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  • Writer's pictureWill Mohring

Understanding Medicare Basics: A Comprehensive Guide on How Medicare Works for Seniors and Retirees

As you approach retirement age, the landscape of healthcare options changes dramatically. Understanding Medicare becomes not just a choice but an essential step for maintaining your health without derailing your finances. This in-depth exploration of Medicare aims to demystify what can be a complex system for many, ensuring you're equipped to make informed choices about your health coverage. Whether you're enrolled and seeking clarification, or you're about to start the enrollment process, the information here is tailored to help you navigate the Medicare maze with confidence.


Navigating the Medicare Alphabet: What You Need to Know


Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and those with end-stage renal disease. As of 2021, over 62 million Americans were enrolled in Medicare, a testament to its importance in the lives of seniors and those nearing retirement.


The Four Essential Parts of Medicare of How Medicare Works


Medicare is broken down into different parts, each covering specific services to address different aspects of healthcare.


Part A: Hospital Insurance

This covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care services. Generally, you don't pay a monthly premium for Part A if you or your spouse paid Medicare taxes while working.


Part B: Medical Insurance

This covers certain doctors' services, outpatient care, medical supplies, and preventive services. Part B typically has a monthly premium based on your income.


Part C: Medicare Advantage Plans

Part C combines the benefits of Part A and Part B and is provided through private insurance companies that are approved by Medicare. Medicare Advantage plans may also include prescription drug coverage (Part D).


Part D: Prescription Drug Coverage

This helps cover the cost of prescription drugs, which can prevent or manage health conditions. Like Part B, Part D is provided by private insurance plans that are approved by Medicare.


There's also Medigap (Medicare Supplement Insurance), a policy sold by private insurance companies to fill the gaps in Original Medicare coverage (Part A and Part B), such as copayments, coinsurance, and deductibles.



Digging Deeper: Eligibility and Enrollment


Initial Enrollment Period (IEP)

Most people are automatically enrolled in Medicare when they turn 65. If not, the initial enrollment period begins three months before their 65th birthday, includes the month of their birthday, and lasts for three months after their birthday.


Special Enrollment Periods (SEP's)

These special periods are designated times outside of your initial enrollment period when you can sign up for Medicare. For example, if you didn't sign up for Part B when you first became eligible because you were covered under a group health plan, you can sign up during your employment or within eight months of when employment or group coverage ends, whichever happens first.


General Enrollment Period (GEP)

For those who didn't sign up when first eligible and aren't eligible for a Special Enrollment Period, this period runs from January 1 to March 31 each year, with coverage beginning July 1.


Annual Enrollment Period (AEP)

The Medicare Annual Enrollment Period, also known as AEP, runs from October 15 to December 7 every year. During this time, Medicare beneficiaries can make changes to their coverage, such as switching from Original Medicare to a Medicare Advantage plan, or vice versa, changing Medicare Advantage plans, or adding a Medicare Part D prescription drug plan. It's a crucial period for beneficiaries to review their current coverage and make adjustments to meet their healthcare needs in the upcoming year. Please note that to enroll, one must already be enrolled in Medicare Part A and/or Part B.


Open Enrollment Period (OEP)

The Medicare Open Enrollment Period, also known as OEP, spans from January 1 to March 31 each year. During this window, individuals enrolled in a Medicare Advantage plan have the opportunity to switch to a different Medicare Advantage plan or to Original Medicare. Those who switch to Original Medicare during this period may also join a Medicare Prescription Drug Plan to add drug coverage. It's an essential time for beneficiaries to reassess their healthcare needs and adjust their plans accordingly. To participate, one must already be enrolled in a Medicare Advantage plan. If you got a Medicare Advantage plan in the fall, during AEP, this gives you the ability to test drive your plan and make a one-time change before March 31st.



Understanding these periods is crucial to avoiding late enrollment penalties, which can increase the cost of Medicare Part B and Part D premiums for the life of your coverage.




Medicare Covered Services: What's Included?


Now that you know the basics of Medicare, it's time to understand what services are covered under each part.


Part A Services


Hospital Care

This includes semi-private rooms, meals, general nursing, and other hospital services and supplies.


Skilled Nursing Facility Care

Medicare covers skilled care provided in a skilled nursing facility and, in some cases, at home.


