The ins and outs of Medicare are confusing. And even when you’ve got the basics down, there are still specific questions you need answered. Here is a list of common questions and the answers you’re looking for. To learn about Medicare Basics, get our AGA Guide to Understanding Medicare.
Q: When can I enroll in Medicare?
A: You can sign up for Medicare Part A and/or Part B during a seven month window that includes the three months before the month you turn 65, the month of your birthday, and the three months after you turn 65. If you are receiving Social Security, you will automatically be signed up for Medicare Parts A and B starting the first day of the month you turn 65.
Q: Do I have to be on the same plan(s) as my spouse?
A: No. All Medicare plans are issued on an individual basis.
Q: Does Medicare cover long-term care?
A: Most long-term care isn’t medical care, but rather help with basic personal tasks of everyday life, sometimes called “activities of daily living” or “custodial care.” Medicare does not cover long-term care, if that’s the only care you need.
Medicare does cover:
• Care in a long-term care hospital
• Some skilled nursing care in a skilled nursing facility • Eligible home health services
• Hospice and respite care
Q: Does Medicare cover nursing homes?
A: Medicare Part A only covers skilled care given in a certified nursing facility for individuals who meet certain conditions. To learn more, visit www.medicare.gov and search “Medicare Coverage of Skilled Nursing Care.”
Q: Why would someone opt to buy a Medicare Advantage Plan over getting Medicare Part A and Medicare Part B?
A: When it comes to Medicare, the decision is yours. However, you may want to get a Medicare Advantage Plan instead of Original Medicare if:
- You take prescription drugs. With a few exceptions, most prescriptions aren’t covered in Original Medicare. Many Medicare Advantage Plans include prescription drug coverage.
- You want to cap your out-of-pocket health spending. Original Medicare has no out-of-pocket maximum. You keep paying a portion of the cost of services as you use them. Medicare Advantage plans, by law, have an out-of-pocket maximum of $6,700 per year. Once you hit that limit, the plan pays for all covered expenses.
- You want an alternative to the 20 percent coinsurance charged by Original Medicare Part B.
- You want coverage for vision and dental. Original Medicare doesn’t cover these services. Certain Medicare Advantage Plans do.
Q: What factors make a difference when deciding between a Medicare Advantage (Part C) HMO and PPO?
A: Medicare Advantage Health Maintenance Organization (HMO) plans allow you to choose from a network of contracted doctors. You’ll choose a primary care physician from the plan network and be referred to specialists within the plan network if you need additional care.
HMO highlights:
- Lower out-of-pocket expenses
- Must go to doctors in-network
- May include Prescription Drug Plan
Many retirees and seniors seek out HMO coverage because of the cost savings.
Medicare Advantage Preferred Provider Organizations (PPO) plans offer care within a network of physicians and hospitals. Unlike with an HMO plan, you can also see providers outside of the network of physicians and hospitals, but you’ll pay more out of pocket.
PPO highlights:
- Can stay in-network or go out-of-network to see doctors
- Monthly premiums potentially higher than Medicare Advantage HMO plans • Out-of-network costs potentially higher than staying in-network
- May include Prescription Drug Plan
Q: How do Prescription Drug Plans (Medicare Part D) differ?
A: Each Part D plan has its own formulary, or list of covered generic and brand-name drugs.
All plans must cover certain categories of drugs, but the drugs covered in each category may differ by carrier. Part D Plans also set their own monthly premiums, so the costs may also differ by carrier.
Q: How do I know whether or not it’s better to get a Medicare Advantage Plan, or Original Medicare with a Medicare Supplement Plan?
A: Everyone’s healthcare needs are different. To find the right plan for you, it’s best to reach out to licensed plan representatives for more information.
Q: How do Medicare Supplement/Medigap plans differ from each other? Is it in price only?
A: Medicare Supplement/Medigap plans (Letters A-N) offer different levels of coverage, but each lettered plan includes the same coverage regardless of carrier and location. What differs is the price based on the carrier. Some Medicare Supplement Plans also offer cov-erage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S.
Q: Where can I find out more information?
A: You can download our AGA Guide to Understanding Medicare here, or you can visit the government’s web site, Medicare.gov.
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