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How to Understand Medicare Plans

Medicare on chalkboard
Just the essentials...
  • Medicare offers Original Medicare for hospital and medical coverage
  • Medicare offers Medicare Advantage plans for hospital and medical coverage
  • Medicare offers Prescription Drug plans
  • Medicare has gap insurance to cover coinsurance and copays
  • Original Medicare is a fixed-fee-for-services plan

Medicare plans are not easy to understand. Medicare is not as simple as the Obamacare Marketplace. One can go there find a plan and review many others for comparison. The marketplace aids every step of the way from signing up to signing on to a health plan.

Medicare leaves far more to the individual, and the results can sometimes reflect confusion and missed opportunities. Medicare offers some dramatic choices, and the first is between government-run or private insurance plans.

To find the best Medicare coverage for you, enter your zip above in our free search tool and get multiple private insurer quotes!

Original Medicare is a Large Network

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Medicare Part A is hospital insurance that focuses on inpatient treatment and resources. Medicare Part B is medical insurance concerned with outpatient medical care. There are thousands of doctors and hospitals in the Original Medicare network.

The CMS manages the fixed price style of managed care by setting prices and enlisting more doctors and hospitals to increase available services and meet the needs of a growing and diverse population of older Americans.

Original Medicare operates like a fixed-fee-for-services plan. The CMS uses a large number of support organizations including functional contractors to manage the system.

Original Medicare System

Original Medicare is a government-run plan. The Centers for Medicare and Medicaid operate Original Medicare through a system of contractors. Called MACs and Carriers, these companies handle payments, billings, and maintenance of the system. The CMS exercises oversight and approves each private insurance plan sold through Medicare.

The CMS system is a nationwide program involving more than $300 billion in payments.

Contractors work closely with medical service providers to answer questions, handle payments, and resolve disputes.

Penalties for Lateness

Medicare penalizes individuals that do not exercise their option when first available. For example, persons that take Part A and delay taking Part B will pay a fine later.

Medicare will levy a fine that the applicant must pay in every monthly premium payment. Applicants can avoid the fine by taking Part B when first available during the initial eligibility period.

Medicare Advantage Managed Care

A person getting their blood pressure taken

Medicare Advantage consists of private insurance plans that meet or exceed the coverage of Medicare Parts A and B or Original Medicare. The Congress enacted Medicare Part C, the Medicare Advantage, to offer participants the energy and variety of the private insurance business as an alternative to the government-run Original Medicare. The below-listed items describe the types of managed care in Medicare Advantage plans.

HMO is the health maintenance organization. It focuses on prevention and wellness in addition to keeping prices low with simple operations. The HMO uses a primary care physician to provide care and referrals to network resources and specialists.

PPO is the preferred provider organization. This type of managed care does not use a primary care doctor. Clients can use any doctor or hospital in the network. They can also use services from providers that are outside of the network. The PPO covers outside resources but at a much lower rate of cost sharing than with network resources.

EPO is the exclusive provider organization. This simple structure gets costs savings by using a network with no primary care physician. Clients choose their doctors and hospitals as they wish. The EPO does not support outside resources. It offers no cost sharing for outside specialists and medical service providers.

HMOPOS is a variation on the HMO that uses a primary care physician to provide services and referrals to network resources. The point of sale option permits the primary care physician to refer clients to outside specialist with costs sharing from the insurer.

PFFS is the private fee-for-services organization. This type of organization can stand alone as a closed network that does not use a primary care physician. It can also connect to other organizations to expand geography and resources. For example, the federal Office of Personnel Management uses this form to connect federal employee groups with regional HMO and PPO networks

Medicare Advantage and Prescription Drug Benefits

Medicare Advantage programs can combine Part D Prescription Drugs into the coverage options for consumers. The advantages of such a combination are strong.

The customer can have nearly all their Medicare needs filled by one plan. The costs may be lower than the average costs of Part B premiums added to Part D premiums. The system notes the Medicare Advantage plans with the drug coverage as MA-PD.

Prescription Drug Conflicting Choices

Stethoscope with clipboard and pills on desk

It is possible for a consumer to wind up with a double drug plan. For example, it could be Medicare Advantage Plan with a prescription drug benefit and a Part D plan for prescription drugs. When this occurs, Medicare rules automatically cancel the Medicare Advantage program and return the consumer to Original Medicare.

Medicare does this to protect the consumer against overselling. It also does this to protect the system against billing faults if two programs cover the same transactions.

Alternative and Demonstration Health Insurance plans

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Understanding Medicare plans include the arrangements that add opportunities for choices and savings for consumers. These include the below-described variations that expand customer service and consumer choices.

  • Medicare Medical Savings Account is a plan that uses High Deductible Health Plans and a savings account to pay for expenses. The plan deposits funds into an account for expenses.
  • PACE is an all-inclusive program that helps people stay as independent as possible through a network of support services. Pace requires Medicare and Medicaid and eligibility in an area served by a PACE organization. PACE services include detailed levels of support for persons that might otherwise need a nursing home.
  • Medicare Costs Programs offer low-cost alternatives to Medicare Advantage with greater freedom for using outside resources.
  • Demonstration Projects can come to a given area from time to time as the CMS tries new methods for improved payments, service delivery, and customer selections.

PACE Model for All-Inclusive Plans

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The all-inclusive PACE program delivers services through teams of specialists as well as medical professionals. The system provides total care for patients that could not otherwise maintain independent lifestyles and would need nursing home care.

