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The 10 Medigap Plans

The 10 Medigap Plans

Medicare Supplement insurance (also called Medigap) is private insurance that helps fill the “gaps” left in Original Medicare, Part A and Part B. Medigap helps you pay for costs such as Original Medicare’s deductibles and copayments, which can add up over the year.

In most states, these plans come in 10 standardized types, meaning that each Medigap plan of the same name offers the same benefits, no matter which insurance company you get it from. They are also standardized in 47 of the states (Massachusetts, Minnesota, and Wisconsin offer their own Medicare Supplement plans). So, for example, if you choose a Medicare Supplement Plan F in one of those 47 states, it will have the same benefits as a Medicare Supplement Plan F from another company or in another state. However, Medicare Supplement premiums may vary, and insurance companies aren’t required to offer all 10 of the Medigap plans.

Here is a comparison of benefits available in the 10 standardized Medicare Supplement plans:

How to Read This Chart:

  • The benefit is fully covered.
  • %The benefit is covered up to the indicated percentage.
  • Click for more information about this benefit.

2015 Medicare Supplement Plans

Medigap Plan Benefits Plan A Plan B Plan C Plan D Plan F* Plan G Plan K Plan L Plan M Plan N
2016 Out-of-Pocket Limit**
$ 4960 $ 2480
Part A coinsurance hospital costs up to an additional 365 days after Medicare benefits are exhausted
Part B copayment or coinsurance 50% 75% ***
First 3 pints of blood 50% 75%
Part A hospice care coinsurance/copayment 50% 75%
Part A deductible 50% 75% 50%
Skilled nursing facility care coinsurance 50% 75%
Foreign travel emergency coverage (up to plan limits) 80% 80% 80% 80% 80% 80%
Part B deductible
Part B “excess charges”

* There is also a high-deductible version of Plan F in which beneficiaries pay for Medicare-covered costs up to a $2,180 (in 2016) deductible amount before the plan begins coverage.

** After the out-of-pocket limit and annual Part B deductible are reached for Medigap Plans K or L, the plan pays 100% of covered services for the remainder of the calendar year.

*** Plan N pays 100% of Part B coinsurance costs, except for up to $20 copayment for certain office visits and up to $50 for emergency room visits that don’t result in an inpatient admission.

After comparing Medigap plan options, you can get help choosing a plan that suits you through one of the following methods.

Contact the Medicare plan directly.

Call 1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
24 hours a day, 7 days a week

Contact a licensed insurance agency such as eHealth.

Call eHealth’s licensed insurance agents at
1-888-391-2659, TTY users 711
Monday through Friday, 8AM to 11PM ET, Saturday through Sunday, 8AM to 9PM ET.

You may receive a messaging service on weekends and holidays from February 15 through September 30.
Please leave a message and your call will be returned the next business day.

Or visit eHealthMedicarePlans.com and enter your zip code where requested to see a quote.

Medicare has neither reviewed nor endorsed this information.
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How the Medicare Part D Coverage Gap (“Donut Hole”) Works (infographic)

How the Medicare Part D Coverage Gap (“Donut Hole”) Works (infographic)

 

The Medicare Part D coverage gap, also known as the “donut hole,” is a temporary limit on what your Medicare Part D Prescription Drug Plan pays for covered prescription drugs. While in the coverage gap, you’ll pay a higher share of out-of-pocket costs for these medications.

You enter the coverage gap once you and your Medicare Part D Prescription Drug Plan have spent a certain combined amount on covered drugs. (In 2016, you’re in the coverage gap once you and your drug plan have spent $3,310, including the deductible.) Every Medicare Prescription Drug Plan and Medicare Advantage Prescription Drug plan has this spending limit, which may change from year to year.

Not everyone reaches the coverage gap, but you’re more likely to do so if you take a lot of prescription drugs, or your copayments and coinsurance costs are higher.

Take a look at our infographic showing how the Medicare Part D coverage gap works now and in the coming years.

medicare-donut-hole-04152016

 

Some Medicare Advantage Prescription Drug plans and Medicare Prescription Drug Plans offer additional coverage if you enter the coverage gap. To learn about your Medicare Part D options, feel free to contact one of eHealth’s licensed insurance agents at the telephone number listed below.

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Medicare Coverage of Counseling and Mental Health Services

Medicare Coverage of Counseling and Mental Health Services

 

Caring for your mental well-being is just as important as taking care of your physical health. As you get older, you might feel sad or frustrated sometimes, especially when you have health problems. However, if you’re feeling persistently sad or anxious or having thoughts of suicide, your doctor can be a good resource for helping you get the care you need.

Medicare covers many mental health services to help you stay healthy, such as psychological counseling services, diagnostic evaluations, and preventive screenings.

Medicare coverage of preventive mental health services

Medicare Part B covers preventive services that address your mental health, including screenings to identify your risk for depression or substance abuse. You generally need to get these services from a Medicare-assigned health provider in a Medicare-enrolled facility to make sure Part B covers them.

Preventive benefits related to mental health coverage include:

  • Depression screening: All Medicare Part B beneficiaries are covered for one depression screening every year at no cost, so long as the doctor accepts Medicare assignment.
  • Alcohol misuse screening: All Medicare Part B beneficiaries who aren’t alcohol-dependent are covered for one alcohol misuse screening every year. If your doctor determines you misuse alcohol, you may qualify for up to four counseling sessions per year.
  • “Welcome to Medicare” visit: This one-time preventive exam includes a review of your overall health and includes an evaluation of your risk for depression. The visit is completely covered if you have the visit within the first year of having Medicare Part B.
  • “Wellness” visit: After the introductory visit, all Medicare Part B enrollees are covered for one preventive visit every year. If you have any questions or concerns about your mental well-being, you’ll have the chance to speak with your doctor during this exam. Your doctor may discuss treatment options or refer you for additional care.

Medicare outpatient mental health services

Medicare Part B covers outpatient mental health services, such as care you’d get in a health clinic or doctor’s office. You’ll generally pay 20% of the Medicare-approved cost for outpatient care delivered by providers that accept Medicare assignment.

