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As we age, we grow more vulnerable to chronic and seasonal illnesses. And many times these illnesses can hit hard and fast, sometimes making it difficult to recover. But taking preventative measures against illnesses, like getting vaccines, is a safe course of action. To help accomplish this, Medicare beneficiaries have access to comprehensive benefits for routine vaccinations. In this guide to Medicare vaccine coverage, we’ll review how vaccines are covered by Original Medicare and the various private Medicare insurance plans on the market. The Importance Of Vaccines For Adults Over 65 It’s much easier to avoid getting sick with some illnesses than it is to treat, recover or survive them. This is especially true for those ages 65 and up: Illnesses such as the flu, pneumonia, and COVID-19 can take a heavy toll on this population. And since most of these illnesses are seasonal by nature, they’re perfect candidates for vaccines. In fact, the CDC recommends that adults ages 65 and over have annual vaccination against the flu. Studies have shown that seniors who are vaccinated are more likely to avoid seasonal illnesses and have fewer severe symptoms, including a decreased chance of: Doctor’s visits Hospitalizations Death However, there are non-seasonal vaccinations for adults over age 65. These may include: Varicella / Shingles Tdap Pneumococcal Hepatitis A and B Quick Medicare Tip: Be sure to check with your doctor for advice on which vaccines to get and how frequently you should receive them. This is especially important because of the potential for interactions with existing health conditions. What Vaccines Does Medicare Cover? Medicare vaccination coverage depends on how the specific vaccines are categorized. In other words, vaccines can be covered by Medicare Part B. But in other cases, vaccines are covered by Medicare Part D drug plans. Medicare Part B Vaccine Coverage Medicare Part B covers outpatient medical care, broken down into two groups of services: Medically necessary services, and Preventative services You’ll use Part B for routine healthcare like doctor’s visits and lab work. Unlike Part A of Original Medicare, you’ll probably have to pay a monthly premium to have Part B coverage. Medicare Part B covers vaccinations under the preventive services category. And many recommended elderly immunizations are included in Medicare Part B vaccine coverage. The following vaccines are among the most important. Flu Vaccines Medicare Part B covers influenza vaccinations. Medicare will cover one flu shot per person, per flu season. And you will pay nothing as long as you receive your flu shot from a doctor or other qualified health care worker who accepts Medicare “assignment.” This means that they agree to accept Medicare’s payment as payment in full. Most doctors and health care practitioners take Medicare Assignment. Hepatitis B Shots Medicare Part B vaccine coverage for the Hepatitis B vaccine is a little more complicated. Part B will cover it, but only if you’re at moderate or high risk. You’re considered to have medium or high risk if any of these apply to you: You have hemophilia You have End Stage Renal Disease (ESRD) You have diabetes You live with someone who has Hepatitis B You’re a healthcare worker and frequently exposed to bodily fluids If you meet these criteria and receive the shot from a practitioner who accepts Medicare assignment, you’ll pay nothing. The Hepatitis B vaccine may be given as a series of two or three injections, depending on which vaccine is used. Pneumococcal Shots Medicare Part B will cover a total of two pneumococcal shots for seniors. You can get the first shot at any time, and Part B will cover the second shot as long as you receive it at least one year after your first injection. Like other instances of Medicare vaccine coverage, you’ll pay nothing out of pocket if you get the pneumococcal shots from a qualified practitioner who takes Medicare assignment. COVID-19 Vaccine As the newest and most urgently needed vaccine on the block, Medicare Part B will cover the COVID-19 vaccine. We’ll review some of the specifics of COVID-19 Medicare Part B vaccination coverage shortly. For now, COVID-19 vaccine coverage through Medicare Part B is all available for no out-of-pocket cost. Quick Medicare Tip: Need more help understanding Medicare Part B? Visit our Guide to Medicare Part B to learn how Medicare Part B coverage works. Medicare Part D Vaccine Coverage Medicare Part D is the prescription drug program for Medicare beneficiaries. Drug coverage is not available as part of the Original Medicare Fee-for-Service program. Instead, it’s offered by private insurance companies. Medicare Part D drug coverage is available as 2 types of plans: Standalone Prescription Drug Plans (PDP), and Medicare Advantage Prescription Drug (MAPD) Plans. Whether you get prescription drug coverage from a standalone plan or a Medicare Advantage plan, the drug coverage works the same. In both cases, your insurance company helps pay part of the cost of your medications. Unlike Medicare Part B vaccine coverage, you’ll generally have to pay some share of the cost for Medicare Part D vaccination coverage. The formal list of drugs and vaccines covered is known as a Medicare Part D formulary. The formulary is an exclusive list. Two things to know: If a drug or vaccine isn’t on the formulary, then the plan doesn’t cover it. If you receive medications of vaccines that aren’t on your plan’s formulary, then the plan won’t cover it and you’ll pay full price. That said, it’s important to make sure that you only use medications or vaccines that are on your plan’s formulary. With Part D drug coverage, you’ll usually pay a copayment or coinsurance amount for each drug or vaccination you receive. But this amount can change during the course of the calendar year as you move through the four coverage stages of Medicare Part D. Part D drug plans cover vaccines that are not covered by Medicare Part B. Generally speaking, these vaccines are considered to be less necessary than the vaccines covered by Part B. And since Medicare Part D vaccine coverage is provided by a private insurance plan, you don’t have to worry about whether your practitioner accepts Medicare assignment. As long as they accept your Part D plan, you’ll only pay the required copayment or coinsurance. Zoster (Shingles) Vaccine The shingles vaccine is covered by Medicare Part D plans. The CDC recommends that people over age 65 receive two doses of this vaccine. MMR Vaccine Private Part D drug plans cover the Measles, Mumps, and Rubella vaccine in one or two doses if you were born after 1957. Tdap Vaccine The tetanus, diphtheria, and pertussis vaccine is eligible to be covered by Medicare Part D plans. The CDC recommends that you receive a new shot every ten years. A more frequent dose may be required in response to some wound care situations. Again, your vaccine costs will vary based on your individual plan formulary as part of Medicare Part D vaccine coverage. To find out how much you’ll pay, you’ll need to contact your Part D plan. If you have trouble affording medications including Part D covered vaccinations, you may be able to get assistance through the Extra Help program. Extra Help is available to people who meet certain income and asset requirements. If you qualify, you’ll pay less for your medications, and you may even get help paying for your Medicare Part D premium. You will have to recertify for Extra Help each year, but the savings are worth the effort. Quick Medicare Tip: Visit our Guide to Medicare Part D to read more about how Part D coverage works. How Does Medicare Cover The Coronavirus Vaccine? As we covered earlier, adults ages 65 and up are more vulnerable to coronavirus than other age demographics. And COVID-19 has definitely taken its toll on this age group. That’s why it’s especially key that Medicare beneficiaries take advantage of their Medicare benefits, including Medicare coverage for COVID-19. Under a provision of the 2020 CARES Act, any FDA-approved coronavirus vaccine will be covered by Medicare Part B. This includes both two-shot vaccines and single dose COVID-19 vaccines. As long as the coronavirus vaccines are FDA-approved, Medicare will cover the costs. Also, since Medicare Advantage is required to have the same coverage as Original Medicare, Medicare Advantage plans also cover the coronavirus vaccine. Other key things to know about Medicare coverage for coronavirus includes: Medicare covers COVID-19 testing. Medicare covers COVID-19 antibody tests. Medicare covers all medically necessary hospitalizations, including hospital stays for COVID-19 treatment and quarantine requirements. Medicare Advantage plans can’t charge deductibles, copayments and coinsurance for tests that detect or diagnose COVID-19. Medicare Advantage plans may offer additional benefits like telemedicine to keep you out of the waiting room and get non-emergency care at home. How Does Medicare Cover Travel Vaccinations? As a general rule, Medicare does not cover vaccinations for international travel. However, some Part D drug plans may offer coverage for vaccinations necessary for travelling outside the U.S. Be sure to contact your Medicare Part D plan to see if this is the case. Otherwise, you’ll need to pay out of pocket for your travel immunizations. Conclusion: Medicare and Vaccines Vaccines aren’t just for kids - they’re an important way for all ages to keep healthy and prevent illnesses. And Medicare vaccine coverage gives those ages 65 and up the support needed to get access to crucial vaccines. After all, preventing infection is much easier than treating certain illnesses, especially those that affect the respiratory system like COVID-19, flu, and pneumonia. Through Medicare Part B of Original Medicare and Medicare Part D drug plans, you can be sure that necessary vaccines will be covered at the optimal doses and frequency. But just because a vaccine is recommended for most people and covered by Medicare doesn’t mean that you should run out and get it. Some vaccines may not be suited to you based on your individual health status and history. For this reason, it’s critical that you speak with your doctor about the vaccines you should and shouldn’t receive. You can also learn more about Medicare coverage for vaccines on the benefits provided by your Medicare insurance plan. Just remember: Part D plans change their formularies every year, so the costs of Medicare Part D vaccines may change. Always review your coverage during the Medicare Open Enrollment Period, and consider switching to a plan that better suits your needs if necessary. If you’d like to get help finding a Medicare plan, call 800-620-4519 to speak with one of our licensed insurance agents, or click to try our Medicare plan comparison tool to find Medicare Advantage or Prescription Drug Plans near you. The above information does not constitute medical advice. Always consult with a medical professional regarding your health needs. If you are experiencing a health emergency, contact your local emergency health services immediately or visit the nearest emergency room or urgent care.
