tier” the drug is in.
• Which phase of your drug benefit that you’re in (some examples include whether or not you met your deductible, if you’re in the coverage gap, etc.)
• The plan you choose. Remember, plan costs can change each year.
• Which pharmacy you use (whether it offers preferred or standard cost sharing, is out-of-network, or is mail order). Your out-of-pocket prescription drug costs may be less at a preferred pharmacy because it has agreed with your plan to charge less.
• Whether you get Extra Help paying your Part D costs due to your income.
• Stand-alone Part D Prescription drug plans charge a monthly premium that vary by plan. You pay this in addition to the Part B premium.
• If you’re in a Medicare Advantage Plan (like an HMO or PPO) there is no separate premium for the part D coverage