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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). Generally, there are two tracks for the Medicare consumer: Original Medicare/Medicare Supplement Insurance and Medicare Advantage Insurance.

What is the difference between Original Medicare/Medicare Supplement and Medicare Advantage Insurance?

A Medicare Advantage policy bundles all Medicare benefits, plus additional benefits; a Medicare supplement policy is a supplement to Original Medicare. It is illegal to be sold both. You can only have one or the other.

Some Medicare Advantage plans include extra benefits not covered by Original Medicare such as vision, hearing, or dental. Medicare Supplement plans also called Medigap plans don’t typically cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Original Medicare/Medicare Supplement Insurance

A plan to fill the gaps in Medicare

When you turn age 65 and qualify for Medicare, you get coverage for a range of hospital and medical expenses. But the federal health insurance program doesn’t include benefits for all of your healthcare costs and, of course, you’ll still be on the hook for your deductible and coinsurance. That’s why you’ll want to consider Medicare supplement insurance.

Medicare supplement plans can help reduce what you pay out-of-pocket for items and services that Medicare doesn’t cover. The different plans are lettered A through N (more on that later), each offering a different blend of benefits.

What is Medicare supplement insurance?

Medicare supplement insurance is designed as extra coverage to help pay for some of the healthcare costs Medicare doesn’t cover. Supplement plan benefits include coinsurance and deductible amounts for Medicare Part A and Part B as well as foreign travel emergency benefits. Which specific benefits you receive with your Medicare supplement insurance will depend on which policy you choose.

Medicare supplement insurance is also known as Medigap because it fills the “gaps” in Medicare coverage.

What Medicare supplement insurance isn’t

Medigap plans are not the same as Medicare Advantage plans, Medicare prescription drug plans, Medicaid, employer or union plans, TRICARE, veterans’ benefits, long-term care insurance, and Indian Health Service, tribal, and Urban Indian Health plans.

Medicare 101

Before we dive much deeper into the ins and outs of Medicare supplement plans, it will be helpful to understand some basics related to Medicare.

Original Medicare comes in three main parts (Part C is Medicare Advantage):
Part A (hospital insurance) helps cover inpatient care, skilled nursing facility care, hospice care, and home healthcare.
Part B (medical insurance) helps cover outpatient care, home healthcare, services from doctors and other healthcare providers, durable medical equipment, and many preventive care services.
Part D (prescription drug coverage) helps cover the cost of prescription drugs; plans A and B do not include prescription drugs.

Together, Part A and Part B are known as Original Medicare. The Medicare Modernization Act of 2003 added Part D for prescription drugs that can be added as a stand alone insurance plan.

If you have a Medicare Advantage plan(Part C), you cannot enroll in a Medicare supplement plan.

What do Medicare supplement plans cover?

Medicare supplement policies are standardized under federal and state laws. They must offer the same core benefits. Through a federal waiver, three states standardize their policies differently than the rest of the U.S.; these states include Massachusetts, Minnesota, and Wisconsin.

Standardized Medigap plans are labeled A through N; however, plans E, H, I, and J are no longer open to new enrollees. Benefits typically covered by Medigap plans include a combination of the following, which can be compared in detail at Medicare.gov:

  • Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
  • Part B coinsurance or copayment
  • Blood (first 3 payments)
  • Part A hospice care coinsurance or copayment
  • Skilled nursing facility care coinsurance
  • Part A deductible
  • Part B deductible
  • Part B excess charge
  • Foreign travel exchange (up to plan limits)

You may be interested to know that standard Medigap plans C, D, F, G, M, and N provide foreign travel emergency healthcare benefits—plans E, H, I, and J do as well but are no longer sold to new enrollees and in 2020 plans C and F will no longer be sold to new enrollees. These plans will cover foreign travel emergency care if it begins in the first 60 days of your trip and Medicare doesn’t otherwise cover the care; these plans pay 80% of the billed charges for medically necessary emergency care outside the U.S. after you meet a $250 annual deductible.

Would a person have more than one Medicare supplement policy?

No. You will select one plan. It is also important to know that Medigap plans only cover one person. If your spouse also needs coverage, they will need their own policy.

Who can buy Medicare supplement insurance … and when?

