Medicare Overview

Medicare provides health coverage to over 49 million people who are age 65 and older, under age 65 with certain disabilities, and people of any age with End-Stage Renal Disease (ESRD). Beneficiaries enroll in Medicare by calling Social Security (800.772.1213), by visiting ssa.gov or their local Social Security office. If they don't enroll on time, they may pay late enrollment penalties and their healthcare expenses may not be covered.
There are four parts to Medicare:
Part A - Hospital coverage
Part B - Medical coverage
Part C - Medicare Advantage
Part D - Prescription drug coverage

When Should Clients Enroll in Medicare?

Have your clients sign up early to avoid a delay in getting coverage for Part B services. In order to get their Part B coverage the month they turn 65, they must sign up during the first three months before they turn 65. If they wait until the last four months of their Initial Enrollment Period to sign up for Part B, their start date for coverage will be delayed.

Dual Special Needs beneficiaries are those who are entitled to both Medicaid and Medicare services. They must meet certain criteria to be eligible for both, and requirements vary by state.​

There are two ways to get Medicare.

Original Medicare
Operated by the Federal government. Medicare pays fees for your care directly to your doctors/providers.
Part A
Pays for part of your hospital costs.

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Part B
Pays for your doctor and outpatient care.

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Part D (+ Medicare Supplement)
Stand-alone prescription drug plans can be added to help with the cost of prescription drugs.
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Medicare Advantage (Part C)
Plans are private health plans that contract with Medicare.
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PPO-HMO-PFFS-SNP
Medicare pays a fixed fee to the plan for your care at the doctor and hospital. The plan pays the doctor and hospital directly. 
Part D
Prescription drug coverage can be part of these plans. A PFFS plan is the only plan that can add drug coverage (separate) to the plan.
Additional Benefits
Often included, such as dental and vision, and nurse help lines. Most plans have a cap on out of pocket expenses.

Medicare Supplements vs. Medicare Advantage

Medicare Supplement

Medicare Advantage
Choice of doctors
Any doctor who accepts Medicare.
Any doctor in the plan's network.
referrals
Policy holder can see any specialists who accept Medicare.
May need a referral but can also see any specialists in the plan's network.
Coverage while travelling
Policy holders are covered when traveling domestically, and Plans F, G and N cover travel abroad.
Emergency and urgent services are covered domestically and abroad.
prescriptions
Prescription drug plans are separate.
Many plans include drug coverage.
Dental & vision
Separate Dental, Vision and Hearing plans provide optional coverage.
Most plans include Dental, Vision and Hearing.
plan cancellation
Plans cannot be cancelled as long as the policy holder pays their premiums.
Plans can change, but most plans renew each year.
co-pays & co-insurance
Co-pays and co-insurance depend upon the plan.
Co-pays and co-insurance depend upon the plan.
premiums
There is a monthly premium in addition to the Part B premium.
Most plans have a low or $0 monthly premium, along with the Part B premium.
benefits
  • Plans are standardized which makes comparing plans simple
  • Can change a Medicare Supplement plan at any time (may be subject to medical underwriting)
  • Makes budgeting easy, know out of pocket medical costs for the year
  • Guaranteed renewal-pay premium and plan will continue
  • Rates don’t increase with age
  • No medical underwriting required to join, and pre-existing conditions are covered
  • A set maximum out of pocket limit to cap medical costs for the year
  • Fitness memberships, transportation and other benefits are often included

​Deductible and Co-insurance Amounts for 2021

Type of Cost Sharing
2020
2021
Part A Hospital Inpatient
​Deductible for each benefit period
$1408
$1484
Hospitalization Days 61 - 90
​Co-insurance per day of each benefit period
$352
$371
Hospitalization Days 91 and beyond
​Co-insurance per each "lifetime reserve" day after day 90 for each benefit period (up to 60 days over your lifetime)
$704
$742
Skilled Nursing Facility Care
Co-insurance per day of each benefit period (21 - 100 days)
$176
$185.50
Part B Deductible
​Calendar year deductible for Medicare approved amounts for covered services
$198
$203
Standard Monthly premium for Medicare Part B enrollees
$144.60
$148.50
High Deductible Plans F & G
(plans purchased prior to 2010)
$2340
$2370
Out of Pocket Limit Plan K
$5580
$6220
Out of Pocket Limit Plan L
$2940
$3110

Medicare Resources

Two Open Enrollment Periods

October 15th - December 7th
Medicare Open Enrollment Period

  • Change from Original Medicare to a Medicare Advantage plan (or vice versa)
  • Switch from one Medicare Advantage plan to another Medicare Advantage plan
  • Switch from a Medicare Advantage plan that doesn't have drug coverage to one that does offer drug coverage (or vice versa)
  • Join a Medicare Prescription Drug Plan (PDP)
  • Switch from one Prescription Drug Plan (PDP) to another PDP
  • Drop Medicare Prescription Drug coverage completely

January 1st - March 31st
​Medicare Advantage Open Enrollment Period

  • If your client is in a Medicare Advantage Plan (with or without drug coverage), they can switch to another Medicare Advantage Plan (with or without drug coverage).
  • They can disenroll from their Medicare Advantage Plan and return to Original Medicare. If they choose to do so, they'’ll be able to join a Medicare Prescription Drug Plan.
  • If they enrolled in a Medicare Advantage Plan during their Initial Enrollment Period, they can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without drug coverage) within the first 3 months they have Medicare.
Source: CMS.gov

The Differences Between Open Enrollment & Guaranteed Issue >