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If you’re approaching your 65th birthday or caring for an older relative, you may be wondering how to apply for Medicare. Do you have to apply specifically, or is coverage provided automatically? What form(s) do you need? The answer depends on your unique situation and medical needs. In this article, we’ll help you understand how to apply for Medicare in a variety of situations. How To Apply For Medicare Part A and B? Medicare Part A is hospital insurance, while Medicare Part B is medical insurance. For most Americans with sufficient work history, there’s no monthly premium associated with Part A coverage. There is a monthly cost for Medicare Part B. Curious how to apply for Medicare Part A? You may not need to! You’ll receive Medicare Part A and B automatically without applying if you’re receiving Social Security or Railroad Retirement Benefits (RRB) for at least four months before you turn 65. If you’re not receiving Social Security benefits before you turn 65, you’ll have to enroll with Social Security to get the coverage you need. If you’re still working and have a group health insurance plan when you become Medicare-eligible, you can choose to delay enrollment in Medicare Part B without later paying a penalty when you enroll. When your group health insurance plan ends, you can apply online or by using the Part B enrollment form. If you have qualifying disabilities and you’re under 65, you’ll receive Part A and Part B automatically after you’ve received Social Security disability benefits for 24 months. If you have ALS (Lou Gehrig’s Disease), you’ll automatically get Medicare Parts A and B the month your disability benefits begin. Finally, if you have End-Stage Renal Disease, Medicare benefits are optional. If you want them, you will need to sign up by contacting Social Security. How To Apply For Medicare Part C & D Medicare Part C, also known as Medicare Advantage, is an all-in-one replacement for Original Medicare and includes additional benefits. For instance, most Medicare Advantage plans include prescription drug coverage, and some include vision, dental, and other benefits. You can purchase Medicare Advantage plans directly from private insurance companies. The plans vary in terms of price, benefits, and medical network. That’s why it’s important to get multiple quotes and compare your options before you make a decision. Medicare Part Dis an optional add-on that you can have in addition to Parts A and B. Part D, also known as a Medicare drug plan, provides prescription drug coverage and costs an additional monthly premium. How to Apply for Medicare Part D You can apply for Medicare drug plans using the Medicare Plan Finder tool or by calling the provider directly. Applying For Medicare FAQs As you review your Medicare options, you may find that you have a few questions. Here are some of the most common concerns we hear. What Documents Do I Need To Apply For Medicare? If you’re automatically enrolled in Medicare Part A and B, you won’t need any additional documentation. However, if you enroll yourself, you will need to provide your date and place of birth and information on any current health insurance, whether that’s Medicaid, private coverage, or group coverage from your employer. How Do I Sign Up For Medicare Online? Signing up for Medicare online is the easiest option if you aren’t automatically enrolled. Find and compare Medicare plans online. Learn More About How to Apply for Medicare With its various parts and enrollment dates, navigating Medicare can be a challenge. We’re here to make it easier for you. Contact us to speak to a licensed insurance agent who can answer all of your Medicare application questions.
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Medicare was originally designed for individuals who had retired from the workforce. As a result, the standard was set that you qualify for Medicare when you’re 65 years old. However, there are now additional ways to qualify for Medicare. Younger people with qualifying disabilities can also be eligible, along with individuals with end-stage renal disease. If you meet certain qualifications, you can get Medicare Part A for free, but Medicare Part B comes with a monthly premium. It’s important to understand who is eligible for Medicare Part A and Part B and who is not eligible for Medicare so you get the benefits you understand your medical benefits and costs. Medicare Eligibility Requirements There are a variety of requirements to be eligible for Medicare, especially if you want Part A with no monthly premium. Below are some of the more specific details on Medicare eligibility requirements. To qualify for Medicare you need to: Be a U.S. citizen or permanent legal resident who has been in the U.S. for at least five years Be 65 or older You can qualify for Medicare if you’re under 65 but have a qualifying disability or end-stage renal disease Who Qualifies for Premium-Free Medicare Part A? You can get Medicare Part A without a premium if: You are 65 or older and you or a spouse worked and paid Medicare taxes for at least 10 years You receive benefits from Social Security or the Railroad Retirement Board You or your spouse had government employment that was Medicare-covered Who Can Apply For Medicare Part A and Part B? Anyone who meets the eligibility requirements can apply for Medicare coverage. Your initial enrollment period begins three months before your 65th birthday and lasts seven months. If you sign up during the first three months of your enrollment period, your Medicare coverage will go into effect the first day of the month you turn 65. If you qualify for premium-free Medicare Part A and you are receiving Social Security benefits when you become eligible for Medicare, your Part A coverage will begin automatically when you turn 65. . If you’re not receiving benefits, you can still get Medicare Part A on time by enrolling online or contacting Medicare directly. While Part A may be automatic for some, all individuals must apply to enroll in Part B. You can sign up for Part B during your initial enrollment period that occurs around your entitlement to Part A, and then generally only between January 1 and March 31 of each year (unless you have delayed because you continue to work). . If you don’t apply for Medicare Part B when you’re eligible, you’ll most likely have to pay a late enrollment penalty. If you have to pay for Medicare Part A, it follows the same rules as Medicare Part B. You can only enroll at specific times, and you have to sign up. Who can Apply for Medicare Online? Any qualifying individual can apply for Medicare online, however, you can only sign up during the initial enrollment period and then between January 1 and March 31 of each year. Medicare Eligibility FAQs Here are a few common questions we hear about Medicare eligibility: Can I Get Medicare at 62? Some people begin to claim retirement benefits from social security at age 62 and might wonder if they can also get Medicare benefits at that time. Generally, the answer is no. You can only get Medicare before age 65 if you have been on Social Security disability for at least two years, have ALS (Lou Gherig’s disease), or suffer from end-stage renal disease. Can You Get Medicare If You’ve Never Worked? If you haven’t worked, you can still qualify for Medicare, but you may have to pay a monthly premium for both Medicare Part A and Part B. You may still be able to get Medicare Part A premium-free if your spouse worked, or if you have specific disabilities or medical conditions. Who Can Get Premium-Free Medicare Part A? You can qualify for premium-free Medicare Part A if you qualify for Original Medicare and have the appropriate work history as described above (i.e. paid Medicare taxes for 10 years). Generally, you have to pay a premium for Medicare Part B, but there are options for those with limited income and limited assets. The Medicare Savings Program (MSP) can help pay your Medicare Part A and B premiums if you qualify. Learn More About Medicare Eligibility Requirements If you’re curious about your Medicare eligibility and want to talk to a licensed insurance agent, we’re here to help. Simply give us a call at 1-866-955-0898 (TTY 711) or visit our website to review your options today!
