ORIGINAL MEDICARE and my options

Here is the basic differences between Original Medicare and Medicare Advantage:

Medicare provides health care coverage either through Original Medicare (Parts A and B) or a health plan offered by a private company, sometimes referred to as Medicare Advantage plans.

Let’s review the two plans to get a better understanding.

Original Medicare also called "fee for service" Medicare allows you to any doctor or hospital that takes Medicare patients and you usually pay a deductible and part of the cost of the services you get. Medicare governs what health care providers can charge for the services Medicare covers. Since Original Medicare does not cover the prescription drug coverage you would need to join a prescription drug plan.

If you choose to join a Medicare health plan, you still have Medicare Parts A and B, but your health care services are through a private plan contracted with Medicare. You continue to pay the Part B premium, plus any premium your plan charges. These plans usually cover the same areas as Medicare Part A and B and can cover prescription drugs. Generally, you will use network providers, like doctors, hospitals, facilities and pharmacies and if you go out of network it will cost you more money. Sometimes you receive additional benefits that Original Medicare does not pay for, like vision, hearing care and exercise facilities.

"Ok, what does this all mean to me" 

Let's get started looking at the different aspects of Texas Medicare.

What is Medicare?
It is a federal health insurance program referred to as Original Medicare, which includes people 65 years of age, or older, certain people with disabilities who are under age 65 and those with end-stage renal disease (permanent kidney failure). It pays for a large portion of the health care expense but not all of it. The portion that Medicare does not pay is what the individual must pay for out of pocket such as coinsurance, co-payments, and deductibles. The gaps in Original Medicare coverage are commonly filled by a Medicare Supplement plan. Medicare in Texas and Texas Medicare plans are the same as Medicare in any state because it is a federal government that defines what the benefits are.

Medicare has four parts:

• Medicare Part A: This covers area such as inpatient hospital, inpatient skilled nursing facility, home health, and hospice services. Most people do not have to pay for Part A due their contributions over 10 years.
• Medicare Part B: provides covers outpatient and physician services. It also pays for other areas such as durable medical equipment, prosthetic devices, supplies incident to physician's services, and ambulance transportation. Most people pay monthly for Part B.
• Medicare Part C: Are Medicare Advantage plans are offered by private insurance companies that serve as an alternative to Medicare. These plans can cover medical only or medical and dental. These plans are subsidized and regulated by the Federal government.
• Medicare Part D: Prescription Drug Coverage plans are offered by private companies to provide coverage for prescription drug costs. These plans are subsidized and regulated by the Federal government.

Can you tell me more about Medicare Part A and Part B?
Part A referred to as hospital insurance, helps pay expenses for inpatient hospital care, some skilled nursing facility care, hospice care, and some home health care. The medical costs you incur with Medicare Part A include a large deductible per benefit period and copays if you are in the hospital for over 61 days. The benefit period for part A is your time in the hospital including 60 days after you are release.

Part B referred to as medical insurance, helps pay for outpatient hospital care, doctors' services, and some other medical services and supplies when they are medically necessary that Part A does not cover. The Part B deductible is based on a calendar year and is generally affordable. After the deductible is met you will be responsible for 20% of your Medicare Part B expenses. This can be quite expensive if you have any major medical treatments.

What is a benefit period?
A benefit period starts on day one of a Medicare approved inpatient stay and ends when you have been out of the hospital for 60 consecutive days. This also applies to a skilled nursing facility. After that a new benefit period begins and the beneficiary must pay a new inpatient hospital deductible. There may be as many as five benefit periods in a calendar year.

What is a Medicare Supplement plan?
A Medicare supplement insurance plan is a health insurance policy sold by private insurance companies (Texas Medicare carrier) to cover some or all of the gaps created my Original Medicare. In the end, a Medicare Supplement plan may help you save on out of pocket costs even though you have to pay a monthly premium to the insurance company you purchase the policy from. You are eligible for this plan if you have Medicare Part A and B and are at least 65 years of age (unless disabled). Since the Texas Medicare Supplement plans do not have an open enrollment period you can switch another Texas Medicare Supplement plan with another Texas insurance company at any point throughout the year as long as you qualify medically.

How many Texas Medicare Supplement Policies are there?
The modernized benefit policies are “A, B, C, D, F, High-Deductible F, G, K, L, M, and N.” Since they are standardized, by law each insurance companies plan offers the same basic benefits.

What is the most popular Texas Medicare Supplement Insurance plan?
Probably the most popular plan is probably Plan F. Most people choose Plan F because it covers all the deductibles and all the coinsurance. In order not to have any additional out of pocket costs it has to be a Medicare approved expense, and then you will pay nothing. Another popular is Plan G. The main difference between the two plans is that Plan G Medicare Supplement does not cover the Medicare Part B deductible.

