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Medicare Insurance

A step-by-step guide to help you understand your Medicare choices

- Part A, B, C and D -

An introduction to Medicare

Medicare is a federal health insurance program for seniors who are 65 years or older. People with certain disabilities who are younger than 65 can also be eligible for coverage, as well as those with End-Stage Renal Disease.

Medicare is an entitlement program that is similar to Social Security. US citizens who have worked for a prescribed period and paid their taxes have the right to enroll. If you are a US citizen and have not worked for the minimum period, you may still be able to enroll but would probably have to pay more.

There are four different parts to Medicare - Parts A, B, C and D. Parts A and B are often referred to as Original Medicare. Then there are Medicare Supplement Insurance (Medigap) plans that can help pay for out-of-pocket expenses like coinsurance, copayments and deductibles.

Medicare choices - decide which plan is right for you

Medicare Part A - Hospital Insurance

Part A Coverage includes:

  • Inpatient hospital care
  • Skilled nursing facility care
  • Home health care services (with limitations)
  • Hospice care

Some of the above are subject to certain limitations and conditions.

Hospital care services

  • Inpatient care includes a semi-private room (unless medically necessary, the cost of a private room is not covered).
  • Private duty nursing is not covered.
  • Medications that are part of your inpatient treatment are covered.
  • If you require blood, you will be required to pay for the first three units per calendar year unless you have the blood donated by someone else, or the hospital gets the blood from a blood bank at no charge.

Skilled nursing care

  • Covered after a qualifying hospital inpatient stay for related illness or injury.
  • Covers a semi-private room, meals, skilled nursing, medical social services, rehabilitation, medications and medical supplies received while under this care, dietary counselling.
  • If medical services are not provided at this facility, ambulance transportation to the nearest provider is covered.
  • Part A does not cover long-term care.

Home health care services

  • Intermittent or part-time skilled nursing care (24 hour care, meals or homemaker services, help with bathing and dressing are not covered if they are unrelated to your treatment).
  • Medical social services.
  • Physical therapy.
  • Language-speech pathology services.
  • Occupational therapy.

Hospice care

  • Covered if your doctor certifies that you have a terminal illness with an estimated 6 months or less to live.
  • The focus is on palliative care (relief from the symptoms).
  • You agree not to receive curative treatments.
  • You must be enrolled in Medicare Part A.
  • This care is usually received in the patients home.

Medicare Part B - Medical Insurance

  • Covers services and suppliers necessary to treat your non-hospital health expenses.
  • You pay a monthly premium for Medicare Part B which can be higher for people with high incomes.
  • You will be responsible for certain out-of-pocket expenses like the deductible, coinsurance or copayments. A Medigap policy (Medicare Supplement Insurance) can help cover these expenses.
  • Services and supplies covered include (but not limited to):
    • Doctor's visits
    • Laboratory tests and X-rays
    • Emergency ambulance services
    • Durable medical equipment
    • Preventative services
    • Mental health services
    • Rehabilitative services

Medicare Part C - Medicare Advantage

  • Includes all benefits and services covered under Medicare Part A and Part B.
  • These plans are offered by private health insurance companies and usually include Medicare Part D (Prescription Drug Coverage) as part of the plan.
  • Some plans may cover certain services not offered by Part A and Part B such as, dental care, eye exams, hearing aids and health care received while travelling outside the United States.
  • Enrolling in a Medicare Advantage Plan is optional. However, you must be enrolled in the Original Part A and Part B to be eligible as these plans are Medicare approved.
  • You cannot use a Medigap policy if you enroll for Medicare Advantage.

Medicare Part D - Prescription Drug Coverage

  • Is available from private health insurers. As different plans are offered, the premiums and out-of-pocket expenses (deductible, copayment and coinsurance) for different drugs will vary.
  • Coverage is available to anyone who is eligible for Original Medicare.
  • To break it down, all Medicare Part D plans have the following phases:
    • Deductible phase - for most plans you will pay 100% for drug costs until you reach the deductible amount. When this is reached the plan will start to cover its share of the costs. Remember, the deductible amount may vary by plan.
    • Initial coverage limit - after the deductible has been reached, this phase begins and you pay the plans cost share for covered drugs.
    • Coverage gap ("donut hole") - the out-of-pocket limit is the amount the individual must pay before catastrophic coverage begins.
    • Catastrophic coverage - once this stage is reached, the Part D plan covers approximately 95% of drug expenses incurred.

Enrollment periods

 

Initial Enrollment Period

Your Initial Enrollment begins three months before and ends three months after the month of your 65th birthday.

When you first become eligible and you still have employer or plan-sponsored coverage, you do not need to enroll until you retire or otherwise lose that coverage.

 

Open Enrollment - October 15 to December 7

During Open Enrollment you can add, drop pr change your Medicare plan. This period is also called the Annual Enrollment Period.

 

Medicare Advantage Disenrollment Period

You can disenroll from a Medicare Advantage plan and return to original Medicare between January 1 and February 14.

 

Special Election Period

You may be able to enroll in a Medicare plan outside of the Initial Enrollment Period depending on certain circumstances:

  • Retire and lose employer coverage.
  • Move out of the plan's service area.
  • Have been diagnosed with certain qualifying disabilities or chronic health conditions.
  • Receive state assistance.

 

Medicare insurance