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Medicare is a health insurance program provided by the federal government. Medicare is provided for individuals who are 65 and older, as well as younger people with disabilities or end-stage renal disease. Medicare includes several parts, each of which provides coverage for specific medical needs. Original Medicare includes Part A (hospital coverage), Part B (medical coverage), and Part D (prescription medication coverage). Medicare Part C is known as Medicare Advantage. Who Qualifies for Medicare? As we mentioned above, an individual qualifies for Medicare if he or she is 65 or older. Younger individuals can qualify for Medicare if they are permanently disabled or diagnosed with end-stage renal disease. What Is The Purpose Of Medicare? Medicare is available to make health coverage accessible to older Americans age 65 and over, including those who are traditionally retired and no longer have access to employer-based health insurance. Medicare also provides coverage to those under 65 with certain disabilities to cover their health needs and associated expenses. These Americans often cannot work and don’t have access to employer coverage or other health insurance. Types of Medicare Medicare is divided into several parts, labeled from A to D: Medicare Part A is known as hospital insurance. It offers coverage for inpatient hospital care, lab tests, and surgery, as well as home health care and skilled nursing facilities. These services must be deemed medically necessary to be covered by Medicare. You may have to pay a deductible or coinsurance Medicare Part B is used for medical visits to a doctor. Medicare covers medically necessary services and preventive services. Each Medicare participant pays a monthly premium for Medicare Part B and there may also be deductibles and coinsurance that apply, depending on the care you receive Medicare Part C is known as Medicare Advantage. This isn’t part of Original Medicare but instead is an all-in-one replacement plan. Medicare Advantage plans include hospital coverage and doctor’s visits, along with prescription drug coverage. Many also offer additional benefits Original Medicare doesn’t cover, such as vision and dental care. However, you will often need to use medical professionals within the provider’s network. You’ll pay different copayments and deductibles with Medicare Advantage than with Original Medicare, which may allow you to save money. You may also have an additional monthly premium Medicare Part D is prescription drug coverage. It helps you pay for both brand-name and generic drugs, depending on your needs. The drug plans for Medicare are offered by insurance companies and other approved private companies. If you choose Medicare Part D, you will have a separate Part D premium each month Medicare FAQ In addition to the different types of Medicare, qualified individuals, caregivers, and loved ones often have questions about Medicare coverage. Here are some additional Medicare FAQ and answers. What Does Medicare Cover? Medicare covers a wide variety of healthcare services. The specific coverage depends on the Medicare policy you choose. Services covered by Medicare include: Ambulance services Anesthesia Artificial eyes & limbs Bariatric surgery Blood processing & handling Cardiac rehabilitation programs Cardiovascular disease screenings Cervical & vaginal cancer screenings Chemotherapy Depression screenings Diabetes prevention programs Diagnostic tests (laboratory and non-lab) Eye exams (routine) Eyeglasses & contact lenses Flu shots Foot care Hearing aids Hepatitis B and HIV screenings Inpatient hospital care Kidney transplants Lung cancer screenings Mammograms Mental health care (inpatient and outpatient) Occupational therapy Opioid use disorder treatment services Organ transplants Pain management Prescription drugs (outpatient) Preventive & screening services Radiation therapy Sexually transmitted infections screenings & counseling Sleep studies Surgery Urgently needed care X-rays Yearly "wellness" visits Do I Need Medicare if I Already Have Health Insurance? Whether or not you need Medicare if you already have health insurance depends on your individual medical needs. You may need Medicare even if you already have other health insurance if your current plan doesn’t meet the minimum coverage requirements. Most plans offered by employers meet these standards. So if you have insurance through your job, you probably don't need Medicare. However, by staying on an employer plan, you can delay enrolling in Part B without a penalty and avoid paying Part B premiums. An important note: When you have Medicare plus additional insurance policies, each provider becomes a "payer." The policy that pays for your specific medical services first depends on the coordination of benefits rules for your plans. In other words, the primary payer will pay what it owes on your medical bills first, then the provider will send the remaining amount to the secondary payer to pay the rest. What is the Difference Between Medicare and Medicaid? Medicare is a federal health insurance program for older Americans and those with disabilities regardless of income. Medicaid is a state-based health insurance program for lower-income Americans that need help paying for medical care. To learn more about costs, eligibility, and coverage, visit this guide to Medicare vs. Medicaid. Who Do You Call for Medicare Questions? If you have additional questions about Medicare and what it covers, you can call 1-866-955-0898 (TTY 711) to speak with one of our licensed insurance agents. Agents are available Monday - Friday from 8am - 9pm and Saturday - Sunday 10am - 5pm ET. Where Can I Get Free Medicare Advice? For information on Medicare coverage, open enrollment, the different types of Medicare, and more, visit our Medicare learning center. For specific Medicare questions, contact us to speak with a licensed insurance agent. Learn More About Medicare Medicare is a valuable way to cover your healthcare costs if you are older or disabled. To compare your options and find the right Medicare plan in your area, visit our Medicare plans page today!
