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If there is a carrier that we are not appointed to and we have the perfect plan for you as a client; contact the 1-888-306-3070, the Inshura Medicare Referral Program and an agent will assist. Provide them Agent Garrick Hines name and referral code GH9192.
Medicare Basics
- Medicare is the Federal health insurance program for individuals who are aged (65 and over) and younger individuals who are disabled.
- Medicare eligibility does not take into consideration an individual’s income. However,
- individuals may pay higher premiums based on income, and
- low-income individuals may be eligible for additional assistance.
- Individuals can receive their Medicare medical coverage:
- directly from the Federal Government, which pays for services on a fee-for-service basis (this program is known as “Original Medicare” or “Fee-for-Service Medicare”); or through a private health plan.
- Individuals must receive their Medicare Part D outpatient drug benefits through a private health plan (even if they get their medical coverage through Original Medicare).
Medicare Background
- Medicare began as a fee-for-service program (now referred to as “Original Medicare”) under which beneficiaries could receive their health care benefits from any Medicare provider and have the provider paid directly by the Federal government.
- Medicare evolved to give beneficiaries the option of receiving their benefits and care through managed care plans that maintained contracts with networks of providers.
- Beginning in 2006, Medicare began providing coverage for outpatient prescription drugs, such coverage is only available through private health plans.
Overview of Medicare Benefits and Coverage -- Parts A, B, C, and D
- Medicare coverage is often known by the part of Medicare law under which it is authorized or regulated
- Part A is referred to as “Hospital Insurance Benefits.” Part A also covers other inpatient care, including skilled nursing facilities, rehabilitation facilities, and hospice.
- Part B is referred to as “Supplementary Medical Insurance Benefits.” Part B covers a broad range of outpatient services such as physician care, and drugs that are administered by physicians or other health care professionals (such as vaccines and intravenous medications).
- Part C regulates and authorizes Medicare Advantage plans, which must cover Part A (except for hospice) and Part B benefits.
- Individuals enrolled in a Part C plan still get hospice benefits, but they are paid for by Original Medicare.
- Part D covers prescription drug benefits (for self-administered drugs, such as those picked up at a pharmacy and taken at home) and regulates Medicare prescription drug plans
Overview of Medicare – Part E
- There is also a lesser-known Part E of Medicare law that regulates other miscellaneous programs including:
- Medicare cost plans (which also cover Part A and Part B benefits) Medicare cost plans are only offered in a limited number of states and are most frequently found in rural areas.
- Medicare supplemental insurance (Medigap Plans)
- The program for all-inclusive care for the elderly (PACE)
Parts A and B After the Initial Enrollment Period
- Individuals who do not enroll in Part B (or Part A if they have to buy it) when they are first eligible, can enroll during a General Enrollment Period each year from January 1 – March 31.
- Prior to January 1, 2023, coverage begins on July 1 of the year they enroll.
- On or after January 1, 2023, coverage begins the first day of the month following the month in which the beneficiary enrolls.
- Individuals who have group health plan coverage based on their current employment or the employment of a spouse may enroll in Part A (if they have to buy it) and/or Part B anytime while covered under the group health plan or during a Special Enrollment Period that occurs during the 8-month period immediately following the last month they have group coverage.
- Beginning January 1, 2023, the Secretary may establish special enrollment periods in the case of individuals who are entitled to Part A, have attained age 65, meet residency requirements and meet such exceptional conditions as the Secretary of HHS specifies.
Help for Individuals with Limited Income/Resources
- Beneficiaries may qualify for help to pay the Medicare Part A (if any) and Part B premium, the Part A and Part B deductibles and cost-sharing, and/or some Part D prescription drug costs.
- Beneficiaries may qualify for the following programs by applying to the State Medicaid office:
- Medicare Savings Program: help paying for the Medicare Part A and Part B premiums and, in some cases, deductibles and cost-sharing.
- The “Qualified Medicare Beneficiary” program is one type of Medicare Savings Program. Qualified Medicare Beneficiaries enrolled in Medicare Advantage plans also get help with their Medicare Advantage cost-sharing amounts.
- Part D low-income subsidy (also known as “Extra Help”): help to pay for prescription drug coverage. Persons interested in Part D help only may also call the Social Security Administration (SSA) at 1-800-772-1213 or apply online at www.ssa.gov/prescriptionhelp. Extra help isn’t available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa.
- Persons who do not qualify for the Part D low-income subsidy but are of limited means may qualify for help in paying Part D drug costs through a State’s Pharmaceutical Assistance Program.
- Medicaid: help with health care costs not covered by Medicare, such as custodial/long term care.