Hospice

Hospice care is a special way of caring for people who are terminally ill, and support is also provided to the patient's family.


Home Health Services

Home health services include part-time, skilled nursing care, and physical therapy, occupational therapy, and speech-language therapy.



Part B Services


Medical Services and Supplies

This includes doctor's visits, outpatient care, emergency department services, clinical laboratory services, and some preventive services such as flu shots and pap smears.


Preventative Services

Part B also covers services aimed at preventing illness, including a “Welcome to Medicare” preventive visit, cardiovascular screenings, cancer screenings, and more.



Part D Services


Medicare Part D plans cover prescription medications, but the cost and specific drugs covered can vary by plan. It's important to regularly review your plan during the annual enrollment period in the fall to ensure it continues to meet your needs.



Medigap and Medicare Advantage: What They Cover


Both Medigap and Medicare Advantage can help cover costs that Parts A and B do not, but they do it in different ways:


Medigap (Medicare Supplement Insurance)

Medigap policies only work with Original Medicare and help pay your out-of-pocket costs such as deductibles, copayments, or coinsurance.


Medicare Advantage (Part C)

Medicare Advantage plans are required to cover everything that Original Medicare covers (Part A and Part B). However, because they are provided through private insurance companies, the rules of Medicare Advantage, including what you pay for the services you use, can differ from Original Medicare. Many plans have a $0 monthly cost and cover extra services such as dental, vision, hearing and more.



Managing Your Medicare: Understanding Costs and Coverage Gaps


While several parts of Medicare cover a wide range of services, they don't pay for everything. Here's a closer look at what you can expect to pay.


Medicare Part A and Part B Costs


Part A

For those who have to buy Part A, premiums can go as high as $471 per month in 2021, but most people don't pay a premium for Part A because they or a spouse paid Medicare taxes while they were working. If you or your spouse has 40 working quarters (10 years) of paying into Medicare while working, your Part A will not have a premium. This is the part that the Medicare payroll taxes pay for.


Part B

The standard Part B premium is $174.70 per month (in 2024). However, high-income beneficiaries may pay more. You'll also normally pay a deductible each year before Part B starts paying.


Other Costs

Both Part A and Part B have additional costs such as coinsurance, copayments, and additional coverage if you have Medigap or Medicare Advantage. For example, Part B has 20% coinsurance, which is why it is so important to consider adding a Medicare Advantage or Medigap plan on top of it.



The Infamous "Donut Hole" in Part D


Until recently, Part D had a coverage gap referred to as the "donut hole." If your total drug costs, including what you and your plan have paid, hits a certain threshold, you would pay more for your prescriptions out of pocket. However, this coverage gap has been gradually closing with the Affordable Care Act. It is expected to be completely eliminated in 2025.



Managing Your Medicare Costs


To manage the cost of Medicare, it's crucial to shop around for the best plan that suits your needs. Utilize the resources available, such as plan finders and the annual enrollment period, to ensure you have the right coverage at the best price.



Medicare Advantage & Prescription Drug Plan Finder


This tool allows you to search for and compare Medicare Advantage and Part D plans in your area. It's a critical resource for finding the coverage that fits your needs. Enter your zip code, and that 4 tabs at the top will have all the plans in each category in your area. The tabs in include: 1) Medicare Advantage Plans WITH Prescription Drug Coverage; 2) Medicare Advantage Plans WITHOUT Prescription Drug Coverage; 3) Medicare Supplement Plans; and 4) Stand-Alone Part D Prescription Drug Plans.




There, you will see a list of plans in your area. Once you find one that looks good to you, you can click on "Plan details" to review the full information of the plan or "Add to cart" to enroll in the plan. If you have any questions you can always schedule an appointment and we'll be happy to walk you through it.





In Conclusion: The Importance of Informed Decision-Making


Understanding your Medicare options is key to ensuring you have the healthcare you need as you enter into retirement. By delving into the details of each part, navigating the enrollment process, and managing costs, you can take control of your health coverage and financial well-being.


As you continue your journey with Medicare, keep in mind that the program evolves, and so do your healthcare needs. Regularly reviewing your coverage and staying informed about changes will help you make adjustments as necessary.


For personalized guidance on your Medicare journey, feel free to reach out to our knowledgeable team. We're here to support you in making the right choices for your health and future. Remember, in the world of Medicare, knowledge truly is power.


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