Medicare covers the following types of psychotherapy (also called counseling):

  • Psychiatric assessment
  • Individual counseling
  • Group counseling
  • Family counseling, when the primary goal is to treat your condition
  • Alcohol misuse counseling, up to four sessions

You may need to meet other criteria to be eligible for therapy coverage, and the doctor, psychologist, or other health-care professional must accept Medicare assignment. Medicare doesn’t cover certain types of therapy, such as pastoral counseling or marriage counseling.

If you need more structured or frequent treatment, Medicare Part B also covers partial hospitalization programs, which are outpatient mental health programs where treatment is provided throughout the day and doesn’t require an overnight, inpatient stay. The programs are usually run through a community mental health center or a hospital’s outpatient department. Services may include therapy with a mental health professional, diagnostic services, and occupational therapy (if it’s part of your treatment). These programs don’t cover meals or transportation to the facility.

Partial hospitalization programs can be another treatment option for those who need more intensive care, but don’t want to be fully hospitalized or are transitioning from an inpatient hospital stay. To be eligible, your doctor must certify that you’d need inpatient hospitalization without the program.

Medicare inpatient mental health services

If you do need inpatient care as part of your treatment, Medicare Part A covers services during an inpatient hospital or psychiatric hospital stay. There’s a limit to Medicare coverage if you stay at a psychiatric hospital that’s dedicated to treating mental health patients, as opposed to a general hospital. Medicare Part A pays for up to 190 days of psychiatric hospital care in your lifetime.

Even during inpatient stays, Medicare Part B still covers certain mental health benefits, such as physician services.

Medicare Part D coverage

Your doctor may prescribe medications as part of your treatment. Keep in mind that Original Medicare, Part A and Part B, includes only limited prescription drug coverage, although Part B covers certain prescription drugs you get in an outpatient setting, such as medications you can’t give yourself. For most other prescription needs, you’ll need to enroll in a stand-alone Medicare Part D Prescription Drug Plan if you have Original Medicare.

Another option is to sign up for a Medicare Advantage Prescription Drug plan, which includes both health and drug benefits. These plans must provide at least the same level of coverage as Medicare Part A and Part B, but may include additional coverage, including drug benefits, routine vision and dental, and more. You need to continue paying your Medicare Part B premium along with any plan premium. There are only certain times when you can enroll in a Medicare Advantage plan.

Antipsychotics, anticonvulsants, and antidepressants are under protected drug classes under Medicare Part D, meaning all Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans must cover nearly all of the medications in these categories (with some exceptions). You can find out if a specific Medicare Part D Prescription Drug Plan covers your medications by checking the plan’s formulary, which is a list of covered prescription drugs. If a drug plan doesn’t cover a medication you need, you or your doctor may be able to file an exception to have the drug covered. The formulary may change at any time. You will receive notice from your plan when necessary.

Keep in mind that prescription costs may vary by plan, even for the same medications. One way to minimize your costs is to compare plans and find a Medicare Part D Prescription Drug Plan that covers your prescriptions with low cost-sharing. Remember, costs to consider include not only premiums and copayments or coinsurance, but also deductibles and out-of-pocket maximum limits.

To browse plans in your area, simply enter your zip code where indicated on this page.

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Medicare Eligibility When You’ve Just Moved or Returned to the U.S.

Medicare Eligibility If You Live Overseas or Are Moving Back to the U.S.

 

Whether you currently live overseas, or you’re returning to the U.S. after living outside of the country, you may be wondering whether you qualify for Medicare and how to sign up. Typically, U.S. citizens and legal permanent residents of at least five continuous years are eligible for Medicare when they turn 65 or at any age through disability. You can also get Medicare before 65 if you have end-stage renal disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease). However, eligibility and enrollment works differently if you first become eligible while you’re out of the country.

Here’s an overview of different situations, including what to do if you become eligible for Medicare while abroad and how to sign up for Medicare if you’re moving back to the U.S. Please note that Medicare considers the U.S. to include the 50 states, the District of Columbia (Washington, D.C.), Puerto Rico, Guam, American Samoa, the U.S. Virgin Islands, and the Northern Mariana Islands.

Are you an American living abroad and turning 65?

If you’re an American citizen living abroad when you turn 65 and first become eligible for Medicare, you may not be able to enroll in Original Medicare, Part A and Part B, until you return to the United States. You must be a U.S. resident to sign up for Part A and/or Part B.

In certain situations, you can delay enrollment in Part A and/or B without a late-enrollment penalty if you’re living out of the country when you first become eligible for Medicare. See below for more information on Special Enrollment Periods.

Are you already enrolled in Medicare and moving out of the country?

If you signed up for Medicare while you were living in the U.S., and then later moved overseas, Medicare won’t cover your medical expenses outside of the country in most cases. You may want to contact Social Security in this case to disenroll from Part B, since you’ll otherwise be paying a monthly premium for coverage you can’t use. You can call Social Security at 1-800-772-1213 (TTY users, call 1-800-325-0778); Monday through Friday, from 7AM to 7PM.

At the same time, keep in mind that you may have to pay a late-enrollment penalty for Part B if you ever do move back to the U.S. and decide you want this coverage later. This comes in the form of a 10% higher premium for every full 12-month period that you were eligible for Part B and went without it. You may also owe a late-enrollment penalty for Part A if you haven’t worked enough quarters to get it without a premium and go without it any time after you’re first eligible.

Are you a citizen of a different country who just moved to the U.S.?

Most people qualify for Medicare when they turn 65. However, even if you’re 65 years or older, you may not be eligible for Medicare until you’re either a United States citizen or a permanent resident who has lived in the country for at least five continuous years.

If you meet the citizenship and residency requirements for eligibility, you can also qualify for Medicare at any age if you’ve been receiving Social Security Administration (SSA) or Railroad Retirement Board (RRB) disability benefits for two years or if you have end-stage renal disease or amyotrophic lateral sclerosis.

If you have questions about whether you qualify for benefits, you can contact Medicare or the Social Security Administration; contact information is at the end of this article.

Are you a returning U.S. citizen?

