Medicare

  • Medicare –  is federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions. Medicaid is a joint federal and state program that provides health coverage for some people with limited income and resources.
  • Medicare Supplement (Medi-gap) -A Medigap policy is private insurance that helps supplement Original Medicare. This means it helps pay some of the health care costs that Original Medicare doesn’t cover (like copayments, coinsurance, and deductibles). These are “gaps” in Medicare coverage. If you have Original Medicare and a Medigap policy, Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap policy pays its share. A Medigap policy is different from a Medicare Advantage Plan (like an HMO or PPO) because those plans are ways to get Medicare benefits, while a Medigap policy only supplements the costs of your Original Medicare benefits. Note: Medicare doesn’t pay any of your costs for a Medigap policy.
  • Medicare Advantage – sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits.

Who can by a Medigap policy?

  • Generally, you must have Medicare Parts A and B to be able to buy a Medigap policy.
  • The best time to buy a Medigap policy is on the first day of the month in which you’re 65 or older and enrolled in Part B. This time period, called your Medigap Open Enrollment Period, ends 6 months later. During this period, an insurance company can’t refuse to sell you a policy or charge you more because of your health.

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.

How do you qualify?

  • 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.

When can I enroll?

Annual Election Period (AEP)

    • If you are not new to Medicare, you can typically only join, switch or leave an MA plan at certain times of the year. One of these times is the Annual Election Period (AEP) from October 15 to December 7. Plan changes are effective January 1 of the following year. Prior to this time, MA plans are required to:
    • Inform you if they are leaving or reducing their service area the following year
    • Provide information on future changes in benefits, copayments and premiums
    • In addition, MA plans may decide to close enrollment to new members except for those who are initially enrolling in Medicare or moving into the MA plan’s service area.

Initial Coverage Election Period (ICEP)

    • If you are newly eligible for Medicare, you have an Initial Coverage Election Period (ICEP) to join an MA plan that begins 3 months before you first become eligible for both Medicare Part A and Part B and ends on the later of:
    • The last day of your Part B Initial Enrollment Period (IEP)
    • The last day of the month preceding your eligibility for both Part A and Part B

Medicare Advantage Open Enrollment Period (MA OEP)

    • The Medicare Advantage Open Enrollment Period (MA OEP) runs from January 1 – March 31 each year. It allows you, if you’re already enrolled in a Medicare Advantage plan, to:
    • Switch to another Medicare Advantage plan (with or without drug coverage), or
    • Disenroll and return to Original Medicare. If you do so, you can also join a Part D prescription drug plan.

Special Enrollment Periods (SEPs)

    •  SEPs allow you to enroll in or disenroll from a Medicare Advantage (MA) plan or Part D plan depending on your situation. In addition, if you believe you made the wrong plan choice because of inaccurate or misleading information, including using Medicare’s Plan Finder, you can call 1-800-MEDICARE and explain your situation. They can give you a SEP on a case-by-case basis.

 

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