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Supplemental Health Care Plans, Qualifications, Deadlines, Terms

Medicare and Medicaid Program Information

Medicare is a federal health insurance program that pays for most medical expenses for people age 65 and older. It will also pay for health care for some people under 65 who have disabilities. You can buy Medicare supplement insurance to help pay some of the out-of-pocket costs that Medicare doesn’t pay. Because it helps fill some of the coverage gaps (gaps), Medicare supplement insurance is often called Medigap insurance.

Do you need a supplement for Medicare?

Not all people need a Medicare supplement policy. If you have other types of health coverage, the coverage gaps may already be covered. You probably don’t need Medicare supplement insurance if:

Medicaid or the Qualified Medicare Beneficiary Program (QMB) pays your Medicare insurance premiums and other out-of-pocket expenses. The QMB is a Medicare savings program that helps pay for Medicare insurance premiums, deductibles, copay’s, and coinsurance. If you have other health insurance, ask your insurance company or agent how it works with Medicare.

Basic information about Medicare

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Original Medicare has two parts. Part A covers hospital services, while Part B covers other types of medical expenses. You can go to any doctor or hospital that accepts Medicare. Medicare supplement policies only work with Original Medicare.

Medicare Part A (hospital coverage) pays for

  • Inpatient services
  • care in a skilled nursing facility after a hospital stay
  • home care
  • hospice care
  • All blood, except the first three pints for each calendar year.
  • Medicare Part B (medical coverage) pays for
  • medical expenses
  • home health care
  • laboratory services
  • outpatient treatment in a hospital
  • durable medical equipment and supplies
  • preventive medical services, including exams, health evaluations, and immunizations.

Medicare Part D (prescription drug coverage) pays for brand name, generic and prescription drugs. You can get prescription drug coverage either by joining a stand-alone prescription drug plan or by purchasing a Medicare Advantage plan that includes drug coverage. If you have group health insurance, your health plan may already cover prescriptions. Ask your plan sponsor if the plan has prescription drug coverage comparable to Medicare Part D.

Insurance companies approved by Medicare offer Part D coverage.

The Centers for Medicare and Medicaid Services (CMS) publishes the Medicare & You handbook that describes Medicare coverage and health plan options. CMS mails the handbook each year to all Medicare beneficiaries. The handbook is also available by calling 1-800-MEDICARE (1-800-633-4227).

Services Medicare Doesn’t Cover

Most of long-term care. Medicare only pays for medically necessary care provided in a nursing facility. Attendant care, if it is the only type of care you need. Assistive care may include help with walking, getting up and lying in bed, dressing, bathing, going to the bathroom, shopping, eating, and taking medicine. More than 100 days of skilled nursing facility care during a benefit period after a hospital stay. The Medicare Part A benefit period begins on the first day you receive a Medicare-covered service and ends when you are out of the hospital or skilled nursing facility for more than 60 days in a row. Help services with housework. Private nursing care.
Most of dental care and dentures. Medical care received while traveling outside of the United States, except under limited circumstances. Cosmetic surgery and routine foot care. Routine eye care, glasses (except after cataract surgery), and hearing aids.

What you will have to pay with original Medicare

For Medicare Parts A and B, you will generally have to pay monthly insurance premiums, as well as deductibles, copay’s, and coinsurance. You also pay the full cost of services that Medicare doesn’t cover.

Medicare Advantage Plans

You may have the option to join a Medicare Advantage plan, also called Medicare Part C. To be eligible, you must have Medicare Part A and Part B and live in the area that has a plan. The federal government contracts with insurance companies and managed care plans to offer Medicare Advantage plans in certain geographic areas. Medicare pays the plan a set monthly amount for the plan to provide Medicare Part A and Part B services to its members. You pay your monthly Medicare Part B insurance premium and any insurance premiums charged by the Medicare Advantage plan. You will also have to pay any co-payments, deductibles, and coinsurance the plan requires. If you are in the Medicare Advantage plan, you will not receive a Medicare Summary Notice. Instead, you will receive monthly statements from your plan and you may be able to view your claims on the plan’s website.

Medicare Advantage options vary by ZIP code and county. Options available in Texas include:

  • Managed care plans, such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) ) and Provider-Sponsored Organizations (PSOs)
  • private fee-for-service plans
  • Medicare plans for special needs.

