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More About Medicare
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Q. What is Original Medicare?
In most cases, Medicare is a federal health insurance program for people 65 years old or over and for certain disabled people under 65 years of age. You are automatically enrolled in Medicare hospital insurance (Part A) when you apply for Social Security benefits – usually upon reaching 65 years of age. Part A covers inpatient care in a hospital or a limited stay in a skilled nursing facility. Part B covers physician and outpatient hospital services. The premium you pay for Part B is deducted from your Social Security benefits.
Medicare pays for many healthcare services and supplies, but it doesn’t cover all of your healthcare costs. For example, you pay a deductible for each hospital stay and coinsurance anytime you use the services of a physician or surgeon. Also, drug coverage is limited. Because Medicare rarely pays the full cost of covered services, you may want to consider a Medicare Advantage or Medicare Supplement plan.
Q. What is Medicare Advantage?
Medicare Advantage is the new name for Medicare+Choice plans. This type of health plan is an alternative to Original Medicare and was created by the Balanced Budget Act of 1997 and the Medicare Modernization Act of 2003. Medicare Advantage plans include:
- Medicare Health Maintenance Organization plans (HMO)
- Medicare Preferred Provider Organization plans (PPO)
- Medicare Private Fee-for-Service plans (PFFS)
Medicare Advantage plans feature prescription drug benefits, fixed costs, limits on out-of-pocket expenses, and worldwide coverage for emergency and urgent care.
Q. What is a Medicare Advantage HMO plan?
An HMO is an alternative to Original Medicare and features specific lists of doctors, hospitals, and other providers that you must use to receive benefits. HMOs often provide additional benefits not found in Original Medicare, including coverage for deductibles, steep reductions in coinsurance when you see a doctor, a drug benefit plan, and wellness or fitness programs. If you select a Medicare Advantage HMO, it is an alternative to your Original Medicare coverage. However, you can return to Original Medicare down the road if you wish. How Humana's HMO plans work.
Q. What is a Medicare Advantage PPO plan?
With a Medicare Advantage PPO, you can see any doctor you want. However, if you use a doctor who participates in the network, you get a better benefit and lower copayment/coinsurance than if you visit a non-network doctor. Plus, referrals aren’t needed, and you don’t have to see a primary care physician first. In addition to prescription drug benefits, Medicare Advantage PPOs may offer other benefits such as dental, vision, and nutritional supplements. If you select a Medicare Advantage PPO, it is an alternative to your Original Medicare coverage. However, you can return to Original Medicare down the road if you wish. How Humana's PPO plans work.
Q. What is a Medicare Advantage PFFS plan?
With a Medicare Advantage PFFS plan, you have the freedom to select any doctor, hospital, or healthcare provider who accepts Humana’s payment terms and conditions – without worrying about referrals or a list of doctors who participate in the plan’s network. PFFS plans feature limits on out-of-pocket expenses, coverage for emergency and urgent care, and in some cases, a prescription drug benefit. If you select a PFFS plan, it is an alternative to your Original Medicare coverage. However, you can return to Original Medicare down the road if you wish. How Humana's PFFS plans work.
An Insurance Company with a Medicare Advantage contract to offer a Private Fee-for-Service plan available to anyone enrolled in both Part A and Part B of Medicare through age or disability. Enrollment period restrictions apply, call Humana for details. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan's terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Website at www.humana-medicare.com/humana-gold-choice-terms-conditions.asp.
Q. What is a Medicare Prescription Drug (Part D) plan?
Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future.
Q. What is a Medicare Supplement plan?
A Medicare Supplement insurance plan helps cover the “gaps” in coverage that are left unpaid after Original Medicare pays its portion of your healthcare expenses. For this reason, these plans are often referred to as Medigap plans. Unlike a Medicare Advantage plan, which is an alternative to your Original Medicare benefits, a Medicare Supplement plan is purchased in addition to your Original Medicare benefits.
Medicare Supplement policies are standardized into 12 plans – labeled “A” through “L,” each with its own set of benefits. Plan A covers the most basic benefits. These basic benefits are also covered in each of the remaining Medicare Supplement plans – B through L. Plans B through L provide additional coverage beyond the basics, with Plan J offering the most benefits.
Medicare Supplement policies are sold by private insurance companies. While the costs of these policies may vary, individual insurance companies must provide the same standardized benefits as outlined by law. To purchase a policy, in general you must be enrolled in Medicare Part A and Part B. In addition to paying the monthly Medicare Part B premium to Medicare, you will have to pay a premium to the insurance company providing your coverage.
