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Medicare spending is trending upward. In 2018, Medicare benefit payments totaled $731 billion - an increase from $462 billion in 2008. And Medicare-aged people can sometimes have chronic conditions and limitations, which can lead to costly medical services and treatment - all while living on a modest income. So it might be important for you to know the cost of an impending medical procedure to treat your condition. But finding the true cost of a medical procedure can be tricky, so we used Medicare's procedure price lookup tool to find rough costs of every procedure covered under Medicare. It's not a perfect science though: The average costs found on Medicare's procedure price lookup tool are based on Original Medicare. That said, the prices do not account for physician fees and Medicare Advantage or Supplemental plans. Still, the tool can give you a ballpark estimate for medical procedures so you can plan ahead and budget accordingly. With this in mind, let's take a look at five common procedures for Medicare recipients and the costs associated with each procedure. (Note: All costs are based on Medicare's procedure price lookup tool. Current Procedural Terminology (CPT) is a medical code used to report medical, surgical and diagnostic procedure codes for tracking and billing purposes.) 1. Cataract surgery Cataract surgery is a common surgery procedure designed to correct blurry vision and reduce glare from lights. During the procedure, an ophthalmologist removes the lens of your eye and replaces it with an artificial lens. How much does cataract surgery cost? According to Medicare’s tool, the average out-of-pocket cost of cataract surgery is between $51 and $101 for CPT 66821, but the treatment may involve more than one procedure so the final Who typically needs cataract surgery? The need for cataract surgery increases with age. In fact, one in five people ages 65 and up need the procedure, and that ratio increases to three in five people by age 80. Not everyone with cataracts will need surgery to correct the problem, though. Only those having trouble doing everyday activities because of their cloudy, blurred vision will need the surgery. Is cataract surgery covered by Medicare? Yes. 2. Upper GI endoscopy An upper GI endoscopy involves inserting a small camera into the esophagus, so your doctor can see the inside of your stomach and small intestine. This procedure is often performed to diagnose the cause of persistent heartburn. If abnormalities are found, additional procedures may be performed at that time or scheduled for a later date. How much does an upper GI endoscopy cost? The average cost to the patient for this procedure is between $57 and $112 for CPT 50572, depending on the type of facility used. Who typically needs an upper GI endoscopy? People who suffer from acid reflux. Their symptoms often include abdominal pain, difficulty swallowing, nausea, or stomach bleeding. Is an upper GI endoscopy covered by Medicare? Yes. 3. Colonoscopy and biopsy Like an endoscopy, a colonoscopy involves inserting a small camera attached to a tube into the intestinal tract — in this case into the colon. The main purpose of a colonoscopy is to check for colon cancer. During this procedure, it’s not uncommon to find polyps, which are removed and sent for a biopsy. A biopsy is a lab test to determine whether tissue is cancerous. How much does a colonoscopy cost? It can be tricky to calculate the cost of a colonoscopy because there are several variables involved. For example, there's no need for a biopsy if polyps aren't found. But if something else is found, like a tear in the lining of the colon, an on-the-spot procedure might be performed. Generally, the patient cost for a colonoscopy with no complications is between $100 and $195 for CPT 45380. And there may be additional costs from the facility where the colonoscopy is performed. Who typically needs a colonoscopy? Colonoscopies are recommended for anyone with a family history of colon cancer or over the age of 50, making this one of the most common procedures for seniors. Your doctor is likely to order a colonoscopy if you have such symptoms as: Rectal bleeding A change in bowel habits including constipation or diarrhea Narrow or thin stools Abdominal discomfort including gas pain and bloating Chronic fatigue Unexplained weight loss Unexplained anemia Is it covered by Medicare? Yes. 4. Arthroplasty knee (knee replacement) ”Arthroplasty knee” is a fancy way of saying “knee replacement.” No matter the term you use, this procedure repairs worn knee sockets, which can include complete or partial knee replacement. Two out of three seniors will need knee replacement surgery at some point, making this the most common medical procedure for those over 65. How much does a knee replacement cost? It can be difficult to estimate the exact cost in advance because the surgeon may not know exactly what's needed until taking a look inside the joint. The cost can also vary depending on whether the knee replacement is performed in a hospital or at an ambulatory surgical center. In many instances, knee replacement procedures might cost less in a hospital setting. The costs for arthroplasty knee surgery range from $524 to $1,364 (CPT 29879) when performed as a hospital outpatient. But it may be higher if it's performed in a clinical setting. Look into costs associated with the facility where the knee replacement will be done. That's because hospital outpatient departments must cap Original Medicare patient costs at $1,364. Who typically needs knee replacement? Osteoarthritis is the most common reason for knee replacements, but other factors may lead to the deterioration of the knee joints, including: Rheumatoid arthritis Gout Knee injuries Knee deformities Hemophilia Bone disorders Is it covered by Medicare? Yes. 5. Total or partial hip replacement A hip replacement, also known as hip arthroplasty, is a surgical procedure in which a damaged hip joint is removed and replaced with an artificial joint, often made of titanium and ceramic. During the procedure, the