If you didn’t sign up for Medicare because you were out of the country, you may be able to enroll in Part A and Part B after you return to the country and establish residency. As mentioned, you must be either a U.S. citizen or permanent legal resident of at least five continuous years to be eligible. In addition, you must be either 65 or older, collecting disability benefits for two years, or have end-stage renal disease or amyotrophic lateral sclerosis. There are different enrollment periods and options depending on your situation.

Generally, if you return to the U.S. after living abroad, you can sign up for Medicare Part A and/or Part B during the General Enrollment Period (January 1 through March 31). You might have to pay a late-enrollment penalty. But, in some cases, you might qualify for a Special Enrollment Period (see below for some examples of qualifying situations).

Special Enrollment Periods

If you turned 65 while living overseas and you didn’t sign up for Medicare when you were first eligible, you may qualify for a Special Enrollment Period that starts when you return to the U.S. and lasts three months. You generally don’t need to pay a late-enrollment penalty if you enroll during this three-month period.

You may also qualify for a Special Enrollment Period if you were living overseas and covered by an employer-based health plan. You can sign up for Medicare Part A and/or Part B anytime as long as either you or your spouse is working and covered through health coverage based on current employment. If your employment or group coverage ends, your Special Enrollment Period begins after you or your spouse stops working or the group health insurance based on current employment ends (whichever occurs first). This Special Enrollment Period lasts for eight months. Note that COBRA and employer retirement health plans don’t typically qualify you for a Special Enrollment Period because this coverage isn’t based on current employment.

You might also be eligible for a Special Enrollment Period if you were a volunteer serving outside the U.S. for at least 12 months on behalf of a tax-exempt organization and had health insurance coverage for the duration of the service. Your six-month Special Enrollment Period begins when one of the following happens:

  • Your volunteer service outside of the U.S. ends.
  • The volunteer organization loses its tax-exempt status.
  • Your health plan that was providing coverage overseas ends.

Usually, you don’t pay a late-enrollment penalty if you sign up during a Special Enrollment Period.

Enrolling in Medicare after you return to the U.S.

Once you return to the U.S. and establish residency in the country, you may be eligible for Medicare Part A and/or Part B if you meet the above-mentioned citizenship and legal permanent residency requirements. You can sign up through the Social Security Administration:

If you worked for a railroad, contact the Railroad Retirement Board (RRB) to enroll in Medicare. You can call 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM, to speak to an RRB representative.  TTY users, call 1-312-751-4701.

Signing up for a Medicare Advantage or Prescription Drug Plan after moving to the U.S.

If you already have Original Medicare and you move back to the U.S., you can do either of these during the two-month period after the month you return:

  • Enroll in a stand-alone Medicare Part D Prescription Drug Plan that works alongside your Original Medicare, Part A and Part B, coverage.
  • Switch to a Medicare Advantage plan. If you do this, you get your Medicare Part A and Part B benefits through a private insurance company that contracts with Medicare. Most Medicare Advantage plans include prescription drug coverage, and many of them offer extra benefits beyond Original Medicare.

With either of these choices, you may need to continue paying your Medicare Part B premium, in addition to any premium required by your plan. 

If you’d like more information about the Medicare options available to you, you can start browsing plan options in your area with the plan finder tool on this page. Or, for more personalized assistance with your Medicare needs, contact eHealth today to speak with a licensed insurance agent.

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How Your Income May Affect Your Medicare Costs

How Your Income May Affect Your Medicare Costs

The federal Medicare program has costs that come with it. There may be premiums, copayments, coinsurance, and deductibles associated with Medicare Part A, Part B, and the optional Part D (prescription drug coverage). If your income is below certain limits, you might qualify for programs that reduce your Medicare costs. On the other hand, if your income is higher than a certain level, you might have to pay a higher Medicare Part B premium and a higher Medicare Part D premium (if you have a Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan).

Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) make up Original Medicare. If you’re automatically enrolled in Medicare, as many Americans are when they turn 65, Original Medicare is the type of insurance you get. You can add to this insurance by enrolling in prescription drug coverage through Medicare Part D and/or buying a Medicare Supplement (Medigap) plan to help with Original Medicare costs; or you can get your Medicare coverage through a Medicare Advantage (Medicare Part C) plan.

Medicare Part A premium

Most beneficiaries qualify for premium-free Medicare Part A. This insurance isn’t income-based; rather, the premium depends on how many years you worked and paid Medicare taxes. Here’s a breakdown of the Part A monthly premium in 2016. If you’ve worked while paying Medicare taxes:

  • For at least 10 years (40 quarters) while paying Medicare taxes, you don’t pay a premium
  • For 30 to 39 quarters, you pay $226
  • For less than 30 quarters, you pay $411

Medicare Part B premium

Beneficiaries typically pay a monthly Medicare Part B premium, although if you have a low income, you may qualify for help paying it. This premium amount may vary, depending on your situation. Here are a few different scenarios:

  • If you enrolled in Part B before 2016, your premium will generally be $104.90 per month.
  • You’ll generally pay $121.80 for your monthly premium if any of the following situations applies to you:
    • You enroll in Part B for the first time in 2016.
    • You aren’t receiving Social Security benefits yet.*
    • You are billed directly for your Part B premium.
    • You have both Medicare and Medicaid coverage (you’re dual eligible), and Medicaid pays for your premiums.

*If you worked for a railroad, contact the Railroad Retirement Board (RRB) to learn more about your Part B premium costs. You can contact the RRB at 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM, to speak to an RRB representative. TTY users call 1-312-751-4701.

In some situations, your Part B premium may be higher than the above amounts. The government looks at your income as reported on your tax return from two years ago to set your Medicare Part B premium. This table refers to your 2014 income and your 2016 Medicare Part B monthly premium.

 

Your income if you filed an individual tax return Your income if married and you filed a joint tax return Your income if married and you filed a separate tax return Your Medicare Part B premium
$85,000 or less $170,000 or less $85,000 or less $121.80

 

More than $85,000 and up to $107,000 More than $170,000 and up to $214,000 Not applicable $170.50
More than $107,000 and up to $160,000 More than $214,000 and up to $320,000 Not applicable $243.60
More than $160,000 and up to $214,000 More than $320,000 and up to $428,000 More than $85,000 and up to $129,000 $316.70
More than $214,000 More than $428,000 More than $129,000 $389.80

Your Medicare Part B premium payment is typically deducted from your monthly Social Security benefit. If you have to pay an income-related monthly adjustment amount, you’ll get a notice from Social Security.

