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Medicare

The Area Agency on Aging understands the intricacies of Medicare, and we’re always ready to share our knowledge with you. This pages contains basic information about Medicare, but we encourage you to call us at 937-223-HELP and speak to one of our experts.

Medicare is health insurance for the following:

  • People age 65 and older.
  • People under age 65 with certain disabilities.
  • People of any age with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.

There are four different parts of Medicare to help cover specific services:

  • Part A – Hospital Insurance
  • Part B – Medical Insurance
  • Part C – Medicare Advantage Plans (like an HMO or PPO)
  • Part D – Medicare Prescription Drug Coverage

Visit www.MyMedicare.gov to view the current Medicare and You handbook.
You can also sign up to receive future handbooks electronically.

Medicare Coverage Choices

You can choose how you get your health and prescription drug coverage under Medicare.

Original Medicare

  • Run by the Federal Government.
  • Provides Part A and/or Part B coverage.
  • You can go to any doctor or hospital that accepts Medicare.
  • You can join a Medicare Prescription Drug Plan to add drug coverage.
  • You can buy a Medigap policy (Medicare Supplement Insurance sold by private insurance companies) to help fill the gaps in Part A and Part B.

Medicare Advantage Plans (like an HMO or PPO)

  • Run by private insurance companies approved by and under contract with Medicare.
  • Provides your Part A and Part B coverage but can charge different amounts for certain services. Many offer extra coverage and prescription drug coverage, sometimes for an extra cost. Cost for items and services vary by plan.
  • If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of plan.
  • If you want drug coverage, you must get it through your plan (in most cases).
  • You don’t need and you can’t use a Medigap policy with a Medicare Advantage Plan.

Medicare Part A - Hospital Coverage

Part A helps cover the following hospital expenses:

  • Inpatient hospital care,
  • Some skilled nursing facility care,
  • Hospice care, and
  • Some home health care.

If you have a chronic illness or disability, Medicare pays only a small portion of the long-term care you may need in a nursing facility or at home. It does not cover personal or custodial care.

You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working. If you are not eligible for premium-free Part A, you may be able to buy coverage, but in most cases you must also have Part B and pay monthly premiums for both. If you have limited income and resources, there may be help available to pay for Part A and/or Part B expenses.

Medicare Part B - Medical Coverage

There are two kinds of Part B covered services:

  • Medically-necessary services – services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive services – Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best. Examples include pap tests, flu shots, and colorectal cancer screenings.

A list of common services covered under Medicare Part B (both medically-necessary and preventive) is available in the annual Medicare and You handbook.

Costs for Part B services depend on whether you have Original Medicare or are in a Medicare Health Plan. If you choose to enroll in Part B, you pay a monthly premium and an annual deductible. If you have limited income and resources, there may be help available for Part B expenses.

If the Part B deductible applies, you must pay all costs until you meet the yearly Part B deductible before Medicare begins to pay its share. After your deductible is met, you typically pay 20% of the Medicare-approved amount of the service.

Medicare Part C - Medicare Advantage Plans

A Medicare Advantage Plan (like an HMO or PPO) is an alternative to having Medicare Part A and Part B. They are offered by private companies approved by Medicare and provide all hospital and medical coverage. They are not considered supplemental plans.

Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care, and may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Original Medicare covers hospice care even if you are in a Medicare Advantage Plan. Most include Medicare prescription drug coverage.

Not all Medicare Advantage Plans work the same way, so before you join, find out:

  • The plan’s rules and limitations,
  • What your costs will be, and
  • Whether the plan will meet your needs.

Medicare Part D - Prescription Drug Coverage

Medicare offers prescription drug coverage to everyone with Medicare Part A and Part B. To get drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.

You can join, switch, or drop a Medicare drug plan at any of the following times:

  • When first eligible for Medicare – the 7-month period beginning 3 months before the month you turn age 65, including the month you turn 65, and ending 3 months after the month you turn 65.  If you choose to enroll after your initial eligibility period, you may pay a penalty for late enrollment.
  • Annual Open Enrollment – October 15 through December 7.  Your coverage will begin on January 1 of the following year.  Plans can change, and it is important to review your plan each year during open enrollment to be sure it continues to be the best plan for you. For help comparing plan costs, visit www.medicare.gov and select “Compare Drug and Health Plans.”
  • Special Enrollment Periods – when certain events happen in your life, such as if you move or you lose other insurance coverage.

Exact coverage and costs are different for each Medicare drug plan, but all plans must provide at least a standard level of coverage set by Medicare.

If you have limited income and resources, there may be help available to pay for Part A and/or Part B expenses.

Medicare Part A and B - Medicare Savings Plans

People with limited income and resources may qualify for help paying Medicare premiums, deductibles, and copayments. The income and resource limits change annually, so contact us for current eligibility guidelines and information on the application process.

Extra Help with Medicare Prescription Drug Coverage

People with limited income and resources may qualify for Extra Help, also called the low-income subsidy (LIS), to pay prescription drug costs. The income and resource limits change annually, so contact our Information & Assistance Staff for current eligibility guidelines and information on the application process.

If you qualify for Extra Help and join a Medicare drug plan, you will get the following:

Help paying your Medicare drug plan’s monthly premium.
Help paying any yearly deductible.
Help paying coinsurance and copayments.
No coverage gap.
No late enrollment penalty.

You automatically qualify for Extra Help if you have Medicare and meet one of these conditions:

You have full Medicaid coverage.
You get help from your state Medicaid program paying your Part B premiums.
You get Supplemental Security Income (SSI) benefits.

Medicare will mail you a purple letter to let you know that you automatically qualify for Extra Help. You do not need to apply for Extra Help if you get this letter.

You can apply for Extra Help at any time.

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