Medicare Advantage plans generally have more benefits than original Medicare. For example, some Medicare Advantage plans cover dental and vision services. However, Medicare Advantage may not be the best option for some people. Your selection of doctors and hospitals in a Medicare Advantage plan is limited. If you have other insurance, such as a group retirement plan, ask your group plan if it works with a Medicare Advantage plan or with Original Medicare. Because Medicare negotiates contracts with Medicare Advantage plans each year, the plans available and the benefits they offer can change each year. If your plan stops any services, you will have to find another plan in your area or return to Original Medicare. To find out what plans are available in your area, call Medicare or visit the Medicare Plan Finder. If your Medicare Advantage plan leaves your area, or if you move out of the plan’s service area, you may have the right to enroll in another Medicare Advantage plan. You may also be eligible to purchase Medicare Supplement Plans A, B, C, F (including Plan F with a high deductible), K, or L, regardless of your medical history or condition. If your Medicare Advantage plan ends, it must notify you in writing of your options and let you know how long you have to purchase a Medicare supplement policy. The written notice is proof to the Medicare supplement company that you have the right to purchase Medicare supplement insurance. If you are under 65 and have Medicare, this right in Texas is limited to Medicare Supplement Insurance Plan A.

The open enrollment period for Medicare Advantage and for prescription drug plans is October 15 – December 7.

Medicare will mail you the Medicare & You Handbook each year prior to open enrollment. The handbook contains a list of Medicare Advantage plans and prescription drugs. Use the handbook to check for any changes and costs in your Medicare Advantage or prescription drug plan. The Texas State Health Insurance Assistance Program (SHIP) can help you compare plans and costs in your area. Call the SHIP at 1-800-252-9240. The Medicare Open Enrollment Period does not apply to Medicare Supplement Plans.

Medicare Supplement Insurance

Medicare supplement insurance covers the gaps between what Original Medicare pays and what you pay out of pocket for deductibles, coinsurance, and co-payments. Medicare supplement policies only pay for services that Medicare deems medically necessary, and payments are generally based on the Medicare-approved amount. Some plans offer benefits that Medicare does not offer, such as emergency care outside of the United States. Medicare supplement policies are sold by private insurance companies that are licensed and regulated by TDI. However, the federal government establishes Medicare supplemental benefits.

Basic Benefits

The 10 Medicare Supplement Plans (Plans A, B, C, D, F, G, K, L, M, and N) provide the following benefits:

Hospitalization: You pay your daily copays for inpatient hospital expenses from day 61 to day 90 of the Medicare benefit period. You pay Medicare Part A copay’s for any hospital stay after the 90th day in a benefit period, up to an additional 60 days during your lifetime. (Those are your inpatient reserve days. You can use these days when you need to spend more than 90 days in the hospital during a benefit period. When you use a reserve day, that day is deducted from the total available for life. and you will not be able to use it again).

  • Medicare Part A coinsurance in addition to coverage for 365 additional days after Medicare benefits end. This part pays coinsurance for skilled nursing facility care.
  • Hospice: Pays copay for outpatient pain medications and coinsurance for inpatient long-term respite care. Plans K and L pay this cost at a different price. You must meet Medicare requirements, including obtaining a doctor’s certification that you are terminally ill.
  • Medical expenses: After you’ve met the Part B deductible, you pay your 20 percent Part B coinsurance portion of doctor bills, hospital or home care, and some other expenses. eligible for Medicare. Plans K, L, and N require you to pay a portion of the 20 percent coinsurance for Part B.
  • Blood: Pays for the first three pints of blood each year under Medicare Parts A and B.
    Further:

Plans B, C, D, F, G, and N pay the full amount of the Part A deductible.

  • Plans K, L, and M pay a percentage of the Part A deductible. The money limits you pay out of your own pocket apply to Plans K and L.
  • Plan N requires a $ 20 co-payment for most office visits and $ 50 for emergency room care.
  • Plans C and F pay the Part B deductible.
  • Plans C, D, F, G, M, and N pay for copay’s for skilled nursing facility care from the 21st through the 100th day in a benefit period for skilled nursing facility care after the hospitalization eligible under Medicare Part A. This is not attendance care. Plans K and L pay a portion of the cost until you meet annual out-of-pocket limits. Then the plan will pay 100 percent.

Plans C, D, F, G, M, and N pay for emergency care while traveling outside the United States. They pay 80 percent of the charges that Medicare would have paid if you had been in the United States. Care must begin during the first 60 days that you are outside the United States. The deductible for the calendar year is $ 250. The maximum lifetime benefit is $ 50,000.

