Frequently asked questions about Medicare
Q. What are the 4 parts of Medicare?
A. Medicare is made up of four parts: Hospital Insurance (Part A), Medical Insurance (Part B), Advantage Plans (Part C) and Prescription Drug (RX) Insurance (Part D). Part A also includes skilled nursing facility and some home health care but not long term care. Part B covers Medicare eligible physician services, outpatient hospital services and certain home health services and durable medical equipment.
Part D coverage is for both short and long-term prescription needs not given in the hospital, coverage for both brand name and generic drugs and can differ dramatically from one company to the other. Part D is not deducted from your Social Security check.
Q. Can you explain the difference between a Deductible, co-pay(ment) and out-of-pocket?
A. The deductible is the amount you must pay for health care before Medicare begins to pay. These amounts can change every year. A co-payment is a partial cost you will spend to see the doctor. These can be zero or more. These are out-of-pocket, which are costs that you must pay on your own because they are not covered by Medicare.
Q. What are the differences in HMO, PPO, PFFS, SNP and MSA plans?
A. Health Maintenance Organizations (HMO)- Just like the private sector, HMO is a group of doctors, hospitals and other care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You get your care from the provider in the plan.
Preferred Provider Organization (PPO)- Doctors, hospitals and providers that belong to the network and with most PPO plans, you can use doctors, hospitals and providers outside the network for an additional cost.
Private Fee for Service (PFFS)- These are sometimes referred to as regional PFFS since the doctor or hospital accepts payments from the insurance plan rather than Medicare. The Insurance plan decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare covered benefits.
Special Needs Plan (SNP) – A type of plan for people with chronic illnesses or conditions with special needs.
Medical Savings Plans (MSA) – A type of savings plan for those people who do not go to the doctor often but need a savings plan to pay some of the costs of the deductibles and co-payments.
Q. My Doctor takes Blue Cross, but he does not take Medicare Advantage Blue Cross. What does that mean?
A. Medicare Advantage plans are a hybrid of coverage offered from an insurance company. When you are eligible for Medicare at age 65, you select Part C–Medical Insurance offered by a company. You still pay your premiums out of your social security check for Part B, but the government pays the insurance company to administrate the benefits. These Medicare Advantage Plans appear to have many benefits and include Drug coverage (Part D). Medicare Advantage plans are the best of both worlds, but they have some drawbacks. If your doctor is not a Medicare Advantage plan doctor, you will pay additional costs to see him/her, but with most plans you can see another doctor (usually not available with HMO plan). You will be subject to separate deductibles and separate co-payments, and often need a referral for approval before you can get care from the specialist. If you do not get a referral, the plan may not pay for your care.
Q. Since Medicare Advantage provides all Medicare health care through that plan, what if I don’t like it? I have heard Doctors payments will be cut and the company I sign up with may stop insuring them. What protection do I have?
A. Since Medicare is a government provided plan for those 65 and older, you have many options for coverage. Every year in fall, you can switch from one Medicare Option to another–you can enroll in any Medicare Advantage or Part D at this time. This is called the Annual Enrollment Period (AEP) or Open Enrollment Period (OEP).
Q. What other benefits do I get with a Medicare Advantage Plan?
A. You may get extra benefits by selecting a Medicare Advantage Plan. These may include vision, hearing, dental and/or health and wellness program including membership to a specific gym. Because you do not need to buy a Medigap or Medicare Supplement policy, the premium are supplemented by the government and are less expensive than a traditional supplemental plan.
Q. I hear there are many gaps in the Part D (Drug) coverage and I take 5 prescriptions a day. How do I get most of my drugs covered?
A. Every insurance company that offers Part D coverage has a written list of drugs. These include generic and brand name drugs. (Check the websites or ask your agent for a printed formulary drug book.) Your plan may have several tiers, and your co-payment amount depends on which “TIER” your drug is listed. Not all brand names will be covered and these can be very expensive if you have a high co-payment, or it is not listed. Always ask your doctor whether the drugs prescribed are available as generic. Be sure to ask your doctor whether you can split a high-dose version of the prescribed drugs as they are often the same price as the low-dose version, or go to http://www.medicare.gov to compare drug plans in your State.
Q. How much are the current Medicare premiums?
A. You can check the current Medicare premiums here.