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Retirement should be a time of joy and freedom, but too often these years can unfortunately be tainted by battles with chronic illnesses. And one of the most common is cardiovascular disease (CVD), often called heart disease. In fact, heart disease is the leading cause of death in the United States. That’s why February marks American Heart Month - a way to bring awareness to heart disease and help spread tips on heart disease prevention. And to help celebrate American Heart Month, we’ll review some of the facts about cardiovascular disease, along with tips to combat it. Then we’ll dive into how your Medicare coverage can help you prevent, treat or manage cardiovascular diseases. What Is Heart Disease? Heart disease, also known as cardiovascular disease CVD is a broad term for several different medical conditions. But generally speaking, heart disease is an illness that affects the heart or circulatory system. The illnesses that fall under the heart disease category include: Coronary artery disease (CAD) Heart rhythm problems Congenital heart disease Infections of the heart tissue Heart valve disease Cardiovascular Disease Risk Factors Many of the biggest risk factors of cardiovascular disease are lifestyle related. And while there’s a general assumption that these factors are the sole cause, many people are actually born with heart disease. It can be congenital and hereditary. But those with lifestyle risk factors have control over heart disease prevention. The main risk factors and causes of heart disease include: Obesity High cholesterol Diabetes Smoking High blood pressure And these causes of heart disease can be directly tied to such behaviors as: Poor diet Poor physical activity Too much alcohol Tobacco use Genetics or heredity Simply put, the lifestyle habits (good or bad) that we form are what lead to the major risk factors for cardiovascular disease. Genetics and heredity may then play a role in whether or not we actually develop heart disease. 4 Tips To Prevent Cardiovascular Disease CVD As we mentioned above, the fact that so many of the risk factors for CVD are lifestyle related can be a silver lining, meaning we can make smart choices and avoid unhealthy behaviors to protect our hearts. Now let’s walk through some healthy habits to maintain good heart health. #1. Stop Smoking Quitting smoking is almost universally hailed as the biggest step to reduce your risk of heart disease. Smoking is considered the most easily avoidable lifestyle factor that leads to cardiovascular disease. So if you currently smoke, make an attempt to stop now. Quitting smoking will also save you money, making this heart disease prevention tip a no-brainer. #2. Eat Healthy Diet also plays a big role in the health of your heart. A poor diet multiplies and compounds risk factors, but a smart, healthy diet can reduce your risks and get your heart in great shape. You should always speak with your doctor about nutrition and heart healthy diet options. But generally speaking a heart healthy diet may include: Fruits and vegetables Whole grains Low-fat dairy products Skinless poultry and fish Nuts and legumes In addition to eating these nutritious foods, another suggested tip is to limit your saturated fat, sodium, and sugar intake. This type of diet fits into the DASH (Dietary Approaches to Stop Hypertension) eating plan. #3. Stay Active There’s no getting around the fact that an active lifestyle is a healthy one. But you don’t have to jump right in and overdo it. In fact, gentle but steady exercises can be great way to help prevent heart disease, including: Walking 30 minutes per day Cycling Swimming The main point is to pick an activity that you enjoy. So if you have a scenic path, beach, or lake nearby, consider talking walks or riding your bike there. You should also have a backup plan for poor weather or to keep safe and healthy during COVID-19. Research home workout apps or programs on platforms like YouTube or you Smart TV. But just remember: If you over-commit to exercise and activity, you may fall off the wagon completely. Instead, start small, and add time and distance gradually. If you make it a firm part of your routine, you’ll stick to it. Again, always be sure to consult your doctor before developing an exercise or activity regimen for heart health. #4. Stay Informed About Your Cardiovascular Disease CVD Risks One of the most important heart disease prevention tips is to stay proactive and empowered about your own personal health. This is especially true if you have a family history or genetic predisposition. Here are some key strategies: Don’t miss or delay your doctor’s appointments. If recommended, make sure you get cardiovascular screenings and tests. If you’re on heart disease medications, be sure to consistently take them and follow your treatment plan. Ask questions and be proactive when it comes to your health and wellbeing. How Does Medicare Cover Cardiovascular Disease CVD? If you’re on Medicare or aging into Medicare,and cardiovascular disease prevention and treatment is important to you, you’re in luck. All aspects of the Medicare program cover heart disease related measures. This includes Medicare cardiovascular screening, treatment, and healthy lifestyle tools. Heart disease prevention and treatments are covered by: Original Medicare Part A Original Medicare Part B Medicare Part D drug plans Medicare Advantage plans (Part C) Medicare Supplement Insurance (Medigap plans) In the most basic sense, Medicare will cover all the stages of cardiovascular disease, including: Annual screenings (covered by Part B) Doctor’s visits, both primary and specialists (covered by Part B) Heart condition medications (covered by Part D) Cardiovascular tests and procedures (covered by Part B) Hospitalizations (when admitted as an in-patient, covered by Part A) When you use Medicare Part B under Original Medicare, you can expect to pay: Part B deductible ($203 for 2021) Part B coinsurance (20% of the Medicare-approved charges) Part B excess charges (up to 15% of the Medicare-approved charges if you use providers who don’t agree to Medicare’s prices) When you use Part A coverage under Original Medicare, your costs may include: Part A deductible ($1,484 per benefit period) Part A coinsurance of $0 per day (after you pay the deductible) for hospital stays of up to 60 days Part A coinsurance of $371 per day for hospital stays over 60 days Medicare Cardiovascular Screenings Medicare covers cardiovascular screenings, which involves a blood test once every five years. But if your doctor orders more frequent cardiovascular screenings and tests, Medicare will cover them. However, you’ll pay your share of costs as we outlined above. Medicare Cardiac Rehabilitation Programs Medicare Part B will cover part of the costs for cardiovascular disease rehabilitation programs. These covered programs include exercise, education, and counselling designed to maintain your heart health. Note: Medicare Part B will cover these cardiac rehabilitation programs, only if any of these scenarios apply to you: You’ve had a heart attack in the last 12 months. You’ve had heart bypass surgery. You’re experiencing stable angina or chronic heart failure. You’ve had a heart of lung transplant. You’ve had a valve or artery repair or replacement. Once again, you’ll pay your standard 20% coinsurance if you use these cardiac rehab programs under Medicare Part B. Cardiac Tests Covered By Medicare Beyond standard cardiovascular disease screenings and rehabilitation programs, Medicare will cover medically necessary cardiac tests ordered by your doctors. These types of heart tests may include: Blood tests Echocardiograms (ECG) Exercise stress tests - MRI or x-rays Just as with the other services, you’ll pay 20% cost-sharing under Part B of Original Medicare. Cardiovascular Medications Most prescription drugs are not covered by Original Medicare. But you may be able to get heart and cardiovascular prescription drug coverage through a Medicare Part D plan. The 2 types of Medicare plans that offer Part D: Standalone Prescription Drug Plans (PDP) and Medicare Advantage plans that include Prescription Drugs (MAPD) It’s important to note that not all drugs are covered by all Medicare Part D drug plans. However, all Part D plans must cover at least two drugs in every therapeutic category, including heart disease or cardiovascular disease. Tip: You can use our prescription lookup tool to see if your drugs are covered under Medicare Part D. Medicare Chronic Condition / Disease Management Programs If you have more than one chronic condition, you can qualify for special disease management programs. These are also covered by Original Medicare, but you’ll still be responsible for your standard cost sharing. You may also have to pay a monthly fee to participate in these chronic care management services. Under these management programs, you’ll work with your healthcare professionals to craft a comprehensive health plan tailored to your heart condition. A chronic care management plan may include: Goal setting and health evaluations Working with all of your specialists Managing your medications Cardiovascular Disease And Private Medicare Plans So far, we’ve reviewed your coverage and costs under Original Medicare. But if you choose a private plan option like Medicare Advantage or Medigap, these plans will cover your cardiovascular health as well. If you enroll in a Medicare Supplement plan, your plan will pay part of the costs you’d normally pay out of pocket. If you enroll in a Medicare Advantage plan, you’ll likely pay small copayments - similar to what you’d pay under Original Medicare. But with Medicare Advantage, you’ll have out-of-pocket spending protection, since these plans put a cap on your annual health spending. Most Medicare Advantage plans and some Medigap plans also offer access to non-Medicare health and wellness benefits. These can include gym memberships, SilverSneakers or other health programs that can help you lower your risks of cardiovascular disease. Conclusion: Medicare & Cardiovascular Disease Coverage With lifestyle and healthy habits, you can control many of the factors that may lead to cardiovascular disease. And if you currently have heart disease, you can manage your condition with a healthy lifestyle and tests, specialists, and medications covered by Medicare. To make the most of your private Medicare coverage (Part C or Part D): Check to ensure your medications are covered by the plan you’re considering. Make sure you’ll remain in-network with your doctors and specialists. And if you want help choosing a Medicare plan, you can work with a licensed insurance agent who can help you find Medicare plans and give you free Medicare quotes (with no obligation to enroll in a plan). Just call 1-800-620-4519 to speak with one of our licensed insurance agents, or use our Medicare plan comparison tool to find Medicare plans in your area. Note: This article is for general education purposes and does not replace the advice of a medical professional. Always seek the guidance of your physician or a medical professional for medical advice, diagnosis, and treatment.
