Medicare Plans

 For many seniors, the two biggest concerns they have are retirement income and health insurance coverage; especially retirees on a fixed income.  The older they get, the more they begin to use the benefits and services that their health plan provides.   

Original Medicare is an 80/20 plan.  Medicare pays 80% whereas the Medicare beneficiary pays the deductible and the remaining 20%.  This may become quite costly, especially when there is also no out-of-pocket max to safeguard them from the maximum financial risk in each calendar year, worst-case scenario.  

Fortunately, there are additional plan options available to help offset the portion that Original Medicare does not pay for. 

Medicare is a federally funded health insurance program for:
 

a.  People age 65 or older

• Or people with certain disabilities, receiving Social Security Disability Insurance (SSDI) for at least 24 months
• Or people with End-Stage Renal Disease

                    And...
b.  People who have lived in the US for at least 5 consecutive years as legal residents or citizens.

                   And...

c.  People (or their spouse) who have worked in the US, paying into Medicare and Social Security for at minimum, 40 quarters (equivalent to 10 years.)  

Part A  (Hospital Insurance) - generally $0/month for those who qualify

*Once deductible of about $1,400 (per benefit period) is met, Part A will pay 80%.  Medicare Beneficiary is responsible for 20%.  There is no out-of-pocket max.

-Hospital stays

-Home health services (following an acute stay)

-Hospice care

-Skilled nursing care

-Transplants

Part B (Medical Insurance)- currently $148.50/month in 2021

*Once deductible of about $200 (per calendar year) is met, Part B will pay 80%. Medicare Beneficiary is responsible for 20%.  There is no out-of-pocket max.

-Doctor/specialist visits

-Home health services (not following an acute stay)

-Ambulance services

-Outpatient physical, speech, and occupational therapy

-Outpatient surgeries

-Durable medical equipment

-X-rays & bloodwork

-Diagnostic testing

-MRI/CT scans

-Preventative Services

1.  STEP 1 (Apply for Medicare through Social Security Administration):

2.  STEP 2 (Apply manually through Private Insurance Companies):

OPTION 1:  

a. Medicare Supplement (Medigap) 

Private insurance plans that are secondary to Medicare and pay the deductible and 20% that Original Medicare does not cover.  Medigap plans have a premium that ranges between$100-$400/month.  This premium is in addition to the monthly Medicare Part B premium. 

Plans A, B, C, N, G, F, etc. are options available (don't be confused by Plan vs Part.)

Most Medigap plans exclude long-term care, vision, dental care, hearing aids, eyeglasses, or private-duty nursing, etc.

              Plus...

b. Part D (Rx Drug Coverage)

A stand-alone Prescription Drug Plan to help pay for medication costs in the form of copays.  These plans vary between $7-80/month.  There are over 30 plans to choose from in LA/OC.

• Each plan offers its own formulary (list of covered medications)
• Copays vary based on brand vs. generic medications & drug Tiers 1-6

OPTION 2:  

Part C-  Medicare Advantage HMO/PPO 

Part A + Part B + Part D + additional benefits = Part C

On Original Medicare, Medicare takes on 80% of the risk for every claim on a service/benefit.  With Medicare Advantage plans, instead of Medicare taking on that risk, it is transferred to an insurance company.  Medicare pays the insurance company chosen on a monthly basis and that insurance company is responsible to pay 100% of the member's claims.  The insurance company that is chosen by the Medicare Beneficiary then takes the monthly funding that Medicare gives them and creates a variety of plan options to offer.  There are over 50 plans to choose from in LA/OC and are generally $0/month.  The plans are regulated by Medicare and have to cover, at the very least, everything that Medicare Part A + B covers but oftentimes, they use some of the funding to provide additional benefits that Medicare does not cover such as:

• Prescription drug coverage
• Dental
• Vision allowance
• Hearing aid allowance
• Fitness program
• Acupuncture/Chiropractic care
• Over-the-Counter allowance
• Transportation
• Grocery allowance

(These plans are all offered through private insurance companies.)


A Medigap/Supplement Plan is different from a Medicare Advantage Plan.  Medicare Beneficiaries cannot have a Medigap/Supplement Plan simultaneously with a Medicare Advantage Plan. 

For additional information, click here.