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Medicare vs. Medicaid Comparison

Medicare vs. Medicaid Comparison

 

It can be easy to confuse Medicare and Medicaid, as they are both government health-care programs. That’s where the similarities end, however, because who they serve, what they cover, and how much they cost are very different. In some situations, you may be eligible for both programs.

Medicare overview

Medicare is a health insurance program created and administered by the federal government. It is generally available to U.S. citizens and permanent legal residents who have lived in the country continuously for at least five years. You’re usually eligible once you’re age 65 or older, although younger individuals may qualify if they have received 24 months of Social Security disability benefits (or certain disability benefits from the Railroad Retirement Board). You can also qualify for Medicare under 65 if you have end-stage renal disease (permanent kidney failure and require dialysis or a kidney transplant), or if you have amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Original Medicare refers to the two parts of the program that are federally run, Medicare Part A and Part B. Part A covers inpatient hospital care, and Part B covers medical insurance like doctor visits, preventive services and screenings, and durable medical equipment.

Medicare Advantage (also called Medicare Part C) is offered through Medicare-contracted private insurance companies, and Medicare Advantage plans must offer at least the same benefits as Original Medicare (with the exception of hospice care, which is still covered through Part A of Original Medicare). Medicare Advantage plans may also include benefits beyond what Original Medicare covers, including routine vision or dental, hearing, wellness programs, or prescription drugs.

Medicare Part D is prescription drug coverage, also available through Medicare-approved private insurance companies. You can get this coverage either through a Medicare Prescription Drug Plan, which is stand-alone prescription drug coverage that can be added to Original Medicare insurance, or through a Medicare Advantage plan that includes prescription drug benefits, also known as a Medicare Advantage Prescription Drug plan.

Medicaid overview

Medicaid is funded jointly at the state and federal levels. It supports low-income individuals and families by covering medical costs as well as other services, such as long-term custodial care or case management services. Medicaid eligibility is determined by income and certain other requirements, and those requirements are set by the state where the beneficiary lives.

Medicare and Medicaid coverage may intersect (for example, during an inpatient hospital stay or a visit to the doctor), but Medicaid coverage varies by state and potentially includes coverage beyond what Original Medicare offers.

While each state determines the breadth of its Medicaid coverage, there are some services that the program is required to include in all states:

  • Inpatient and outpatient hospital services
  • Early and periodic screening, diagnostic, and treatment services
  • Nursing facility services
  • Home health care
  • Doctor services
  • Rural health clinic services
  • Federally qualified health center services
  • X-ray and laboratory services
  • Family planning services
  • Midwife services
  • Freestanding birth center services (when this care is licensed by or recognized in the state)
  • Certified pediatric and family nurse practitioner services
  • Tobacco cessation counseling for expectant mothers

States are also free to include optional benefits in their Medicaid programs, including prescription drug coverage, custodial care, podiatry services, and more. Contact the Medicaid program in your state to learn more about the specific benefits covered by your state program.

As mentioned earlier, some beneficiaries may qualify for Original Medicare, Part A and Part B, and Medicaid. They are known as “dual eligibles.” They must meet certain income and asset requirements to qualify for Medicaid, and depending on their eligibility, they may get “full” or “partial” Medicaid benefits.

In addition to services covered through the Medicaid program, dual eligibles may also be eligible for help with Medicare costs through Medicare Savings Programs. These programs are administered by state Medicaid programs and help with Medicare costs like Part A and Part B premiums, deductibles, copayments, and coinsurance costs. There are four types of Medicare Savings Programs available, and each one comes with different income and asset criteria to qualify.

For a dual eligible beneficiary, Medicare-covered services are paid first by Medicare. After Medicare has paid its share (up to coverage limits), Medicaid may act as a secondary payer and cover services that Medicare either doesn’t cover or only covers in part. As mentioned, Medicaid may help with benefits that Medicare does not cover, such as custodial care or chiropractic services. If you’re not covered for a certain benefit through Medicare, check if your state’s Medicaid program covers it.

Dual eligibles may also qualify for the Extra Help program, which helps them with Medicare Part D (prescription drug coverage) costs like premiums, deductibles, and coinsurance. If you qualify for certain Medicare Savings Programs (the Qualified Medicare Beneficiary Program, Specified Low-Income Medicare Beneficiary Program, or Qualifying Individual Program), you’ll automatically be eligible for Extra Help as well.

Would you like help finding Medicare plan options that fit your budget and health needs? An eHealth licensed insurance agent can give you one-on-one help; just pick up the phone and dial the number on this page to get connected with us. Or, if you prefer to browse plan options at your own convenience, use the plan finder tool on this page to get started.

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How to Notify Medicare of an Address Change

How to Notify Medicare of an Address Change

If you’ve recently moved or the address on your Medicare card is incorrect for any reason, then you need to notify the Social Security Administration (SSA) and request a change to prevent any potential service interruptions, billing issues, or complications.

You can contact the SSA in a number of ways:

  • By calling 1-800-772-1213 (TTY1-800-325-0778) to speak with a live representative Monday through Friday, from 7AM to 7PM.
  • By visiting the SSA website to submit an address change notice online. Simply log into your My Social Security account to update your address; if you don’t have a My Social Security account, you can create an account here.
  • By visiting your local SSA office in person or by contacting that office by phone.

If you are a Railroad Retirement Board (RRB) beneficiary, you can use the RRB Zip Code Locator tool to locate your local RRB office. You can submit your current information either in person or over the phone. To reach the RRB by phone, call 1-877-772-5772 (TTY users may call 1-312-751-4701), Monday through Friday, 9AM to 3:30PM. If you receive both RRB and SSA benefits, then contact the SSA as well.

Once you have reported your new address with either the SSA and/or RRB, please note that it may take 7 to 14 days for the change to be filtered through the system entirely and show up on all statements.

