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By: Kimberly Ramseur, Staff Writer

With all the talk about health care financing, it is easy to get confused and overwhelmed with all the information being disseminated. If an individual falls under one of the following, he or she may be eligible for Medicare, a national health insurance program administered by the Center for Medicare and Medicaid Services (CMS):

  • 65 years or older;
  • Living with a disability, entitled to SSDI benefits for 24 months without a waiting period or;
  • Have end-stage renal disease (ESRD)

Medicare is made up of four parts: A, B, C, D

Part A (Hospital Insurance) helps cover:

  • Inpatient care in hospitals;
  • Care at skilled nursing facilities (SNF);
  • Hospice care;
  • Home health care;
  • Blood

 

Part B (Medical Insurance) helps cover:

  • Services from health care providers;
  • Outpatient care;
  • Home health care;
  • Durable medical equipment (DME);
  • Preventive services

 

Part C (Medicare Advantage) CMS works with other insurance companies to administer Medicare benefits via:

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Special Needs Plan (SNP)

 

Part D (Prescription Drug) helps cover:

  • Cost of prescription drugs (drugs administered in the doctor鈥檚 office are covered by Part B)

 

Original Medicare v. Medicare Advantage

Medicare benefits are administered in two ways, Original Medicare and Medicare Advantage.

Original Medicare聽includes Part A (hospital insurance) and/or Part B (medical insurance). To help pay out-of-pocket costs in Original Medicare (such as deductible and 20 percent coinsurance), individuals can shop for and buy supplemental coverage, otherwise known as a Medigap plan. Patients can also choose to buy Medicare prescription drug coverage (Part D) from a Medicare Prescription Drug Plan (PDP).

Medicare Advantage聽(MA) plans provide coverage via care organizations such as a health maintenance organization (HMO) or a preferred provider organization (PPO), which covers Part A and Part B services and supplies. They also may include Medicare prescription drug coverage (MA-PD).

Medigap policies do not work with MA plans. If a patient plans to join an MA plan, the patient can鈥檛 use a Medigap policy to pay for out-of-pocket expenses.

In addition to Original Medicare and Medicare Advantage coverage options, patients may also be able to join other types of Medicare health plans like Medicare Cost Plans or Programs of All-inclusive Care for the Elderly (PACE) or get certain services through demonstrations and pilot programs.

Medicare Supplement Plans (Medigap)

Medicare Supplement Insurance (Medigap) policies health plans sold by private insurance companies to fill gaps in Original Medicare. Medigap policies can help cover some out-of-pocket expenses for Medicare covered services, such as coinsurance, copayments or deductibles, which also cover various benefits not covered under Original Medicare.

Since each plan varies in what benefits they offer, it鈥檚 extremely important to always compare policies. Each company decides which Medigap plan it will offer and the price for each plan, with state review and approval. Some of the factors that plans take into account when developing a policy include, pre-existing conditions waiting period, crossover of claims from Medicare Administrative Contractor to Medigap policy, guarantee issue and others.

Enrollment

There are specific times designated for potential enrollees to apply for Medicare coverage benefits. The Social Security Administration (SSA) is responsible for enrolling most people in Medicare, however

Once someone is eligible to apply for Medicare, it is ideal to sign up first during the Initial Enrollment Period (IEP). This period may vary depending on birthday, but the length of time to enroll remains the same 鈥 seven months.

This seven-month period starts three months prior to an individual鈥檚 65th聽birthday, the actual birth month and the three months directly after the birth month. This period allows them the ability to select a plan along with any qualifying add-ons needs. If someone is unable to apply during the IEP, there are other opportunities to subsequently apply.

For more information on Medicare plans, eligibility, and enrollment, check out medicare.gov or contact at (202) 675-6984

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