‘Medicare and You,’ a primer to help seniors pick the right option

Seniors on Medicare and those becoming eligible for the program this fall can get a wealth of information from www.medicare.gov and from the program’s 2019 "Medicare and You" handbook.

The 120-page handbook walks Medicare members and enrollees through plan options and answers information about benefits and costs. It can be downloaded at www.medicare.gov/sites/default/files/2018-09/10050-medicare-and-you.pdf.

If you already have Medicare, you don’t need to sign up for Medicare each year, but if you find a better plan, you can switch during the annual Oct. 15 to Dec. 7 open enrollment period.

Medicare encourages seniors to start now comparing their coverage with other options. Visit Medicare.gov/find-a-plan. Open enrollment is the time to change health or prescription drug coverage for 2019 or join a Medicare Advantage Plan. 

Changes made during open enrollment take effect Jan. 1, 2019.

Between Jan. 1. and March 31, 2019, seniors in a Medicare Advantage Plan can make one change to a different plan or switch back to Original Medicare (and join a stand-alone Medicare Prescription Drug Plan). 

Here are some other frequently asked questions covered in the handbook:

What services does Medicare cover?

Medicare Part A and Part B cover certain medical services and supplies in hospitals, doctors’ offices, and other health care settings.

Prescription drug coverage is provided through Medicare Part D.

If you have both Part A and Part B, you can get all of the Medicare-covered services, whether you have Original Medicare or a Medicare health plan.

To get Medicare-covered Part A and/or Part B services, you must be a U.S. citizen or be lawfully present in the United States.

What does Part A cover?

Part A (Hospital Insurance) helps cover:

• In-patient care in a hospital

• In-patient care in a skilled nursing facility (not custodial or long-term care)

• Hospice care

• Home health care

• In-patient care in a religious nonmedical health care institution

You can find out if you have Part A by looking at your red, white and blue Medicare card. If you have it, it will be listed as “HOSPITAL” and will have an effective date. If you have Original Medicare, you’ll use this card to get your Medicare-covered services. If you join a Medicare health plan, in most cases, you must use the card from the plan to get your Medicare-covered services.

What do I pay for Part A-covered services?

Copayments, coinsurance, or deductibles may apply for each service. Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get specific cost information. TTY users can call 1-877-486-2048.

If you’re in a Medicare Advantage Plan or have other insurance – like a Medicare Supplement Insurance (Medigap) policy, or employer or union coverage – your copayments, coinsurance, or deductibles may be different.

Contact the plans you’re interested in to find out about the costs, or visit the Medicare Plan Finder at Medicare.gov/find-a-plan.

What does Part B cover?

Medicare Part B (medical insurance) helps cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, mental health services, and other medical services.

Part B also covers many preventive services.

Find out if you have Part B by looking at your red, white, and blue Medicare card. If you have it, it will be listed as “MEDICAL” and will have an effective date.  

To find out if Medicare covers a service, visit Medicare.gov/coverage, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

For more details about Medicare covered services, visit Medicare.gov/publications to view the booklet “Your Medicare Benefits.”

Call 1-800-MEDICARE to find out if a copy can be mailed to you.

What do I pay for Part B-covered services?

If you see doctors or providers who don’t accept assignment, you will pay more.

If you’re in a Medicare health plan or have other insurance, your costs may be different.

Contact your plan or benefits administrator directly to find out about the costs.

Under Original Medicare, if the Part B deductible ($183 in 2018) applies, you must pay all costs (up to the Medicare-approved amount) until you meet the yearly Part B deductible.

After your deductible is met, Medicare begins to pay its share and you typically pay 20 percent of the Medicare-approved amount of the service, if the doctor or other health care provider accepts assignment.

There’s no yearly limit for what you pay out-of-pocket.

Visit Medicare.gov, or call 1-800-MEDICARE to get specific cost information.

You pay nothing for most covered preventive services if you get the services from a doctor or other qualified health care provider who accepts assignment. However, for some preventive services, you may have to pay a deductible, coinsurance, or both. These costs may also apply if you get a preventive service in the same visit as a non-preventive service.

What’s NOT covered by Part A and Part B?

Medicare doesn’t cover everything. If you need certain services that aren’t covered under Medicare Part A or Part B, you’ll have to pay for them yourself unless:

• You have other coverage (including Medicaid) to cover the costs.

• You’re in a Medicare Advantage Plan that covers these services. Some of the items and services that Medicare doesn’t cover include most dental care, eye examinations related to prescribing glasses, dentures, cosmetic surgery, massage therapy, acupuncture, hearing aids and exams for fitting them, long-term care, and concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care).

How does Original Medicare work?

Original Medicare – managed by the federal government – is one of your health coverage choices as part of Medicare.

You’ll have Original Medicare unless you choose a Medicare Advantage Plan or other type of Medicare health plan.   

With Original Medicare you can go to any doctor, other health care provider, hospital, or other facility that’s enrolled in Medicare and accepting Medicare patients.

You generally have to pay a portion of the cost for each service covered by Original Medicare.

Visit Medicare.gov to search for and compare health care providers, hospitals, and facilities in Georgia.

Are prescription drugs covered?

With a few exceptions, most prescriptions aren’t covered, but you can add drug coverage by joining a Medicare Prescription Drug Plan (Part D).  

Members can buy a Medicare Supplement Insurance (Medigap) policy to cover costs Original Medicare doesn’t.

What are Medicare Advantage Plans?

A Medicare Advantage Plan – HMO, PPO, PFFS, SNPs, MSA – is another way to get your Medicare coverage. Sometimes called “Part C” or “MA Plans,” Advantage Plans are offered by Medicare-approved private companies that must follow rules set by Medicare.

If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan – not Original Medicare.

In most cases, you’ll need to use health care providers who participate in the plan’s network. Some plans offer out-of-network coverage. In most cases, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare.

Medicare Advantage Plans operate with a network of doctors, other health care providers, or hospitals.

There are six advantage types:

• Health Maintenance Organization (HMO)

• Preferred Provider Organization (PPO)  

• Private Fee-for-Service (PFFS)

• Special Needs Plans (SNPs)

• HMO Point-of-Service (HMOPOS) plans

• Medical Savings Account (MSA) Plans 

SNPs plans limit membership to specific groups like people who live in certain institutions like nursing homes, or who require nursing care at home, or who have specific chronic or disabling conditions like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia.

HMO Point-of-Service (HMOPOS) are HMO plans that may allow members to get some services out-of-network for a higher copayment or coinsurance.

Medical Savings Account (MSA) Plans combine a high deductible health plan with a bank account that the plan selects. The plan deposits money into the account (usually less than the deductible). Members can use the money to pay for health care services during the year. They don’t offer Medicare drug coverage.

For more information, visit Medicare.gov/find-a-plan.