You may also receive a Social Security statement with an incorrect address. These addresses are generated by the Internal Revenue Service (IRS) and, if this is the case, you must also notify them of any changes. The IRS website has a “change of address” form for download. You can fill this out and bring that to your local office, or contact the IRS via its toll-free telephone number at 1-800-829-3676.

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Late Enrollment Penalties for Medicare Part A, Part B, and Part D

Late-Enrollment Penalties for Medicare Part A, Part B, and Part D

 

Medicare coverage comes in multiple “parts,” such as Medicare Part A (hospital coverage), Part B (medical coverage), and Part D (prescription drug coverage). Each of these parts of Medicare may have late-enrollment penalties if you don’t sign up when you’re first eligible and don’t have other coverage. These penalties can be incentives for people to sign up as soon as they’re eligible, instead of waiting to get health or prescription drug coverage when they have health problems.

This article will first discuss the financial consequences of delaying enrollment in Medicare Part A, Part B, and Part D, and then go over how you can avoid late-enrollment penalties.

Medicare Part A late-enrollment penalty

American citizens and legal permanent residents of at least five continuous years are first eligible for Original Medicare, Part A and Part B, when they turn 65. You may qualify before the age of 65 because of disability, end-stage renal disease, or Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS). You’re automatically enrolled when you turn 65 if you’re already receiving Social Security Administration (SSA) or Railroad Retirement Board (RRB) benefits. You’re also automatically enrolled if you’ve been receiving SSA or RRB disability benefits for at least 24 consecutive months. If you have ALS, you’ll be automatically enrolled in Medicare the same month you start receiving SSA or RRB benefits.

If you have end-stage renal disease, you may qualify for Medicare before age 65, but you need to enroll manually; information is at the end of this article.

If you’ve worked at least 10 years (40 quarters) and paid Medicare taxes while working, you’ll get Medicare Part A at no cost. People who get premium-free Medicare Part A don’t usually decide to delay enrollment, since the coverage comes at no cost.

However, you may not get Medicare Part A at no cost if you haven’t worked long enough. If you don’t qualify for automatic enrollment or premium-free Part A, and you don’t sign up for Medicare Part A when you’re first eligible, you may face a late enrollment penalty when you do enroll. The Medicare Part A penalty is a 10% higher monthly premium for twice the number of years you were eligible for Part A but didn’t enroll.

Medicare Part B late-enrollment penalty

There’s also a late-enrollment penalty for Medicare Part B if you don’t sign up when you’re first eligible. In most cases, eligibility for Medicare Part B is the same as for Part A, described above. Again, many people are automatically enrolled in Part B along with Part A. But if you don’t qualify for automatic enrollment, you may need to sign up manually.

Medicare Part B comes with a monthly premium, so some people choose not to enroll or to defer enrollment. If you don’t sign up for Medicare Part B when you’re first eligible or drop your coverage later, a late-enrollment penalty may apply when you do sign up. This is a 10% higher premium for every full 12-month period that you were eligible but didn’t enroll in Medicare Part B. You’ll have to pay this penalty for as long as you have Part B. However, in some situations you may qualify for a Special Enrollment Period when you can sign up without a penalty; see “Avoiding Medicare late enrollment penalties” below.

Medicare Part D late enrollment penalty

You’re first eligible for Medicare Part D (prescription drug coverage) when you’re enrolled in Medicare Part A or Part B and live in the service area of a Medicare Prescription Drug Plan. Note that Medicare Part D coverage is optional. Original Medicare, Part A and Part B, covers certain prescription drugs in specific situations, but doesn’t cover most of the prescription drugs you’d take at home. If you need prescription drug coverage, you can enroll in a Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan.

You may face a late penalty if you don’t sign up when you’re first eligible for Medicare Part D and go without creditable prescription drug coverage for more than 63 days in a row, and then decide to sign up for this coverage. Creditable prescription drug coverage is coverage that’s expected to pay, on average, as much as standard Medicare Part D coverage.

Your Medicare Part D penalty depends in part on how long you didn’t have creditable prescription drug coverage. To determine the penalty, multiply 1% of the national base premium times the number of full months you were eligible for Medicare Part D but didn’t enroll and didn’t have creditable prescription drug coverage. This amount is rounded to the nearest $0.10 and added to your Medicare Prescription Drug Plan premium. The national base premium is calculated by the Centers for Medicare & Medicaid Services and may increase from year to year, meaning your penalty may also cost more the longer you wait. For the most current national base premium, visit Medicare.gov.

If you owe a penalty when you sign up for a Medicare Prescription Drug Plan, you may have to pay this higher premium for as long as you have Medicare Part D coverage.

Avoiding Medicare late enrollment penalties

The simplest thing you can do to avoid paying a late-enrollment penalty for Medicare Part A, Part B, and Part D is to sign up when you’re first eligible.

You’re usually first eligible to enroll in Medicare Part A and Part B during your Initial Enrollment Period, which starts three months before you turn 65, includes the month you turn 65, and ends three months later. Medicare eligibility and enrollment work differently if you qualify before age 65 – for example, because of disability. See Medicare Enrollment and Election Periods for more information.

If you delay Medicare Part A and/or Part B enrollment because you have other health coverage, you can avoid the late penalties for both if you qualify for a Special Enrollment Period and sign up during that time. Some people wait to enroll in Medicare Part B if they have coverage through an employer or union-sponsored plan, since Part B always comes with a premium. Individuals who pay a monthly premium for Medicare Part A may decide to delay enrollment for similar reasons. In this case, you may be able to sign up for Medicare Part A and/or Part B during a Special Enrollment Period, which starts when your health coverage or the employment it’s based on ends, whichever happens first. If you’re not sure whether you qualify for a Special Enrollment Period, talk to your employment-based health plan administrator, or call Medicare (1-800-MEDICARE, or 1-800-633-4227). TTY users can call 1-877-486-2048). Medicare representatives are available 24 hours a day, 7 days a week.