entire hip joint is surgically opened to remove the damaged head of a thigh bone and replace it with man-made materials, which eventually fuses with the bone. At the same time, the eroded lining of the hip socket is also removed and replaced, restoring mobility and resulting in pain-free movement. Hip replacements are typically caused by osteoarthritis, a degenerative condition that erodes the surface of a joint. More than 10 million American seniors suffer from osteoarthritis. How much does a total or partial hip replacement cost? As with any medical procedure, pricing varies by your location and provider. On average, the patient's cost of a total hip replacement ranges from $548 to $1,139 for CPT 29862. But remember: If a surgery like this is performed in a clinic setting, the Original Medicare cap of $1,364 doesn’t apply — which could increase the cost to you. Always look into costs associated with the facility where the hip replacement will be performed. Who typically needs a hip replacement? People over age 60 with osteoarthritis or other degenerative joint conditions of the hip. Is it covered by Medicare? Yes. Both partial and full hip replacement surgery is covered under Medicare. Don't get surprised by medical procedure costs Remember: Though the projected costs of these common medical procedures may help you prepare your wallet for the given procedure, they're just ballpark figures. Procedure costs can vary by your location, so it's always wise to check with your Medicare provider to get additional procedure cost estimates. It's also worth noting that your doctor may order tests or additional procedures that may not be covered by Medicare. And if your procedure requires a hospital stay, there are plenty of ways to avoid costly hospital bills. Also keep in mind that you may need additional services after your procedure, such as physical therapy, so you may need to factor rehabilitative services into the equation. Choosing a Medicare plan Having a general idea how much common medical procedures cost is a good first step to be prepared for them. But choosing the optimal Medicare plan for you is also important because coverage for some procedures may depend on whether you have Original Medicare or Medicare Advantage. Medicare Advantage and Medicare Supplement are two common ways to replace or supplement Original Medicare, but they serve different purposes: Medicare Advantage plans also known as Part C usually cover Parts A, B, and D with one bundled insurance policy for all Medicare coverage. Medicare supplement insurance is not comprehensive medical coverage. Instead, it provides extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t cover. These plans, also known as Medigap, can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits. Additionally, a standalone prescription drug plan must be purchased to get prescription drug coverage. If you need help choosing the right Medicare plan for your specific medical needs, you can find and compare Medicare plans through our comparison tool or contact one of our licensed Medicare insurance agents. We've also put together Medicare FAQs for more information.

Cancer statistics are telling: The median age for a cancer diagnosis is 66, and the highest age category for diagnosis is between ages 65-74 (27.6%), with men being diagnosed more frequently than women. But the good news is the rate of new cancer diagnoses and death are trending down. Still, a cancer diagnosis can be life-changing. And the last thing you want to think about is how your health insurance will cover your diagnosis - whether it’s for surgery or treatment. In a study by Fidelity Investments, a 65-year old couple retiring in 2019 can expect to spend $285,000 on health care and medical expenses throughout retirement unless a critical illness occurs or the wrong insurance plan is selected. Rest assured, your cancer treatment costs will be covered, but the coverage depends on the type of Medicare plan you have - standalone Medicare coverage (Part A, Part B, and Part D), Medicare coupled with a Medicare supplement plan, or a Medicare Advantage (also known as Part C) plan. What Original Medicare Covers Original Medicare is a combination of Part A (hospitalization) and Part B (medical) and Part D (prescription coverage). It provides cancer benefits if you're diagnosed before you age into Medicare or after you have enrolled. Relating to cancer, here’s what Original Medicare covers: Part A You pay your Part A deductible for common cancer treatments like: Up to 150 days of inpatient hospital care (on day 61 you begin to pay a daily copay) Inpatient surgeries related to cancer Skilled nursing for cancer recovery Home health services Short-term nursing home care Hospice, also known as End of Life care Part B You pay your Part B deductible and 20% of outpatient medical services for treatments like: Visits to your oncologist and other physicians Second opinion consultations Outpatient surgery in a doctor’s office Diagnostic imaging Chemotherapy Radiation Durable medical equipment Physical therapy and rehabilitation Participation in clinical trials for experimental treatments through clinical studies Part D You’re responsible for your prescription drug copays until you reach the catastrophic coverage limit, which will then cover 95% of your prescription costs, including: Medications for chemotherapy Medications to ease side effects, such as prescriptions to treat nausea Original Medicare pays for a broad spectrum of covered cancer services but it can have its limits. Let’s look at an example: In 2020, Medicare Part A pays the full cost for a semiprivate room and board, general nursing and miscellaneous services up to 60 days in the hospital. Up to that point, you are only responsible for a $1,408 deductible. The rest of your hospitalization costs are covered. However, if you are in the hospital for 61-90 days, Medicare payments are reduced, and you have to pay $352 a day for treatment. If you’re in the hospital for more than 91 days, the benefits are further reduced and you’re responsible for paying $704 a day. What Original