Medicare Health Benefits FAQ

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Medicare FAQsYou have access to a wide range of health care options under Medicare. Use this FAQ to help you choose the best plan for your situation.

What is Medicare?

Medicare is a federal health insurance program. You qualify for it if you are age 65 or older, or if you are younger but have certain disabilities or end-stage renal disease. Medicare coverage is divided into four parts: A, B, C and D.

What is Original Medicare?

Medicare Part A and Medicare Part B together make up what is called Original Medicare or sometimes referred to as Traditional Medicare. Medicare Part A is hospital insurance. It covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and home health services. Medicare Part B is medical insurance. It covers certain doctors’ services, outpatient care, medical supplies, and preventative services.

Can I go to any doctor I want under Original Medicare?

Yes, you can go to any doctor, hospital or other provider that accepts Medicare patients anywhere in the country.

Has Medicare added any new benefits?

The 2010 Affordable Care Act made many improvements to Medicare, including additional benefits and more coverage. Medicare is stronger than ever. You now have access to benefits to help maintain and improve your health like the “Welcome to Medicare” preventive visit and a yearly “Wellness” visit to discuss your health and health care needs.

What is Medicare Part D?

Medicare Part D adds prescription drug coverage to Original Medicare. These plans are offered by insurance companies and other private companies approved by Medicare to help lower your prescription drug costs and protect against higher costs.

What is this donut hole I keep hearing about?

Drug coverage has become much more affordable over the last couple of years with the gradual closing of the coverage gap (also called the “donut hole”). The coverage gap is when the amount you pay for your prescriptions suddenly increases after you and your plan combined have paid a certain amount in drug costs (usually about $3,000). Now, thanks to health care reform, if you reach the Part D coverage gap, you’ll get a 50 percent discount on covered brand-name drugs and some coverage for generic drugs in the gap.

What is Medigap?

Medigap is supplemental insurance to cover some of the out-of-pocket expenses in your Original Medicare coverage.

What are Medicare Advantage Plans (Part C)?

A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. They primarily include HMOs and PPOs. A drawback to these plans is that they control what health care provider you are allowed to see and they place administrative restrictions on physicians for claim payments and referrals, which may ultimately compromise the treatment you receive.

Are there any resources to help me choose a Medicare plan that fits my needs?

Use the Medicare Plan Finder at the official Medicare website [Medicare.gov] or call the Medicare helpline for assistance at 1-800-MEDICARE (1-800-633-4227). You may also want to get advice from your state’s health insurance assistance program or a local agency on aging, which you can find through the government’s eldercare.gov website.

What will I have to pay out of pocket on average for Original Medicare?

You most likely will get your hospital insurance (Part A) premium free, though you will have to pay about a $1,100 hospital deductible per episode of illness. There is also a monthly premium for medical insurance (Part B), which is about $100.

In addition to paying a monthly premium, you pay fees for the services you receive…

  • For Medicare-covered services, you must first pay the Medicare Part B annual deductible, which is about $140. After you have met your deductible, you pay a Part B coinsurance for Medicare-covered services.
  • For doctors’ visits you generally pay 20 percent of the Medicare-approved amount.
  • For mental health services you pay 40 percent of the Medicare-approved amount.
  • Home health services are fully covered, though there is an additional cost for durable medical equipment if needed.

 

What if I have high drug costs? What should I do?

If you have high drug costs, you may save money through a Medicare drug plan. But make sure the plan you choose covers the drugs you need and works at the pharmacies you use most frequently.

What if I have low drug costs? What should I do?

If you have low drug costs, having Medicare drug coverage may cost you more now, but could protect you from high drug costs in the future. There may be a Medicare drug plan in your area with a low monthly premium you can afford. If you don’t currently take any drugs, you may want to choose the plan with the lowest premium to get coverage at the least cost.