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The popularity of Medicare Advantage plans is growing at a rapid pace. In 2020, more than 36% of all Medicare beneficiaries were enrolled in Medicare Advantage health care plans. Whether you’re already in a Medicare Advantage plan, you’re curious about them, or you’ve never heard of them, this Medicare Advantage guide is for you. In this in-depth Medicare Advantage guide, we’ll provide a Medicare Advantage overview that will answer your frequently asked Medicare questions and cover the following topics: What is Medicare Advantage and who qualifies for it The different types of Medicare Advantage plans and how they work The difference between Original Medicare and Medicare Advantage What Medicare Advantage plans cover Who should consider getting Medicare Advantage How much Medicare Advantage costs Medicare Advantage and special scenarios Medicare Advantage plan ratings When to enroll in Medicare Advantage How to enroll in Medicare Advantage What Is Medicare Advantage? Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. The Medicare Advantage program is a way for beneficiaries to access their benefits and rights under Original Medicare, but through a private insurance company instead of the Federal Government. A Medicare Advantage plan is a contract between a private insurance company and the Medicare program. By law, every Medicare Advantage plan must cover everything covered by Original Medicare (Medicare Part A and Medicare Part B. This means that if you choose to enroll in a Medicare Advantage plan, you can be confident that you’ll receive all the benefits you’re entitled to under Original Medicare. Who Qualifies For Medicare Advantage? To qualify for Medicare Advantage, you must be enrolled in Original Medicare Parts A and B. You also must continue to pay your Part B premium in order to keep your Medicare Advantage coverage. There are no age restrictions for Medicare Advantage plans. If you’re enrolled in Part A and B before age 65 due to a disability or chronic condition, you’re still eligible for Medicare Advantage coverage. How Do Medicare Advantage Plans Work? Medicare Advantage health care plans work like the employer-sponsored health insurance plans you may be used to from your previous or current job. Medicare Advantage plans provide comprehensive coverage, and you usually need to stay in-network to receive care. You’ll typically have some out-of-pocket expenses when you receive services and procedures under your Medicare Advantage policy. These costs typically come in the form of copayments or coinsurance that you’ll pay to your provider when you receive care. An important point to remember is that all Medicare Advantage plans have an annual out-of-pocket (OOP) maximum that limits the total amount you can spend in any year. But you do not have an OOP with Original Medicare. What Types Of Medicare Advantage Plans Are Available? There are 6 types of Medicare Advantage plans, including: Medicare Advantage HMOs (Health Maintenance Organizations) Medicare Advantage PPOs (Preferred Provider Organizations) Medicare Advantage PFFS (Private Fee-For-Service Plans) Medicare Advantage SNP (Special Needs Plans) Medicare Advantage HMO-POS (HMO Point-Of-Service Plans) Medicare Medical Savings Plans (MSPs) In this Medicare Advantage guide, we’ll focus on Medicare Advantage PPO plans and Medicare Advantage HMO since they’re the most common types of MA plans. The Difference Between Original Medicare and Medicare Advantage The primary difference between these programs is that Medicare Advantage is an alternative to Original Medicare. When you join a Medicare Part C plan, you no longer receive your Medicare benefits through Original Medicare. Medicare Advantage plans are offered and administered by private insurance companies. But these private insurance companies must comply with many rules and regulations set by the Medicare program. Pros And Cons Of Medicare Advantage Plans vs. Original Medicare Medicare Part C plans have many advantages when compared to Original Medicare. The 3 biggest pros of Medicare Advantage plans are: Annual Out-of-Pocket Maximum spending cap Availability of prescription drug coverage* Extra benefits for things not covered by Original Medicare *Note: Some MA plans are available without prescription drugs. These additional benefits from Part C make Medicare Advantage a more complete coverage option than Original Medicare. MA plans can have their drawbacks in comparison to Original Medicare, depending on your healthcare needs. The 3 biggest pros of Original Medicare are: #1. You can see any doctor or go to any facility anywhere in the country, as long as they accept Medicare. #2. There are no networks. Most Medicare Advantage plans have some kind of network restrictions. #3. You don’t need referrals to see specialists. With some Medicare Advantage health care plans, such as HMOs and Special Needs Plans, you usually need referrals from your primary care physician to visit a specialist. What Does Medicare Advantage Cover? Medicare Advantage plans provide coverage that matches Original Medicare Parts A and B. Generally speaking, your Medicare Advantage plan will cover the same service or procedure as Original Medicare. But there is one exception to this rule, which we’ll cover below. Medicare Advantage plans cover the following services. Medicare Part A Services Medicare Part A covers services that take place in healthcare facilities or institutions like: Inpatient hospital stays Skilled nursing services (not room and board) Hospice care In-home care Note: Hospice care is usually not covered by Medicare Advantage plans. Instead, hospice care is covered under Original Medicare, even if you’re enrolled in a Medicare Advantage plan. However, a new test program in 2021 will explore Medicare Advantage plans providing hospice benefits. Medicare Part B Services Medicare Part B services and procedures are considered more routine and non-emergency in nature than Part A. Common Medicare Part B services include: Doctor’s visits, including specialists Physical and occupational therapy Lab and diagnostic testing services like blood work and x-rays Durable medical equipment Mental health services Ambulance services Some cancer treatments, including chemotherapy As mentioned, Medicare Advantage plans cover all of these services with the exception of hospice care. Medicare Advantage And Prescription Drugs Most Medicare Advantage plans offer prescription drug coverage. These plans are also known as Medicare Advantage Prescription Drug Plans (MAPDs), and they include Medicare Part D. Medicare Advantage Extra Benefits When considering Medicare Advantage pros and cons, it’s essential to take extra benefits that Medicare Advantage could offer to you. Many of these benefits are not provided through Original Medicare. Medicare Advantage benefits may include: Fitness programs: SilverSneakers, gym memberships, and fitness trackers. Vision care: Eye exams, contact lenses, and sometimes eyeglass frames. Hearing care: Exams and often discounted hearing aids. Dental coverage: Some plans have basic dental benefits built in, others offer dental coverage for an extra premium. Transportation: Rides to and from medical appointments. Meal Deliveries: For qualified people returning home from the hospital or skilled nursing facility Telemedicine services and virtual healthcare. Note: Medicare Part C plans have the ability to choose which, if any, extra benefits to offer. These insurance companies may also make changes to their Medicare benefits and offerings each year. Who Is Medicare Advantage Good For? You should consider enrolling in Medicare Advantage if: You want to put a cap on your total out-of-pocket spending under Original Medicare. You want prescription drug coverage without paying for a separate Part D drug plan. You need some of the extra benefits (vision, hearing, private home aides) that come with many Medicare Part C plans. You don’t want to pay for Medicare Supplement (Medigap) plans. You don’t mind using a network of doctors and facilities. You don’t mind needing referrals to see specialists. You don’t mind paying small copays each time you see a doctor. How Much Does Medicare Advantage Cost? Medicare Advantage plans have several costs associated with them. Before we dive into each cost, it’s important