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The Medicare Plan:

Medicare refers to a health insurance policy for:

  • Individuals aged 65 years and above.
  • People with particular disabilities and aged below 65 years.
  • Persons who are suffering from End-Stage Renal Disease (requiring a kidney transplant or dialysis due to permanent renal failure).

The original Medicare Program Incorporates Two Parts:

Medicare Part A (Hospital Insurance)

Helps cover Inpatient care in a hospital, Inpatient care in a skilled nursing facility, Hospice care, and Home health care.

Medicare Part B (Medical Insurance)

Covers physician services, laboratory services like blood and urine tests and outpatient services like physical therapy.

You can opt to choose Medicare Advantage Program Part C, as well as, a Medicare Prescription Drug Policy Part D.

Advantage Program Part C

Part C or Medicare Advantage is one of the various ways you have to receive services provided by the Medicare Plan. You can choose the different options depending on your area of residence. Most customers start with the Original Medicare Program. You can also select a Medicare Advantage Program such as PPO or HMO that includes the benefits of Parts A, B, and in many cases also Part D. After becoming eligible for Medicare, you can choose your ideal plan. Every year, you are free to consider your prescription and health needs and shift to another plan if necessary.

Medicare Advantage Programs are efficient health plan choices that are approved by CMS (Centers for Medicare & Medicaid Services), but operated by private insurance companies. Medicare Advantage plans are also called “Part C”. A customer is still deemed to be in Medicare after joining the Medicare Advantage Plan. Whether you have either Medicare Advantage Program or the Original Medicare Program, you will have all the items covered in parts A and B.

Medicare Prescription Drug Policy Part D

The Prescription Drug Programs are available through insurance carriers and other private firms approved by the Medicare.

Medicare Health Programs

Your current choices for Medicare coverage:

  • The Original Medicare Program.
  • Medicare Advantage Plans, featuring:
    • Medicare Health Maintenance Organization Plans (HMO)
    • Medicare Preferred Provider Organization Plans (PPO)
    • Medicare Private Free-for-service Programs

Medicare Advantage Plans are available in most regions. Various factors such as quality, convenience, doctor choice, benefits, and costs are directly affected by the Medicare Health Program that you have selected.

Medicare Part A

Part A (Hospital Insurance) helps cover Inpatient care in a hospital, Inpatient care in a skilled nursing facility, Hospice care, and Home health care.


  • Majority of beneficiaries are entitled to Part A (Hospital) Medicare coverage by paying taxes while still working. They do not have to pay a monthly premium for Part A.
  • If you are required to purchase part A, and if you do not have premium-free Part A, you will be required to pay approximately $411 every month this year. The amount can be higher if you sign up late and are forced to pay an enrollment penalty.

Medicare Part A Assists Beneficiaries in paying for Their Medical Necessities:

Hospital Inpatient Care

Includes coverage for room, meals, and general nursing and hospital services. Coverage includes impatient care you get in critical care hospitals. Stays in mental health facilities are covered with a 190 days lifetime limit.


Include pints of blood a patient gets at a skilled nursing facility or hospital during a stay covered by the Medicare Part A.

Hospice Care

Ideal for patients suffering from terminal diseases. This care incorporates drugs for pain relief and symptom control, support and medical services and hospice care approved by the Medicare plan, and additional services that are not included in Medicare. In most cases, hospice care is provided in your home. Medicare also covers certain inpatient and short-term respite care. Respite care refers to the care provided to you at your home so as to allow the usual caregiver enough time to rest.

Skilled Nursing Facility Care

When you are hospitalized for at least 3 consecutive days and your doctor certifies you need daily skilled care in a Medicare Approved skilled nursing facility which you enter within 30 days after you are discharged from the hospital.

Medicare Part B

Part B (Medical Insurance) covers physician services, laboratory services like blood and urine tests and outpatient services like physical therapy.


The 2016 Medicare Premium for Part B is $121.80 monthly. In some instances, this sum might be greater if you did not sign up for Part B when you initially became eligible. The cost might rise 10% for every single 12 month interval you could have had Part B but did not sign up. . Late enrollment penalties are applied as long as you are enrolled in Part B.

Part B Helps You With Medically Necessary Services:

Medical and Other Services

Physicians' services (not including annual physical exams), outpatient health-related and surgical services and necessary supplies, diagnostic tests, ambulatory surgery center service costs for approved procedures, and durable medical equipment (including wheelchairs, hospital beds, oxygen, and walkers). Additionally, 2nd medical opinions are included, outpatient work-related and physical therapy and outpatient mental-health treatment including speech-language therapy. The services above also benefit long-term nursing home residents.