Q. How do I know if I have Medicare Parts A and B?
Look at the “Is Entitled To” section of your red, white, and blue Medicare card. If you have Part A, “HOSPITAL (PART A)” is printed on your card. If you have Part B, “MEDICAL (PART B)” is printed on your card.
Q. Can you help me compare Original Medicare to the Medicare Advantage plans?
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Original Medicare (managed by the government) |
Medicare Advantage (sponsored by the government and offered by private insurers, including Humana) |
| Benefits |
Part A - Inpatient hospital
Part B - Doctors' services
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Inpatient hospital and provider services, plus additional benefits such as vision and dental |
| Premium |
Part A - $0 for people who have worked 40+ quarters
Part B - $93.50 per month
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Monthly plan premium varies by plan and geographic area. Some plans have no additional monthly premium. |
| Types of plans |
Fee-for-service |
Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee for Service (PFFS), and specialty plans |
| Is additional - coverage necessary? |
Yes - additional policy from private insurance company, at added cost |
No - not needed because benefits are extensive |
| Billing procedures |
Provider bills Medicare first, insurance second |
Simplified administration - in most cases, provider bills only the Medicare Advantage insurance company |
Q. Can you help me compare Original Medicare to Medicare Supplement (Medigap) plans?
Medicare doesn’t pay for all of your healthcare costs. There are “gaps” or “out-of-pocket” costs that you must pay in the Original Medicare plan. The chart below gives some examples of these gaps. A Medicare Supplement policy covers some, but not all, of the gaps in the Original Medicare plan.
If you are in the Original Medicare plan, a Medicare Supplement policy might help you:
- Lower your out-of-pocket costs, and
- Get more health insurance coverage
To view examples of costs you could pay if you are in Original Medicare, without a Medigap Policy, see the chart on page 8 of the Choosing a Medigap Policy publication from Medicare.gov.
Q. Where can I get more information about Medicare Advantage plans, Prescription Drug plans, Medicare Supplement plans and my Social Security benefits?
- Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-1850
1-800-633-4227
TTY 1-877-486-2048
24 hours a day; seven days a week
www.medicare.gov
- Social Security Administration
Office of Public Inquires
Windsor Park Blvd.
6401 Security Blvd.
Baltimore, MD 21235
1-800-772-1213
TTY 1-800-325-0778
7 a.m. – 7 p.m.
www.ssa.gov
- Railroad Retirement Board
Chicago District Office
844 N. Rush Street
Ninth Floor
Chicago, IL 60611-2092
1-800-808-0772
TTY 312-751-4701 24 hours a day, 7 days a week
www.rrb.gov
Q. What is the Medicare Modernization Act?
The Medicare Modernization Act – or “MMA” – introduced the most sweeping changes to Medicare since the program was first signed into law in 1965. The full name of the Act is Medicare prescription drug Improvement and Modernization Act of 2003.
The changes went into effect January 1, 2006, providing you more choices in Medicare coverage – including prescription drug benefits. At its core, the Medicare Modernization Act extends prescription drug coverage to everyone who has Medicare. This prescription drug benefit is known as “Medicare Part D.”
Q. What are the basic parts of the Medicare program now?
There are four parts to Medicare.
Medicare Part A is hospital insurance – including hospital stays, rehabilitative nursing facilities, home healthcare, and hospice. Most people don’t have to pay a premium for Part A because it was prepaid through their payroll tax while they were working.
Part B is medical insurance – including doctors’ services and outpatient care. There is a monthly premium for Part B. If you don’t sign up for Part B when you first become eligible at age 65 or when you have been disabled for two years and you decide you need to join in the future, you may have to pay a penalty for each year you didn’t belong.
Medicare Part C is the Medicare Advantage plan. With this option, you can opt to have your Medicare Parts A and B provided by a private company like Humana.
Medicare Part D is prescription drug coverage. In one way, Part D is like Part B: If you don’t join at age 65, you may have to pay a penalty when you do join.
Q. What’s the difference between traditional Medicare and Medicare prescription drug coverage?
Original Medicare covers hospital costs under Part A and medical costs like doctor’s office visits under Part B. Medicare Part D provides benefits for prescription drugs obtained at a pharmacy – a growing part of many peoples’ healthcare budgets.
Prescription drug plan coverage differs from Original Medicare in two ways: (1) It is available only through private insurance companies like Humana and (2) you have to use certain providers, called in-network pharmacies, to take advantage of your coverage.
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