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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.

Learn More About Medicare

  • People often have questions about Medicare as they get close to age 65: Does Medicare cover my prescription drugs? Will my doctor accept my Medicare plan? Does my Medicare plan cover dental, vision, and hearing? These are questions we often hear, and we’re here to help get you these answers and more. Let’s start by reviewing the basics of Original Medicare, including coverage and out-of-pocket costs. Then we’ll cover some options to reduce your Medicare costs and add valuable benefits to your coverage. How Original Medicare coverage works Original Medicare is split into two parts – Part A and Part B. Medicare Part A Covers some of the costs of care provided by the following facilities and providers: Inpatient hospital care Hospice Care Home Health Care Skilled Nursing Facility Care Medicare Part B Covers medically necessary services and supplies, including: Doctor’s visits Diagnostic tests (x-rays, blood work, MRIs, etc.) Therapy visits (physical, occupational) Some cancer treatments like chemotherapy Outpatient surgeries like arthroscopic surgeries Outpatient mental health visits Durable medical equipment like bottled oxygen How much does Original Medicare cost? When you use your Medicare insurance, you will have to pay for some of the costs out of pocket. But the out-of-pocket costs are different for Parts A and B. When you have a hospital stay, you’ll have to pay the Part A deductible which is $1,408 in 2020. You’ll pay this inpatient hospital deductible each time you are admitted to the hospital, provided you haven’t received hospital or skilled nursing facility services within the previous 60-day benefit period. Meanwhile, Part B has three types of charges: Part B deductible: $198 for 2020, which you only pay once each year. After that, Medicare will pay 80% of the cost, and you’ll pay 20% for every Medicare-covered Part B service or procedure you receive. Part B coinsurance: 20% of the cost for each service or procedure Part B excess charges: Up to 15% of the Medicare-approved charge if your doctor does not accept the Medicare-approved amount for a service (known as Medicare assignment). For the most part, your out-of-pocket costs could be quite low if you’re healthy and don’t need many health care services. And if you get the flu or need some therapy for a sprained ankle, your 20% coinsurance could total a few hundred dollars for the entire year. But your out-of-pocket costs could be very high if you suffer a major illness or need specialized surgery. Plus, Original Medicare does not cover prescriptions. So if you need medications, costs could be high. One last point on costs: There’s no cap on your spending with Original Medicare. This means there’s no out-of-pocket maximum cap like you may have seen with your previous traditional, private health insurance plan. And this means your out-of-pocket costs could be extremely high if you require treatment for a chronic condition or illness. Medicare Advantage may help control costs Many Medicare beneficiaries choose to enroll in Medicare Advantage plans to curb out-of-pocket costs and get prescription drug coverage. Medicare Advantage (also known as Medicare Part C) is a contract between the Centers for Medicare and Medicaid Services (CMS) and a private health insurance company. Medicare Advantage plans must cover everything that Original Medicare covers. When you join a Medicare Advantage plan, you may still pay for certain expenses including: Monthly plan premium (if any): Many plans have a low-cost or $0 monthly premium. (You must continue to pay your monthly Part B premium). Annual deductible (if any) Copayments and/or coinsurance Still, these costs are often lower than what you’d pay under Part A or B. One big benefit of a Medicare Advantage plan is that it includes an annual out-of-pocket maximum - so you’ll know your costs are capped, no matter what services or treatments you might need during a year. Medicare Advantage provides extra benefits Medicare Advantage can serve as a way to cover services that Original Medicare doesn’t. That’s because these plans often go beyond Original Medicare coverage offerings. These extra benefits can vary by state and health plan, but they often include: Chiropractic care and acupuncture. Dental coverage: Sometimes for an additional premium. Emergency coverage outside of the United States Fitness benefits: Discounted or free gym memberships and silver sneakers programs. Hearing coverage: Exams, and sometimes