If you delay Medicare Part D enrollment because you have other prescription drug coverage, such as through an employer or veterans’ benefits, your plan should let you know every year whether your drug coverage is still creditable. Make sure to review these plan documents carefully and keep records in case you need to prove you had creditable prescription drug coverage later.

  • If your coverage is no longer creditable, your plan must notify you. If this happens, you may qualify for a Special Election Period (SEP) when you can sign up for a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan. In this case, your SEP runs for two full months after the month the plan notifies you that your coverage is no longer creditable. Similarly, if you lose your creditable prescription drug coverage (for example, if your current plan ends coverage in your area), your SEP runs for two full months after you lose your creditable coverage. There may be other situations that qualify you for an SEP; if you have questions, you can talk to your plan administrator; or you can either call Medicare or talk to one of eHealth’s licensed insurance agents (contact information for both are at the bottom of this page).
  • If you don’t qualify for an SEP or if you let the SEP expire, be aware that the longer you wait to sign up for a Medicare Prescription Drug Plan, the higher your penalty will be if and when you decide to sign up for this coverage.

If you’re not signing up for Medicare Part A, Part B, or a Medicare Prescription Drug Plan because you can’t afford to pay for coverage, there may be financial help available. Individuals with limited income may qualify for Medicare Savings Programs, which help pay for premiums, deductibles, coinsurance, and co-payments. Medicare Savings Programs are run by Medicaid programs in your state. The Medicare Extra Help program is also available to help with Medicare prescription drug costs. You can contact the Medicaid or State Health Insurance Assistance program in your state for more information on these programs.

Should I delay Medicare enrollment?

Aside from the Medicare late-enrollment penalties (which may be considerable, depending on how long you wait), you may want to consider the financial and health risks involved in going without hospital, medical, and drug insurance. Out-of-pocket costs for hospital stays and prescription drugs can be costly. It’s important to carefully weigh all your options when deciding whether to delay Medicare enrollment.

For more information on enrolling in Medicare Part A and/or Part B, see these articles on Medicare enrollment. If you’d like to see what your Medicare prescription drug coverage options are, you can enter your zip code in the form on this page.

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Medicare Enrollment and Election Periods

Medicare Enrollment and Election Periods

 

Whether you’re enrolling in Original Medicare for the first time or looking at all your Medicare plan options, there are rules about when you can enroll or make changes to your Medicare coverage, depending on the type of Medicare coverage. For example, if you’re interested in signing up for a Medicare Advantage plan, one of the times you can enroll is the Annual Election Period, which occurs from October 15 to December 7 every year.

Medicare initial enrollment and election periods

Each type of Medicare coverage has a period when you’re initially eligible to enroll. Note that in most cases, enrollment in Medicare happens automatically.

  • Initial Enrollment Period for Original Medicare: This is the seven-month period when you’re first eligible to enroll in Original Medicare, Part A and Part B. For most people, it starts three months before you turn 65, includes the month you turn 65, and ends three months later. In most cases you’re automatically enrolled in Medicare when you turn 65 if you’re already receiving Social Security Administration (SSA) or Railroad Retirement Board (RRB) benefits.
  • If you receive disability benefits from the SSA or RRB, enrollment in Medicare is usually automatic. Your Initial Enrollment Period depends on the type of condition you have, but in most cases it’s a seven-month period starting your 22nd month of receiving disability benefits.
  • If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS), you qualify for Medicare and are automatically enrolled the same month you start receiving disability benefits.
  • If you have end-stage renal disease (ESRD), which is kidney failure that necessitates a regular course of dialysis or a kidney transplant, you may be eligible for Medicare regardless of age. If you have ESRD, contact Social Security to enroll (contact information is at the end of this page).
  • Initial Coverage Election Period for Medicare Part C (Medicare Advantage): This is the period when you’re first eligible to enroll in a Medicare Advantage plan, and usually takes place at the same time as your Initial Enrollment Period for Original Medicare. It starts three months before you have both Medicare Part A and Part B and live in the service area of a Medicare Advantage plan. If you enroll during your Initial Enrollment Period, this period lasts for seven months and takes place at the same time. If you delay Medicare Part B, it starts three months before your Part B coverage becomes effective, and lasts for only those three months.
  • Initial Enrollment Period for Part D: This is the period when you’re first eligible to enroll in a stand–alone Medicare Part D Prescription Drug Plan and may take place at the same time as your Initial Enrollment Period for Original Medicare. It starts when you have Medicare Part A or Part B, and live in the service area of a prescription drug plan. During this period, you can sign up for a stand-alone Medicare Prescription Drug Plan.
  • Medigap Open Enrollment Period: This is the six-month period when you’re initially eligible to enroll in a Medicare Supplement (Medigap) plan with guaranteed-issue rights. It automatically starts when you’re 65 and enrolled in Medicare Part B. After this period is over, you can apply for a Medicare Supplement plan at any time, but you may be required to go through an underwriting process, and your acceptance isn’t guaranteed.

Medicare open enrollment and election periods

Both Original Medicare and private Medicare-approved insurance companies have certain times of the year when you can enroll or make changes to your coverage. These include:

  • General Enrollment Period: This is the period when you can enroll in Medicare Part A and/or Part B if you didn’t do so when you were first eligible. It occurs every year from January 1 to March 31. You may have to pay a late-enrollment penalty for Medicare Part A and/or Part B, unless you qualify for a Special Enrollment Period (described in the next section).
  • Annual Election Period: This is a period when you can switch from Original Medicare to Medicare Advantage coverage or vice versa; add or drop prescription drug coverage; switch plans; or disenroll from Medicare Advantage to return to Original Medicare. The Annual Election Period takes place every year from October 15 to December 7.