Medical Expenses

Dr. visits and services, inpatient or outpatient medical and surgical services, physical & speech therapy, diagnostic testing.

Medical Lab Services

Blood tests, some screening tests, and urinalysis.

Home Health Care

Part-time medically necessary skilled care services and medical supplies.

Outpatient Hospital Treatment

Medical and surgical services and supplies for treatment of an illness or injury.


Pints of blood you get as an outpatient

*Health care providers may agree to accept Medicare “assignment” on all Medicare covered expenses. The patient will not be required to pay any expense in excess of the Medicare approved charge. The patient would be obligated to pay 20% of the approved charge not paid by Medicare.

*Health care providers who do not accept a Medicare assignment claim will be limited on the amount they can charge for Medicare covered services.

Medicare Part D (Prescription Drug Plan)

Medicare is a nationwide insurance coverage plan designed to help beneficiaries when it comes to settling medical bills. The Part D option is specifically aimed at assisting clients with prescription drugs. For a monthly premium, the prescription drug coverage will essentially assist you in paying more than 50% of your drug costs.

Important Facts on Medicare Part D

  • Part D will assist you in paying for the prescription drugs you need.
  • All Medicare beneficiaries are eligible.
  • Additional assistance is accorded those who need it most.
  • Medicare Part D covers both generic and branded drugs.

Your Medicare Part D Coverage

Essential Information

What is Medicare Part D Coverage?
Medicare prescription drug coverage is essentially designed to provide protection for people whose prescription drugs are costly. The insurance can also provide relief from unexpected drug bills that might occur in future. The plan includes both branded and generic drugs that can be obtained from selected pharmacies in your locality.

Who is Eligible for Part D Coverage?
All Medicare beneficiaries are eligible for the Part D option. There is no discrimination whatsoever on the basis of your financial status, health status, or cost of the drugs.

When is it appropriate to get the Part D?
You may enroll in Part D once you are eligible for Medicare. You are eligible to enroll in Medicare 3 months prior to your 65th birthday until 3 months after your 65th birthday. In case you sign up for Medicare due to disability, you are eligible for Part D 3 months from the period before your 25th disability cash disbursements until 3 months after your 25th disability cash disbursements. If you do not register the first time you are eligible you will be required to pay a penalty. In case you fail to register the first time you are eligible, your next option is to enroll during the Open Enrollment Period, October 15th to December 7th.

How Does Part D Coverage Function?
Essentially, there are two ways you can enroll in the prescription drug coverage. The first option is for you to sign up for a stand-alone Medicare Prescription Drug Plan. The second option is to sign up for Medicare Advantage Plan or any other Medicare plan that covers prescription drugs. The insurance coverage may require you to pay a monthly premium depending on the plan you choose. However, the coverage will still require you to share some amount of your prescription drug bill. You can enjoy more benefits and additional drugs for higher monthly premiums. However, you can apply for help if your income is limited. You can get more information on extra help by contacting social security on 1-800-772-1213 (TTY-1-800-325-0778) or by visiting

Why Medicare Part D Coverage is Essential for you?
Like any other insurance coverage, Part D is meant to give you relief from unplanned expenses in the future. The coverage is not just meant for people who are currently on costly prescription drugs. This is because you never know when you will fall ill and require costly prescription drugs. On the other hand, most age-related illnesses require prescription drugs. Therefore, you can plan for an unexpected future by enrolling in Part D.

What can I do if I have Limited Income and Resources?
Part D provides extra help for those who have limited income and resources. If you qualify for extra help you may qualify for almost all of your prescription drug bill to be covered.

Factors to Consider when enrolling for this insurance Coverage

Once you enroll you will be required to pay a monthly premium. The amount of premium you pay will depend on the plan you choose.

  • Deductibles are the amount you pay before the benefit begins to assist with the costs. Deductibles differ from plan to plan therefore in some plans deductibles may be zero.
  • Co-payment/Co-insurance: This is the part of the bill you are responsible for after paying your deductibles. In some plans, you are responsible to pay a specific amount or percentage of the cost while in some plans the co-payment depends on whether the drugs are branded or generic. In other plans, your share of the cost might rise after exceeding a certain limit.