Medicare Doesn’t Cover While Medicare has extensive coverage for cancer treatment, there are a few benefits that are not covered by Medicare which include: Room and board in assisted living facilities. Adult daycare. Long-term nursing home care. Food or nutritional supplements (except enteral nutrition equipment). Services outside of skilled care that help you with activities of daily living (like cooking or eating). As a reminder, if you have standalone Original Medicare with no supplemental coverage, you're also responsible for your deductibles and coinsurance, which is a set percentage you have to pay for hospital stays, medical treatment and prescription drugs. What Medicare Advantage (Part C) Covers Medicare Advantage is required to cover the same amount as Original Medicare, but can offer extra benefits and services. Medicare Advantage plans are offered through private health insurance companies - most plans have deductibles, copays and out-of-pocket limits. Once you've reached your out-of-pocket pocket limit, your Medicare Advantage plan will cover all additional medical costs during your plan year. Keep in mind, you could be limited to doctors within a specific HMO or PPO network, which can be a problem if you are in the middle of a medical regimen or often travel out-of-state. So if you like your current cancer doctors providing your treatment, this may be a downside. You’re also required to get a referral to see a specialist, which means you are required to pay for two doctor visits instead of just one. Two important things to note about Medicare Advantage: You must enroll in Original Medicare and obtain a Medicare number before you can enroll in a Medicare Advantage plan. Medicare Advantage plans cannot be paired with a Medicare supplement plan. If you have cancer, it’s wise to shop around for Medicare Advantage plans and compare plan benefits with Original Medicare to determine what your out-of-pocket costs will be under each plan. Consider the pain point of having to see different doctors if you’re required to stay within a specific Medicare Advantage network. In the end, nothing is permanent. If you enroll in one plan and find it’s not working for you, you can switch to a different coverage during the open enrollment period on October 15 - December 7 each year. What Medicare Supplement (Medigap) Covers Medicare supplement plans, also referred to as Medigap plans, fill gaps in coverage that Original Medicare doesn’t pay for, such as a Part A deductible or Part B coinsurance. Medicare supplements also help pay for extended sickness and treatments for diseases like cancer. Medigap plans and cancer coverage: Medigap policies don’t cover long-term care, or in-home health care with a private nurse. Medigap policies only cover one person so you and your spouse cannot share a Medigap plan. You must each purchase separate supplemental plans. Medigap supplement plans do not offer prescription drug coverage like Medicare Advantage plans. You must enroll in Part D to get drugs covered. There are 11 different Medigap Plans to choose from (in most states), but some plans are no longer available for new enrollments as of 2020. Still, it’s important to compare Medicare supplement plans because different insurance companies can charge different amounts for the same plan. For example, some plans might only cover 50% of Medicare Part B coinsurance, resulting in a lower monthly premium, while other plans will pay the entire amount of coinsurance, and have a higher monthly premium. Cost is usually the only difference between Medigap policies with the same letter sold by different insurance companies. So it comes down to what you can afford to pay on a monthly basis and what out-of-pocket costs you can afford for your cancer treatment. Medicare Enrollment Dates and Timelines If you have cancer and are aging into Medicare, it’s important to start the application process early. You have a seven-month period to enroll, which includes: Three months before your 65th birthday The month of your 65th birthday Three months after your 65th birthday Many people will automatically be enrolled in Medicare Part A and Part B - especially if they’re receiving Social Security retirement benefits when becoming eligible for Medicare coverage. If you’re still working and receive health insurance through an employer, it’s a good idea to enroll in Part A to receive extra benefits through Medicare in addition to your employer health insurance. You can enroll in Part B after you’ve retired. If you’re already on Medicare and want to change your coverage, you have some options. Medicare Open Enrollment (October 15 - December 7) You can sign up, switch, or leave Medicare Advantage and Part D prescription drug plans.. General Enrollment Period (January 1 - March 31) You can enroll in Parts A, B, or both. Medicare Supplement Enrollment You’re eligible to enroll in a supplemental plan for exactly six-months after your Part B coverage begins with guaranteed coverage. For example, you have until November 30 to enroll in a Medicare supplement plan if your Medicare Part B coverage began on June 1. If you miss this six-month window, the insurance company has the right to ask medical questions on its application and can deny you coverage if your health conditions make you ineligible. If you enroll during the enrollment period and are approved, the insurance company can refuse to cover out-of-pocket costs for any pre-existing health problem for up to six months. It is known as a “pre-existing condition waiting period.” After six months, the Medigap policy will cover the pre-existing condition. You generally don’t need to renew coverage each year, no matter what type of Medicare plan you have. But benefits may change, so it’s still smart to review your plan each year to make sure it’s the best. For example, a pharmacy or provider network may change, causing your costs to increase. Questions? Need more information about Medicare and cancer? We have licensed Medicare agents available to walk you through your plan options that may cover your specific cancer treatment and care.