In addition to your monthly premium for Part B, you also pay an annual deductible of $166 in 2016.

Medicare Part D premium

Medicare Part D is optional prescription drug coverage, available as a stand-alone Medicare Prescription Drug Plan that you enroll into to augment your Original Medicare coverage or through a Medicare Advantage Prescription Drug plan.

Although Medicare Part D is offered by private Medicare-contracted insurance companies, the government still sets an income-related monthly adjustment amount. Here’s a breakdown of the Medicare Part D payment adjustments (in 2016, based on your income in 2014). Please note that you typically pay your Part D premium regardless of income level; the amount in the far right column is the income adjustment payment.

Your income if you filed an individual tax return Your income if married and you filed a joint tax return Your income if married and you filed a separate tax return You pay your Medicare Part D premium, plus this amount
$85,000 or less $170,000 or less $85,000 or less $0

 

More than $85,000 and up to $107,000 More than $170,000 and up to $214,000 Not applicable $12.70

 

More than $107,000 and up to $160,000 More than $214,000 and up to $320,000 Not applicable $32.80
More than $160,000 and up to $214,000 More than $320,000 and up to $428,000 More than $85,000 and up to $129,000 $52.80
More than $214,000 More than $428,000 More than $129,000 $72.90

 

Your Medicare Part D income adjustment payment is typically deducted from your monthly Social Security benefit; it isn’t added to the premium bill you get from the Part D Prescription Drug Plan. If you have to make an adjustment payment, you’ll get a notice from Social Security.

If you’re charged the income adjustment payment outlined above for Medicare Part B (and Part D, if applicable) but your income has dropped, you can contact the Social Security information and apply to reduce your adjustment amount.

Help with Medicare Part A and Part B costs

Please note that the income and resource limits listed here are for 2016.

If you’re disabled or have a low income, you might qualify for a Medicare Savings Program (MSP) through Medicaid. Besides helping with your Medicare Part A and/or Part B premiums, some MSPs might help with other Medicare Part A and Part B costs, such as coinsurance. There are four types of MSPs, each with different eligibility criteria:

  • A Qualified Disabled and Working Individuals (QDWI) policy helps pay your Medicare Part A premium (if you pay this premium). You may be eligible if you are a working disabled individual under 65; if you lost your premium-free Part A when you returned to work; if you aren’t getting state medical assistance; and/or if you meet the income and resource requirements set by your state. To qualify, your monthly income cannot be higher than $4,045 for an individual or $5,425 for a married couple. Your resource limits are $4,000 for one person and $6,000 for a married couple.
  • A Qualified Medicare Beneficiary (QMB) policy helps pay your Medicare Part A and Part B premiums, along with other costs such as copayments, coinsurance, and deductibles. To qualify, your monthly income cannot be higher than $1,010 for an individual or $1,355 for a married couple. Your resource limits are $7,280 for one person and $10,930 for a married couple.
  • A Qualifying Individual (QI) policy helps pay your Medicare Part B premium. To qualify, your monthly income cannot be higher than $1,357 for an individual or $1,823 for a married couple. Your resource limits are $7,280 for one person and $10,930 for a married couple.
  • A Specified Low-Income Medicare Beneficiary (SLMB) policy helps pay your Medicare Part B premium. To qualify, your monthly income cannot be higher than $1,208 for an individual or $1,622 for a married couple. Your resource limits are $7,280 for one person and $10,930 for a married couple.

“Resources” include, but aren’t limited to, money you have in the bank, stocks, and bonds; they don’t include certain possessions, such as your home. To find out if you qualify for a Medicare Savings Program, contact your state Medicaid office.

Help with Medicare Part D costs

If you have a low income, you might qualify for help paying your Medicare Part D (prescription drug coverage) costs through Medicare’s Extra Help program. If you qualify, you’ll generally pay a maximum of $2.95 per generic drug prescription and $7.40 per brand-name drug prescription. These are 2016 amounts, and they apply only to medications that your Medicare Prescription Drug Plan covers.

If you qualify for certain Medicare Savings Plans described above (specifically, QMB, SLMB, or QI), you’re automatically eligible for Extra Help.

More resources for low-income or disabled beneficiaries

If you’re disabled or have a low income, you might qualify for financial help through Medicaid, an assistance program run jointly through the federal government and individual states. You might qualify for other financial assistance programs.

Some Medicare policies that are offered by Medicare-approved private insurance companies may save you money, depending on your situation. If you have questions about Medicare plan options, you can contact eHealth to speak with a licensed insurance agent and learn more about your coverage options.

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Premium-Free Medicare Part A for Non-Working Spouses

Premium-Free Medicare Part A for Non-Working Spouses

 

Your Medicare coverage doesn’t cover your spouse. Medicare beneficiaries who need health-care coverage need to receive their own Medicare insurance. However, this is a little different when it comes to eligibility and enrollment for premium-free Medicare Part A.

Most people who are eligible for Medicare don’t pay a monthly premium for Medicare Part A (hospital insurance) if they or their spouses paid Medicare taxes while working. If you or your spouse has worked at least 10 years (or 40 quarters) in Medicare-covered employment, then premium-free Part A is available to both of you. If you don’t have enough work quarters to qualify for premium-free Part A through your own work history, you may be able to qualify through your spouse. Note that you’ll both have to separately enroll in Medicare, but neither of you would have to pay a monthly premium for Part A. 

There may be situations when you have a non-working spouse who will turn 65 before you. If you are at least age 62 and worked at least 10 years (or 40 quarters) in Medicare-covered employment, then your spouse is eligible to receive premium-free Medicare Part A once he or she turns 65.

However, if you are not yet age 62 at the time your spouse turns age 65, then he or she cannot get premium-free Part A until you reach age 62. Your spouse can still enroll in Part A at age 65 and pay a premium for it, which will vary depending on long he or she worked and paid Medicare taxes. (Remember, you may owe a late-enrollment penalty for Part A if you must pay a premium for it and don’t sign up when you’re first eligible.) Once you turn 62, your spouse can qualify for premium-free Part A based on your work history.

