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Medicare is divided into four main parts, each offering coverage for specific services. Here's what you need to know.
What is Medicare Part A?
Most people don't have to pay a premium for Part A. However, if you don't qualify for premium free Part A, you will have to pay a monthly premium.
What Does Part A Cover?
Part A covers care you receive after being formally admitted to a hospital by a doctor. Each benefit period covers you for up to 90 days, plus 60 lifetime reserve days. Medicare will also cover up to 190 lifetime days in a Medicare-certified psychiatric hospital. There are certain conditions that need to be met in order for Part A to cover inpatient care at a facility.
Skilled nursing facility care
Part A will also cover a range of services provided at a skilled nursing facility when deemed medically necessary by a provider for ongoing treatment. These services include room and board, administration of medications, wound care, and tube feedings.
Like inpatient care, you need to meet specific criteria for Part A to cover your stay at a skilled nursing facility. Part A covers up to 100 days per benefit period once you qualify, with the first 20 days paid in full. However, the remaining 80 days require copayment.
Medicare won't cover long-term care, daily living, or custodial care. Nursing home care may not covered. This is because it is usually custodial care, which is activities of daily living like bathing, dressing, and eating.
Home health care
Medicare Part A will cover care administered in your home if you're homebound and need skilled care. To qualify for coverage, you will have to spend at least three consecutive days as a hospital inpatient within 14 days of getting home health care. Eligible services may include physical therapy, occupational therapy, speech language pathology, and more.
Hospice care
You can receive hospice care when a provider determines you're terminally ill. Part A covers this for as long as your provider decides you need care. Coverage includes: symptom control prescriptions, medical support, grief counseling, and other services. Patients usually receive hospice care at their residence or an inpatient hospice facility.
How Can I Enroll in Part A?
- Apply online at www.ssa.gov
- Call the Social Security number at 800-772-121
- Mail a signed and dated letter to Social Security that includes: your name, Social Security number, and the date you wish to be enrolled in Medicare
It covers medical services and medically necessary supplies to treat your health conditions. This can include ambulance services, preventive care, outpatient care, and durable medical equipment. It can even cover part-time rehabilitative services such as physical therapy or home care if a doctor orders them to treat a medical condition.
There's a monthly premium for Medicare Part B, and there may be co-payments and deductibles when you get care. The monthly premium may change from one year to the next and vary depending on your financial situation.
Though most people are eligible for Part B when they turn 65, special circumstances might allow you to enroll in Medicare before your 65th birthday.
What Does Part B Cover?
Preventive services
Part B covers a wide range of preventive services to help maintain your health and detect illnesses at an early stage. These services include annual wellness visits, screenings for cardiovascular disease, cancer, diabetes, and more. Many of these preventive services are provided at no cost to you if you meet eligibility requirements.
Outpatient care
Part B covers medically necessary services you receive as an outpatient from a Medicare-participating provider. This includes services received in a doctor's office, clinic, or hospital outpatient department. Examples of covered outpatient services are X-rays, lab tests, certain vaccinations, and durable medical equipment like wheelchairs and walkers.
Mental health services
Part B covers outpatient mental health services, such as psychotherapy, family counseling, and yearly depression screenings. These services can be provided by doctors, clinical psychologists, clinical social workers, and other qualified professionals. Partial hospitalization programs are also covered if they're offered by a hospital outpatient department or community mental health center.
Ambulance services
Medicare Part B covers ground ambulance transportation to a hospital, critical access hospital, or skilled nursing facility when medically necessary. It covers air transportation (airplane or helicopter) only when you require immediate and rapid transportation that cannot be provided by ground transportation.
Limited outpatient prescription drugs
While most prescription drugs are covered under Medicare Part D, there are some exceptions. Part B covers certain drugs that you wouldn't usually give to yourself, like those you get at a doctor's office or hospital outpatient setting.
How can I Enroll in Part B?
If you're not automatically enrolled and want to sign up for Part B, you can do so during the following enrollment periods:
- Initial Enrollment Period (IEP): This is a seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65. If you enroll during this time, your coverage will start the first day of your birthday month, or the first day of the month after you enroll if your birthday has passed.