“Medicare for All” has been a popular phrase as Obamacare and rules surrounding the health insurance landscape continue to shift. But why is it such a popular topic? For starters, Medicare has the highest rate of satisfaction among its users. In fact, enrolled ranked both Original Medicare and Medicare Advantage highly according to a 2019 survey. Still, it can be a difficult task to pick the best Medicare plan. Let's simplify the process by looking at Original Medicare, then discussing how Medicare Part C (Medicare Advantage) plans and Medicare Supplement (Medigap plans) work. What is Medicare? Medicare is health insurance for: People who are 65 and over. People under 65 years old who are disabled and have been receiving Social Security Disability benefits for at least 24 months. People suffering from End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease. Medicare Part A costs Original Medicare is broken up into two parts: Part A (for hospitalization) and Part B (for medical services). In most cases, there is no cost for Part A. But you would have to pay a $458 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $252. Medicare Part B costs Part B premiums are determined by your modified adjusted gross income. If your income for 2019 was less than or equal to $87,000 for a single or $174,000 for a married couple filing jointly, you will pay the standard Medicare Part B rate, which is $144.60 a month in 2020. Part B premiums rise to a maximum of $491.60 a month if your income exceeds $500,000 for an individual or $750,000 for a couple filing jointly. Many people are automatically enrolled in Medicare Part A and Part B when they turn 65 and begin to receive Social Security retirement benefits. But you might be in a situation where you have other health insurance besides Medicare, like a plan through your employer, so you can delay your enrollment in Part B without being penalized and save paying the monthly premium as long as you’re on that plan. Enrolling in Medicare If you don’t receive Social Security benefits at age 65, you need to sign up on your own. There are three ways to enroll: Go online to www.SocialSecurity.gov. Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Visit your local Social Security office in person. The seven-month Initial Enrollment Period (IEP) for Medicare begins three months before you turn 65, continues during your birthday month, and runs for three months after you turn 65. If you don’t enroll in Medicare during this timeframe, you could face penalties for not complying with Medicare rules. There’s also a Medicare annual enrollment period each year after your initial enrollment, which allows you to make changes to your coverage for the following year. What are the different types of Medicare plans? Part A is hospital insurance. It helps cover inpatient care, skilled nursing facility care, hospice care, and home healthcare. In most cases, there is no cost for care, but there is a deductible of $1,408 in 2020. Part B is medical insurance. This plan helps cover doctor visits, outpatient care, home healthcare, durable medical equipment, and many preventive care services. Monthly premiums vary based on your income, and there is a deductible of $198 in 2020. Part C is Medicare Advantage. Medicare Advantage combines Medicare Part A and Part B into a health plan and many of these include Part D and additional health benefits. (More on this below). Part D is prescription drug coverage. Part D helps cover the cost of prescription drugs. The standard maximum deductible is $435 in 2020. Plans A-N is Medicare supplemental coverage. Also known as Medigap, there are a host of differences between the plans, which help cover benefits that Medicare Part A and Part B may not cover. Medigap prices vary by plan benefits, not income. Note that Plans C, E, F, H, I, and J are no longer sold to new enrollees. So, the big question is: Should you consider Medicare Advantage, or enroll in Original Medicare and get a supplemental plan instead? And the short answer is: It depends. You have to evaluate your healthcare needs and how much you can afford to pay out-of-pocket for health insurance. What is Medicare Advantage (Medicare Part C)? Medicare Advantage provides all of your Part A (hospital) and Part B (medical) coverage. A majority of Medicare Advantage plans offer extra coverage, such as vision (78%), hearing, dental care (67%) or wellness programs (72%). Most include Part D prescriptions drug coverage (90%). Those with Private Fee For Service (PFFS) plans that do pay a drug premium pay $65 a month on average. As a Medicare beneficiary, you have a choice between selecting Original Medicare or choosing a Medicare Advantage plan (also known as Part C), which is provided by private health insurance companies. How much does Medicare Part C (Medicare Advantage) cost? Medicare Part C premiums vary by the plan (many plans have $0 premiums). And each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get medical services. For example, most insurance companies require Medicare Advantage plan participants to get pre-approved before they can have a procedure done, but another insurance company might not have that requirement. Do Medicare Advantage plans cover pre-existing conditions? Yes, your acceptance is guaranteed except for people who suffer from End State Renal Disease (ESRD) until that changes in 2021. Other than that, Medicare Advantage plans have zero coverage restrictions, and you’re not required to complete any medical history forms. What is a Medicare Supplement (Medigap) plan? Medicare supplement plans (Medigap) plans provide extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t pay. These plans can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits. It’s important to note that you can’t have more than one Medicare supplement plan. And though Medicare supplement plans may have higher monthly premiums than Medicare Advantage plans, you may want to consider buying a Medicare supplement insurance plan if: You’re likely to have numerous hospital stays during a year. You have regular doctor visits and/or medical services. You live in different places during the year and cannot be confined to a local network. You frequently travel outside the U.S. and want insurance coverage for emergency medical care overseas, which Medicare Part A and Medicare Part B may not provide. Note: Some Medicare supplement plans provide international travel coverage. A Medicare supplement plan may also be a good fit if you want to visit a specific top-tier medical facility like the Mayo