Options for Medicare Beneficiaries
A Medicare Supplement insurance policy, sold by private companies, can help pay some of the health care costs that original Medicare doesn’t cover, like co-payments, co-insurance, and deductibles. Some Medicare Supplement policies also offer coverage for services that original Medicare doesn’t cover, like medical care when your client travels outside the U.S. If your clients have original Medicare and your clients buy a Medicare Supplement policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your clients’ Medicare Supplement policy pays its share.
A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide your clients with all of their Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If your clients are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. CMS Approved Scope of Appointment
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More about Medicare Options
There are 2 main ways to get your Medicare coverage—Original Medicare or a Medicare Advantage Plan (Part C). If you choose Original Medicare, you can add a Medicare Supplement Plan to reduce your clients exposure to medical costs not covered by Original Medicare.
What does Medicare Part A cover?
What’s covered? Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. If your client is in a Medicare Advantage Plan or other Medicare plan, they may have different rules, but your clients plan must give them at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions. In general, Part A covers:
- Hospital care
- Skilled nursing facility care
- Nursing home care (as long as custodial care isn’t the only care you need)
- Home health services
2 ways to find out if Medicare covers what your clients need Have them talk to their doctor or other health care provider about why they need certain services or supplies, and ask if Medicare will cover them. If they need something that’s usually covered and their provider thinks that Medicare won’t cover it in their situation, they will have to read and sign a notice saying that they may have to pay for the item, service, or supply. Find out if Medicare covers your item, service, or supply. Medicare coverage is based on 3 main factors Federal and state laws. National coverage decisions made by Medicare about whether something is covered. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
What does Medicare Part B cover?
What’s covered? Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. If your clients in a Medicare Advantage Plan or other Medicare plan, they may have different rules, but their plan must give them at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions. Part B covers 2 types of services Medically necessary services: Services or supplies that are needed to diagnose or treat your clients medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. Your clients pay nothing for most preventive services if they get the services from a health care provider who accepts assignment. Part B covers things like: Clinical research Ambulance services Durable medical equipment (DME) Mental health Inpatient Outpatient Partial hospitalization Getting a second opinion before surgery Limited outpatient prescription drugs 2 ways to find out if Medicare covers what your clients need talk to their doctor or other health care provider about why your clients need certain services or supplies, and ask if Medicare will cover them. If your clients need something that’s usually covered and your provider thinks that Medicare won’t cover it in their situation, they’ll have to read and sign a notice saying that your clients may have to pay for the item, service, or supply. Find out if Medicare covers your clients item, service, or supply. Medicare coverage is based on 3 main factors Federal and state laws. National coverage decisions made by Medicare about whether something is covered. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
What do drug plans cover?
Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks your clients need that drug instead of a similar drug on a lower tier, your clients prescriber can ask your clients plan for an exception to get a lower copayment. A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug they’re currently taking, your clients plan must do one of these:
- Provide written notice to your clients at least 60 days prior to the date the change becomes effective.
- At the time your clients request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.
What do Medicare Advantage plans cover?
Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if your clients in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, they’re always covered for emergency and urgently needed care. The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare. If your clients are not sure whether a service is covered, check with their provider before they get the service. Medicare Advantage Plans may offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your clients Part B premium, they usually pay a monthly premium for the Medicare Advantage Plan.
If your clients need a service that the plan says isn’t medically necessary, they may have to pay all the costs of the service, but your clients have the right to appeal the decision. Your clients can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won’t pay for a service your clients think they need, they’ll have to pay all of the costs if your clients didn’t ask for an advance coverage decision. Get their plan’s contact information from a Personalized Search (under General Search), or search by plan name.
What do Medicare Supplement plans cover?
