The Centers for Medicare and Medicaid services have

rules on when you become eligible for the Medicare 

Initial Enrollment Period.

• Three months before you turn 65

• The month you turn 65

• Three months after you turn 65

• If you retire after 65, enrollment depends on when your employer-sponsored health insurance ends.

To enroll in Medicare you must be a US citizen or permanent resident who has lived in the United States for at least 5 years.

Think of Medicare Advantage Plans (also known as MA plans) as your one-stop-shop for all of your healthcare services and prescription drugs.

Part A + Part B + Part C + Part D

 

Part A & B together make up what is called Original Medicare. These are the only parts that you will sign up for through the social security office or Railroad Retirement Board.

 

PART A- HOSPITAL INSURANCE

Helps you cover common expenses for things such as hospital stays, hospice, home health care and even skilled nursing facility stays.

 

PART B- MEDICAL INSURANCE

For outpatient services that are deemed medically necessary including services like doctor office visits, lab testing, diagnostic imaging, preventive care, surgeries, ambulance rides, chemotherapy and radiation, and even extensive dialysis care for people with renal failure.

Originally called Medicare Part C, a Medicare Advantage plan is a private Health Insurance plan contracted with Medicare. It provides the same basic coverage as Parts A and B, including hospital and doctor’s visits, plus supplemental benefits that many people want or need.

Medicare Advantage plans are not free, but some plans have what is called a $0 premium. This means you pay no premium for the plan itself, but you will still pay the Part B premium to Medicare and you pay deductibles, copays, and coinsurance as you use your benefits.

 

When you enroll in a Medicare Advantage plan, Medicare pays the Advantage plan insurance company a monthly fee to take on all of your medical risks. That is the reason why some plans can offer a $0 premium - they are already getting paid by Medicare on your behalf.

Many Medicare Advantage plans offer additional benefits at low or no cost. These include:

• Dental

• Vision – Routine Eye Exam, Frames and Lenses

• Hearing Aids

• Mail Order and Home Delivery of Prescription Drugs

• 100s of Non-Prescription Pharmacy items like Vitamins and Aspirin

• Gym Membership

• Transportation Services

• Access to Doctors Online and Over the Phone

• Chiropractic / Acupuncture

• Emergency Worldwide Coverage including Mexico

• Special Needs Plans for Diabetes, Heart Disease, Dementia, Alzheimers, Individuals with Medicare and Medi-Cal Coverage, and More

Medicare is divided into 4 parts. Medicare itself has different Parts, not Plans. Let’s review the A, B, C, and Ds of Medicare:

PART A- HOSPITAL INSURANCE

Part A helps you cover common expenses for things such as hospital stays, hospice, home health care and even skilled nursing facility stays.

PART B- MEDICAL INSURANCE

Part B is for outpatient services that are deemed medically necessary including services like doctor office visits, lab testing, diagnostic imaging, preventive care, surgeries, ambulance rides, chemotherapy and radiation, and even extensive dialysis care for people with renal failure.

Part A & B together make up what is called Original Medicare. These are the only parts that you will sign up for through the social security office or Railroad Retirement Board.

PART C- MEDICARE ADVANTAGE PLANS (MA)

Part C plans are private health plans that you can choose instead of Original Medicare. MA covers everything from Parts A and B and often covers other services like dental, vision and wellness programs.

PART D- MEDICARE PRESCRIPTION DRUG PLAN

Part D is offered by private insurance carriers who are contracted by the federal government. These plans give you lower copayments on your medicines than you would pay without Part D insurance.

In most cases, if you don’t sign up for Part B when you’re first eligible, you’ll have to pay a late enrollment penalty for as long as you have Part B.

With Original Medicare you may be subject to deductibles and coinsurance.

You have a lot of choices when it comes to Medicare, which is good, but can also be overwhelming. To help you understand the options that you can choose from, we have broken it down:

 

ORIGINAL MEDICARE

Includes Parts A and B:

Part A: Covers hospital visits and prolonged stays

Part B: Covers doctor visits and outpatient care

 

PRESCRIPTION DRUG COVERAGE

Part D: Helps cover the cost of prescription drugs

 

MEDICARE ADVANTAGE

Provided through Medicare Part C:

Combines Parts A and B, and usually Part D

May include additional coverage for benefits not covered by Parts A and B

 

MEDICARE SUPPLEMENT INSURANCE

Helps pay for costs not covered by Parts A and B

Also known as Medigap Policy

Medicare Part D, also known as a prescription drug plan, helps you pay for your doctor prescribed medications.

INSURANCE FOR PRESCRIPTION DRUGS

• You pick your plan through a private insurance carrier in your state.    

• Pick your prescriptions from a pharmacy that is in-network with your plan.    

• If you want to shop your Part D plan, you can change plans each year during the Annual Enrollment Period.

There are 2 ways to get prescription drug coverage:

1. Enroll in a Medicare Advantage Prescription Drug plan (Parts C and D). This will combine your medical and prescription drug coverage. 

2. Enroll in a standalone Medicare Part D plan that will be in addition to your Original Medicare (Parts A and B)

Every Medicare Part D plan has a list of drugs it covers, called a formulary. When you research a plan, check the medications you are currently taking against the plan’s list. Formularies include both brand name and generic prescription drugs. Your plan will not remove any drugs from its formulary until the start of the new plan year, unless there’s an extenuating circumstance, like a recall.

Medicare HMO or PPO networks are the most common type of networks within Medicare Advantage plans. 

Medicare HMO networks account for over two thirds of all Medicare Advantage plans on the market. For the most part, Medicare HMO networks require treatment be done solely with in-network providers, except in certain circumstances. If you need to see a specialist, you will need to have a referral from your primary care physician. 

Medicare PPO networks allow for visits out-of-network, but you will have to pay significantly more out of pocket.

 

MEDICARE ADVANTAGE

Covers the same benefits as Original Medicare

May offer extra benefits like vision, dental, hearing aids, and fitness programs like SilverSneakers

 

BOTH

Available through private insurance companies

 

MEDICARE SUPPLEMENTS

Generally, doesn’t cover vision or dental care

Helps pay some of those costs that Original Medicare does not cover (copayments, coinsurance, and deductibles)

 

Medicare’s Special Needs Plans (SNP) cater to members who have specific needs that are not already covered in Medicare Parts A and B. This allows members to tailor things like their drug formularies and provider choices to better meet the care they need

Chronic Illness Special Needs Programs:

Chronic Illness Special Needs Programs (C-SNPs) are specialized health plans designed for members with with conditions like:

• Cardiovascular Disease

• Congestive Heart Failure

• Dementia / Alzheimers

• Diabetes / High Blood Sugar

• Chronic and Disabling Mental Health Conditions

• History of Stroke

• Hypertension / High Blood Pressure

 

Institutional Special Needs Program (I-SNP) is for members who live in an institution or facility, or those who require nursing care at home. If qualified, you can enroll year-round.

Dual Eligible Special Needs Program (D-SNP) are those who qualify for both Medicare and Medi-Cal. If qualified, you can enroll year-round.