Anyone who is Medicare-eligible and not enrolled in a Medicare Advantage plan can buy a Medigap plan. There are, however, specific times during which you can buy a Medicare supplement policy. The best time is during your 6 month Medigap open enrollment period which begins the month that you turn 65. During this time period, you are guaranteed coverage and at the same rate as anyone else in good health.

You may be able to buy Medicare supplement insurance outside of the open enrollment period, but you are not guaranteed coverage. Medicare supplement policies may be subject to underwriting, which means your application may be denied or you may be charged more based on your health. There are some exceptions to this rule; for instance, you may be able to provide evidence that you’re entitled to a guaranteed issue right. You can learn more about Medigap eligibility during and outside of open enrollment at Medicare.gov.

Medigap plans are guaranteed renewable, regardless of whether or not your health remains the same. That means an insurance company can’t typically drop you. Exceptions include not making premium payments on time or providing false information on your application. You can cancel your Medigap policy by contacting your insurance company.

Already have Medicare Advantage? You can’t enroll in a Medicare supplement policy at the same time. It is illegal for insurance companies to sell you one if you have the other. If you are moving from a Medicare Advantage plan to a Medicare supplement plan, do not cancel your coverage until you are sure you have been approved.

How much does Medicare supplement insurance cost?

The cost of Medicare supplement policies is usually the only real difference between those of the same letter. The premium you pay may be based on any of the following factors:

  • What type of plan you buy (generally, the higher the level of benefits you select, the higher the monthly premium)
  • Your insurance company
  • Your age at the time of application as well as your age as you get older
  • Where you live

Rates can vary greatly from one region to the next. One analysis found that monthly premiums for Medigap Plan F averaged as high as $162.25 in Massachusetts and as low as $109.16 a month in Hawaii.

You’ll want to gather quotes for the Medicare supplement policies you’re considering to see what coverage could cost you.

Can you buy Medicare supplement plans online?

Yes. Private companies sell Medicare supplement insurance, and you can get a quote and fill out an application online. Not every company that sells Medigap plans will sell every Medigap plan available. They must all offer Medigap Plan A along with Plan C or Plan F.

How to compare and choose Medicare supplement plans

The only real difference between Medigap policies is typically price. As discussed earlier, Medicare supplement plans of the same letter must offer the same benefits—you can get a basic overview at medicare.gov or read about plan details at insurance company websites. Some plans will offer additional benefits. Once you decide which letter plan you want, rates set by the companies selling them will be the key differentiator.

Waiting periods are one more thing to consider. While a company can’t deny you coverage during your initial enrollment period, regardless of pre-existing conditions, it can impose a waiting period of up to six months for pre-existing conditions that were treated or diagnosed six months before your enrollment in the Medigap policy plan. During this time the company will not pay out-of-pocket costs for these conditions; Original Medicare will continue to provide benefits, but you will be responsible for Medicare coinsurance or copayment amounts.

Make sure that the plan you’re considering is definitely a Medicare supplement plan. Insurance companies must clearly identify Medigap plans as Medicare Supplement Insurance on the front.

Again, not all companies that sell Medigap plans sell all Medigap plans available.

Is a Medigap policy right for you?

Does everyone on Original Medicare need a Medicare supplement policy as well? Choosing to enroll in a Medicare supplement plan is an individual decision, of course. If you find the premium affordable, it can be a way to help with out-of-pocket expenses not covered by Medicare as you get older and require more healthcare.

It would seem more Medicare beneficiaries are enrolling in Medicare supplement policies. An AHIP report on the state of Medigap showed that 13.1 million people had enrolled in Medigap plans as of December 2016—an increase from 12.3 million in the prior year.

Enrollees are not evenly distributed across the U.S. Another report by the Kaiser Family Foundation found that Medigap enrollees accounted for 3% all Medicare beneficiaries in Hawaii and 51% in Kansas.

The best way to decide if Medicare supplement insurance is right for you is to explore and compare your options. Make this research a part of your retirement planning, before you turn age 65 and enroll in Medicare. Gather quotes. Consider your ability to cover out-of-pocket healthcare expenses on your own. Then decide what best meets your healthcare and financial needs month to month and in the long term.

If you have questions about Medigap plans, contact the insurance company that sells the coverage you’re considering or a licensed health insurance agent.

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Learn More About Medicare

  • 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.
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  • “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.
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  • 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.
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