to remember that you always have to pay your Part B premium in order to have Medicare Advantage. Now, some Medicare Advantage plans offer a benefit that covers part, or all, of your Part B premium. But check the plan benefits closely to see if this is offered by a specific Medicare Advantage plan. Beyond this Part B premium, you might face the following Medicare Advantage plan costs: Monthly premium Annual deductible Copayment Coinsurance You might have a monthly premium for your Medicare Advantage plan, but many plans do not have them. If they do, these premiums tend to be low. Some Medicare Part C plans have an annual deductible, but again, many do not. If your plan does have an annual deductible, this means you’ll have to pay a certain amount before the plan begins paying benefits. Note that there may be separate deductibles for drug coverage and medical benefits. Beyond premiums and deductibles, the most common expenses you’ll have with Medicare Advantage plans are copayments and coinsurance. These two terms are referred to as “cost-sharing.” This is what you’ll pay out of pocket when you receive covered services. All the amounts you pay during the year count towards your annual out-of-pocket cap. Examples Of Medicare Advantage Costs Let’s look at 3 examples of how these Medicare Advantage costs work in a Medicare Advantage HMO plan. (Note: These costs are not the actual costs for any specific plan, but rather, in the range of costs for plans that you may have access to.) Scenario 1: Medicare Part B Services You injure yourself shoveling snow on your property, and you go to the doctor for an examination. You’ll pay a copay of $20 to see your primary care physician who then refers you to an orthopedic specialist. Your orthopedic specialist charges you a $35 copay for the office visit and wants you to get x-rays. You pay a $50 copay for the x-rays. Fortunately, nothing is broken or torn, so your specialist refers you to physical therapy. You pay a copay of $40 for four physical therapy sessions. Your total out-of-pocket spending for this injury is $265, spread out over a month-long period. All of these costs count towards your Medicare Advantage out-of-pocket maximum. Scenario 2: Medicare Part A & B Services You experience the symptoms of an irregular heartbeat, so you’re admitted to the hospital as an inpatient. You spend two nights in the hospital. You pay a copay of $300 per day, which amounts to a total of $600. After you’re released from the hospital, you continue to see a cardiologist, and you pay a $35 copay to see this specialist each time you visit. Scenario 3: Cancer You’re diagnosed with a treatable cancer, and you’re given chemotherapy. The copay for this treatment is 20% of the Medicare-approved cost. Although 20% amounts to more than $20,000, you hit your annual out-of-pocket maximum, so your costs are capped at $5,900 for the year. When Can You Enroll In Medicare Advantage? You can normally enroll in or change your Medicare Advantage coverage during 3 periods of time: Your Initial Enrollment Period (IEP) when you’re first eligible for Medicare. The Medicare Annual Enrollment Period (AEP), which runs from October 15 to December 7 each year. The Medicare Advantage Open Enrollment Period from January 1 to March 31 each year - however, this MA open enrollment is only for those already in a Medicare Advantage plan. Enrolling In Medicare Advantage For The First Time If you’re turning 65, you can enroll in Medicare Advantage during your Initial Enrollment Period (IEP). Your IEP lasts for 7 months, which begins 3 months before your 65th birthday, includes that birthday month, and ends 3 months after you turn 65. If you’re under 65, your first chance to enroll in Medicare Advantage starts: After your 24th month of receiving Social Security disability benefits, or At any age if you have Amyotrophic Lateral Sclerosis (ALS), also called Lou Gherig’s Disease, or if you have End-Stage Renal Disease (ESRD). Changing Your Medicare Coverage During AEP The Medicare Open Enrollment Period, also called the Medicare Annual Enrollment Period or Annual Election Period, is a good time to decide whether Medicare Advantage or Original Medicare is right for you. Also keep in mind that Medicare Advantage plan benefits can change annually. So if you have a MA plan, you should check to make sure the plan still meets your needs. Here are the actions you can take during AEP: Change from Original Medicare to a Medicare Advantage plan. Change from one Medicare Advantage plan to another. Disenroll from your Medicare Advantage plan and go back to Original Medicare. Change from one prescription drug plan (Medicare Part D) to another. Enroll in a prescription drug plan. Cancel your prescription drug coverage. If you enroll in, or switch your Medicare Advantage insurance during AEP, your new coverage will be effective on January 1st of the following year. You may also be able to enroll in a Medicare Supplement plan if you drop your Medicare Advantage coverage during AEP. The Medicare Advantage Open Enrollment Period If you’re enrolled in a Medicare Advantage plan, you have access to another enrollment period beyond AEP: The Medicare Advantage Open Enrollment Period (MA-OEP). MA-OEP runs from January 1 to March 31 of each year. During the MA-OEP, you can: Change from one Medicare Advantage plan to another. Drop Medicare Advantage, and return to Original Medicare. Add a Prescription Drug Plan if you return to Original Medicare. It’s important to keep in mind that the MA-OEP is only for people who already have a Medicare Advantage plan. If you change plans during the MA-OEP, your new coverage will be effective on the first day of the month after you enroll. Medicare Advantage & ESRD Coverage As of January 1, 2021, End-Stage Renal Disease (ESRD) patients are now able to enroll in or switch Medicare Advantage plans. Previously, there was an exclusion for people with ESRD, also known as permanent kidney failure. ESRD patients could not get new Medicare Advantage coverage at that time. Medicare Advantage And Other Special Scenarios We mentioned earlier that Special Needs Plans (SNPs) are a type of Medicare Advantage insurance. Let’s take a look at some common types of SNPs, and how Medicare Advantage health plans are also helping people to get access to care and benefits during the coronavirus pandemic. Medicare Advantage And Chronic Conditions There are Medicare Advantage plan options for people with chronic conditions like diabetes and heart disease. These plans are known as Chronic Special Needs Plans (Medicare C-SNPs), and the benefits are tailored to help you treat and manage your chronic condition. These health plans often provide you with a care coordinator to make sure your needs are being met. These Special Needs Plans have Special Enrollment Periods (often called SEPs), so if you qualify for a C-SNP, you can enroll in it at any time. You won’t have to wait for an annual enrollment window. Medicare Advantage And Medicaid Another kind of Special Needs Plan exists for “Dual Eligibles” – people who are eligible for both Medicare and Medicaid. These plans, called Dual Eligible Special Needs Plans (D-SNPs), have cost-sharing that conforms to the Medicaid program, which means that most costs are $0. D-SNPs incorporate various prescription drug discount programs, depending on your income level - so you’ll save money on your prescriptions if you qualify. D-SNP plans also have more favorable enrollment windows, which allow you to access the benefits once you become eligible for Medicaid or extra help and at certain times during the year without waiting for an annual enrollment window. Medicare Advantage And COVID-19 Medicare provides Coronavirus coverage to help people combat the virus, which includes: No-cost lab testing. Antibody testing. All medically-necessary services and procedures, including hospitalizations and doctor’s visits. Coronavirus vaccine coverage, when one becomes available. Many Medicare Advantage health plans are waiving cost-sharing for these services. In this case, you wouldn’t pay a copayment or coinsurance for seeing a doctor or going to the hospital if you have COVID-19. Medicare has also approved an expanded role for telehealth and virtual doctor’s visits. And many Medicare Advantage health care plans offer these no-contact services with no