Why do I need a Texas Medicare Supplement Insurance plan?
The original Medicare program is designed to provide health benefits but it does not cover the total cost of health care, or leaves gaps in coverage such as co-pays and deductibles for hospitalization, doctor visits and other medical services. Individuals that have enrolled in original Medicare program may decide that they need a Medicare Supplement often referred to as Medigap insurance because it provides supplemental health insurance coverage to fill in the gaps. Supplement plans may cost you more that the Medicare Advantage plans but once you pay the premium there will be less or no out of pocket expenses for most plans.

In both of Medicare programs Part A and Part B they have gaps in coverage that may be covered by supplemental insurance.

Here's an example of how having a Texas Medigap Policy can benefit you:
Say you were on Original Medicare only, you're out of pocket could consist of 2017 Medicare Part A deductible of $1,316 and Medicare Part B deductible of $183 deductible. Medicare will then pay 80% of the Medicare approved expenses. That can be a hefty unplanned expense! Now let’s say you have a Medigap policy, like a Plan F that picks up the Medicare Parts A and B deductibles as well as the 20% of Medicare Part B expenses. So by purchasing a Medicare supplement plan and combining it with Medicare your out of pocket expenses can end up being next to nothing. This type of advance planning for the unexpected covered medical expenses can be very advantageous.

Do supplements cover all medical charges that Medicare doesn’t?
Medicare Supplements will not cover expenses if Medicare does not pay a portion of the bill. Generally, if it is not a Medicare approved expense then a Supplement will not pick up its portion, with some exceptions.

Is Medigap the same as a Supplement?
The Original Medicare Plan has health care areas that are not covered that are commonly referred to as “gaps.” Private insurance companies created supplemental insurance polices to fill gaps in the Original Medicare Plan. The Medigap or Supplement policies are sold to individuals who have Medicare Part A and Part B and are the exactly the same.

What does a Benefit Period mean?
The Benefit Period is a span of time that Medicare uses to gage a person’s use of skilled nursing or hospital care. The Benefit Period support starts the day the person enters the hospital or skilled nursing covered by the insurance. The Benefit Period will end once the person is released from care and does not require any other care for 60 days. Once the benefit period has ended, if the person of whom it concerns goes back into a hospital a new benefit period will start. The inpatient hospital dues may be charged for every single benefit period. The number of benefit periods does not have a cap on limit.

If I move what happens to my Medicare supplement plan?
Your Medicare supplemental plan is renewable and guaranteed; you will still have coverage if you move in state. If the move is into another state, the supplement insurer may have to go over different premiums due to the states plans. If you have a select insurance plan, which do include network restrictions, you will be asked to change your Medicare coverage. You will be given the opportunity to buy supplemental insurance A, B, C or F in the state you move to without having to medically qualify.

What is the General Enrollment Period?
This period is during the time period between January 1 and March 31 when a Medicare beneficiary is eligible to sign up for Part B coverage. The beneficiary’s benefits will begin on July 1 of that year, and the beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare.

What is the Medicare Open Enrollment Period?
“Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65”
Open enrollment period is when the applicant is guaranteed a Medicare supplement insurance plan regardless of their current or past health history (generally, outside of this period the applicant must meet medical underwriting guidelines to qualify). Open enrollment is a six-month period from the date the beneficiary enrolled in Medicare Part B if age 65 or older (also includes a six-month period when you turn 65 if you were eligible for Part B benefits before age 65). No individual can be denied any Medicare supplement policy sold by any Medicare supplement issuer if the application is submitted during the six month period beginning with the first day of the first month in which an individual first enrolls for benefits under Medicare Part B at age 65 or older; or upon attaining age 65 for individuals that were previously enrolled in Medicare Part B prior to turning age 65. Additionally individuals under the age of 65 can purchase Plan A from any insurer during the six-month period beginning with the first month in which the individual first enrolled for benefits under Medicare Part B. Please note that, in, Texas, Medicare beneficiaries under age 65 have two open enrollment periods, one when they first enroll in Part B and a second one when they turn age 65.

What makes the open enrollment period so critical?
The open enrollment period starts the first day of the month you turn 65 and have Medicare Part B extending for 6 months from that date. This period is critical because no company can not offer you any Medicare Supplement Policy that they sell for any reason. After this your open enrollment period ends companies then are allowed to use medical underwriting and can accept or deny your application. This can make it very difficult and expensive, due to certain health conditions to obtain coverage after your open enrollment period expires.

