Decoding Medicare

Sage Aging Podcast Episode 73

Medicare basics with Karen Dean, Sage Aging podcast episode 73

Decoding Medicare isn’t necessarily easy, but it’s not as difficult as you may think when you understand the basics. With Open (annual) Enrollment upon us, Karen Dean, licensed Agent, joined me to break down the alphabet soup of Medicare to help you gain a better understanding the what is available to you. I’ll hit the highlights in this post but click above to view or listen to the conversation in its entirety.

What is Medicare?

Medicare is the federal health insurance program for:

  • People who are 65 or older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

Put simply, Medicare helps to pay for medical care services, including hospitalizations, physician visits, prescription drugs, preventive services, skilled nursing, and hospice care. Plans vary according to your zip code.

Original Medicare

Original Medicare includes Medicare Part A and Medicare Part B. Similar to traditional health insurance, you pay for services as you get them. You’ll have a deductible and you’ll usually pay 20% of the cost of the Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D – more on that later).

  • Medicare Part A (Hospital Insurance): Premium-free for most who paid Medicare taxes while working, covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Medicare Part B (Medical Insurance): The $164.90 (2023) premium is deducted from your Social Security check monthly. covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Original Medicare does not cover all services. Some of the items and services Medicare doesn’t cover include:

  • Long-term and/or custodial care including medical and non-medical care provided to people who are unable to perform basic activities of daily living,
  • Most dental care
  • Eye exams (for prescription glasses)
  • Dentures
  • Cosmetic surgery  
  • Massage therapy
  • Routine physical exams
  • Hearing aids and exams for fitting them
  • Concierge care (retainer-based medicine, boutique medicine, platinum practice, or direct care)
  • Covered items or services you get from an opt-out doctor or another provider (except in the case of an emergency or urgent need)

Other Plan Types

  • Medicare Part D (Prescription Drug Coverage): An additional premium applies. Each plan can vary in cost and specific drugs covered but must give at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.
  • Medicare Advantage Plans: Also known as Part C, Medicare Advantage is a Medicare-approved plan sold by a private company that offers bundled coverage as an alternative to Original Medicare for your health and drug coverage. Plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare’s coverage rules. The plan must notify you about any changes before the start of the next enrollment year. Premiums for Advantage plans vary as do the rules for obtaining services.
  • Medigap: a Medicare Supplement Insurance that helps fill “gaps” in Original Medicare. It is sold by private companies and premiums vary. A Medigap policy can help pay some of the remaining health care costs, like copayments, coinsurance, and deductibles.

When to Enroll

There are multiple enrollment periods for Medicare:

  • Initial Enrollment: your Initial Enrollment Period lasts for 7 months, starting 3 months before you turn 65, and ending 3 months after the month you turn 65. *If you miss your Initial Enrollment Period, you may have to wait to sign up and pay a monthly late enrollment penalty for as long as you have Part B coverage.
  • Open (Annual) Enrollment: Runs each October 15 to December 7. This Annual Enrollment Period allows Original Medicare enrollees to make several changes to their coverage. These changes include: switching from Original Medicare to Medicare Advantage, going from Medicare Advantage to Original Medicare, switching from one Medicare Advantage plan to another, and enrolling in, changing, or dropping your Medicare Part D prescription plan.
  • General Enrollment Period: between January 1-March 31 each year. *You might pay a monthly late enrollment penalty if you don’t qualify for a Special Enrollment Period.
  • Special Enrollment Period: In some situations, such as a move or change in employment or income, you can sign up for Part B (and Premium-Part A) without paying a late enrollment penalty. A Special Enrollment Period is only available for a limited time. *If you don’t sign up during your Special Enrollment Period, you’ll have to wait for the next General Enrollment Period and you might have to pay a monthly late enrollment penalty.

Where to Find Help

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Liz Craven
Author: Liz Craven

Liz Craven, along with her husband Wes, owns Pro-Ad Media, publisher of Sage Aging ElderCare Guide, serving the local community for over 28 years. Liz lives in Lakeland and is very active in the local community, specifically in the area of aging. Liz serves on a number of local boards and committees including the Lakeland Vision and Age Friendly Lakeland.