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Medicare Supplement

What is Medicare?

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

Medicare coverage is based on 3 main factors

  1. Federal and State laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. 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 areas.

The different parts of Medicare help cover specific services:

MEDICARE Part A (Hospital Insurance)

Part A covers:

  • Hospital Care
  • Skilled Nursing Facilities
  • Nursing Home care (as long as custodial care isn’t the only care needed)
  • Hospice Care
  • Home Health Services

MEDICARE Part B (Medical Insurance)

Part B covers 2 types of services

  • Medically necessary services: services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Certain medically necessary services such as, doctors’ services, outpatient care and medical supplies.
  • Preventative services: Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best.
  • Clinical Research
  • Ambulance services
  • Durable medical equipment
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs

MEDICARE Part D (prescription Drug Coverage)

Part D adds prescription drug coverage to the Original Medicare, some Medicare Cost Plans, and some Medicare Private-Fee-for-Service Plans. These plans are offered by insurance companies and other private companies approved by Medicare.

What 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 and drugs in different “tiers” have a different cost associated with the “tier”.

A drug in a lower tier will generally cost you less than a drug in higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug in a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

  • Provide written notice to you at least 60 days prior to the date the change becomes effective.
  • At the time you 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 is Medicare Supplement Insurance (Medigap)?

A Medicare Supplement Insurance Policy, sold by private insurance companies can help pay some of the health care cost that Original Medicare (Part A& Part B) do not cover, like copayments, coinsurance and deductibles.

Some Medicare Supplement policies also offer coverage for services that Original Medicare (Part A& Part B) do not cover like medical care when you travel outside the United States. If you have Original Medicare and you buy a Medicare Supplement policy, Medicare will pay its share of the Medicare-approved amount for the covered health care costs, then your Medicare Supplement policy pays its share, many times leaving you with zero out of pocket expenses (depending on which Medicare Supplement plan you chose).

7 Things to know about Medicare Supplement Policies

  1. You must have Medicare Part A and Part B.
  2. If you have a Medicare Advantage Plan, you can apply for a Medicare Supplement policy, but make sure you can leave the Medicare Advantage Plan before your Medicare Supplement policy begins.
  3. You pay the private insurance company a monthly premium for your coverage in addition to the monthly Part B premium that you pay Medicare. Many plans today will cover the deductibles and out of pocket expenses associated with Part B.
  4. A Medicare Supplement policy only covers one person. If you and your spouse both want Medicare Supplement policies, you will each have to purchase separate policies.
  5. You can buy a Medicare Supplement policy from any insurance company that is licensed to sell in your state. Check with your State Insurance Department.
  6. Any standard Medicare Supplement policy is guaranteed renewable even if you have health problems. This means the insurance company cannot cancel your coverage as long as you pay the premiums.
  7. Medicare Supplement policies sold after January 1, 2006 do not include prescription drugs coverage. If you want or need prescription drug coverage You can join a Medicare Prescription Drug Plan (Part D)

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