out-of-pocket cost to you. Medicare Advantage Plan Ratings Every established Medicare Advantage plan is given a Medicare Star Rating by the Centers for Medicare & Medicaid Services (CMS). Star ratings range from 1 to 5, with 5 stars being the highest. Here’s a breakdown of what each rating means: 5-star rating: Excellent 4-star rating: Above Average 3-star rating: Average 2-star rating: Below Average 1-star rating: Poor Medicare Advantage plans are rated on several different metrics and are given an overall rating. This Medicare star ratings system is designed to help you get a feel for the level of quality and satisfaction a MA plan offers. Star ratings also give you an idea of how well a plan treats its members. Plans are rated on how quickly it responds to appeals and complaints and how they cover health screenings and preventative services. Plans are also rated for both medical benefits and prescription drug benefits, if the plan has drug coverage. How To Enroll In A Medicare Advantage Plan If you want to enroll in a Medicare Advantage plan, you’ll want to consider 3 things before joining: Make sure you find a plan that’s available in your area. Most Medicare Advantage plans are restricted to specific counties or states. Make sure your current doctors and medications are covered. This is especially important if you’re looking at a Medicare Advantage HMO plan. You’ll have to use the doctors that are in-network, and you’ll only get coverage for medications that are on the plan formulary. So make sure you investigate these before enrolling. Pay attention to star ratings. This can help you compare the overall quality among different plans. But keep in mind that new plans are not given star ratings until enough data has been collected for CMS to calculate a rating. Once you’ve found a plan, you have a few options to enroll, including: Online, by phone, or paper enrollment directly with the insurance company. Working with a licensed health insurance agent who can help you find, compare, and enroll in a Medicare Advantage plan of your choice. Medicare Advantage Guide Conclusion Medicare Advantage plans can be a great way to manage your out-of-pocket spending while enjoying extra benefits we covered, if you qualify. And they can offer some compelling advantages over Original Medicare, depending on your healthcare needs. So if you'd like to learn more about Medicare Advantage plans in your area, call 800-620-4519 to reach a licensed insurance agent who may be able to guide you to the right plan for your needs. You can also try our online Medicare plan comparison tool.
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Before the Medicare Part D program started in 2006, thousands of Medicare beneficiaries faced high price tags on drugs and had little help with curbing those costs. But now, Medicare Part D plans, also known as Medicare Prescription Drug Plans, give Medicare beneficiaries prescription drug coverage options. So if you’re soon becoming eligible for Medicare Part D plans, or thinking about switching your existing Medicare coverage, this Medicare Part D guide will cover all the basics and answer your questions, including: What is Medicare Part D? Who is eligible for Medicare Part D? When can you enroll in Medicare Part D? What does Medicare Part D cover? How does Medicare Part D work? How much does Medicare Part D cost? How can I get help with Medicare prescription drug costs? What is the Part D Senior Savings Model? Tips to shop for Medicare Part D plans What Is Medicare Part D? Medicare Part D is one of the four “parts” of the Medicare program. Under Original Medicare, also known as Medicare Parts A and B, only very limited drug coverage is provided. Any medications covered are generally restricted to medicines that must be administered by a doctor. So as we mentioned before, the Medicare Part D program was created to help combat the high cost of prescription drugs. Medicare Prescription Drug Plans (PDPs) are available through private insurance companies. These plans help Medicare beneficiaries with the cost of medications, and are available in 2 forms: Standalone Prescription Drug Plans (PDPs) Medicare Advantage Prescription Drug Plans (MAPDs) Standalone Medicare drug plans work with Original Medicare. You stay enrolled in Medicare Part A and/or B, and obtain your prescription drug coverage through a Part D plan from a private insurance company. An MAPD plan is an alternative to the Original Medicare program, and combines all the benefits of Medicare Part A and B with drug coverage. All these benefits are provided by a private insurance company. Many private insurance companies provide Medicare Part D drug plans, including large nationally known ones and smaller, local companies. You can get Medicare Part D drug coverage in all 50 States. Who Is Eligible For Medicare Part D? Medicare Part D eligibility depends on meeting two criteria. To be eligible, you must be either: 1) Enrolled in Medicare Part B, or entitled to Medicare Part A; and 2) Live in the plan service area. If you qualify for Medicare Part A or are actively enrolled in Medicare Part B, then you can sign up for a standalone Medicare Prescription Drug Plan. Note: You must have both Medicare Part A and B if you want to enroll in Medicare Advantage. Medicare PDPs are a great fit for those who are Medicare-eligible and don’t have other creditable drug coverage. Examples of other prescription drug coverage include: Employer or retiree coverage Union coverage Certain military coverage, like VA benefits or Tricare, may provide good drug coverage. But they may not meet the criteria of “creditable coverage." Medicare Part D Enrollment Periods Medicare Initial Enrollment Period You generally have an initial enrollment window when you first become eligible for Medicare Part D. This first enrollment window is known as your Initial Enrollment Period (IEP), which lasts for seven months that include: Three months before the month you become eligible for Medicare The month you become eligible for Medicare Three months after the month you become eligible for Medicare Note: Your IEP lasts for seven months, regardless of whether you’re entering Medicare because you turn 65, or if you will enter due to permanent disability. If you have other creditable drug coverage, like from an employer or spouse’s employer, then you can delay enrollment into Part D without being subject to a penalty. Be sure that your drug coverage is considered creditable though. If you enroll in Medicare Part D after your IEP and don’t have other creditable drug coverage, then you will be subject to a late enrollment penalty. You can be subject to this penalty for either of 2 reasons: You had no drug coverage at all after becoming eligible for Medicare. You had drug coverage from another source, but it wasn’t considered creditable by Medicare. Your late enrollment penalty will increase for each month that you go without creditable coverage. So it’s very important to get Medicare Part D drug coverage as soon as you’re eligible, or make certain that your non-Medicare drug plan will satisfy Medicare coverage requirements. Medicare Part D Special Enrollment Periods Beyond your IEP, you may qualify for a Special Enrollment Period (SEP) that will allow you to enroll in, or change, your Medicare Prescription Drug Plan. Generally, you’ll qualify for an SEP when you experience abrupt changes in your circumstances. Some common SEPs include: Moving out of your plan’s service area. Losing creditable drug coverage from your employer. Your Medicare Drug plan doesn’t renew its contract with the Centers for Medicare & Medicaid Services (CMS). During a Special Enrollment Period, you generally will only have one chance to enroll in a Medicare Part D drug plan. Medicare Annual Enrollment Period Everyone eligible for Medicare can enroll in or switch Medicare Part D plans during the Annual Election Period (AEP), also called the Medicare Open Enrollment Period. AEP runs from October 15 to December 7 each year. If you enroll in a plan during this window, your coverage will be effective on January 1 the following year. During the Medicare AEP, you can: Change from one Prescription Drug Plan to another PDP. Switch from a Medicare Prescription Drug Plan to a Medicare Advantage Prescription Drug Plan (MAPD). Switch from one Medicare Advantage Prescription