Medicare special enrollment and election periods

Outside of regular enrollment and election periods, you have limited opportunities to enroll or make changes to your Medicare coverage unless you qualify for one of the periods described below.

  • Special Enrollment Period for Medicare Part A and/or Part B: Some people may delay enrollment in Medicare Part A and/or B if they have other health coverage, such as through an employer. You won’t have to pay a late enrollment penalty for Medicare Part A and/or Part B if you sign up during a Special Enrollment Period. International volunteers and disabled TRICARE beneficiaries may also qualify for a Special Enrollment Period in some instances.
  • Special Election Period: You’re allowed to make changes to your Medicare Advantage or Medicare prescription drug coverage in certain situations. These may include, but aren’t limited to: moving out of your plan’s service area, losing Medicaid eligibility, or Medicare terminating your plan’s contract.
  • 5-Star Special Election Period: From December 8 to November 30 of the following year, you can switch to a Medicare Advantage, Medicare prescription drug plan, or Medicare Cost plan that Medicare has given a 5-star rating. You can only use this Special Election Period once during this timeframe.

Disenrollment periods

Medicare Advantage is the only part of Medicare that has a dedicated disenrollment period.

  • Medicare Advantage Disenrollment Period: If you’re enrolled in a Medicare Advantage plan and change your mind, you can disenroll during this period to return to Original Medicare. This period takes place from January 1 to February 14. If you leave your Medicare Advantage plan, you can also use this period to enroll in a Medicare prescription drug plan.
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Medicare Claims and Reimbursement

Medicare Claims and Reimbursement

 

In most cases, you won’t have to worry about filing Medicare claims. Here are some situations where you might or might not need to get involved in the claim process.

  • If you have Original Medicare, Part A and/or Part B, your doctor and supplier are required to file Medicare claims for covered services and supplies you receive. If your doctor or the supplier doesn’t file a claim, you can call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Phone representatives are available 24 hours a day, seven days a week.
  • The process is a bit different when it comes to Medicare insurance plans like Medicare Advantage plans. Under the Medicare Advantage (Medicare Part C) program, providers typically don’t file claims with Medicare, because Medicare pays these Medicare-approved insurance companies a fixed monthly amount. If you go outside of the plan’s network for services, however, you may have to file a claim with the health insurance plan, not with the Medicare program. If you have questions or concerns about claims, contact your Medicare Advantage insurance company.

There may be a situation where your doctor prescribes a high-cost medication when no substitute is available that would be suitable for your medical condition. If you have prescription drug coverage–whether it’s through a stand-alone Medicare Part D Prescription Drug Plan, or through a Medicare Advantage Prescription Drug plan–and your plan doesn’t cover a drug prescribed for you, you can file an appeal to get your plan to cover the prescription drug or to get it at a lower cost.

Any Medicare claims must be submitted within a year (12 months) of the date you received a service, such as a medical procedure. If a claim is not filed within this time limit, Medicare cannot pay its share.

One reason to make sure that Medicare processes a claim is to ensure that deductible amounts are credited to you. It may be worthwhile for you to contact your doctor’s office to remind them that you’re waiting for them to file a claim. You can also contact 1-800-MEDICARE (1-800-633-4227) to see if they can assist with the claim. If these efforts fail, you may file the Medicare claim yourself. You’ll need to start by filling out the Patient Request for Medical Payment form (CMS 1490S).

Checking the status of a claim

You can check the status of a claim by using the Blue Button feature at MyMedicare.gov.

Avoiding the need for claims

Make sure that your doctor accepts Medicare assignment. For Original Medicare, Part A and Part B, this means that your doctor or provider agrees to be paid by Medicare, and that they accept the Medicare-approved amount for a particular service. When your doctor accepts Medicare assignment, it also means she or he agrees not to bill you for more than the Medicare deductible and/or coinsurance. Private insurance companies contracted with Medicare may bill Medicare differently.

If your health-care provider doesn’t accept Medicare assignment, you may have to pay the full cost for the service up front, and get reimbursed by Medicare. You also might have to pay more than the Medicare-approved amount. In most cases, the doctor’s office should file the reimbursement claim for you.  If you have to file your own claim, see below.

Medicare reimbursement claim forms

Reimbursement claim forms are available from the Centers for Medicare & Medicaid Services (CMS) website. If you need to file a claim for reimbursement, in most cases you’d need form CMS 1490S, Patient Request for Medical Payment.

If you don’t have the ability to access the form online or print it, CMS 1490S is also available at your local Social Security Administration office. Instructions for completing the form are on listed on the back, and you can contact Medicare by calling 1-800-MEDICARE (TTY users 1-800-633-4227) 24 hours a day, 7 days a week, to find out where to mail the completed form.

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Checklist for Choosing a Medicare Advantage Plan

Checklist for Choosing a Medicare Advantage Plan

If you’re thinking of a signing up for a Medicare Advantage plan or switching from Original Medicare to Medicare Advantage, here’s a list of things to keep in mind.

  1. Start by confirming your eligibility for Medicare Advantage (also known as Medicare Part C).
  2. You can sign up for a Medicare Advantage plan if:

    • You’re enrolled in Medicare Part A and Part B (Original Medicare).
    • You don’t have end-stage renal disease (ESRD). There are some exceptions. If you have ESRD, ask the plan you’re considering whether you qualify, or call Medicare (contact information is at the end of this article). In some cases, you can enroll in a Special Needs Plan if you have ESRD.
    • You live in the service area of the Medicare Advantage plan you’re considering.

    Some Medicare Advantage plans require you to meet additional criteria. For example, a Special Needs Plan is a type of Medicare Advantage plan that limits membership to people who have chronic conditions, have both Medicare and Medicaid, or live in an institution (such as a nursing home). These plans cater benefits to people with unique needs who eligibility requirements.