How much you pay for Medicare Part A

Those who do have to pay a premium for Medicare Part A will pay up to $411 in 2016 each month. As mentioned above, 10 years or 40 quarters results in premium-free Part A for most beneficiaries, but those who haven’t worked 40 quarters may need to pay out of pocket for their Part A premiums.

  • People with 30 to 39 quarters of Medicare-covered employment pay a monthly premium of $226 in 2016.
  • Those with less than 30 quarters of Medicare-covered employment and who are not eligible for free or reduced Medicare premiums for any other reason pay a monthly premium of $411 in 2016. 

How Social Security and Medicare taxes are calculated and withheld together as a federal tax

The taxes you pay while working that eventually qualify you for premium-free Medicare Part A come from the Federal Insurance Contributions Act (FICA). This tax law takes a percentage from paychecks and income, putting these subtractions toward the Social Security and Medicare programs.

The taxes have different rates, but both employers and employees must share the FICA payments as described below.

  • The Social Security tax rate is 12.4%, split between the employer and employee with a rate of 6.2% for each (self-employed people are responsible for paying the 12.4% themselves).
  • The Medicare tax rate is 1.45% for the employer and 1.45% for the employee, or 2.9% total.

There are many Medicare options available, and it’s normal for you to have questions. If you need help getting answers, feel free to give eHealth a call to speak with a licensed insurance agent about your coverage needs. Or, if you prefer, you can view Medicare plan options in your area right from your home; just enter your zip code into the plan finder tool on this page to get started.

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Medicare Special Needs Plans and Other Assistance Programs

Medicare Special Needs Plans

 

There are a variety of federal and state-run programs available to help Medicare beneficiaries with specialized health or financial needs. Some of these situations might include:

  • High-risk groups of individuals having one or more severe or disabling chronic condition.
  • Living in an institution.
  • Being eligible for Medicaid.

If you’re a Medicare beneficiary with one of the above circumstances, you may not realize that there are Medicare plans available that are specifically designed to help you manage the complex health challenges that may come with your situation.

Special Needs Plans tailor their benefits and services for Medicare beneficiaries with unique health or situational challenges. Here’s an overview of how they work, including what they cover, eligibility, and how to enroll.

How Special Needs Plans work

Special Needs Plans (SNPs) are a type of Medicare Advantage plan for beneficiaries who meet certain eligibility criteria. Like other types of Medicare Advantage plans, these plans are available through Medicare-contracted private insurance companies. Each type of plan limits enrollment to the group that it targets, and there are three kinds:

  • Chronic-Condition Special Needs Plans are for beneficiaries with severe or disabling chronic health conditions. There are 15 conditions approved by the Centers of Medicare & Medicaid Services (CMS) (see below for a full list).
  • Institutional Special Needs Plans are for beneficiaries who live or are expected to live in an institution or require nursing care in their home for 90 days or more. This includes assisted living or nursing homes, long-term care skilled nursing facilities, inpatient psychiatric facilities, or intermediate care facilities for people with developmental disabilities. Enrollment of a special needs individual on the basis of the potential for a 90-day stay must be based on a CMS-approved assessment.
  • Dual-Eligible Special Needs Plans are for beneficiaries who have both Medicare and Medicaid, also known as dual eligibles.

Like all Medicare Advantage plans, these plans must cover the same benefits as Original Medicare, Part A and Part B, with the exception of the hospice benefit (which is still covered under Original Medicare). Medicare Advantage Special Needs Plans may also include coverage beyond Part A and Part B, such as routine vision and dental, hearing services, or wellness programs. Unlike other types of Medicare Advantage plans that may or may not cover prescription drugs, these plans always include prescription drug coverage.

One notable difference between Special Needs Plans and other types of Medicare Advantage plans (such as HMOs or PPOs) is that each plan tailors its benefits, provider networks, and covered medications to serve the unique needs of its members. For example, a Chronic-Condition Special Needs Plan for cancer patients may include doctors and oncologists in its network who specialize in treating various types of cancer. A Dual-Eligible Special Needs Plan may cover care-coordination services that help members better manage their Medicare and Medicaid benefits.

Eligibility for a Special Needs Plan

To be eligible for a Medicare SNP, you must:

  • Have Medicare Part A and Part B.
  • Live in the service area of the plan.
  • Meet the plan’s eligibility criteria (for example, have the chronic condition(s) that the plan targets).

You can only stay enrolled in the Special Needs Plan as long as you continue to meet the membership criteria. For example, if you enroll in a Dual-Eligible Special Needs Plan and then lose your Medicaid eligibility, you’ll get a Special Election Period to enroll in another type of Medicare Advantage plan (such as an HMO or PPO) or return to Original Medicare.

Chronic-Condition Special Needs Plans can target a single health condition or a group of conditions, such as stroke and cardiovascular disorders. For Chronic-Condition Special Needs Plans that target more than one health condition, prospective enrollees need to have at least one of the health conditions to be eligible to enroll. Medicare Advantage SNPs can target any of the following 15 conditions:

  • Chronic dependency on alcohol or drugs
  • Autoimmune disorders
  • Cancer (with the exception of pre-cancer conditions)
  • Cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-stage renal disease that requires dialysis
  • Severe hematologic disorders
  • Human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS)
  • Chronic lung disorders
  • Chronic and disabling mental health conditions
  • Neurologic disorders
  • Stroke

Enrolling in a Special Needs Plan

If you are a dual eligible or live in an institution, you can enroll in a Special Needs Plan or switch plans at any time with a Special Election Period.

Otherwise, you can enroll in a Special Needs Plan during your Initial Coverage Election Period, which is when you’re first eligible for Medicare Part C coverage. In most cases, this period takes place at the same time as your Initial Enrollment Period for Part B and starts three months before your 65th birthday or the 25th month of disability benefits from Social Security or the Railroad Retirement Board, includes the month of eligibility, and lasts for seven months.

