Knowing Your Medicare Coverage Options

Medicare is a health insurance program that caters to people age 65 and up. According to our blog post on a ‘Comprehensive Guide to Health Insurance and Coverage Options’, it’s a government-led program, much like VA Insurance and the Children’s Health Insurance Program. As with any insurance program, opting for one or another requires careful planning. Depending on your circumstances, you may need to apply for multiple Medicare coverage plans as well as private health insurance.

In fact, statistics from the AARP Public Policy Institute reveal that of the 44 million beneficiaries enrolled in Medicare, only 10% rely solely on its benefits. The rest availed supplemental medical coverage. So, to create the best possible plan to suit your needs, it’s important to know what Medicare entails before signing up for it.

In line with this, here are your Medicare coverage options to help you plot out your health insurance plans.

Part A & B (Original Medicare)

Part A and Part B comprise the Original Medicare plan. Part A covers inpatient care and other facilities-related services. These include:

• Hospitalizations and any inpatient treatments
• Inpatient mental health services
• Inpatient rehabilitation processes
• Hospice care
• Home health care*
• Skilled nursing facility stay*

*for a limited time

Inpatient services refer to serving meals, nursing care, therapy, and required treatments. However, it’s important to note that Medicare Part A doesn’t cover all hospital expenses. Here are some of the things that aren’t included in Part A coverage:

• The first three pints of blood for transfusion
• A private room in any healthcare facility
• Any extra room amenities, such as a television, telephone, or toiletries
• Private nursing care
• Long-term care

Medicare Part A is primarily funded by payroll and Social Security taxes. Because of this, it’s free for individuals and their partners who’ve been in the workforce for at least 10 years.

Meanwhile, Part B covers outpatient services and preventative treatments that are deemed medically necessary for the individual’s health status or condition. These include:

• Emergency transportation
• Emergency room treatment
• Medical tests (e.g. blood tests, imaging tests, urinalysis)
• Use of medical equipment, such as wheelchairs, walkers, and stretchers
• Physical and occupational therapy
• Outpatient medical and mental health care
• Screenings for different medical conditions, such as diabetes, cancer, and STIs

Much like Part A, there are some services that don’t fall under Part B coverage. Here are some examples:

• Regular medical examinations
• The majority of prescription medications
• Optic care and dental care
• Cosmetic surgery

Medicare Part B is funded by corporate, excise, and income taxes. It also requires monthly premiums paid by the beneficiaries. Note that Part B is an optional program of Original Medicare. Thus, individuals can choose whether to include it in their plan.

You may also like: How Important is Medical Indemnity Insurance for Medical Professionals?

Part D (Prescription Drug Coverage)

Part D is a supplementary Medicare program that covers medications. It helps individuals pay for prescription drugs. To avail of Part D, one needs to choose a medication plan, and each has its own list of covered medications or “formularies.” A formulary often contains at least two drugs from the most commonly prescribed medication categories. These are as follows:

• Anticonvulsants
• Antidepressants
• Antipsychotics
• Cancer maintenance and treatment medicines
• HIV medicines
• Immunosuppressants

As for medicines that are not covered in Medicare Part D, these are as follows:

• Most over-the-counter drugs, such as vitamins, health supplements, and cosmetic pills
• Fertility drugs
• Medication for erectile dysfunction
• Cold or cough medicine*
• Medication for weight or eating disorders (e.g. anorexia, bulimia)*

*unless symptoms are part of the diagnosis

Medicare Part D requires a monthly premium and can be availed by anyone with an Original Medicare Plan. According to the AARP Foundation, it is an optional program, like Part B. However, it’s essential to decide whether you want to avail early on, as late enrolments can lead to penalties and delayed coverage.

Part C (Medicare Advantage)

Part C is the last on the list because it presents an alternative to Original Medicare and its supplemental programs. Also known as MA Plans, Medicare Part C coverage is offered by private insurance companies with the approval of the Centers for Medicare & Medicaid Services (CMS).

Individuals can choose Part C, over Parts A, B, and D if they’re looking for an all-in-one health insurance option. What makes Medicare Part C appealing is that its coverage often extends further than Original Medicare plans. Moreover, individuals have plenty of options. There are four types of Part C plans, and these are as follows:

1. Health Maintenance Organization (HMO) Plans

HMO plans require you to receive care and healthcare services specifically from your provider. Otherwise, you’ll be shouldering the full costs. In most HMO plans, you will be assigned a primary doctor, who will refer you to other specialists as needed. Some HMO plans cover prescription drugs, while some do not, so be sure to double-check.

2. Preferred Provider Organization (PPO) Plans

PPO plans work the same way as HMO plans, with the only difference being the lack of an assigned primary doctor. You still pay less when consulting health professionals within your plan’s network and more when you go to those outside it. Essentially, PPO plans provide more flexibility than HMO plans.

3. Private Fee-for-Service (PFFS) Plans

PFFS plans are even more flexible than PPO plans. By availing of this plan, you’re allowing the contracted company to pay for any healthcare services covered in the insurance. Thus, you can consult with healthcare professionals freely. However, one drawback is that not all healthcare professionals will accept your PFFS plan.

4. Special Needs Plans (SNPs)

Finally, SNPs are specifically for individuals with certain medical conditions, including those chronic in nature or those that require institutional care, such as in a nursing home. These plans focus on providing individuals with specialized care to cater to their medical conditions.

One thing worth noting about Medicare Part C is that the plans depend on geographical location. This is due to how local companies network with nearby healthcare service providers to partner with them. For example, in the Chicago area, one can apply to Cigna Fundamental Medicare’s MA Plan, which features telehealth coverage, preventive care, and even alternative treatments like acupuncture.

Meanwhile, in the Greater Houston area, individuals can apply to the MA Plan on KelseyCare Advantage. It includes vision- and dental-related treatments, as well as fitness and transportation costs. Overall, the coverage of a Part C plan is dependent on where the individual resides.

To search for MA Plans in your area, you can use the Medicare Advantage Plan Finder on their website. Simply input your details, and the site will display all the options closest to you.

Medicare plans are complex and extensive, so it’s best to weigh your options before opting for one or another. Remember to take your current status and health conditions into account, and try to foresee what specific health services you’ll need in the future. This is so you can fully optimize your Medicare plan.

For more information do check out our other articles on Online Health Media.

Read Also:

• Medical Conditions Associated With Grieving Seniors
• How to apply for a medicare flex card?