  3. Decide what additional benefits are important to you.
  4. Medicare Advantage plans are required to provide at least the same level of coverage as Original Medicare (except hospice care, which Medicare Part A covers). However, some people prefer Medicare Advantage because of the additional benefits these plans may offer, such as routine vision services, wellness programs, or medical savings accounts. These benefits aren’t covered under Original Medicare, and you’d normally pay the full cost to get them.

    Many Medicare Advantage plans include prescription drug coverage, which isn’t included in Original Medicare except in limited situations. Known as Medicare Advantage Prescription Drug plans, they provide your health and medication benefits all in one plan. If you decide to enroll in a plan that includes this coverage, make sure that the plan covers all the medications you take. A plan’s formulary (list of prescription drugs it covers) may change at any time. You will receive notice from your plan when necessary.

    You can get prescription drug benefits through a Medicare Advantage Prescription Drug plan as described above, or through a stand-alone Medicare Part D Prescription Drug Plan.

    Keep in mind that there may be a late-enrollment penalty for Medicare Part D if you don’t sign up for this coverage and go without creditable prescription drug coverage for longer than 63 days in a row.

  5. Figure out your budget.
  6. Medicare Advantage plans may have different costs, depending on where you live and the company offering the plan. Some plans may cost less than Original Medicare.

    You’ll need to keep paying your Medicare Part B premium, regardless of the plan you sign up for. Some Medicare Advantage plans can have premiums as low as $0, but remember to consider all costs, like copayments, coinsurance, and deductibles, which can affect your total spending. If you’re enrolling in a Medicare Advantage Prescription Drug plan, pay attention to copayments and coinsurance amounts for the medications you need. Different plans may have higher or lower costs to cover the same medications.

    You should also note the plan’s spending limit, which is different for each plan and can change from year to year. Medicare Advantage plans have an annual out-of-pocket spending cap, meaning the plan will pay the full cost for health services and supplies once you reach this limit. For example, if you have a health emergency and incur a lot of medical expenses, there’s a maximum you’ll pay before you’re fully covered for the rest of that year. Original Medicare doesn’t have this spending limit.

  7. Find out if your doctors accept the Medicare Advantage plan.
  8. Depending on the type of Medicare Advantage plan you choose, you may be required to use providers in the plan’s network. A Health Maintenance Organization (HMO) plan typically requires that you use providers in the plan’s network to be covered, while a Preferred Provider Organization (PPO) plan lets you see doctors outside of its preferred provider network, but at a higher cost. Some Health Maintenance Organization plans come with a Point-of-Service option that lets you use out-of-network providers for some services. Make sure to follow the plan’s rules, or you could have to pay the full cost for services.

    If it’s important to you to continue using a specific provider, verify that your doctors accept the Medicare Advantage plan you’re considering.

  9. Take your time to research and compare plans.
  10. Not every Medicare Advantage plan is offered in every location, and costs can vary among plans. Particularly if you take prescription drugs, it’s worth taking the time to research what plans are offered in your service area to make sure you’re getting coverage that fits your  needs. Each Medicare Advantage Prescription Drug plan maintains its own formulary (a list of covered prescription drugs), so you may want to make sure a plan covers your medications before signing up. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.

    You can only enroll in a Medicare Advantage plan or make coverage changes during certain times of the year. For more information, see Medicare Enrollment and Election Periods.

If you’re ready to research Medicare Advantage plans in your area, you can type your zip code where indicated on this page to display them in a list.

To contact Medicare directly, call 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048; 24 hours a day, 7 days a week.

Feel free to contact an eHealth licensed insurance agency. eHealth is Medicare Consumer Guide’s parent company.

Call an eHealth licensed insurance agent at 1-888-391-2659, TTY users 711; Monday through Friday, 8AM to 8PM ET, Saturday, 9AM to 6PM ET.

Enter your zip code where requested on this page to see a quote.

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Checklist for Finding a Medicare Supplement (Medigap) Plan

Checklist for Finding a Medicare Supplement (Medigap) Plan

 

If you’re new to Medicare Supplement (Medigap) coverage, here are the most important things to keep in mind before joining a plan. 

  1. Apply during your Medigap Open Enrollment Period.
  2. When joining a Medicare Supplement plan, one of the most important things you can do is enroll during the Medigap Open Enrollment Period. This is the six-month period when you can join any Medigap plan with guaranteed-issue rights, meaning insurance companies can’t turn you down for coverage or charge you more because of your health status. Your Medigap Open Enrollment Period starts automatically when you’re 65 and have Medicare Part B.

    Outside of this period, it may be difficult to join a Medigap plan or switch plans with guaranteed issue. The insurance company is allowed to turn you down because of your health status, require medical underwriting, or make you pay a higher premium.

  3. If you do need to switch, see if you’re eligible for guaranteed-issue rights.
  4. In spite of your best efforts, you can’t always plan for every health need or financial situation. You may want to switch Medicare Supplement plans if your current plan is too expensive, you’re paying for unnecessary benefits, or you find yourself needing more benefits than your plan covers.

    If you do need to switch, see if you qualify for guaranteed-issue rights. There are limited situations where you may be able to switch Medigap plans with guaranteed issue and outside of your Medigap Open Enrollment Period. These include, but may not be limited to:

    • If you move outside of your Medigap plan’s service area.
    • If you’re in a Medicare Advantage plan and you move out of your plan’s service area.
    • If your Medigap insurance company goes out of business.
    • If your Medigap insurance company misled you or broke the rules.

    If you have a guaranteed-issue right, the Medicare Supplement plans available to you may vary depending on your situation. You may only be able to enroll in certain plans with guaranteed issue.