You’ll also get a Special Election Period to enroll in a Special Needs Plan or switch plans in certain situations. These may include, but aren’t limited to:

  • You have Medicare and develop a chronic condition.
  • You move into a nursing home or other institution.
  • You move out of your plan’s service area.
  • Your Special Needs Plan leaves the Medicare program.

If you live in an institution, have Medicare and Medicaid, or have a chronic condition, you can enroll in a Special Needs Plan at any time.

The types of Medicare Special Needs Plans offered in your area will depend on your state and zip code. If you’d like help finding Special Needs Plans, you can contact eHealth to speak with a licensed insurance agent; we can check if there are Medicare plan options available in your area with coverage that may fit your specific health needs.

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An In-Depth Look at Medicare Costs for 2016

An In-Depth Look at Medicare Costs for 2016

 

Health-care expenses are some of the major financial obligations that you may have to deal with each year, so it may be important for you to figure out how much you’ll have to spend on Medicare premiums, deductibles, and other costs. Here’s a look at the main out-of-pocket expenses for Medicare in 2016.

Costs for Original Medicare (Part A and Part B)

Original Medicare encompasses Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Most people don’t have to pay a premium for Medicare Part A. They do, however, have to factor in the following Medicare Part A costs for inpatient hospital stays for each benefit period. Medicare considers a benefit period to start the day that a hospital or skilled nursing facility (SNF) admits you as an inpatient. The end of the benefit period occurs when you haven’t received any inpatient hospital care (or skilled care in an SNF) for 60 consecutive days.

  • Deductible: $1,288
  • Coinsurance for days 1 to 60: $0
  • Coinsurance for days 61 to 90: $322 per day
  • Coinsurance for days 91 and beyond: $644 per day

Note that every Medicare Part A beneficiary is entitled to 60 “lifetime reserve days” as a hospital inpatient. You begin using these reserve days after you spend 90 days as a hospital inpatient within one benefit period. You will pay all costs for days beyond lifetime reserve days.

Medicare Part A also covers qualifying stays in a skilled nursing facility. In 2016, you pay:

  • $0 for the first 20 days of each benefit period
  • $161 per day for days 21-100 of each benefit period
  • All costs for each day after day 100 of the benefit period

If you don’t qualify for premium-free Medicare Part A, you can enroll in Part A for $226 per month if you’ve worked and paid Social Security taxes for 30 to 39 quarters, or $411 per month if you’ve worked and paid Social Security taxes for fewer than 30 quarters. Note that beneficiaries who delay enrollment in Medicare Part A after they first become eligible may be subject to a late-enrollment penalty in the form of a higher premium.

Medicare Part B has an annual deductible ($166 in 2016). The deductible amount is the same across the board for all Medicare Part B beneficiaries, but the monthly premium depends on your situation .

    • If you were enrolled in Medicare Part B prior to 2016, your 2016 monthly premium is generally $104.90.
    • Your 2016 monthly premium is typically $121.80 if any of the following is true for you:
  • You enrolled in Medicare Part B in 2016 for the first time.
  • You don’t receive Social Security benefits.
  • You get a bill for the Part B premium. If your premium is automatically deducted from your Social Security benefits, you wouldn’t get a bill.
  • You quality for both Medicare and Medicaid benefits, and Medicaid pays for your premiums. This is called being “dual-eligible.”
  • Your income exceeds a certain dollar amount. Your premium could be higher than the amount listed above, as there are different premiums for different income levels.

For more details about the Medicare Part B premium, see How Your Income May Affect Your Medicare Costs.

If you receive Railroad Retirement Board benefits, see RRB information about your Part B premium.

Here’s your monthly Medicare Part B premium amount for 2016 if you filed an individual tax return for your yearly income in 2014:

  • Annual income $85,000 or less: $104.90 ($121.80 if the conditions above apply to you)
  • Annual income $85,001-$107,000: $170.50
  • Annual income $107,001-$160,000: $243.60
  • Annual income $160,001-$214,000: $316.70
  • Annual income above $214,000: $389.80

If you filed a joint return for your yearly income in 2014, your monthly Medicare Part B for 2016 is as follows:

  • Annual income $170,000 or less: $104.90 ($121.80 if the conditions above apply to you)
  • Annual income $170,001-$214,000: $170.50
  • Annual income $214,001-$320,000: $243.60
  • Annual income $320,001-$428,000: $316.70
  • Annual income above $428,000: $389.80

If you’re married but filed a separate tax return from your spouse for your yearly income in 2014, you will pay the following Medicare Part B monthly premium in 2016:

  • Annual income $85,000 or less: $104.90 ($121.80 if the conditions above apply to you)
  • Annual income $85,001-$129,000: $316.70
  • Annual income above $129,000: $389.80

Costs for Medicare Advantage (Medicare Part C)

Premiums and deductibles for Medicare Advantage plans vary depending on which plan you choose. In brief, Medicare Advantage plans are offered by private health insurance companies contracted with the Centers for Medicare & Medicaid Services (CMS) to provide your benefits, and it is required by law to offer at least the same coverage as Original Medicare (with the exception of hospice care, which is still covered under Medicare Part A). Some plans offer extra coverage (routine dental or vision services, for example).

Costs for Medicare Supplement (Medigap)

Those who need help paying for such health-care costs as deductibles, premiums, and other Original Medicare expenses may want to purchase a Medicare Supplement plan, also known as Medigap plan. There are 10 standardized Medigap plans in most states, and while a Medigap plan of a certain letter name includes the same benefits nationwide, their availability may vary according to the area in which you live. (For example, a Medigap Plan N in Nevada carries the same benefits as a Plan N in Georgia, but Plan N might not be available in your zip code.) Like Medicare Advantage, Medigap is private insurance, so costs vary depending on which company and which specific plan you choose.