discounted hearing aids. Prescription drug coverage: You’ll typically share the cost of your medications with your insurance company in the form of copayments or coinsurance for each prescription. Transportation: To and from medical appointments. Vision coverage: Exams, lenses, and the cost of frames. An example of how it works Let’s take vision coverage as an example. Original Medicare doesn’t cover basic vision services like eye exams and lenses. If you pay out of pocket, you can expect to pay (on average): $114 for an eye exam $113 for lenses $238 for frames Based on these averages, you could pay a total of $465 for an exam, lenses, and frames. While benefits vary by state and insurance company, many Medicare Advantage plans have exams and lenses for $0. Many companies could also give you a credit towards the purchase of frames. And though you probably don’t buy new glasses every year, it’s unlikely that prices for lenses and frames will decrease. Getting frames from a Medicare Advantage plan can save you quite a bit of cash, especially given the relatively low (or $0) plan premiums they charge. You will find that other extra benefits work in the same way. The hearing or dental coverage available from Medicare Advantage plans may not be completely comprehensive or free, but it’s often less expensive than what you can get from an individual policy. How Medicare Supplements can help control costs Medicare Supplement insurance is another way to lower your Medicare out-of-pocket costs. These policies are offered by private insurance companies and work with Original Medicare, paying for some or all of the costs that you’d normally pay. The costs you have to pay with Original Medicare are known as “gaps in coverage.” Medicare Supplements help to fill these gaps - hence the name “Medigap” plans. You’ll pay a premium directly to your insurance company for Medigap coverage. And Medigap can help with some or all of: Part A deductibles Part B deductibles Part B coinsurance Part B excess charges Medicare Supplement plans come in standardized plans, with each plan paying a slightly different portion of the Original Medicare gaps. The standardized plans are known by letter: A, B, C, D, F, G, K, L, M, and N. Plans F, G, and N are among the most popular with people on Medicare. Medigap plans offer a lot of freedom when it comes to choosing a doctor. Your coverage is portable all over the country, so you can see any doctor who accepts Medicare patients. You don’t have to deal with a network, or get a referral from a primary care physician. As an added bonus: Many Medigap plans also cover you outside the United States, so you can have emergency coverage while you’re traveling as part of your retirement routine. What Medigap plans don’t cover There are a number of items that Medicare Supplement insurance doesn’t cover. For starters, they don’t cover prescription drugs, so you’ll need to enroll in a stand alone prescription drug plan to help cover costs. These are also available from private insurance companies. Medigap plans also don’t cover vision, hearing, or dental. While it’s possible that some Medigap plans offer discounts on these items, none provide comprehensive coverage. Medigap plans also provide no coverage for staying in a nursing home or other facility for long-term care. Instead, you’ll have to purchase individual coverage from an insurance company to cover these items. Or, you may be able to purchase coverage for some of these items from your Medigap insurer in a separate supplemental policy. With either option, you’d pay an additional premium for the coverage, but buying standalone vision or dental coverage from another company might be the more expensive option. How to enroll in a Medicare Advantage or Medigap plan The most important thing to know is that you’re not “stuck” in a Medicare plan: If you want to switch Medicare plans, you can do so during the Annual Enrollment Period, which is from October 15 to December 7 each year. You can also switch from one Medicare Advantage plan to another, or go back to Original Medicare during the Medicare Advantage Open Enrollment Period, which is from January 1 to March 31 each year. And if you want to learn how to reduce your out-of-pocket medical expenses in the meantime, you just need to get smart on maximizing your Medicare benefits. Save time, learn more Let us do the hard work for you, so you can save time and find the best Medicare plan for your needs. Working together, we can find and compare Medicare Advantage plans in your area to see if they work with your doctors and cover your medications.