Plans F and G pay for medical charges in excess of Part B that Medicare doesn’t cover. They pay 100 percent of the excess charges, which is limited to 15 percent over the Medicare-approved amount.
This table summarizes the benefits offered by each plan: Medicare Standard Supplement Insurance Plans.

How to keep your coverage if you move

If you move to another county or state, make sure your Medicare plan will remain in effect after you have moved. If you have Original Medicare, federal regulations generally allow you to keep your Medicare supplement policy. There are some exceptions if you have a Medicare Select plan or if you have a plan that includes added benefits, such as coverage for vision services or discounts that were only available where you bought the plan. If you have a Medicare Advantage plan, ask if the plan is available in your new ZIP code. If the plan is not available, you will have to get a new one. You can switch to another Medicare Advantage plan in your new area or to Original Medicare.

Alternatives to Medicare Supplement Insurance

Before you buy a Medicare supplement policy, find out if you have other options for paying Medicare costs out of your own pocket. The following plans and programs may help you pay the costs.

Group plans for employees

If you stay in your job after becoming eligible for Medicare and you still have health insurance through your job, you probably don’t need Medicare supplement insurance. The same is true if you have health coverage through a health plan from your spouse’s employer. Some employers offer coverage to their retired employees through group Medicare supplement or a Medicare Advantage plan. Because health plans work differently, ask your employer’s benefits coordinator how well the plan covers the gaps for parts of Medicare coverage. Then make a decision about Medicare supplement insurance.

COBRA coverage from an employer plan

Federal and state law allows people who quit their jobs to continue their employer-sponsored health coverage for a specified period of time. Consider the following: You have an eight-month period after your employment ends to enroll in Medicare. If you don’t sign up during that eight month period, you may have to pay a penalty when you sign up. If you are in your initial Medicare enrollment period, you must enroll in Medicare during that period to avoid a possible penalty. If you do not purchase a Medicare supplement policy during your open enrollment period, you will be able to purchase a Medicare supplement plan within 63 days of losing your COBRA coverage. Talk to your employer about COBRA and Medicare eligibility.

Medicaid

Medicaid is a state and federal program that pays for health coverage for people with low incomes. If you are eligible for Medicaid, the state will pay your Medicare insurance premiums and your out-of-pocket costs. Medicaid will also pay for some services that Medicare doesn’t cover. If you have Medicaid, you don’t need Medicare supplement insurance.

Medicare Savings Programs

Medicaid-sponsored Medicare savings programs pay for Medicare insurance premiums, deductibles, and coinsurance‘s for those who qualify. These programs allow people to use their savings to cover other expenses or to buy more coverage.

The Medicare savings programs are as follows:

  • The Qualified Medicare Beneficiary Program (QMB, for its name and acronym in English).
  • The Medicare Program for Low-Income Beneficiaries (Specified Low-Income Medicare Beneficiary –SLMB).
  • The Qualified Individuals Program (QI).
  • The Qualified Disabled Working Individuals (QDWI) Program.
  • The federal QMB program pays the Medicare Part B insurance premium and covers all Medicare deductibles and copay’s. You do not need Medicare supplement insurance if you are in the QMB program.

The other Medicare savings programs pay for Medicare Part A or Part B insurance premiums. You may need a Medicare supplement policy to help cover your other expenses.

Your Rights

Open enrollment for people 65 and older. The open enrollment period for Medicare Supplement Plans is a six-month period during which you can purchase any Medicare Supplement Plan offered in Texas. During this period, companies must sell you a policy, even if you have health problems. The open enrollment period begins when you enroll in Medicare Part B. You must have both Medicare Part A and Part B to buy a Medicare supplement policy. You can use your open enrollment rights more than once during this six-month period. For example, you can change your mind about a policy you bought, cancel it, and buy any other Medicare supplement policy. Although companies must sell you a policy during the open enrollment period, they may require a waiting period of up to six months before starting to cover your pre-existing conditions. However, there is no waiting period if you are 65 or older and had prior coverage. Pre-existing conditions are those for which you received treatment or medical advice from a doctor within the previous six months.

Open enrollment for Texas residents with disabilities

People under the age of 65 who receive Medicare due to disabilities have a six-month open enrollment period that begins the day they enroll in Medicare Part B. This open enrollment right only applies to Medicare Supplement Plan A. Note: People who have Medicare because of disabilities have another open enrollment period for the first six months after they turn 65.

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