    For example, you have certain protections if you enroll in a Medicare Advantage plan for the first time, but switch back to Original Medicare within the first year. In this case, you may have a right to enroll in a Medicare Supplement plan if you dropped your Medigap policy to enroll in Medicare Advantage. In this situation, you can enroll in the same Medigap plan you had previously if the same insurance company you had previously still offers it. Otherwise, you have a right to enroll in a Medigap Plan A, B, C, F, K, or L that is offered by any insurance company in your state.

    Medicare Supplement benefits can only be used with Original Medicare, so some people drop their Medigap coverage if they switch to Medicare Advantage. For more information, see this article on guaranteed-issue protections when switching Medigap plans.

  5. Take advantage of your “free look period.”
  6. If you’re thinking of changing Medicare Supplement plans, you may not realize that you have 30 days to try out a new Medigap plan while keeping your original policy; this is known as your “free look period.” Here’s how it works: When applying for a new Medigap plan, you must agree on your application that you’ll cancel your original policy after the 30 days. Then, you have a month to try out your new plan and decide if you want to keep it. If after 30 days, you like your new policy and decide to keep it, you can cancel the first plan. Or, if you’d rather stay with your original policy, you can cancel the second policy. You’ll have to pay premiums for both policies for that one month.

    This trial period is an important benefit because once you drop your Medigap policy, you may not always be able to get it back if you don’t have guaranteed-issue rights. During your “free look period”, you can try out a new plan without worrying that you won’t be able to get back your original plan if the new policy doesn’t end up working out (this right ends after 30 days).

  7. Review the Medigap rules for your state.
  8. Although most states offer 10 standardized Medigap plan offerings, the rules may be different depending on where you live, and insurance companies aren’t required to offer all 10 plan types. If you live in Wisconsin, Massachusetts, or Minnesota, the Medicare Supplement plans have different standardized benefits.

    Also, insurance companies aren’t required to sell Medigap plans to individuals under 65. However, some states offer at least one Medicare Supplement policy for people under 65 who may qualify for Medicare because of end-stage renal disease or disability. Contact your state’s insurance department to see what the rules are in your state.

  9. Check which method the insurer uses to set premium prices.
  10. Insurance companies use different methods to calculate premiums, and the method they use affects how much you’ll pay for premiums both now and in the future. For example, some insurance companies use community-rated pricing, meaning everyone pays the same premium cost, regardless of age. Other insurance companies use attained-age pricing, where premiums are based on your current age. A Medigap plan that uses an attained-age method can cost more for members who join when they’re older.

  11. Keep in mind there may be a waiting period before your pre-existing conditions are covered.
  12. Some insurance companies can make you wait up to six months before covering your pre-existing conditions. This waiting period can apply even if you apply during your Medigap Open Enrollment Period. During this waiting period, you’ll have to pay for the full out-of-pocket cost of health services to treat your health condition. After this period is over, the Medicare Supplement plan will cover your pre-existing condition.

    If you’re joining a Medicare Supplement plan and you have health problems or disabilities, the insurance company can’t refuse to cover them if you have guaranteed-issue rights. However, it can make you wait to be covered. 

  13. Take the time to research plans.
  14. Perhaps even more so than other types of Medicare coverage, it’s worth it to shop around. The biggest difference between Medigap plans of the same type will be the price, since most states require insurers to sell the same standardized benefits across each plan type, with the exception of Medigap plans in Massachusetts, Minnesota, and Wisconsin (which have their own set of standardized plans). This means the benefits will be exactly the same, regardless of insurer. However, insurance companies aren’t required to offer every single Medicare Supplement plan, and availability will depend on your location.

In other words, if you’re going to be getting the same Medigap coverage, researching plans lets you get those benefits for the best price. If you’d like to compare Medicare Supplement plans in your area now, just use the plan finder tool on this page to get started. Or, feel free to give us a call if you’d like personalized help with a licensed insurance agent.

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Medicare Coverage in Nevada

Medicare Coverage in Nevada

 

The Medicare program provides health insurance coverage to eligible U.S. citizens and legal permanent residents (of five years or longer) who are age 65 or older, or who qualify under the age of 65.

As of 2015*, there were 445,997 total beneficiaries enrolled in the Medicare program in Nevada, according to the Centers for Medicare & Medicaid Services (CMS). Of this total, there were 149,826 residents enrolled in the Medicare Advantage (Medicare Part C) program, through which they are guaranteed the same coverage provided through Original Medicare (except for hospice care, which Medicare Part A covers). In 2015, 150,293 Nevada beneficiaries received their prescription drug coverage through stand-alone Medicare Part D Prescription Drug Plans, while 144,634 received coverage for both their medications and Original Medicare benefits through Medicare Advantage Prescription Drug plans.

Types of Medicare coverage

A bit of background: the federal fee-for-service Medicare health insurance program is called Original Medicare, and includes Part A (hospital insurance) and Part B (medical insurance). Some beneficiaries stay with this program and choose no other coverage. You can add to this coverage by enrolling in a stand-alone Medicare Part D Prescription Drug Plan and/or a Medigap plan (both described in the table below).

Medicare Advantage (Medicare Part C) offers an alternative way to get your Original Medicare coverage; you’re still in the Medicare program if you have a Medicare Advantage plan. See more information in the table below.

Each plan type may have different out-of-pocket costs or coverage details. In the case of Medicare Advantage, different plans might have different additional benefits beyond Medicare Part A and Part B. However, no matter what kind of Medicare plan you sign up for, you still need to continue paying your Medicare Part B premium.

As a Medicare beneficiary in Nevada, you may want to compare all available plans in your service area with your health and prescription drug needs in mind.