- General Enrollment Period (GEP): If you didn't sign up for Part B during your IEP, you can enroll during the GEP, which runs from January 1 to March 31 each year. If you enroll during this time, your coverage will start July 1. Keep in mind that you may have to pay a late enrollment penalty if you didn't sign up for Part B when you were first eligible.
- Special Enrollment Period (SEP): If you have coverage through current employment (your own, a spouse's, or a family member's), you may qualify for a Part B SEP. This allows you to delay enrolling in Part B without penalties for up to eight months after your employment or coverage ends, whichever happens first.
- Apply online at www.ssa.gov
- Call the Social Security number at 800-772-1213
- Visit your local Social Security office. Click here for a locator tool
If you need guidance on navigating the enrollment process or have questions about your specific situation, contact the Guided team today for personalized assistance.
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Part A and Part B) offered by private insurance companies approved by Medicare. These plans bundle Part A, Part B, and often Part D (prescription drug coverage) into a single plan, providing a convenient way to manage your Medicare benefits.
When you enroll in a Medicare Advantage plan, you're still in the Medicare program and must continue paying your Part B premium (and your Part A premium, if applicable). In addition, you may have to pay a monthly premium for your Medicare Advantage plan, although some plans have $0 premiums.
Medicare Advantage plans must cover all the services that Original Medicare covers, but they can do so with different rules, costs, and restrictions. Many plans offer additional benefits that Original Medicare doesn't cover, such as routine dental, vision, and hearing care, fitness programs, and over-the-counter medications.
It's important to review the details of each Medicare Advantage plan carefully before enrolling, as the costs and benefits can vary significantly from plan to plan and from region to region.
You'll also want to ensure that your preferred healthcare providers are included in the plan's network, as some plans may have limited provider networks or require referrals to see specialists.
What Does Part C Cover?
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Part A and Part B) offered by private insurance companies approved by Medicare. Part C plans include both Part A and Part B coverage, and often provide additional benefits. Here is a list of services typically covered by Medicare Part C:
Part A and Part B benefits
All Medicare Advantage plans must cover the same services that Original Medicare covers under Part A and Part B. This includes inpatient hospital care, skilled nursing facility care, home health care, preventive services, outpatient care, mental health services, and ambulance services.
Prescription drug coverage
Most Medicare Advantage plans (known as MA-PDs) include prescription drug coverage, which is usually equivalent to Medicare Part D. This means you can get your Medicare benefits and prescription drug coverage through a single plan, rather than enrolling in a separate Part D plan.
Additional benefits
Many Medicare Advantage plans offer extra benefits that Original Medicare doesn't cover. These may include:
- Routine dental care, such as cleanings, X-rays, and dentures
- Routine vision care, including eye exams and glasses
- Routine hearing exams and hearing aids
Fitness memberships, such as SilverSneakers - Transportation to medical appointments
- Over-the-counter medications and health products
One advantage of Medicare Part C is that it limits your annual out-of-pocket expenses. Once you reach your plan's yearly limit, you pay nothing for covered services for the rest of the year. This can provide financial protection and peace of mind, especially if you have significant health care needs.
It's important to note that the specific benefits and costs of Medicare Advantage plans can vary widely. They may also have different rules and restrictions compared to Original Medicare, such as requiring referrals to see specialists or only covering services from providers within the plan's network. Be sure to carefully review a plan's details before enrolling.
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How Can I Enroll in Part C?
- Visit the plan's website and enroll online
- Call the plan directly
- Use the Medicare Plan Finder tool on the official Medicare website
- Call 1-800-MEDICARE (1-800-633-4227)
If you need assistance choosing a plan that best fits your needs and budget, contact the Guided team today for expert advice and support.
What is Medicare Part D?
Medicare Part D is prescription drug coverage offered by private insurance companies approved by Medicare. It helps cover the cost of prescription medications and can be added to Original Medicare (Part A and Part B), some Medicare Cost Plans, some Medicare Private-Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
If you have Original Medicare and want prescription drug coverage, you must enroll in a separate Part D plan. If you have a Medicare Advantage plan, prescription drug coverage is often included (known as an MA-PD plan), but you can also choose a plan without drug coverage and enroll in a separate Part D plan.
