Medicare 101

Helping St. Louis Seniors with Medicare & Medicare Health Programs

Upon turning 65, seniors have the ability to receive their healthcare through Medicare. While this is a great tool to use to receive the coverage you need, it can sometimes be complicated to understand the options and figure out what you need. That’s why we’re here – at Sunshine Senior Services, we’ve helped over 10,000 people enroll in Medicare benefits right here in the St. Louis area. Read below for more information about specific parts of Medicare.

Medicare Part A

Medicare Part A is part of traditional Medicare coverage that covers hospital stays and in-patient care, which means anytime you’re treated in a hospital or medical facility where you must be admitted. Additionally, Part A coverage includes the following:

Medicare Part B

Medicare Part B is the other part of traditional Medicare coverage that covers doctors’ visits and outpatient care. This means that any routine medical exam or visit is covered by this part of your plan. Part B includes access to:

Medicare Health Programs

When it comes to Medicare, it’s a convenient way for seniors to receive the medical care that they need. However, Medicare doesn’t always cover all the services they need. Many times, dental insurance, vision insurance and prescription drug coverage are excluded from Medicare plans. Luckily, we provide Medicare health program plans such as:

Medigap (Medicare Supplements)

Medicare supplement plans (also called MEDIGAP) are private health insurance specifically designed to supplement and work only with Original Medicare. Private insurance companies sell Medicare supplement plans. Medicare supplement plans help pay some of the coinsurance, copayments, and deductibles (“gaps”) in Original Medicare. They may also cover certain medical services Medicare doesn’t cover. People who are enrolled in Original Medicare and buy a Medicare supplement plan will generally have 100 Percent of their Medicare-approved health care costs covered (depending on the plan they choose). Medicare supplement plans aren’t Original Medicare or a Medicare Advantage plan because they’re not a way to get Medicare benefits. Medicare supplement plans are identified by letters (such as Plan F,N,G).

Each Medicare supplement plan must offer the same basic benefits, no matter which insurance company sells it.
Usually, the difference between Medicare supplement Policies sold by different insurance companies is the cost, underwriting criteria, extra services (value-added) and customer service.
Medicare supplement insurance companies must follow federal and state laws.
A Medicare supplement plan only covers one person. If a married couple wants Medicare supplement coverage, they must buy separate Medicare supplement plans.

Medicare Advantage

You can get your Medicare benefits through Original Medicare, or a MediAdvantage Plan (like an HMO or PPO). If you have Original Medicare, the government pays for Medicare benefits when you get them. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits. If you join a Medicare Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage.

There are different types of Medicare Advantage Plans:

Health Maintenance Organization (HMO) plans—In most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan’s network, except in an urgent or emergency situation. You may also need to get a referral from your primary care doctor for tests or to see other doctors or specialists.
Preferred Provider Organization (PPO) plans—In a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You usually pay more if you use doctors, hospitals, and providers outside of the network.
Private Fee-for-Service (PFFS) plans—PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.
Special Needs Plans (SNPs)—SNPs provide focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.
HMO Point-of-Service (HMOPOS) plans—These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.
Medical Savings Account (MSA) plans—These plans combine a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA plans don’t offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan.

Who can join a Medicare Advantage Plan? You must have Medicare Parts A and B and live in the plan’s service area to be eligible to join. People with End-Stage Renal Disease (permanent kidney failure) generally can’t join a Medicare Advantage Plan.

Sometimes people ask, what do Medicare Advantage Plans cover? Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs. Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for the plan’s medical and prescription drug coverage.

Medicare Prescription Drugs (Part D)

Plans are administered by various insurance companies, all offering benefits which meet minimum federal standards. Some plans have additional benefits beyond federal requirements. Plans can be reviewed and changed each year. Formularies, deductibles and an individual’s medication need can and do change.

Medicare Part D Plans cover, the types of drugs most commonly prescribed for Medicare beneficiaries as determined by federal standards. Each Part D plan has a formulary or list of drugs that are accepted by plan.

Here is a chart that may help you understand the “coverage gap” also referred to as the doughnut hole.