Clinic. You wouldn’t qualify for an in-network check-up with a Medicare Advantage plan, but you’d have the ability to see a Mayo Clinic doctor with a Medicare supplement plan, with coverage for a large chunk of your services. How much do Medigap plans cost? Pricing for Medicare supplements are based on the plan you select (high/low benefits), your age at time of enrollment, your state of residence, and the health insurance company you select. That’s why it is important to compare when you shop from plan to plan or even between the same company’s plan differences before choosing a Medicare supplement plan. Medicare Advantage vs. Medicare Supplement: What’s the difference? Medicare Advantage offers more choice and covers more medical services than Medicare, while still following all of Medicare’s rules. Meanwhile, Medicare Supplement insurance was created to help Original Medicare recipients cover more of their out-of-pocket expenses. Remember, Medicare Advantage acts as an alternative to original Medicare, while Medicare Supplement plans are additions to Original Medicare coverage.   Medicare Advantage Medicare Supplement Coverage In most cases, copayments (a fixed amount of money you pay) are required. In most cases, it can cover deductibles, copayments, and coinsurance that isn’t covered by Part A and Part B. Cost Many times $0 or a low monthly cost. Higher monthly cost based on state, gender, and age. Travel Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay. Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay. Prescription Drugs Typically included with coverage. Not covered. You must enroll in a Part D plan for drug coverage. Routine dental, vision, hearing coverage May be covered depending on the plan selected. Not covered. Copayments and coinsurance Usually have copayments and/or coinsurance. Typically pays for copayments and coinsurance. Network Medicare Advantage plans have different networks: HMO, PFFS, and PPO. It’s important to understand the rules about going out of network for your healthcare. No network. See almost any doctor or medical facility that accepts Medicare. Medicare Advantage and Medigap plans may provide benefits for the following services (but check the brochure for specific plan details): Hospitalization: Medicare limits the number of days you can spend in the hospital. If you pass the maximum number of days, supplemental insurance pays the copayment that Medicare does not cover. Skilled Nursing Facility: Depending on the plan you select, Medicare supplement covers skilled nursing services that Medicare does not cover. Blood: If you need blood, Medigap coverage could pick up the tab on a few pints. Hospice care: Medicare pays for everything but copayment and coinsurance. Medicare supplement could pay the copayment and coinsurance. Inpatient or outpatient hospital medical expenses: Medicare generally pays 80% of all expenses, and a Medigap plan generally pays the remaining 20%. Other services may be covered based on the supplemental plan you pick. Shopping tips Choosing between a Medicare Advantage plan or a Medicare supplement plan on to your Original Medicare coverage depends on your situation. Ask yourself these types of questions: Do I travel outside of the United States regularly? Do I live in a different state for a portion of the year? Do I want to see any doctor and not be limited to a network? Is my budget more important than my health benefits? Are extra benefits like dental and vision coverage important to me? But you don’t have to go it alone: We can answer your questions about Medicare and help you find the best Medicare plan for your needs. Get Medicare quotes, compare plans, or contact us today. Note: Medicare supplement plan benefits are subject to state rules and regulations. Benefits described here encompass common Medigap plans available in the marketplace. Please check your insurance policy documents or talk to a customer service representative for more information.

The coronavirus is making headlines, so many of us have immunity on the mind. Not to mention: Cases of the flu hit many parts of the United States every year. Though the coronavirus and the flu are two completely different threats, the likeliness of contracting either illness is higher for older Americans: Coronavirus: At least 50% of the U.S. coronavirus cases were in people who are 50 and older (as of Feb. 7, 2020). Flu: Over 60% of seasonal flu-related hospitalizations occur in people who are 65 and older. There’s currently no vaccine for coronavirus, but there is a flu vaccine that can help immunize you against the flu. And the good news is: The flu vaccine is covered by Medicare, along with other vaccinations you may need. Of course, you’ll want to talk with your doctor about which vaccines are appropriate for you and your health. Once you know what you need, you might ask: “Will Medicare cover my vaccine?” Let’s take a look at how Medicare Part B and Medicare Part D cover some common vaccines. Medicare Part B Medicare Part B is medical insurance that covers doctor visits, outpatient care, home healthcare, durable medical equipment, and many preventive care services. Monthly premiums vary based on your income, and there is a deductible of $198 in 2020. Medicare Part B coverage is included in Original Medicare and Medicare Advantage. What Vaccines Does Medicare Part B Cover? Flu shots: Part B covers one flu shot per flu season. Hepatitis B shots: Part B coverage depends. You pay nothing for Hepatitis B vaccines if you’re at medium or high risk for Hepatitis B. You may also pay nothing if your doctor or other qualified healthcare provider accepts assignment. Always consult with your doctor first. Pneumococcal shots: This is a series of two shots: Part B covers the first shot. Part B will cover the second shot if you receive it at least one year after the first. You may also pay nothing if your doctor or other qualified healthcare provider accepts assignment. Shingles shots: Not covered by Part B. Tdap shots: Not covered by Part B, but your Medicare Part D plan may cover them. Part B may also cover vaccines directly related to treatment of an injury or direct exposure to a disease. Still, your vaccines may not be covered if you don’t use the right provider. If you have Original Medicare, make sure your healthcare provider accepts Medicare. If you have Medicare Advantage, see a healthcare provider within your plan’s network. Medicare Part D + How It Works Medicare Part D is prescription drug coverage that supplements Part B. Medicare Part D covers a limited number