EXPLANATION OF COVERAGE TYPES

Medicaid: Medicaid was created in 1965 as a joint federal public assistance program for those in certain Federal poverty limits, who could not afford health care. Since the program is administered by the individual states under federal guidelines, the benefits offered and eligibility requirements vary widely. About 60 million+ people around the US., including children, pregnant women, the elderly, the blind and disabled, are currently covered by Medicaid. States set individual eligibility criteria within federal minimum standards. States have the option to charge premiums and to establish out of pocket spending (cost sharing) requirements for Medicaid enrollees. Out of pocket costs may include copayments, coinsurance, deductibles, and other similar charges.

Medicare: Medicare is a federal insurance program which primarily serves those over 65 years old and younger, disabled people and dialysis patients. It currently covers about 37 million Americans. Medicare is divided into Part A, which covers inpatient hospital services, nursing home care, home health care and hospice care; and Part B, which helps pay the cost of doctors’ services, outpatient hospital services, medical equipment and supplies, and other health services and supplies. Recipients pay some part of the costs through deductibles. Since Medicare doesn’t cover all expenses, recipients often supplement their coverage through separate Medigap policies (also called Medicare Supplement Insurance Plans).

Medicare Prescription Drug Coverage, Part D: To get prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and specific drugs covered.

There are two ways to get Medicare prescription drug coverage:

  1. Medicare Prescription Drug Plans, Part D : These plans, (sometimes called PDPs), when purchased as a stand alone plan, add drug coverage to Original Medicare.
  2. Medicare Advantage Plans, Part C.: You get all your Part A and Part B coverage, and prescription drug coverage ( Part D) through these plans. You must have Part A and Part B to join a Medicare Advantage Plan.

Look in the next column for the enrollment dates you must adhere to if changing plans.

Medicare Advantage: Medicare Advantage, also known as Medicare Part C, is a type of Medicare Plan run by private insurance companies. A Medicare Advantage plan offers all of the benefits covered under Original Medicare and more. Medicare pays a fixed fee to the plan you choose in accordance with the 2003 Medicare Prescription Drug, Improvement, and Modernization Act. When enrolled in a Medicare Advantage Plan, benefits are provided according to the Evidence of Coverage for that particular plan. Providers (doctors, specialists, hospitals, etc.) bill the Medicare Advantage plan, and not Original Medicare. Many Medicare Advantage plans also include a Part D prescription drug plan.

To join a Medicare Advantage Plan, a person must have an enrollment period and meet the following criteria:

  • Enrolled in Medicare Part A and Medicare Part B
  • Live in the service area of the plan
  • Not have End-Stage Renal Disease

Medicare Supplement Insurance Plan (Medigap): A Medicare Supplement Plan will help pay part A and part B deductibles, as well as Part B coinsurance, depending on the plan you purchase. “If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share. ”All Medigap plans are standardized by the federal government and labled “A” thru “N.” This means the only difference in benefits for a standardized Medigap plan, with the same letter, is the premium an insurance company charges. (Massachusetts, Minnesota, and Wisconsin Medigap policies are standardized in a different way). A Medigap policy is different from a Medicare Advantage Plan. Medicare Advantage Plans are ways to get Medicare benefits, administered from a private insurance company, while a Medigap policy only supplements your Original Medicare benefits. One cannot be enrolled in a Medicare Advantage Plan and a Medigap policy at the same time.

Applicants qualify for Open Enrollment during the first six months they are enrolled in Medicare Part B and are age 65 or older; this may vary by state. Generally, one needs to be enrolled in Part A and Part B at the time of the plan effective date. Changing (replacing) to a new carrier's plan can be done throughout the year; there is no annual enrollment date. When replacing one Medicare Supplement Insurance Plan carrier for another, some plans have guaranteed issue (do not require underwriting); this varies by carrier and state although replacing the supplement doesn’t follow the annual enrollment periods/dates, one must adhere to proper the enrollment dates if you’re considering changing Medicare Prescription Part D plans, and that can only be done certain times of each year”.


MEDICARE ENROLLMENT DATES

  • October 15 - December 7: each fall
    Open Enrollment Period lasts thru these dates, for a January 1 st Election Date, following the fall enrollment. One can change Medicare Advantage or Prescription Drug Plans, as many times as you want, in this Enrollment period; the change closest to December 7 takes precedence.
  • January 1 - March 31 (Open Enrollment Period): starting in 2019

    For newly MA- eligible individuals, the OEP occurs the first 3 months in which they have both Part A and Part B.

    Individuals enrolled in a MAPD plan can use the OEP to get a different MAPD plan, a MA-only plan, or Original Medicare (with or without a PDP):one time.

    Individuals enrolled in a MA-only plan can use the OEP to switch to a different MA-only plan , a MAPD plan, or Original Medicare ( with or without a PDP): one time.

    Individuals enrolled in Original Medicare cannot use the OEP to join a MA or MAPD plan, add a PDP, or change their PDP.
  • February 15 - October 14: each year
    No plan changes unless you are on Medicaid, qualify for extra help or are entitled to a special enrollment period. Contact Cheryl if you have any questions
  • Turning 65 or just becoming eligible for Medicare?
    For Medicare Advantage and Prescription Drug Plans you can enroll three months before the month you are eligible and three months after. You can make one more change within six months of the effective date of your enrollment. You are eligible for Medicare under age 65 if you meet the disability qualifications, like ALS, or you have received Social Security or Railroad Retirement income disability benefits, for a 24 month period.
  • What You Can Do If You Are "Dual Eligible" and have a WA Provider One Card?
    There are special plans available for you to join throughout the year. Please call to find out if you qualify for these additional benefits through a Special Needs Plan designed for people who are receiving additional benefits.
  • Other reasons you can join a plan during the year:
    • You may be eligible for a Special Enrollment Period (SEP) if you move out of your plan's service area
    • You can change one-time per year to a Medicare 5-Star rated plan
    • If you are on Medicaid, or on Low Income Subsidy (LIS) you can change one time per quarter of the first 3 quarters of the year, i.e., once January thru March, once April thru June, once July thru September, and a change in October thru December would have a January 1 effective date, of the next year.
    • (please refer to the current year “Medicare and You Handbook,” or go to http://www.medicare.gov to gather more information regarding the plans discussed, and enrollment periods).