Medicare Insurance Plan Type Description
Medicare Advantage Plan A health plan offered by private insurance companies that contract with Medicare. This type of Medicare Advantage plan provides Medicare Part A* (hospital insurance) and Part B (medical insurance) benefits. Many of these plans include additional benefits, such as wellness plans.
Medicare Advantage Prescription Drug plan A type of Medicare Advantage plan that includes prescription drug coverage, so you can get all your Medicare benefits in one plan. The formulary (list of covered prescription drugs) may change at any time. You will receive notice from your plan when necessary.
Stand-alone Medicare Prescription Drug Plan (Part D) Prescription drug coverage offered by private insurance companies that contract with Medicare. Each Medicare Prescription Drug Plan may vary in terms of costs, availability, and prescription drugs covered. As with Medicare Advantage Prescription Drug plans, be aware that a plan’s formulary may change at any time. You will receive notice from your plan when necessary.
Medicare Supplement (Medigap) plan Medigap plans are offered by private insurance companies, and can help you pay your out-of-pocket costs for services covered under Original Medicare.

*Under Medicare Part C, hospice benefits are provided directly through Medicare Part A instead of through the Medicare Advantage plan.

Nevada Aging and Disability Services Division

The Aging and Disability Services Division in the State of Nevada, Department of Health and Human Services, coordinates and delivers supportive services for Nevada’s seniors. Its mission is to help individuals over the age of 60 to lead independent and meaningful lives. Examples of the services provided through this department include the State Health Insurance Assistance Program (SHIP), Advocate for Elders, and the Senior Medicare Patrol (SMP), and more. The Nevada State Health Insurance Assistance Program (SHIP) offers seniors free one-on-one assistance with trained volunteers on topics such as Medicare claims, billing programs, comparing Medicare plans, and long-term care options. The Senior Medicare Patrol (SMP) aims to inform seniors on how to locate and report instances of Medicare fraud, waste, and abuse.

*Statistical data from the Centers for Medicare & Medicaid Services, “On its 50th anniversary, more than 55 million Americans covered by Medicare” as of July 28, 2015.

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Medicare Supplement (Medigap) Plans

Medicare Supplement (Medigap) Plans

 

While Original Medicare covers a variety of health services, it doesn’t cover everything. You’ll still have to pay cost-sharing requirements, like deductibles, copayments, and coinsurance. Medicare Supplement (also called Medigap) plans help fill the “gaps” in coverage by paying for some of the costs that Original Medicare doesn’t cover.

How Medicare Supplement plans work

To enroll in a Medigap plan, you must be enrolled in Original Medicare, Part A and Part B, and live in the service area of the Medigap plan you want to join. If you and your spouse both want Medigap coverage, you must each purchase separate policies. Medicare Supplement plans only cover one person per policy. Keep in mind that not every state offers Medicare Supplement insurance to individuals under 65 (for example, those who qualify for Medicare because of disability). If you’re under 65 and have Medicare, check with your state insurance department to learn if you’re eligible for Medigap coverage in your state.

Medicare Supplement plans only work with Original Medicare. If you are enrolled in a Medicare Advantage plan, a Medigap plan can’t be used to pay for Medicare Advantage costs.

Medicare Supplement plan benefits

In most states, you may choose from up to 10 different Medigap policies, labeled Medigap Plans A through N. Medicare Supplement plans are offered through private insurance companies, but not every plan type is offered in every location. Benefits are standardized across each plan type, meaning that cost is the main difference between insurance companies offering plans of the same letter type. If you live in Wisconsin, Massachusetts, or Minnesota, the Medigap benefits are standardized differently.

Each Medigap plan type varies in the specific benefits it covers, but may include all or some of the following benefits:

  • Medicare Part A coinsurance and hospital costs for an extra year after Medicare benefits are exhausted
  • Medicare Part A hospice care coinsurance or copayment
  • Medicare Part B coinsurance or copayment
  • First three pints of blood
  • Skilled nursing facility coinsurance
  • Medicare Part A deductible
  • Medicare Part B deductible
  • Medicare Part B excess charges
  • Overseas emergency travel coverage, up to plan limits
  • Yearly out-of-pocket limit

Most Medigap plans cover the full cost of the above expenses for covered benefits, but Plan K and Plan L only cover a percentage of certain expenses (either 50% or 75%).

Because benefits are the same regardless of insurance company, it’s important to compare Medigap plan options in your area before enrolling in a plan. Insurance companies determine Medigap costs and decide which policies to sell. Several factors, including the method that the insurer uses to calculate Medigap premiums, can affect how much you pay for a policy, both when you enroll and in the future.

When to enroll in a Medicare Supplement plan

Federal and state laws regulate Medigap policies, and these laws are meant to protect you as a beneficiary.

Guaranteed-issue rights are one of these protections. You have a guaranteed right to join any Medigap plan in your area if you enroll during your Medigap Open Enrollment Period, the six-month period that automatically starts when you’re 65 and enrolled in Medicare Part B. During this time, private insurers must sell you a Medigap policy, regardless of health problems. Insurance companies also can’t charge you more because of health. This is generally the best time to join a Medicare Supplement plan, especially if you have health issues.

After your Medigap Open Enrollment Period, you can join a Medigap plan anytime the plan is accepting new members, but you’ll only have guaranteed-issue rights in limited situations. Unless a guaranteed-issue right applies, if you try to switch Medigap plans, insurers are free to reject you because of your health status or they may require medical underwriting. You may have to pay a higher premium if you have disabilities or pre-existing conditions.

What Medicare Supplement plans don’t cover

Medicare Supplement plans aren’t meant to provide comprehensive health benefits. You’ll continue to get your hospital and medical coverage through Original Medicare, Part A and Part B.

Medicare Supplement plans also don’t cover benefits like routine vision and dental care, hearing aids, or private duty nursing. You may be able to get coverage for some of these benefits, such as routine dental services, through a Medicare Advantage plan. Medicare Advantage offers a different way to get your Original Medicare coverage and can include additional benefits.