When am I eligible for Initial Enrollment Period?
Initial Enrollment Period is when the client can apply for Part B or Part D for the first time. For many it starts 3 months prior to when the person meets Medicare’s requirement for eligibility and goes on for the next 7 months. However, for SSDI, Social Security Disability Insurance applicants the period begins the 24th month of the SSDI’s payments. The person is not liable for medical history review during the enrollment period yet once the period is over any prior conditions that will create exclusionary problems can apply. “Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65.”

I have Medicare Part A and Part B due to a disability and I would like to know which Medicare Supplement I can get since I am not 65 yet?
In Texas, insurance companies that offer Medigap policies are required to sell a Plan A to someone under 65 that qualifies for Medicare. Companies can offer additional plans as an option in addition to a Plan A to someone on disability.

What is a Copayment?
A set amount an individual must pay upon receiving medical services in combination with the amount paid by the insurer. For example, you may have to pay $10 each time you visit the doctor, with the understanding that the health insurance policy covers a large part or the remainder of the balance of the fee owed to the doctor. The copay amount is usually indicated on the prescription or insurance card. It is the portion the insured pays with the balance being paid by the insurer.

What does it mean to have Creditable Coverage?
Your current insurance company can guide you on weather their plans are creditable. When you are going from one health insurance plan to another the prior coverage will reduce pre-existing condition waiting period. However, if you didn’t have any health insurance coverage for more than 63 consecutive days, you cannot count them in the creditable coverage period.

What is a Deductible?
A deductible is the cost a person is required to pay for health services before the insurer or Medicare pays their portion. For instance, Medicare Part B requires one deductible that is paid on a calendar year basis and Medicare Part A has a deductible that must be met for each benefit period.
What does a participating Texas Medicare provider mean?

A participating physician is enrolled in the Medicare program agreeing to accept assignment on all Medicare claims that are submitted. You may only be billed by these doctors for Medicare deductible and/or coinsurance amounts.

What is the best Medicare Supplement Insurance in Texas for me?
There's not one plan that fits all needs. There many areas to consider when selecting a Medigap Insurance. Your personal preferences consisting of current and future financial abilities, benefits, age and current health will determine what the best plan is. Contact us to help you determine which plan is best for you.

How do I get a quote Texas Medicare Supplement Insurance?
Simply click here and we will provide you with a quote from some of the top rated companies that we represent. Please feel free to call us at (469) 293-7080 or send us an email to help you with a Medicare Supplement. We will discuss Texas Medicare coverage and Texas Medicare Guidelines with you and determine what your needs are then review the various plans available for you. Texas Medicare supplement plans are made easy for you to understand how they work with Texas Medicare.

How do I apply for Medicare in Texas?
The Medicare laws and regulations are subject to change for Texas Medicare eligibility and enrollment at any time. Contact Social Security at 1-800-772-1213 to discuss the Texas Medicare application or look here for your local Texas Social Security offices.

How do I know if I am eligible for Medicare?
Generally you are eligible for Medicare if you are a U.S. citizen or have been a permanent legal resident for 5 continuous years, are 65 years or older or if under 65 are disabled and have been receiving either Social Security or the Railroad Retirement Board disability benefits for at least 24 months, or they get continuing dialysis for permanent kidney failure or need a kidney transplant, or they have Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's disease). You can also be dual-eligible which means you are on Medicare and Medicaid. If you have limited income, in some states, Medicaid will actually pay for the Part B premium and for many individuals who have worked long enough won’t have a Part A premium, and also pay any drugs that are not covered by Part D.

How do I determine which type of Medigap plan is best for me?
Your personal requirements, needs and financial situation will determine which the best Medigap plan for you. There are many plans to choose from and many of the plan benefits overlap so review the coverage details, costs and additional or optional benefits offered by the insurance company. Contact us to help you determine which plan is best for you.

Tell me about the Medicare Preferred Provider Organization (PPO) Plan?
A Medicare Advantage PPO allows the individual the choice of visiting providers within the network or seeing a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician to see a specialist.

I want to switch to a different Medicare supplement policy; do I have to wait for it to start?
You generally do not have to wait to switch to a different Medicare supplement policy and can do so any month. However, if you had a Medicare Supplement plan for at least six months and you decide to go to another company your new plan must cover all preexisting conditions. If you are on a plan for less than six months, the new Medicare supplement policy must give you credit for the time the older policy covered you.

Here are the different types of Medicare Advantage health plans

•Health Maintenance Organizations (HMOs)
•Preferred Provider Organizations (PPOs)
•Private Fee-for-Service plans (PFFS)
•Special Needs Plans (SNPs)
•Medical Savings Accounts