of prescription medications and vaccines. Part D can help with the cost of prescription drugs and many recommended vaccines. Medicare Part D is offered only through private insurers, but all Part D plans must offer a standard level of coverage set by Medicare. Your Part D plan's formulary will determine what prescription drugs and vaccines are covered. What Vaccines Does Medicare Part D Cover? Part D plans cover all commercially available vaccines when reasonable and necessary to prevent illness, with exception to those vaccines that are already covered by Medicare Part B. Covered vaccines may include: Hepatitis B shots: Part D may cover Hepatitis B vaccines if you are not considered intermediate or high risk for Hepatitis B, in which case this vaccine is covered by Part B. Shingles shots: Part D generally covers the shingles (herpes zoster) vaccine. Tdap shots: Part D plans typically cover Tdap shots, which is the booster for tetanus, diphtheria and pertussis (also known as whooping cough). Your out-of-pocket costs will depend on your Part D plan formulary and where you get the vaccine (doctor’s office vs. a walk-in clinic). Other factors that impact costs include whether or not you’ve met your plan deductible, your plan’s coinsurance (if you have one), and your plan’s copayment amounts. In 2020, no Medicare drug plan can have a deductible that exceeds $435. Example Vaccine Costs with Medicare Part D Let’s look at two examples of what your cost for a vaccine could be with Part D (based on Healthcare Bluebook's price breakdown): A Hepatitis B vaccine in Miami could cost around $67 at a walk-in clinic and $145 at a doctor’s office. Part D plans in Miami (33101) cover this vaccine as a tier 3 (preferred brand drug) and the beneficiary would pay a copay ranging from $26 to $47. A Tdap vaccine in Miami may cost $67 at a walk-in clinic and $36 at a physician’s office. Part D plans in Miami (33101) cover this vaccine as a tier 3 (preferred brand drug) and the beneficiary would again pay a copay ranging from $26 to $47. Your Part D plan may have prior authorization and could require a copayment for certain vaccines. In some cases, you may be required to pay for the vaccine upfront, up to your plan’s allowable charge. You would then submit a claim to your Part D plan for reimbursement. Check your plan policy to see what's covered under Part D before you get a vaccine. Which Medicare Plan is Right for You? It can be difficult to navigate Medicare, the various plans, and what they cover. But we’re here to help make Medicare easy. Whatever Medicare questions you have, we can help you find, compare and enroll in Medicare plans. Get a complimentary consultation today.

Both Medicare and Medicaid programs provide valuable benefits for millions of Americans. But there’s a lot of questions about them: What they offer and cover, how much they cost, and who is eligible. Medicare and Medicaid do have some similarities: They’re both health insurance programs that are designed to help specific people receive affordable health insurance coverage. They’re both government-sponsored programs. The government collects taxes and fees where necessary and is responsible for the way the programs run. They’re both run by the Centers for Medicare and Medicaid Services (CMS). These two programs also sound the same, which can cause some confusion, but they’re actually very different. Let’s review the basics of both programs and explain how it works when you qualify for both Medicare and Medicaid. Medicare basics Medicare, developed in 1966, is a government program that was created to help retired Americans get affordable health insurance. The basic program is now known as Original Medicare. Original Medicare is split into two “parts.” Original Medicare Part A Part A covers you for inpatient services and procedures, including: Hospital stays Skilled nursing care Hospice coverage Inpatient skilled nursing care You can think of Part A as coverage for when you’re admitted to a facility for care for longer than one day. How much does Medicare Part A cost? When you use Medicare Part A, you have to pay for certain costs out of your own pocket. The biggest expense under Part A is the deductible. For 2020, the deductible is $1,408. This means that you have to pay the first $1,408 of your Part A bill before Medicare will start covering your costs. But the Part A deductible isn’t like the deductible you might have with private insurance. With Original Medicare, you could pay the deductible more than once during a year - which could happen if you go to the hospital more than once in a year, or if you need skilled nursing several times. If these events are separated by more than 60 days, you’ll pay the deductible more than once. Original Medicare Part B Medicare Part B provides covers certain day-to-day medical expenses, including: Doctor’s visits Therapy (physical, occupational) Lab work, x-rays, MRIs, etc. Medical equipment like bottled oxygen Some cancer treatments like chemotherapy How much does Medicare Part B cost? Like Part A, you’ll pay some costs out of pocket for Part B services. The two most common expenses are: Part B deductible – For 2020, you pay the first $198 for Part B services, then Medicare begins covering you. Part B coinsurance – After you’ve paid the deductible, Medicare will pay 80% of the cost for Part B services. You pay the remaining 20%. An important fact to keep in mind is that there is no cap on the amount you could pay in a year. If you go to the hospital several times, or have a major illness, you’ll pay out of pocket the whole year. This is not how most other health insurance works. Most private health insurance like Medicare Advantage has an out-of-pocket maximum limit. Once you hit the limit, the plan pays for everything as long as it’s a covered service. Filling the Medicare coverage gaps Many people worry about spending too much money on Medicare. The lack of a spending cap and prescription drugs are two reasons people often add additional coverage. And while Original Medicare doesn’t cover prescriptions, some private options do: Many Medicare recipients join Medicare Advantage plans, enroll in standalone prescription drug plans (Medicare Part D), or buy Medicare Supplement (“Medigap”) insurance policies to fill gaps in coverage. In addition to annual spending caps, both Medicare Advantage and Medigap plans help pay for the costs you’d normally pay under Original Medicare: Part A and B deductibles Part B coinsurance Emergency coverage outside the United States Who is eligible for