Here is some cost information about certain Medigap plans for 2016:

  • Medigap Plan K out-of-pocket annual maximum: $4,960
  • Medigap Plan L out-of-pocket annual maximum: $2,480
  • Medigap Plan F high-deductible plan annual deductible: $2,180
  • Medigap Plan N copayment for emergency room visits: up to $50
  • Medigap Plan N copayment for office visits: up to $20

Costs for Medicare Part D

Medicare Part D benefits are offered by private Medicare-approved insurance companies offering prescription drug coverage. Costs for Medicare Part D may vary among plans. In 2016, the maximum deductible amount you will pay for any Medicare Part D Prescription Drug Plan is $360 per year. But be aware that you may be subject to a late-enrollment penalty if you fail to sign up for Medicare Part D coverage during your Initial Enrollment Period and remain without creditable drug coverage for 63 days or more. The late enrollment penalty is equal to the number of months you went without creditable coverage multiplied by 1% of the national base beneficiary premium, which is $34.10 in 2016. That figure is then rounded up to the nearest $0.10 and added to your Medicare Prescription Drug Plan (or Medicare Advantage Prescription Drug plan) monthly premium.

Most Medicare Prescription Drug Plans limit the amount that they will pay for prescription drugs in a single year. Once you and your plan have spent $3,310 on drugs in 2016, you will have reached the coverage gap. While in the coverage gap, you may have to pay:

  • 45% of your plan’s cost for covered brand-name drugs
  • 58% of your plan’s cost for covered generic drugs

To learn more about your Medicare plan options, you can call one of eHealth’s licensed insurance agents by calling the number shown below. Or, just enter your zip code into the form on this page to start comparing plans.

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Different Types of Medicare Advantage Plans

Different Types of Medicare Advantage Plans

 

If you’re currently enrolled in Original Medicare, Part A and Part B, you may be wondering about other ways you can expand on your Medicare coverage. Medicare Advantage (Medicare Part C) is one of the ways you can do that. You can think of it as you another way to get your Original Medicare benefits, except instead of getting your coverage through the government-run program, you’ll get your benefits administered through your Medicare Advantage plan instead.

Medicare Advantage plans are offered through Medicare-approved private insurance companies. Each plan is required to offer at least the same level of coverage as Original Medicare, with the exception of hospice care, which is still covered under Part A of Original Medicare. As mentioned, one major benefit of Medicare Part C is that plans can provide a range of benefits not included in Part A and Part B, such as routine vision and dental services, prescription drugs, or health wellness programs.

You’re eligible for Medicare Part C if:

  • You’re enrolled in Medicare Part A and Part B.
  • You live in the service area of a Medicare Advantage plan.
  • You don’t have end-stage renal disease (with some exceptions).

Benefits, costs, and plan availability may vary by insurance company and location. In addition, there may be a variety of different types of Medicare Advantage plans offered in your service area. Some of these plan types can include:

  • Preferred Provider Organization plans
  • Health Maintenance Organization plans
  • Health Maintenance Organization Point-of-Service plans
  • Private Fee-for-Service plans
  • Special Needs Plans
  • Medical Savings Account plans

Understanding all of your options in Medicare Advantage will help you be better informed as you consider the type of coverage that may work best for your needs and preferences.

Medicare Advantage Preferred Provider Organization plans

A Medicare Advantage Preferred Provider Organization (PPO) plan gives you the flexibility to see any doctor, provider, or hospital you want. However, you’ll usually pay less if you use providers in the plan’s preferred network. If you use non-network providers, your cost sharing (for example, copayments and coinsurance costs) is generally higher.

If you’re in a Preferred Provider Organization plan, you won’t have a primary care physician or need referrals to see specialists or other doctors.

Medicare Advantage Health Maintenance Organization plans

A Medicare Advantage Health Maintenance Organization (HMO) plan requires you to use providers in the plan network to get covered. You’re usually not covered if you go out of the plan’s network, although there are often exceptions for medical emergencies, dialysis treatment, and urgent care.

You’ll have a primary care doctor and need referrals to see specialists. Your Medicare Advantage costs are generally lower in a Health Maintenance Organization plan than in a Preferred Provider Organization plan.

Some Health Maintenance Organization plans have a Point-of-Service (POS) option, which lets you use out-of-network providers for some health services. These plans are more of a hybrid between a Health Maintenance Organization plan and a Preferred Provider Organization plan. You’ll usually still have a primary care doctor and get most of your health services through the plan’s network providers. However, you’ll have the option in some cases to go out of this network, usually for a higher cost.

Medicare Advantage Private Fee-for-Service plans

A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan that lets you use any provider that will accept the plan’s payment terms. With a PFFS plan, your doctor or provider must agree, on a case-by-case basis, to contract with the plan and treat you. Each Private Fee-for-Service plan decides how much to compensate providers to treat its members, and doctors are free to accept those terms and conditions or refuse to treat the patient. You should always verify that the provider accepts the plan’s payment terms before getting medical services, or your PFFS plan may not cover the costs. In medical emergencies, however, the plan will cover you even if the provider doesn’t accept the plan.

In some cases, PFFS plans may have provider networks of doctors and hospitals that have contracted with the plan to always provide you medical care, even if you haven’t seen them before. If your PFFS plan has a provider network, your cost sharing will be higher if you use out-of-network doctors.

You won’t have a primary care doctor or need referrals for this type of plan. You’re only responsible for cost-sharing requirements set by the plan.

Private Fee-for-Service plans may come include prescription drug coverage, but not always. If your plan doesn’t include drug benefits, you’re allowed to enroll in a stand-alone Medicare Prescription Drug Plan. Please note that this is one of the rare instances when you’re allowed to be in both a Medicare Advantage plan and a Medicare Prescription Drug Plan. (In most cases, if you’re in a Medicare Advantage plan and want prescription drug coverage, you must get it through a Medicare Advantage Prescription Drug plan.)

Medicare Advantage Special Needs Plans

A Special Needs Plans (SNP) is a type of Medicare Advantage plan that limits membership to people who fit specific eligibility criteria. There are three types of Special Needs Plans, each targeting people with certain characteristics:

  • Chronic-Condition Special Needs Plan: You must have a specific chronic or disabling medical condition to be a member, such as end-stage renal disease, AIDS, or diabetes. If the Special Needs Plan targets more than one health condition, you must have at least one of the conditions it targets to be eligible for the plan.
  • Dual-Eligible Special Needs Plan: You must have both Medicare and Medicaid to be a member.
  • Institutional Special Needs Plan: You must live in an institution, such as a nursing home, to be a member.