  • Formulary: this is the list of drugs covered by a Medicare plan and it includes both generic and brand-name drugs. To ensure that people with different medical conditions benefit from the plan, the plan includes two drugs in the categories and classes mostly used by people in Medicare.
  • Prior Authorization: There are some drugs that might be costly even when there are other less expensive drugs that work just as well. Other drugs might also be harmful when taken for too long or have more side effects. The Prior Authorization policy works to promote the correct usage of drugs. What this means is that your doctor might need to contact your plan and verify that you are really in need of a particular prescription drug for the drug to be included in your coverage.
  • Coverage Gap: In case your prescription drugs are costly you might need to opt for plans that offer additional coverage. In some plans there is a set limit that when exceeded you will be required to pay the whole cost. This is what is referred to as coverage gap. Therefore, it is important to choose the option that works for you best without compromising the quality of drugs you use However, it is still important to note that even in cases where a plan requires you to pay for 100% of the cost after a certain limit, the amount you end up paying will still be lower as compared to when you did not have the coverage.

Drug plans work with pharmacies in your locality. Therefore, it is important to ensure that the pharmacy you choose is convenient. For instance, some pharmacies will have a mail-order system that directly mails you your prescriptions.

Choose a plan that is most convenient for you as a beneficiary.
Even if you are not taking many prescription drugs at the moment, you should plan for your future. This is because as we age we tend to need more prescription drugs to keep us healthy and comfortable. In addition, the sooner you register for Part D coverage the better because this will save you from paying any penalties in future.

Medicare Advantage

Medicare Advantage Plans are health plan options that are approved by Medicare but managed by private companies. They are sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare. (see Medicare Part C) With Medicare Advantage Plans:

  • Some of the Medicare Advantage plans require referrals to see specialists.
  • In many cases, the premiums or the costs of services (co-pays and deductibles) can be lower than they are in the Original Medicare Plan or the Original Medicare Plan with a Medigap or Supplement policy. Medicare Health Plans charge different premiums and have different costs of services, so it is important to check with the plan before you join.
  • The plans will provide all of your Part A (hospital) and Part B (medical) coverage and must also cover medically-necessary services.
  • They often have networks, which mean you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.
  • They generally offer extra benefits, and many include prescription drug coverage.
  • In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans.
  • Some of the plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you.
  • You will not buy a Medigap policy if you choose to enroll in a Medicare Advantage Plan.

Medicare Advantage Health Plans include:

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Private Fee-for-Service (PFFS) Plans
  • Medicare Medical Savings Account (MSA) Plans
  • Medicare Special Needs Plans (SNP)

Medigap Policies

A Medicare Supplement Insurance (Medigap) policy, sold by private companies, can help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles. They fill the gaps. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share.

Each policy has its own set of benefits. Two of the standardized policies may have a high deductible option. In addition, any standardized policy may be sold as a "Medicare SELECT" policy. Medicare SELECT policies usually cost less because you must use specific hospitals and, in some cases, specific doctors to get full insurance benefits from the policy. In an emergency, you may use any doctor or hospital.

Outline of Medicare Supplement Coverage

(Benefit Plans A-N)

This chart shows the benefits included in each plan. Every company must make available Plan "A". Some plans may not be available in your state as indicated below.

A B C D F* G K L M N
Medicare Part A Coinsurance hospital costs up to an additional 365 days after Medicare benefits are used up
Medicare Part B Coinsurance or Copayment 50% 75% ***
Blood (First 3 pints) 50% 75%
Part A Hospice Care Coinsurance or Copayment 50% 75%
Skilled Nursing Facility Care Coinsurance 50% 75%
Medicare Part A Deductible 50% 75% 50%
Medicare Part B Deductible
Medicare Part B Excess Charges
Foreign Travel Emergency (Up to Plan Limits) 80% 80% 80% 80% 80% 80%
Out-of-Pocket Limit** $4,940 $2,470

*Plan F also offers a high-deductible plan. If you choose this option, this means you will pay for your Medicare-covered costs up to the deductible amount of $2,180 in 2015 before your Medigap plan pays anything
**For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible ($147 in 2015), the Medigap plan pays 100% of covered services for the rest of the calendar year.
***Plan N pays 100% of the Part B coinsurance, except for your copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don't result in your admission to the hospital.

What's the Original Medicare Strategy?

The Original Medicare Plan is a "fee for service" program. What this means is you're generally charged a dollar amount for each doctor visit and treatment you receive. This course of action, handled by the Government, is accessible nationally. You utilize your government issued card when you get healthcare. You can stick with this plan or elect to select a Medicare Advantage Plan to help pay for some of the amounts not covered by this plan.

Your prices in the Original Medicare Plan

What your cost are out-of-wallet depends on:

  • Whether you are enrolled in Part A & B
  • Whether your physician or provider agrees to accept "assignment"
  • How often you have a need for wellness care
  • Which type of healthcare you want
  • Whether you choose to get medical services or providers perhaps not included in Original Medicare. In cases like this, you'll pay out of pocket for these services.
  • Whether you've got insurance that is additional

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