Medicare? Medicare is health insurance for: People who are 65 or over. People under 65 years old who are disabled and have been receiving Social Security Disability benefits for at least 24 months. People suffering from End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease. To be eligible for Medicare, you must be a United States citizen, or a permanent legal resident. If you’re a permanent legal resident, you must have lawfully lived in the United States for at least five consecutive years. If you receive Social Security or disability income for two consecutive years, you’ll enter Medicare automatically, as long as you qualify based on citizenship or residence. Medicaid basics Unlike Medicare, Medicaid is based on income and asset levels rather than age. There are two types of Medicaid coverage: traditional and expansion. But we will only cove the basics of traditional Medicaid since most people with Medicare are not eligible for expansion Medicaid. Who is eligible for Medicaid? Eligibility for traditional Medicaid is based on your income, family size, and asset level. Each State can set its own requirements, but the income limit is generally 133% of the Federal Poverty Level. In addition to having a low income, you must have limited assets. The limit for most individuals is $7,730, but it doesn’t include certain assets like your home or car. In general, for Americans aged 65 or over, Medicaid is designed for people who are: Indigent Disabled Blind Terminally ill and in need of hospice services Live in a nursing home In need of long term care, but can reside at home with care service support When you’re on Medicaid, your state will re-verify your eligibility every year. But you may lose your eligibility if your income and asset levels increase. What does Medicaid cover? If you qualify for Medicaid, you’ll receive low-cost health insurance from your state, which may cover you for: Inpatient (hospital-type) care Outpatient (like office visits) care Home health care Nursing care Benefits can vary by state, but Medicaid covers vision, dental, and hearing services in many cases. You may have a small deductible to pay each year, and you might have very low copayments or coinsurance. Key differences between Medicare and Medicaid There are several important differences between these two programs, which mainly involve the way in which you qualify for coverage, and who is responsible for running the program. Medicaid is means or needs based: You must meet certain income, asset, and living situation targets to qualify for Medicaid. Medicare is generally age-based: People age 65 and over are eligible (with a few exceptions like people who are disabled). Medicaid is run by the states: Each state’s program may have slightly different rules or coverage. Medicare is a national program: It’s the same across every state, and there’s a lot of overlap between the government system and private insurance companies. Can you have Medicare and Medicaid at the same time? Yes, it’s possible to be covered by both programs. A person who is eligible for both programs is called dual-eligible (you might also encounter the term “medi-medi”). When you have both Medicare and Medicaid, you need to know that Medicare is your primary insurance. Medicaid is the secondary, or backup, coverage. This means Medicare pays most of the cost for services, and Medicaid pays the rest. In many cases, dual-eligible beneficiaries will receive services but have no out-of-pocket cost. But they must use doctors and facilities that accept both Medicare and Medicaid patients. Dual-eligibility and Medicare premiums One of the most valuable benefits of being dual-eligible is the Medicare Savings Program (MSP), which is based on a range of income levels. If you qualify for the MSP, your state will cover all or a portion of your Medicare premiums. Depending on your income levels, you could get help with Part A premiums, Part B premiums, or both Part A and Part B premiums. Or you may have no premium payment for your health insurance coverage. Dual-eligibility and prescription drugs If you have dual-eligibility for Medicare and Medicaid, you can receive discounts on prescription drugs because dual-eligible beneficiaries participate in a program called Extra Help. With Extra Help, your cost for medications could cost as little as $8.95 for brand name drugs, and $3.60 for generics. You also must enroll in a Medicare Part D prescription drug plan. In fact, you will automatically be enrolled in a plan if you don’t choose one yourself, but you have the freedom to change plans if needed, though there may be time restrictions on when you can make the change. Dual-eligibility and Medicare Advantage plans If you’re dual-eligible, you can get a private Medicare Advantage plan. Medicare Advantage plans can combine several types of coverage into one plan: Part A hospital services (in all plans) Part B outpatient services (in all plans) Part D prescription drugs (in most plans) Non-Medicare benefits like vision, hearing, and dental Insurance companies often have plans designed specifically for dual-eligible people. These plans have the lowest out-of-pocket costs of any Medicare Advantage plans. They can also provide other benefits like transportation to and from medical appointments. Understanding your options Being eligible for both Medicare and Medicaid can be a valuable benefit. Your costs will be capped for all kinds of services and procedures, and your prescription drug costs will be much less than if you only qualify for Medicare. You may want to consider a Medicare Advantage plan to further maximize your benefits. Submit your zip code to get instant Medicare quotes for available plans in your area. 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If you have questions about Medicare like, "Can I keep my doctor with my plan?" Or, "Does Medicare cover my medical procedure or service?" you’re in good company. Understanding and signing up for Medicare can be confusing, whether it's Original Medicare or a Medicare Supplement plan. But fear not: We have the answers you’re looking for. Let's dive into 10 frequently asked questions and answers about Medicare, so you can learn how Medicare plans work and determine what's right for you. 1. What is Medicare? Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare typically covers the costs of emergency, preventative, and long-term healthcare. Medicare is funded by the federal government, but various related programs, like Medicare Supplements, have state oversight. The two main categories of Medicare coverage include Original Medicare (with optional Medicare Supplement and prescription drug insurance) and Medicare Advantage. 