Medicare doesn’t pay any of the costs for your clients to get a Medigap policy. Your clients have to pay the premiums for a Medigap policy. Medigap helps pay your clients’ Part B bills In most Medigap policies, when they sign the Medigap insurance contract they agree to have the Medigap insurance company get their Part B claim information directly from Medicare, and then they pay the doctor directly. Some Medigap insurance companies also provide this service for Part A claims. If your clients’ Medigap insurance company doesn’t provide this service, ask their doctors if they “participate” in Medicare. This means that they “accept assignment” for all Medicare patients. If your clients’ doctors participates, the Medigap insurance company is required to pay the doctors directly, if they request. It is important to compare the costs of Medigap plans because insurance companies may charge different premiums for the same exact policy. As your clients shop for a policy, be sure they’re comparing the same policy (for example, compare Plan A from one company with Plan A from another company). In some states, your clients may be able to buy another type of Medigap policy called Medicare SELECT. If your clients buy a Medigap SELECT policy, they have the right to change their minds within 12 months and switch to a standard Medigap policy.
How Medicare Supplement Policies Work with Medicare Advantage Plans
Medigap policies can’t work with Medicare Advantage Plans. If your clients have a Medigap policy and join a Medicare Advantage Plan (Part C), your clients may want to drop the Medigap policy. Their Medigap policy cannot be used to pay their Medicare Advantage Plan copayments, deductibles, and premiums. If your clients want to cancel their Medigap policy, contact their insurance company. If your clients leave the Medicare Advantage Plan, they might not be able to get the same Medigap policy back, or in some cases, any Medigap policy unless your clients have a “trial right.” If your clients have a Medicare Advantage Plan, it’s illegal for anyone to sell your clients a Medigap policy unless they’re switching back to Original Medicare.
- If your clients had a Medigap policy before they joined, they may be able to get the same policy back if the company still sells it. If it isn’t available, your clients can buy another Medigap policy.
- The Medigap policy can no longer have prescription drug coverage even if your clients had it before, but they may be able to join a Medicare Prescription Drug Plan (Part D).
- If your clients joined a Medicare Advantage Plan when they were first eligible for Medicare, your clients can choose from any Medigap policy.
How to Pay Part A & Part B Premiums
If you get Social Security, Railroad Retirement Board (RRB) benefits, or Civil Service benefits, your client’s Medicare Part B (Medical Insurance) premium will get deducted from your client’s benefit payment. If they don’t get these benefit payments and your clients sign up for Part B, they’ll get a bill called a “Notice of Medicare Premium Payment Due” (CMS-500). If your clients buy Medicare Part A (Hospital Insurance), or your clients owe Part D income-related monthly adjustment amount (IRMAA), they’ll always get a “Notice of Medicare Premium Payment Due”(CMS-500) each month for your premium. Learn more about the “Notice of Medicare Premium Payment Due.” There are 3 ways to pay these bills: 1. Sign up for Medicare Easy Pay, a free service that automatically deducts your clients premium payments from your savings or checking account each month. 2. Pay by check or money order. Mail your clients Medicare premium payments to:
If your clients get a bill from the RRB:
Mail their premium payments to:
If they’re a Civil Service retiree and NOT entitled to Social Security:
Your clients may have your premiums deducted from your clients Civil Service annuity. To do this, send an email to OPMMailbox@cms.hhs.gov.
If your clients have limited income and resources:
Your state may help you pay for Part A, and/or Part B. Your clients may also qualify for Extra Help to pay for their Medicare prescription drug coverage.
How to Apply Online for Medicare Only
Apply for Medicare enrollment using our online application.
It’s convenient, quick, and easy. There’s no need to drive to a local Social Security office or wait for an appointment with a Social Security representative. Use Medicare’s online application to sign up for Medicare. It takes less than 10 minutes. In most cases, once your client’s application is submitted electronically, that’s it. There are no forms to sign and usually no documentation is required. Social Security will process your client’s application and contact your client if they need more information. Otherwise your client will receive his or her Medicare card in the mail. Medicare is managed by the Centers for Medicare and Medicaid Services (CMS). Social Security works with CMS by enrolling people in Medicare. For more information about applying for Medicare only and delaying retirement benefits, visit Applying for Medicare Only – Before You Decide.