Drug Plan to another MAPD. Switch from Original Medicare to an MAPD. Drop your MAPD plan and return to Original Medicare with the option to add a standalone drug plan. Medicare Advantage Open Enrollment Period If you’re enrolled in a Medicare Advantage plan, you have access to an additional enrollment window: the Medicare Advantage Open Enrollment Period (MA-OEP). The MA-OEP is from January 1 to March 31 each year. During the MA-OEP, you can: Switch from one Medicare Advantage plan to another with or without drug coverage. Drop MAPD and return to Original Medicare. You’ll get a chance to enroll in a standalone Medicare Part D plan if you do this. How Does Medicare Part D Work? Medicare Prescription Drug Plans provide coverage for many prescription drugs. These Medicare PDPs are required to cover certain kinds of medications and prohibited from covering others. Generally, medications that are approved for therapeutic use are covered by Part D. It’s important to know, however, that Medicare Part D plans are not required to cover every drug that’s on the market. Instead, Medicare drug plans are allowed to choose which drugs they will cover. There are certain requirements that plans must use when they create their lists. The list of covered drugs is known as a formulary. Because of this freedom, each plan’s formulary is unique. Every Medicare drug plan formulary is organized into tiers. Each tier includes certain kinds of drugs in the following manner: Tier 1 – generic drugs Tier 2 – preferred brand name drugs Tier 3 – non-preferred brand name drugs Tier 4 – specialty drugs Medicare Part D Coverage For Vaccines Medicare Part D covers many vaccines, including: Hepatitis B (if you are not considered intermediate or high risk for Hepatitis B) Shingles Tdap (tetanus) boosters Note: While Medicare PDPs do not cover flu or COVID-19 vaccines, they are covered by Part B. How Do Medicare Part D Costs Work? The amount you pay for a medication changes during the year, depending on your coinsurance, copay, and how much you and your plan have paid for prescriptions. Your costs change as you move through four coverage stages. The 4 stages are: Annual Deductible Stage – you pay full price until you’ve paid $445 (for 2021). Initial Coverage Stage – you pay a small copayment or coinsurance for each prescription until the amount you pay plus what your plan pays hits $4,130 (2021 amount). Coverage Gap Stage (also known as the Medicare donut hole) – you pay 25% of the total cost for both generic and brand name drugs. Catastrophic Coverage Stage – once your total costs, plus the value of manufacturer discounts exceeds $6,550, then you pay no more than 5% of the cost for any medications for the rest of the year. You begin each year at the first coverage stage and move through them as the year progresses. Note: Only drugs on your plan’s formulary count against these coverage stages, so it’s very important that you find a Part D plan that covers your medications. How Much Do Medicare Drug Plans Cost? You pay a monthly premium to the insurance company for Medicare Part D coverage. In exchange, you pay less for many prescription drugs than if you paid cash at the pharmacy. You will likely pay some or all of these costs under Part D: Annual deductible Copayments Coinsurance If your plan has a Medicare Part D deductible, you’ll pay the full price for medications until you’ve met the deductible. For 2021, the maximum Part D deductible is $445. While many PDP plans don’t have an annual deductible, most do, and the average 2021 Medicare Part D deductible across all Part D plans is expected to be around $345. For those plans without deductibles, you would pay a copayment or coinsurance amount for medications starting with your first prescriptions. Premiums for higher-earning Medicare beneficiaries can be higher. Thanks to IRMAA (Income Related Monthly Adjustment Amount), you can expect to pay higher premiums for Medicare Part D coverage if you are single and have an adjusted gross income over $88,000, or if you file jointly and have gross income greater than $176,000. The additional cost of Part D coverage increases in several income bands: The first IRMAA band adds $12.30 per month to the cost of your Medicare Part D coverage. The highest band for single incomes over $500,000 and joint incomes above $750,000, adds an additional $77.10 per month to the cost of your Part D drug coverage. How To Get Help With Medicare Prescription Drug Costs While your Medicare drug plan can help with the cost of medications, you may still find prescriptions to be unaffordable. While there are several possibilities for obtaining lower-cost medications, the first place you should look is the Extra Help Program, also known as the Part D Low Income Subsidy program. Extra Help is provided and designed to help people with limited incomes pay for the costs of prescription drugs, including: Premiums Deductibles Coinsurance/copayments Extra Help benefits are available for those with limited means - both an overall asset or resource limit and an income limit. These limits depend on your marital status. The resource limit does not count the value of your personal residence, vehicles you own, or certain other assets. But the income limits are: $19,140 for single individuals $25,860 for married households Depending on the level of Extra Help you receive, you can expect to pay significantly less on prescriptions. At the full subsidy level, you’d pay no more than $3.70 for each generic drug filled, and no more than $9.20 for each brand name drug prescription filled. What Is The Part D Senior Savings Model? One of the 2021 changes to Medicare is the Part D Senior Savings Model. This program is a voluntary agreement between CMS and Medicare Part D plan sponsors. And it’s intended to bring down the cost of insulin for millions of Medicare beneficiaries. Not all Part D plans are participating, but there is at least one participating plan in every state. Enrollees in participating Medicare Part D plans, including both standalone drug plans, and MAPD plans, will pay no more than $35 for a one-month supply of many kinds of insulin. This is expected to save people an average of $446 per year. Tips To Shop For Prescription Drug Plans When finding Medicare prescription drug coverage, the first thing to understand is how you’re receiving your Part A and B benefits. As an example, if you’re enrolled in Original Medicare, combined with a Medicare Supplement plan, then you’ll want to look for standalone Prescription Drug Plans. But if you’re enrolled in a Medicare Advantage plan or will be, then you’ll want to look for MAPD plans. But it’s important to know that you typically can’t have a Medicare Advantage plan and a standalone Prescription Drug Plan at the same time, so make sure you know your circumstances. Once you know what kind of Medicare Part D drug plan you need, you can start to compare Part D plans. You should pay close attention to such details as: Monthly premiums Annual Part D deductibles Availability of the drugs you need on the plan formulary Tip: Every Part D plan has a different formulary, and two different plans can assign the same medication to two different tiers. So it’s important to look up your medications to get a feel for anticipated out-of-pocket costs for your medications. Also, if you take insulin, look for a Medicare Part D plan that participates in the Senior Savings Model. This alone can save you hundreds of dollars per year in insulin costs. Medicare Part D Guide Conclusion Medicare prescription drug plans are available to help lower the burden of prescription drug prices for Medicare beneficiaries. Some of our final Part D takeaways include: Be sure to sign up for a Medicare PDP during your Initial Enrollment Period or as soon as your creditable coverage ends to avoid a Part D penalty. Do plenty of research, whether you’re signing up for a Medicare Part D plan for the first time or considering switching during an open enrollment period. Look up all of your drugs to ensure they will be covered. If this seems daunting, you can get started by using our Medicare plan comparison tool to compare Part D plans and see if your drugs are covered. You can also call 800-620-4519 to get help from a licensed insurance agent and discuss your Part D options.
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