2. Who qualifies for Medicare? There are three groups who qualify to receive Medicare: People who are 65 and older. People under 65 years old who are disabled and who have been receiving Social Security Disability benefits for at least 24 months. Qualified people with End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease. 3. What does Medicare cover? A wide variety of healthcare services are covered by Medicare, depending on the type of policy you choose, including: 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 4. Am I automatically enrolled in Medicare when I turn 65? Many people automatically get Original Medicare - also known as Part A and Part B - especially if they’re receiving Social Security retirement benefits when becoming eligible for Medicare coverage. Other people may need to sign up for Medicare. If you're aging into Medicare, you have a seven-month Initial Enrollment Period (IEP) to apply for Medicare: three months before you turn 65, the month you turn 65, and three months after you turn 65. And you must sign up individually for the parts of the program - Parts A, B, C and/or D - that you want. 5. Do I need Medicare if I already have health insurance? It depends. You may need Medicare even if you already have other health insurance coverage, or if your current plan doesn’t meet the minimum coverage requirements. Most plans that employers offer 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. 6. What's the difference between Original Medicare, Medicare Advantage, and Medicare Supplement plans? Medicare is divided into two categories, with Medicare Part D as an additional option for prescription coverage. When signing up for Medicare, Part A is mandatory but Parts B, C, and D are optional. But keep in mind that you will incur a late penalty if you don't enroll in Parts B and D when you’re first eligible. Here's a breakdown of the different Medicare parts and plans: Part A (Original Medicare Plan) Covers inpatient care in a hospital, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, skilled nursing home care, and other types of home health care. Part B (Original Medicare Plan) Covers medically necessary services, preventative care, clinical research, mental health care, inpatient and outpatient services, partial hospitalization, and more. Part C (Medicare Advantage Plan) Combines Parts A and B into bundled coverage through an approved private insurance company that uses the Medicare network. Part D (Prescription Drug Coverage) Pays for several tiers of name brand and generic medications, sometimes up to a limit. Medicare Supplement Insurance Extra coverage through an approved private insurance company that fills gaps or "supplements" what Original Medicare doesn't cover. Also known as a Medigap plan. You can buy Medigap insurance online to help you cover the out-of-pocket costs and additional services that are not covered by your primary plan As examples, a Medicare supplement plan may be used to cover copays, coinsurance fees, and deductibles. A Medicare supplement plan is a standalone policy, so you’ll pay an additional cost for the plan outside of your primary Medicare premium. You must also have Medicare Part A and Part B to qualify for Medigap insurance. Lastly, Medigap policies are guaranteed renewable, which means your insurance company can't cancel your policy if your health conditions change. You just have to pay your premiums on time. 7. Does Medicare cover dental and vision services? Not usually. Original Medicare (Parts A and B) plans don't cover most dental services or vision care. But if you're already in the hospital, some dental or vision services may be covered. Certain Medicare Advantage Plans (Part C) may cover dental and vision services, so make sure to check your policy before you enroll. 8. Can I have both Medicare and Medicaid at the same time? In many cases, yes. Medicaid is a federally-supported program that helps states provide medical coverage for individuals with a limited income. So you may qualify for both if you meet the economic requirements for Medicaid and the age or disability requirements for Medicare. Some states also provide expanded Medicaid access to individuals (including those with Medicare) who meet economic qualifications after subtracting their out-of-pocket medical expenses from their income. For example: If you're a single person who earns $26,000 a year, you probably won’t qualify for Medicaid under normal program requirements. But if you live in a state with expanded access, you can subtract your medical expenses from your salary to come to a new income. So if you spend $7,000 on medical expenses, then your final income for your Medicaid application would be $19,000, so you might qualify for coverage. Note: If you qualify for both programs, Medicare is automatically designated as your primary insurance provider while Medicaid becomes the secondary payer. 9. Which medications does Medicare Part D cover? Medicare Part D coverage varies based on your insurance company, but all plans must include a minimum amount of medication coverage that's approved by Medicare. So qualifying Part D plans must offer at least two medication options from each class of drug category on their formulary to treat common health issues. But not all health conditions are covered. Check your insurance company's formulary (a list of generic and brand name prescription drugs covered by your specific health plan) to see what prescription drugs are covered. And fortunately, there are lots of other ways to reduce your prescription costs. If you don't have a Part D plan, it can be added to any Original Medicare policy, Medicare Savings Account (MSA) Plan, some Medicare Cost Plans, and some Medicare Advantage Private Fee-for-Service (PFFS) Plans. 10. How do I check the status of my Medicare application? The short answer is, "It depends." If you applied for a standard Medicare Part A or Part B plan, you can check the status of your application by logging into your account on the Medicare website. Your application should show up in your profile within 24 hours of submission. Still have questions? Though we covered some common Medicare questions, you might still need help breaking through the jargon and choosing the best Medicare plan for your needs and budget. You can get help with Medicare by talking to one of our licensed agents today. Or you can find and compare Medicare plans to see plan options in your area.