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  • Are you turning 65? Turns out, you’ll be joined by thousands of birthday buddies. In fact, 10,000 Americans turn 65 every day - a real cause for celebration, whether it’s the milestone of retirement or your journey to the right Medicare coverage. Still, many Americans are confused by Medicare: how to enroll, when their enrollment period is and what plan to even enroll in. But the process doesn’t need to be so complex. Here’s your Medicare checklist for turning 65. 1. Make Sure You Qualify For Premium-Free Medicare Part A Most people qualify for Medicare Part A because of their work history. If you’re a U.S. citizen or permanent legal resident, you qualify for premium-free Part A as long as you have paid payroll taxes for at least 10 years. Call your local Social Security Office to see if you’re eligible for Medicare Part A. You may receive a paper statement from SSA [sample here] as a reference, or you can create an account online at ssa.gov. What If You Didn’t Work Enough? You may still qualify for Medicare Part A through your spouse if you don’t (or won’t) have 40 quarters of work history. You’re eligible if your spouse qualifies for premium-free Part A, and: You have been married for at least one year and your spouse is eligible for Social Security benefits. You're divorced and your former spouse is eligible for Social Security benefits. You must have been married at least 10 years, and you must be single now. You’re widowed, but were married for at least nine months, and you are currently single. If you don’t meet any of these criteria, you can either continue working until you’ve logged 40 quarters, or pay for Part A. For 2020, the Part A premium is $458 per month, but this amount may be reduced if you have some work history. 2. Figure Out When You’re Going To Need Part B If you are currently employed and you are covered by an employer health plan, and your employer has more than 20 employees, you don’t have to sign up for Part B until you retire and give up your employer-based health coverage. Many people can’t take full Social Security benefits until age 66, so it’s common to delay retirement by a year. You can delay Part B as long as your employer coverage meets Medicare’s minimum requirements. But if you work for a small company with less than 20 employees, you’ll probably need to enroll in Part B when you’re first eligible. Be sure to talk about this with your employer before your 65th birthday. There’s no reason to pay the Part B premium until you’ll actually need Medicare. 3. Decide When You’re Taking Social Security There are a few nuances to receiving Social Security and how it impacts when you can enroll in Medicare Parts A and B: If you take Social Security at age 65, your enrollment in Medicare will be automatic. If you pass on Social Security at age 65, but want to sign up for Medicare, you’ll have to apply for it separately. You can use ssa.gov to enroll if you choose to enroll before your 65th birthday. If you wait until after you’re 65, you’ll have to visit a Social Security office to sign up for Medicare. 4. Know Which Doctors You Want To See When You Have Medicare Make sure the doctors you see, or want to see, accept Medicare. Finding out ahead of time can help you avoid surprises. If you plan to move during your retirement, it’s wise to get recommendations for doctors in your new hometown and see if they accept Medicare patients. 5. Get A Firm Understanding Of Your Medications When it comes to medications and aging into Medicare, there are 3 steps to take: You should always know your medications and their doses. Talk to your doctor about generic versions of your prescriptions to reduce costs. Find out if your doctor thinks you might need a new or different medication in the future. 6. Understand The Gaps In Original Medicare Medicare doesn’t cover 100% of your health care costs. Instead, you’ll pay a portion out of your own pocket. The costs you pay for Part A differ from what you’ll pay for Part B. Gaps In Medicare Part A Part A will cover you for inpatient type of events, like: Hospital stays Home health care Hospice Skilled nursing facilities When you have a hospital stay, you’ll have to pay the Part A deductible. For 2020, the deductible is $1,408. You’ll pay this inpatient hospital deductible each time you are admitted to the hospital, provided you haven’t received hospital or skilled nursing facility services within the previous 60-day benefit period. Gaps In Medicare Part B Part B of Original Medicare covers the services you’d receive in an outpatient setting, including: Doctors and therapy appointments Lab work and diagnostic imaging Outpatient surgeries Medical equipment like oxygen machines Some cancer treatments like chemotherapy When you use Part B coverage, you can expect to pay out of pocket for each service. Your share of cost can include: Part B deductible: $198 for 2020 (you only pay the Part B deductible once each year). Part B coinsurance: 20% of the cost for each service or procedure. Part B excess charges: Up to 15% of the Medicare-approved charge if your doctor does not accept the Medicare-approved amount for a service (known as Medicare assignment). The biggest Part B expense is the 20% coinsurance, which you’ll pay throughout the year. There are other costs you can expect to pay out of pocket with Original Medicare, including things like dental care, eye exams, hearing aids, and more. Keep in mind that there is no cap on how much you can spend out of pocket with Original Medicare. How To Find The Right Plan For You Make sure any Medicare plan you consider: Covers the doctors you want to see Covers the medications you need Has a premium you can afford You can also narrow your choices down further by asking yourself: Do I intend to split my time between two or more States? Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities? If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re comfortable with a particular HMO-type medical group and plan to live in one place, then Medicare Advantage could be right for you. Your Options Beyond Original Medicare There are Medicare plans available that help close the coverage gap of what Original Medicare doesn’t cover. They include: Medicare Advantage Medicare Part D (Prescription Drug Plans) Medicare Supplement (Medigap) Medicare Advantage Plans Medicare Advantage plans, also known as Medicare Part C, is a contract between a private insurer and Medicare. These plans must cover everything that Original Medicare covers. Medicare Advantage plans work like traditional private health insurance, so you may see certain out-of-pocket costs with Medicare Advantage, including: Monthly premium: Many Part C plans don’t have a monthly premium. Annual deductible: Most plans don’t have a deductible. Copayments or coinsurance for services and procedures. Medicare Advantage plans also offer a number of added benefits, which vary by state and health plan. Some benefits include: Fitness programs like Silver Sneakers or free memberships to local gyms. Vision coverage for exams, lenses, and sometimes frames. Hearing coverage for exams and discounted hearing aids. Dental coverage for basic dental services. Transportation to and from medical appointments Prescription drug coverage (some plans) Medicare Advantage plans can also provide emergency coverage outside the United States. With the international coverage, out of pocket maximum protection, and a wide range of extra benefits, you can see why many people choose Medicare Advantage plans. Prescription Drug Plans Prescription Drug plans (PDPs or Medicare Part D) help with the cost of prescription drugs. Each company creates their PDPs differently, but you can expect to pay these costs for coverage: Monthly premium, which varies based on income Annual deductible (although many plans don’t have a deductible) Copayment or coinsurance per filled prescription The copayments and coinsurance costs increase as the total amount your plan pays rises above certain thresholds, also known as coverage stages: Coverage Stage 1 – Deductible Stage: You pay full price until you’ve spent $435 (for 2020). Coverage Stage 2 – Initial Coverage Stage: You pay small copayments or coinsurance for each prescription. Coverage Stage 3 – Coverage Gap Stage: Also known as the Medicare “Donut Hole.” Once your total drug costs (what you’ve paid plus what your plan has paid) exceed $4,020, you hit the coverage gap. You’d then pay 25% of the cost of prescriptions. Coverage Stage 4 – Catastrophic Stage: Once your total drug costs (excluding what your plan has paid) exceed $6,350, you pay no more than 5% for medications These coverage stages reset on January 1 each year. But it’s important to know that there is no out-of-pocket cap on drug costs under Part D. Medicare Supplement Insurance Medicare Supplement Insurance, also known as Medigap, is designed to fill the gaps in Original Medicare. Medigap supplements Original Medicare by paying some or all of the expenses that you’d normally have to pay out of pocket. Medigap policies are issued in 10 standardized plans: A, B, C, D, F, G, K, L, M, and N. Each of these plans cover a slightly different portion of the Original Medicare gaps. Plan G is a popular Medigap option that covers every gap except for the Part B deductible. If you have Plan G, you can expect to pay for the first $198 in Part B expenses (like doctor’s visits). Plan G will then cover every penny of any Medicare-approved service or procedure. Several Medicare supplements provide some international coverage, including plans C, D, F, G, M, and N. Medigap plans also give you maximum flexibility, so you can see any doctor or use any facility that accepts Medicare patients, anywhere in the United States. You’re not bound to a network, or reliant upon referrals. Medicare Supplement Insurance plans don’t cover prescription drugs, so you’ll need to enroll in a stand alone Prescription Drug plan to get drug coverage. Considerations Before Choosing A Plan Make sure any Medicare plan you consider: Covers the doctors you want to see Covers the medications you need Has a premium you can afford You can also narrow your choices down further by asking yourself: Do I intend to split my time between two or more States? Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities? If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re fine with HMO-type medical groups and plan to live in one place, then Medicare Advantage could be right for you. As you approach age 65, it’s important to start your research sooner rather than later. Make sure you know what plans your doctors will accept, and which plans cover your medications. Comparing Medicare plan features and costs doesn’t have to be complicated though. You can find and compare Medicare quotes or enroll in a plan through our site. We also have licensed Medicare agents available to help answer any questions you may have.
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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 cost could be more. And there may be additional costs from the facility where the procedure is performed. 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 plan comparison tool or by contacting one of our licensed Medicare insurance agents. We've also put together Medicare FAQs for more information.
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