Demystifying Medicare Coverage: Everything You Need to Know

Unraveling the complex world of Medicare coverage and providing essential information for individuals seeking Medicare coverage after they retire or have certain disabilities is a must. News media outlets continuously talk about Medicare insurance and there is a lot of information out there about the subject. It can be overwhelming trying to put all the pieces together. But there is a dark side to Medicare when you delay certain things.

In this post, I would like to share some less-known information along with common knowledge about Medicare so that you can make a conscious decision about your health care. Medicare is not a cut-and-dry situation, it has many moving parts and honestly, all the moving parts don't necessarily join together in harmony.

Couple enjoying retirement with friends

Understanding Medicare: A Comprehensive Overview

Medicare is a federal health insurance program that provides coverage for individuals aged 65 and older; as well as, certain younger individuals with disabilities.

It is divided into different parts, each with its coverage options and costs.

Part A (Original Medicare) covers hospital care, skilled nursing facility care, hospice care, and some home health care services. Does not cover most drugs outside of a hospital setting.

Part B (Original Medicare) covers doctor visits, outpatient care, medical supplies, and preventive services. Does not cover most drugs outside of doctor-administered medications.

Part C, also known as Medicare Advantage, is an alternative to Original Medicare and offers additional benefits, such as prescription drug coverage and vision or dental care.

Part D provides prescription drug coverage, which can be obtained through a standalone Prescription Drug Plan or a Medicare Advantage plan that includes drug coverage.

Understanding the different parts of Medicare is essential to make informed decisions about your healthcare coverage.

Different Parts of Medicare Coverage Explained

Medicare Part A is funded through payroll taxes and covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services. If you meet the requirements, Part A will have a $0 premium. While this insurance will help you if you have to go to the hospital, it does nothing for routine doctor visits. There is somewhat of a coverage limit even in a hospital setting. And if you are admitted into the hospital there are still some cost share that you will be responsible for. It is beneficial to speak with a professional and understand how you can be affected. There are more plans available to you than you may know. Plans like hospital indemnity policies help ease the financial burden of a hospital stay, among other things and the premium is very cost effective.

Part B is a voluntary program that requires a monthly premium and covers doctor visits, outpatient care, medical supplies, and preventive services. You must ensure when is the best time to enroll in Part B coverage. If you are still working and your employer is offering benefits as good as or better than Medicare Part B you can delay enrollment. But if you have no coverage, you must enroll in Part B to avoid being penalized for not enrolling in Part B when you are first eligible to enroll. Speak with a Social Security representative to know how a penalty can affect you.

Medicare Part C, also known as Medicare Advantage, is offered by private insurance companies approved by Medicare. Every insurance plan has pros and cons; therefore, consideration must be given to how the plan best benefits your health and lifestyle. 

These plans provide the same coverage as Original Medicare (Parts A and B), and may also include additional benefits like prescription drug coverage or dental and vision care. The main ingredient to Part C plans is making sure you can carry on with daily, monthly, and annual activities with minimum interruptions. When looking at these plans with a licensed broker, have a list of all the medications you are currently taking; as well as, all the doctors you visit. This way you can know if your doctors are in the plans network, and that your medications are covered. The main focus here is to take advantage of all the preventive programs in the plan to keep you healthy and mobile for as long as possible which will improve your quality of life. The best part is that in some areas you may be able to get a $0 premium for these plans.

Medicare Part D provides prescription drug coverage, which helps individuals pay for their medications. A Part D plan is going to have a premium, so keep that in mind when shopping around. The benefit that most people enjoy, is that outside of the additional premium, everything else would stay the same. The enrollee stays on Original Medicare and keeps the same doctors. But it is very important to have a list of your medications, this plan only works when your medications are covered under the formulary. A broker can help you determine this.

It is important to carefully review the different parts of Medicare to determine which coverage options best meet your needs.

Get the care you need with a Medicare Plan

Eligibility Requirements and Enrollment Process

To be eligible for Medicare, you must be a U.S. citizen or a legal resident who has lived in the country for at least five consecutive years.

You are eligible for Medicare if you are 65 years old or older, or if you have a disability and have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months.

You can enroll in Medicare during the Initial Enrollment Period (IEP), which begins three months before your 65th birthday month and ends three months after.

Most individuals enroll or change plans during the Annual Election Period (AEP), it begins on October 15 and ends on December 7th of each year, with coverage beginning January 1.

You can change plans as many times as you want during this period with the last selection being finalized on December 7th. You can also begin taking a look at what next year's plans have to offer in your area from October 1st to October 14th but you will not be able to enroll in a plan during that time.

If you miss your IEP, you can enroll during the General Enrollment Period (GEP), which runs from January 1 to March 31 each year, with coverage starting on July 1.

It is important to understand the eligibility requirements and enrollment process to ensure you receive the Medicare coverage you need.

Medicare Advantage Plans: Pros and Cons

A Medicare Advantage (Part C) plan offers an alternative to Original Medicare, providing the same coverage as Parts A and B, and often including additional benefits like prescription drug coverage, dental care, and vision care.

One of the main advantages of Medicare Advantage plans is that they may have lower out-of-pocket costs compared to Original Medicare. Medicare Advantage plans also have a maximum-out-of-pocket threshold which Original Medicare does not have.

These plans also often include coverage for services not covered by Original Medicare, such as fitness programs or hearing aids.

However, Medicare Advantage plans typically have a restricted network of doctors and hospitals, and may require you to get referrals for specialist care.

It is important to carefully consider the pros and cons of Medicare Advantage plans before making a decision.

Navigating Prescription Drug Coverage with Medicare

Medicare Part D provides prescription drug coverage, which helps individuals pay for their medications.

There are two main ways to obtain Part D coverage: through a standalone Prescription Drug Plan (PDP) or through a Medicare Advantage plan that includes drug coverage (MAPD).

Each plan has its own formulary, which is a list of covered medications.

It is important to review the formulary to ensure that your medications are covered and to compare costs between different plans.

Navigating prescription drug coverage with Medicare can be complex, but understanding your options and doing research can help you find the best plan for your needs. By partnering with AEC you can get the answers you need and get enrolled in the plan you want that fits your needs best. Our goal is to educate people about the impact insurance has on daily lifestyles, by using the information you give us and leveraging experience to guide you to find the plan that works best for you.