Part D plans have a monthly premium, which varies by plan and can be deducted from your Social Security payment or paid directly to the insurance company. You may also have to pay an annual deductible, copayments, or coinsurance for your medications. If your income is above a certain level, you may have to pay an Income Related Monthly Adjustment Amount (IRMAA) in addition to your Part D premium.
It's important to note that Part D plans have a coverage gap, often called the "donut hole," where you pay a higher percentage of your drug costs after you and your plan have spent a certain amount on covered drugs. Once you reach the catastrophic coverage stage, you'll pay significantly lower copayments or coinsurance for the rest of the year.
Like Medicare Advantage plans, Part D plans can vary in terms of costs, covered medications, and pharmacy networks, so it's crucial to compare plans and choose one that best meets your needs and budget.
What Does Part D Cover?
Medicare Part D is prescription drug coverage offered by private insurance companies approved by Medicare. It helps cover the cost of prescription medications and can be added to Original Medicare (Part A and Part B), some Medicare Cost Plans, some Medicare Private-Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
Here is a list of what Medicare Part D typically covers:
Prescription drugs
Part D plans cover a wide range of prescription drugs, including both brand-name and generic medications. Each plan has its own formulary, which is a list of covered drugs divided into tiers. Lower-tier drugs generally have lower copayments or coinsurance, while higher-tier drugs have higher out-of-pocket costs.
Vaccines
Part D plans cover commercially available vaccines, such as the shingles vaccine, when medically necessary to prevent illness. Some vaccinations, like flu shots, are covered under Part B instead of Part D.
Medication therapy management
If you take medications for different medical conditions, you may be eligible for medication therapy management (MTM) services. MTM can help you understand how to manage your medications effectively and safely. Part D plans must offer MTM services to members who meet certain criteria, such as having multiple chronic conditions or taking several medications.
Transitional fills
If you're new to a Part D plan or your plan changes its formulary, you may be able to get a one-time, temporary supply of a drug you're currently taking. This gives you time to work with your doctor to find an alternative medication or request a formulary exception from your plan.
It's important to note that while Part D covers a broad range of prescription drugs, not all medications are covered. Each plan has its own formulary and may have certain restrictions, such as prior authorization, quantity limits, or step therapy.
Additionally, Part D plans may have an annual deductible, copayments, or coinsurance, and a coverage gap (known as the "donut hole") where you pay a higher percentage of drug costs until you reach the catastrophic coverage stage.
How Can I Enroll in Part D?
Initial Enrollment Period (IEP): If you enroll in a Part D plan during your IEP (the seven-month period surrounding your 65th birthday), your coverage will begin on the first day of the month that your Part A and/or Part B coverage starts.
Annual Enrollment Period (AEP): Also known as the Open Enrollment Period, the AEP runs from October 15 to December 7 each year. During this time, you can enroll in a Part D plan, switch from one Part D plan to another, or disenroll from a Part D plan.
Medicare Advantage Open Enrollment Period (MA OEP): If you're enrolled in a Medicare Advantage plan and decide to switch to Original Medicare during the MA OEP (January 1 to March 31), you can also enroll in a Part D plan during this time.
Special Enrollment Periods (SEPs): In certain situations, such as losing your current creditable prescription drug coverage, moving outside your plan's service area, or qualifying for Extra Help, you may be eligible for a SEP to enroll in a Part D plan outside of the regular enrollment periods.
To enroll in a Part D plan, you can:
- Visit the plan's website and enroll online
- Call the plan directly
- Use the Medicare Plan Finder tool on the official Medicare website
- Call 1-800-MEDICARE (1-800-633-4227)
Before choosing a Part D plan, compare the available options in your area and consider factors such as premiums, deductibles, copayments, and the plan's formulary (list of covered drugs).
If you need help navigating the Part D enrollment process or selecting a plan that meets your needs, contact the Guided team today for personalized assistance.
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