Medigap policies sold today no longer cover prescription drugs. If you bought a Medigap plan that included drug benefits, that drug coverage may not be considered creditable. Keep in mind that you could face a penalty for Medicare Part D if you don’t enroll when you’re first eligible and don’t have creditable drug coverage for more than 63 consecutive days. Creditable prescription drug coverage is coverage that’s expected to pay as much as the standard Medicare Part D prescription drug benefit. Your insurance company should notify you every year whether your drug coverage is creditable.

You can get Medicare Part D coverage through a stand-alone Medicare Prescription Drug Plan if you have Original Medicare. Some Medicare Advantage plans also include drug benefits (these are known as Medicare Advantage Prescription Drug plans).

If your Medigap insurer sends you a notice that your drug coverage isn’t creditable, you have a few options. You can:

  • Keep your Medigap policy and join a Medicare Prescription Drug Plan. You can join a Medicare Prescription Drug Plan during the Annual Election Period from October 15 to December 7. If you join a stand-alone Medicare Prescription Drug Plan, you must tell your Medigap insurer to remove the drug coverage from your Medigap plan. This may change your Medigap plan premium.
  • Keep the prescription drug coverage under your Medigap policy. If you decide to keep the drug coverage under your Medigap policy, you can’t also enroll in a Medicare Prescription Drug Plan at the same time. However, if you decide to enroll in Medicare Part D in the future, you may have to pay a late-enrollment penalty for not having creditable prescription drug coverage. The longer you wait, the higher your penalty may be later.
  • Drop your Medigap plan and enroll in a Medicare Prescription Drug Plan. Keep in mind that you may not be able to get the same Medigap plan back.

Do you have questions about Medicare Supplement coverage, or would you like help exploring Medigap plan options in your area? Contact eHealth to speak with a licensed insurance agent about your Medicare needs. Or, to start comparing plan options right away, simply enter your zip code into the plan finder tool on this page.

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Medicare Supplement (Medigap) Plan Costs

Medicare Supplement (Medigap) Plan Costs

 

A Medigap (Medicare Supplement) plan can help cover the medical and related out-of-pocket expenses that Original Medicare, Part A and Part B, doesn’t cover. For example, there’s a cost category called “Part B excess charges” that some Medigap plans cover. This is the amount that a medical provider is legally allowed to charge, in some situations, that’s higher than the Medicare-approved amount.

There are 10 different standardized Medigap available in most states. Each plan is designated by a letter (for example, Medigap Plan F), and benefits are standardized across each plan type. This means that coverage is the same for each plan letter no matter which insurance company you buy from. For example, if you buy a Medicare Supplement Plan F in Athens, GA, its benefits will be the same as a Medicare Supplement Plan F in Fargo, ND. Note that Medicare Supplement plans in Massachusetts, Minnesota, and Wisconsin are standardized differently.

It may be well worth taking the time to compare plans before enrolling in a Medigap plan. Since the benefits are exactly the same for plans of the same letter, the main difference is the cost.

Note: Medigap Plan A, Plan B, Plan C, and Plan D are different from Medicare Part A, Part B, Part C, and Part D, despite the similar-sounding names.

Learning the best time to enroll in a Medicare Supplement plan and how insurers price Medigap premiums can help make sure that you get accepted into a Medicare Supplement plan at a price that may work for your budget.

When to enroll in a Medigap plan

Enrolling when you’re first eligible can strongly affect the cost of your Medicare Supplement plan–or whether you’re even able to enroll. For most people, you’re first eligible during the Medigap Open Enrollment Period. This is the six-month period that starts when you’re 65 and covered by Medicare Part B. During this time, you have guaranteed-issue rights, meaning that insurers cannot use your health status to turn you down for a plan or charge you more. If you apply for a Medigap plan after this period, insurance companies can use medical underwriting, refuse to sell you a policy, or charge you a higher premium because of pre-existing conditions.

If you want to join a Medigap plan when you are most likely to be accepted into the plan and pay a lower premium than you might pay if you enrolled later, you may want to apply during your Medigap Open Enrollment Period.

How insurers price Medigap premiums

When comparing Medigap plans, you should pay attention to not just the current premium cost, but how the insurance company prices its premiums. Private insurers use enrollees’ ages differently to calculate Medigap premiums. The pricing method that the insurance company uses will affect how much you pay for your plan premium later on.

Companies that sell Medigap policies can set premium prices in any one of three ways.

No-age-rated or community-rated: Rates are not affected by age. Premiums can increase due to inflation.

Issue-age-rated: The rate is set at the age you are when purchasing the policy. The younger you are when you buy the policy, the lower your premiums will be. Your premiums will still increase over time because of inflation and other factors, but they cannot increase because of age.

Attained-age-rated: The initial premium cost is based on your age at the time you purchase the policy, but will increase as you get older. These policies may be expensive in the beginning, but can end up being more expensive over the long run. Premiums can increase because of inflation.

Saving on Medigap costs

To keep your Medigap premium down, you may want to purchase a policy as soon as you’re first eligible, during your Medigap Open Enrollment Period. Aside from that, it’s generally a good idea to  shop around and compare prices before getting a Medigap policy.

You can find and compare Medicare Supplement plans in your area by entering your zip code in the form on this page.

When choosing in a Medigap plan, you may want to think carefully about both your present and anticipated future health needs. If you choose to buy a less expensive plan during your Medigap Open Enrollment Period, you may not be able to change to a better plan later on. You may be in good health when you purchase your plan, but your health may decline over time. You may have trouble switching Medigap plans later if your health declines. However, there are a few situations where you can switch Medigap plans with guaranteed issue rights.

Do you have questions about Medigap plans or other Medicare coverage options? We’re here to help. You can talk to one of eHealth’s licensed insurance agents by calling the phone number below.

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