You’ll usually have a primary care physician (or a care coordinator who helps you manage your health) and need referrals to see specialists. You may not need a referral for certain preventive services, such as screening mammograms. Unlike other types of Medicare Advantage plans that may or may not include prescription drug coverage, all Special Needs Plans include prescription drug benefits.

Special Needs Plans usually require that members use in-network providers to be covered, unless it’s a medical emergency. Each Special Needs Plan usually has providers, formularies, and benefits that are tailored to the specific member needs for that plan. For example, a Dual Eligible Special Needs Plan might have special social services to help you manage your Medicare and Medicaid benefits.

If you’re eligible for a Special Needs Plan because you have a chronic condition, live in an institution, or are a dual eligible, you can enroll at any time with a Special Election Period.

Medicare Medical Savings Account plans

A Medicare Medical Savings Account (MSA) plan is a high-deductible Medicare Advantage plan that includes a medical savings account; these plans are similar to Health Savings Account plans that may be available through an employer. Every year, the Medical Savings Account plan deposits money into a savings account that you can use to pay for medical costs until you reach the plan’s high deductible. Money that you withdraw from your medical savings account isn’t taxed as long it’s used to pay for qualified health costs. Any money that is left in the account at the end of the year rolls over to the next year and is added to the amount your plan deposits the following year.

If you use up the money in this savings account, you’ll pay for all health costs until you reach the plan’s high deductible, which varies from plan to plan. After your total spending on covered medical expenses reaches the deductible, the plan pays for all Medicare-covered benefits.

These plans give you provider flexibility and don’t usually require you to use in-network doctors. In addition, Medical Savings Account plans don’t include prescription drug coverage. If you need prescription drug benefits, you can get this coverage through a Medicare Prescription Drug Plan. This is another one of the rare times when you’re allowed to be in both a Medicare Advantage plan and a Medicare Prescription Drug Plan.

For more information on Medicare Advantage plans

Hopefully, you now have a better idea of the different types of Medicare Advantage plans types and how they work. If you have questions about the specific plan options that may be available in your service area, an eHealth licensed insurance agent would be happy to discuss your coverage needs with you over the phone; just call the number on this page to get started. Or, if you prefer to browse plans now, enter your zip code into the plan finder tool on this page to view plan options in your location.

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Medical Durable Power of Attorney for Caregivers

Medical Durable Power of Attorney for Caregivers

 

If you’re caring for a person who’s enrolled in Medicare, you may not realize you can’t make medical decisions for your loved one without legal authorization, such as a durable power of attorney. A durable power of attorney (or other advance directive such as a health-care proxy) is a legal document that authorizes you to act on behalf of your loved one in certain situations.

 

The person granting the power of attorney is known as the principal (in this case, your loved one). The person receiving the power of attorney is generally referred to as an agent or “attorney-in-fact” and is usually a spouse, child, sibling, or trusted friend.

There are several types of power of attorney, with the key difference between them being when legal authority begins and ends.

  • Conventional power of attorney: legal authority is granted to the agent once the principal signs the document and ends when the principal becomes incapacitated.
  • Springing power of attorney: legal authority only begins in certain circumstances or when a specific event occurs, such as mental incapacitation.
  • Durable power of attorney: legal authority is granted once the document is signed and stays in effect throughout the principal’s life.

For a caregiver of a Medicare beneficiary, the durable power of attorney may be the most useful type, since it remains in effect even after your loved one becomes mentally incapacitated. There may be fewer potential disputes over whether it has gone into effect, which can happen with a springing power of attorney. A conventional power of attorney can also be limited, since your legal authority ends when your loved one becomes incapacitated–and that’s often precisely when medical or financial decisions for that person need to be made.

Of course, with regard to the durable power of attorney, it’s important that the agent be someone the principal trusts completely. The power of attorney ends with the principal’s death, unless that person decides to cancel it before then.

When you need durable power of attorney

For purposes of Medicare, you need legal authorization anytime you’re acting on behalf of a beneficiary. For example, you can’t enroll another person in Medicare, even your spouse, unless you have power of attorney, health-care proxy or other authorization to make such decisions for the beneficiary. You also can’t enroll him or her in a Medicare Advantage plan without such authorization.

Your loved one can decide the range of responsibilities to give you as the agent. Depending on the state, a power of attorney may grant broad authority to handle finances, sell real estate, and make charitable donations–or it can be limited to medical decisions.

To help a Medicare beneficiary, the power of attorney or other advance directive needs to grant the agent the ability to make health-care decisions for the principal. If the person being cared for becomes incapacitated, a durable medical power of attorney or other advance directive will generally allow the agent to make decisions on his or her behalf, including actions related to Medicare.

How to get durable power of attorney

When creating a durable power of attorney, the principal signing the document must be mentally competent. As a general rule, it’s best to begin these discussions about power of attorney early, while the principal is still healthy and able to clearly express his or her wishes.

If the person you’re caring for is disabled or has a progressive condition, like Alzheimer’s disease, it’s even more important to begin this process as soon as possible. If you think the mental capacity of your loved one might be challenged later, you may want to get a doctor to verify and provide a statement. Depending on the state, witnesses may also need to be present at the signing.

After a power of attorney has been created, multiple copies should be made and stored safely.

The process and laws for creating a power of attorney vary from state to state. You may want to consult with a lawyer to ensure the power of attorney meets your state’s legal requirements.

If you need more information on creating a durable power of attorney, contact your State Health Insurance Assistance Program (SHIP), which offers free counseling on Medicare and health-related issues.

Medicare disclosure of personal health information

Medicare also has privacy protections that limit access of medical information to people other than the beneficiary.

If you’re caring for a person who’s enrolled in Medicare, it’s useful to have that person fill out a written form authorizing Medicare to disclose health information to you. This Authorization to Disclose Personal Health Information form can be found on Medicare.gov. You may need to provide documentation showing that you have durable power of attorney or other authorization.

For further information, you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users can dial 1-877-486-2048.

This article is for informational purposes only. It should not be construed as legal advice. You should consult a lawyer to make sure your specific legal needs are met in your specific circumstances.

 

 

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