What Is Medicare?
An Overview of the Plans & Options Available to Medicare Beneficiaries.
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What is Medicare?
Medicare is the federal health insurance program for:
- People who are 65 or older
- Certain younger people with disabilities
- People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
What Are the Parts of Medicare?
The different parts of Medicare help cover specific services:
- Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. - Medicare Part B (Medical Insurance)
Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. - Medicare Part D (prescription drug coverage)
Helps cover the cost of prescription drugs (including many recommended shots or vaccines).
What Does Part A Cover?
If you’re in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
In general, Part A covers:
- Inpatient care in a hospital
- Skilled nursing facility care
- Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
- Hospice care
- Home health care
Medicare coverage is based on 3 main factors:
- Federal and state laws.
- National coverage decisions made by Medicare about whether something is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
What Does Part B Cover?
If you’re in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
Part B covers 2 types of services:
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.
Part B covers things like:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health
- Inpatient
- Outpatient
- Partial hospitalization
- Limited outpatient prescription drugs
What Does Part C (Medicare Advantage) Cover?
Part C covers these Services:
Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. These “bundled” plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare drug coverage (Part D).
Part C covers things like:
Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover, like some vision, hearing, dental, and fitness programs (like gym memberships or discounts). Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.
Rules for Part C:
Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.
Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:
- Whether you need a referral to see a specialist
- If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
These rules can change each year.
What Does Part D Cover?
Part D covers these Drugs:
All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
Part D covers things like:
Most Medicare drug plans (Medicare drug plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.
The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.
Rules for Part D:
Medicare drug plans may have these coverage rules. To learn more, please visit Medicare.gov.
- Opioid pain medication safety checks
- Prior authorization
- Quantity limits
- Step therapy
- Part D vaccine coverage
- Drugs you get in hospital outpatient settings
What are Income Related Monthly Adjustment Amounts (IRMAA)?
IRMAA & Part B premiums
You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these:
- Social Security
- Railroad Retirement Board
- Office of Personnel Management
If you don’t get these benefit payments, you’ll get a bill.
2021 IRMAA Requirements
According to Medicare.gov, most people will pay the standard premium amount. If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago. This is the most recent tax return information provided to Social Security by the IRS.
The standard Part B premium amount in 2021 is $148.50. Most people pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.
| If your yearly income in 2019 (for what you pay in 2021) was | You pay each month (in 2021) | ||
|---|---|---|---|
| File individual tax return | File joint tax return | File married & separate tax return | |
| $88,000 or less | $176,000 or less | $88,000 or less | $148.50 |
| above $88,000 up to $111,000 | above $176,000 up to $222,000 | Not applicable | $207.90 |
| above $111,000 up to $138,000 | above $222,000 up to $276,000 | Not applicable | $297.00 |
| above $138,000 up to $165,000 | above $276,000 up to $330,000 | Not applicable | $386.10 |
| above $165,000 and less than $500,000 | above $330,000 and less than $750,000 | above $88,000 and less than $412,000 | $475.20 |
| $500,000 or above | $750,000 and above | $412,000 and above | $504.90 |
Appealing Your IRMAA (Part B Premium)
According to the Department of Health and Human Services, you can appeal your IRMAA decision.
OMHA handles appeals of the Medicare program’s determination of a beneficiary’s Income Related Monthly Adjustment Amount (IRMAA), which determines a Medicare beneficiary’s total monthly Part B insurance premium.
The Social Security Administration (SSA) notifies a beneficiary of his or her Part B insurance premium and any IRMAA with the beneficiary’s annual notice of Social Security benefits (referred to as an initial determination). SSA is responsible for issuing all initial and reconsideration determinations. It is important to remember that IRMAAs apply for only one year. A beneficiary will be notified by SSA near the end of the current year if he or she has to pay an IRMAA for the upcoming year.
As a beneficiary, you have the right to appeal if you believe that an Income Related Monthly Adjustment Amount (IRMAA) is incorrect for one of the qualifying reasons. First, you must request a reconsideration of the initial determination from the Social Security Administration. A request for reconsideration can be done orally by calling the SSA 1-800 number (800.772.1213) as well as by writing to SSA.
Medicare Should Not Be Your Only Coverage
Medicare Supplement Plans (Medigap)
Medigap is Medicare Supplement Insurance that helps fill “gaps” in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like:
- Copayments
- Coinsurance
- Deductibles
Note: Medigap plans sold to people who are newly eligible for Medicare aren’t allowed to cover the Part B deductible. Because of this, Plans C and F aren’t available to people newly eligible for Medicare on or after January 1, 2020. If you already have or were covered by Plan C or F (or the Plan F high deductible version) before January 1, 2020, you can keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans that cover the Part B deductible.
Medicare Advantage Plans
Medicare Advantage Plans are another way to get your Medicare Part A and Part B 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. Most Medicare Advantage Plans include drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs.
These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, to help protect you from unexpected costs. Some plans offer out-of-network coverage, but sometimes at a higher cost. Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare. Below are the most common types of Medicare Advantage Plans.
Compare Today!
A licensed insurance agent from our team will contact you to discuss your Medicare options.