Medicare Part A Benefits
- Part A provides coverage for:
- Inpatient hospital care (including care provided by acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
- Skilled nursing and rehabilitation care, but only after a three-day hospital stay (Medicare Advantage plans may waive the 3-day stay requirement)
- Blood
- Hospice care
- Up to 100 days of home health care after an individual is in a hospital or skilled nursing facility (SNF)
- Inpatient psychiatric care (up to 190 lifetime days) 31. Medicare Part A – Original Medicare Cost-Sharing for Inpatient Hospital Care In 2022, beneficiaries pay the following amounts for inpatient hospital care covered under Original Medicare:
- $1,556 deductible for each benefit period
- A benefit period begins the day an individual is admitted to a hospital or skilled nursing facility (SNF) and ends when an individual has not received hospital or SNF care for 60 days in a row.
- Days 1–60: $0 coinsurance for each benefit period
- Days 61–90: $389 coinsurance per day of each benefit period
- Days 91 and beyond: $778 coinsurance per each "lifetime reserve day" after day 90 for each benefit period
- Lifetime reserve days are days a beneficiary may use after they have been in an inpatient hospital for 90 days. A beneficiary has 60 such days to use in their lifetime.
- Beyond lifetime reserve days: all costs
- Medicare Part A – Original Medicare Cost-Sharing for Skilled Nursing and Rehabilitative Care In 2022 beneficiaries pay the following amounts for skilled nursing and rehabilitative care covered under Original Medicare:
- Days 1-20: $0 for each benefit period (as defined by Medicare)
- Days 21-100: $194.50 coinsurance per day of each benefit period
- Days 101 and beyond: all costs
Medicare Part B Benefits
- Part B generally covers:
- Physician and other health care professional services
- Outpatient hospital services
- Clinical lab and diagnostic tests, such as X-rays, MRIs, CT scans
- Medical equipment
- Home health care is not covered under Part A (because the individual was not in a hospital or SNF or has exceeded 100 days)
- Physical therapy
- Bariatric surgery for individuals who meet certain conditions related to morbid obesity
- Chemotherapy provided on an outpatient basis
Other Part B Items and Services
- Ambulance services
- Chiropractic services – for limited situations
- Opioid use disorder treatment
- E-visits
- Diabetic supplie
- Vaccines
- Kidney dialysis
- Outpatient mental health care (limits apply)
- Certain Telehealth services
- Transplant physician services and drugs 36. Medicare Part B – Original Medicare Cost Sharing In 2022, beneficiaries pay the following amounts for Part B services covered under Original Medicare:
- A $233 annual deductible. The deductible does not apply to certain Part B covered preventive services.
- After the deductible is satisfied, beneficiaries typically pay 20% of the Medicare-approved cost for Part B covered services.
- 12 Medicare Part B Benefits - Preventive Services and Screenings Beneficiaries covered under Original Medicare and Medicare Advantage plans will have no cost-sharing for most preventive services. Preventive servicesinclude, but are not limited to:
- One-time “Welcome to Medicare” physical
- Annual wellness visit after 12 months enrolled in Part B and annually thereafter
- Immunizations – pneumococcal, hepatitis B, annual flu shot (Note: shingles shots are covered under Part D, not Part B)
- Bone mass measurement – every 24 months for certain conditions or meets certain criteria
- Obesity behavior therapy
- Pap test and pelvic examination - every 24 months for all women; every 12 months for those at high risk
- Diabetes self-management training – for persons with diabetes
- Smoking and tobacco-use cessation counseling – for any illness related to tobacco use
- Glaucoma testing – once per year for those at high risk Screenings include, but are not limited to:
- Mammogram (Breast Cancer Screening) – annual screening for most women
- Depression Screening – every 12 months
- Colorectal cancer screening
- Diabetes screenings – up to two per year for those with risk factors
- Prostate cancer screening – every 12 months for men over age 50 38. Not Covered by Medicare Part A & B
- Routine dental care/dentures
- Cosmetic surgery
- Custodial/long term care
- Health care while traveling outside the US
- Hearing aids
- Outpatient prescription drugs (this is covered under Part D)
- Massage Therapy
- Routine eye care and eyeglasses
- Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care)
- Covered items or services provided by a doctor or other provider who has opted out of Medicare (except in the case of an emergency or urgent need)
Original Medicare and Part D Prescription Drug Coverage
- A beneficiary in Original Medicare may receive Part D prescription drug coverage through a stand-alone prescription drug plan (PDP).
- Generally, except for those dually eligible for Medicare and Medicaid, Medicare beneficiaries must actively select a Part D plan.
- Beneficiaries who enroll in Part D typically pay a monthly premium, annual deductible, and per prescription cost-sharing.
- In selecting a Part D plan, beneficiaries should consider expected premiums and cost sharing, formulary, and network pharmacies among other factors.
