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Rick Sobotka, MBA
President &
Independent Advisor


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What is Medicare?

Medicare is the U.S. Federal Government Health Insurance Program for:

  • People 65 years of age and older. 
  • Some people with disabilities under age 65. 
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). 

Medicare has four parts:

Part A (Hospital Insurance) Most people do not have to pay for Part A.

Part B (Medical Insurance) Most people pay monthly for Part B.

Part C (Medicare Advantage Plans) Medicare Advantage plans are offered by private insurance companies as an alternative to Original Medicare; plans are government subsidized and regulated.

Part D (Prescription Drug Coverage) Part D Plans are offered by private companies to provide coverage for prescription drug costs.

Plans are government subsidized and regulated.  

Part A

Part A (Hospital Insurance) helps cover:

  • Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
  • Inpatient care in a skilled nursing facility (not custodial or long term care)  
  • Hospice care services
  • Home health care services
  • Inpatient care in a Religious Nonmedical Health Care Institution

You usually don't pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.  This is called "premium-free Part A."  

If you are not eligible for premium-free Part A, you may be able to buy Part A if you meet one of these conditions:

  • You're 65 or older, you're entitled to (or enrolling in) Part B, and you meet the citizenship or residency requirements. 
  • You're under 65, disabled, and your premium-free Part A coverage ended because you returned to work. 

Part B

Part B (Medical Insurance) helps cover medically-necessary services like doctors' services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Check your Medicare card to find out if you have Part B.

How Much Does Part B Cost?

You pay the Part B premium each month. Most people will pay the standard premium amount.  However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.  Your modified adjusted gross income is your taxable income plus your tax exempt interest income.  Social Security will notify you if you have to pay more than the standard premium.  If you have to pay a higher amount for your Part B premium and you disagree (even if you get Railroad Retirement Board benefits), call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Part C Part C (Medicare Advantage) sometimes called "Part C" or "MA Plans," are health plans offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan provides all your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage.  Medicare Advantage plans always cover emergency and urgent care.  Medicare Advantage Plans must cover all the services that Original Medicare covers, except hospice care. (Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan.)  Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs.  Most plans also include Medicare prescription drug coverage.  Medicare Advantage Plans must follow rules set by Medicare.  However, each plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan).  You usually pay one monthly premium to the Medicare Advantage plan, in addition to your Part B premium.

  • Different Types of Medicare Advantage Plans:
  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Medical Savings Account (MSA)
  • Plans Special Needs Plans (SNP)

Other less common types of Medicare Advantage Plans include:

  • Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out-of-network for a higher cost.  
  • Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.

How to Join a Medicare Advantage Plan

Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs.  Contact the specific plans you’re interested in to get more information about their benefits and costs.  Once you choose a plan, you may be able to join by completing a paper application, calling the plan, enrolling on the plan’s Web site.  Get started comparing Medicare Advantage plans in your area.

Part D Medicare Prescription Drug Coverage (Part D) is available to everyone with Medicare.  To get Medicare drug coverage, you must join a Medicare drug plan. Plans vary in cost and drugs covered.

Two types of plans offer Medicare prescription drug coverage:

  • Medicare Prescription Drug PlansThese plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans
  • Medicare Medical Savings Account (MSA) Plans

Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage.  You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called "MA-PDs."  

Who Can Get Medicare Drug Coverage?

To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or Part B.  To get prescription drug coverage through a Medicare Advantage Plan, you must have Part A and Part B.  

How to Join a Medicare Drug Plan

Once you choose a Medicare drug plan, you may be able to join by completing a paper application, calling the plan, enrolling on the plan's Web site, or through the MPDPF LINK.  You can also enroll by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.  Contact the specific plan you're interested in to find out how to join. Medicare drug plans aren't allowed to call you to enroll you in a plan.  Call 1-800-MEDICARE to report a plan that does this. Visit the Medicare Prescription Drug Plan Finder for a list of Medicare drug plans in your area.  For more information visit http://www.medicare.gov or download Medicare & You 2012 a summary of Medicare benefits, coverage options, rights and protections, and answers to the most frequently asked questions about Medicare.  Click Here for a list of valuable sections of the official Medicare website.

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