The program scales payment for PACE premiums for long-term care and medical insurance to the user’s ability to pay. Medicaid pays for the program for many users, and some users purchase the plan privately.

PACE delivers medical care and medical support services through a primary care facility, a physician, hospital, lab and x-rays, and medical specialties.

PACE provides health maintenance services including preventive care, nutritional counseling, and wellness services.

PACE team includes psychological support, therapeutic counseling, and related service disciplines including a social worker, and physical therapy.

The program supplies meals, transportation to PACE activity center, and medical transportation for non-emergency treatment.

PACE provides a prescription drug benefit that includes prescription drugs needed for care. Consumers cannot use PACE along with a Part D drug plan; the conflict would cause automatic cancellation of the PACE program membership.

MSAs: The Consumer-Driven Model

Social Security cards and money

Medical Savings Accounts can match plans with low premium plans that have very high deductibles, high rates of copays, and low rates of coinsurance. The Medical Savings Account program puts money into a designated bank account for the customer’s usage.

These funds must cover out-of-pocket expenses until the customer reaches the limit. The customer must pay any shortfall until he or she reached the limit. Once at the out-of-pocket limit, the insurance covers all expenses for essential benefits.

Medicare Costs Plans

Members can join these Medicare Costs Plans only in areas in which they are available. They can accept persons with Parts A and B or with Part B only.

These plans offer low prices like an HMO, but use of outside resources. When going outside, members pay the rates the prevail in Original Medicare including copays and coinsurance.

Advantages of Medicare Costs Plans

Medicare costs plans have no limits on enrollment periods and can accept members at any time. Enrollees have the advantage of leaving or joining when they are available, and the automatic return rules take members to Original Medicare. Medicare costs programs offer innovations and savings opportunities for consumers.

Medication Therapy Management Programs

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These free programs track prescription medications and provide information on the medicinal benefits. They can summarize drugs and the overall pattern and interaction of the medications.

This is an information rich program that comes without charge to participants in Part D Prescription Drug plans. These innovative studies can lead to remarkable breakthroughs in managed care.

Understanding Medicare Part D Prescription Drug Plans

Clients can get prescription drug coverage in two ways. They can get them directly in a stand-alone prescription drug plan, or in combination with other plans such as Medicare Advantage plans, a Medicare Savings Account, or a Medicare Costs Plan.

The Importance of Prescription Drug Coverage

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Prescription drugs are a vital component of modern medical care in the US. Doctors use powerful drugs to maintain conditions and to fight debilitating pain. Many drugs have unique positions as one or one of few effective medications for a widespread set of conditions.

Generic drugs help bring down the costs of medications, but some generic drugs are also on the higher tiers, the expensive end of the scale. Prescription drug benefits in Medicare help reduce the burden of costly drugs on older Americans, particularly those on fixed and limited incomes.

Part D Drug Plans

Medicare Part D is insurance that covers the costs of prescription drugs. These plans are private insurance plans approved by the Centers for Medicare and Medicaid. The Customer can choose among the levels of premium prices, deductibles, coinsurance, and copays.

There is still an area of prescription drug spending in which consumers lose price protection. Called ”the donut hole”, the Affordable Care Act made changes that have reduced the impact and will erase it in the next two years. Persons that apply more than six months after they become eligible may face a late enrollment penalty.

Drug Tiers and Formularies

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The CMS reviews and approves prescription drug plans. They must submit detailed and current formularies of the drugs covered by the plan. The consumer must know in advance whether the plan covers the drugs they use or will use. Consumers also need to know whether there are restrictions on the drugs they need.

Some plans limit the number of an item by price or require some extra steps such a permissions or pre-approvals. It is important for the consumer to know of any rules or availability issues with respect to the drugs they need.

Medicare Supplement or Medigap

Medicare Supplement is not a plan by itself, but it makes other parts of Medicare work more favorably towards cost-conscious consumers. Medigap insurance covers the part of Original Medicare left uncovered by cost sharing. When Original Medicare covers outpatient services, the typical rate of cost sharing in Part B leaves about twenty percent unpaid, and that is the customer’s responsibility. Medigap insurance covers that gap.

Understanding Medigap Eligibility

Eligible written on chalkboard

The best time to buy Medicare Supplement is during the six-month period after one gets both Medicare Part A and Part B. There is an advantage when signing up during this initial eligibility period. The seller can neither turn the applicant down nor use medical underwriting to delay entry into the program.

Outside of the initial eligibility period, sellers of Medigap can base the sale and price on health factors and can decide not to offer to certain applicants.

Understanding Medicare Plans is Not Easy

Medicare enrollment form

Medicare plans are complicated. The system grew from separate laws, and they we enacted over a period of years. The best way to understand may be to look at the big choices.

One must choose original Medicare or Medicare Advantage. If one chooses original Medicare then one must get drug coverage, a gap insurance, and possibly add Medicaid. The Medicare Advantage is private insurance. Comparison shopping will help find the best fit.

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MedicareInsurance.com is privately owned and operated. MedicareInsurance.com is a non-government asset for people on Medicare, providing resources in easy to understand format. The government Medicare site is www.medicare.gov.

This website and its contents are for informational purposes only and should not be a substitute for experienced medical advice. We recommend consulting with your medical provider regarding diagnosis or treatment, including choices about changes to medication, treatments, diets, daily routines, or exercise.

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MULTIPLAN_GHHK5LLEN_Accepted Last Updated 3/18/2018