Medicare coverage5 Important points about Medicare Part A and B coverage gaps
Medicare is designed to reduce some of the financial strain of paying for healthcare in your later years. Making the most of your coverage begins with choosing the right plan.
The benefits and costs associated with the different Medicare options can vary greatly. Asking yourself these 10 questions may help you determine which option is likely to work best for you.
1. What is Original Medicare?
Original Medicare refers to Medicare Parts A and B. Part A covers the cost of hospital-related care, including inpatient services, lab tests and surgery. Part B is the medical insurance component of Medicare, which covers doctor visits, outpatient care, and certain preventive services. Both Part A and Part B are administered by the federal government.
2. Will I pay a premium for Part A or Part B?
For most people, Part A coverage is premium-free as long as you or your spouse paid Medicare taxes for at least 10 years while you were working. There's also no premium for Part A if you're receiving Social Security or Railroad Retirement Board (RRB) benefits at the time you enroll.
Part B coverage requires a monthly premium, which is deducted from your Social Security or RRB benefits if you're receiving them. For 2019, the standard premium for Part B coverage is $135.50, but your premium may be higher based on your tax filing status and modified adjusted gross income.1
3. Are there any other costs for Original Medicare?
In addition to premiums, you're also responsible for paying a deductible and coinsurance with Original Medicare. In 2019, the deductible for inpatient hospital stays is $1,364 per benefit period, while the annual deductible for Part B is $185.2 Coinsurance is typically 20% of the Medicare-approved amount for most services.
4. What is a Medicare Advantage plan?
Medicare Advantage, also referred to as Medicare Part C, covers the same healthcare services as Original Medicare for the most part, with some key differences. While hospice care isn't covered, things like vision, dental, and hearing services or health and wellness plans may be included. Many Medicare Advantage plans also offer prescription drug coverage.
5. How much does Medicare Advantage cost?
Medicare Advantage plans are offered by private insurance companies rather than the federal government. When you purchase one of these plans, you'll likely pay 2 premiums: one for the Medicare Advantage plan and a separate premium for Part B coverage.
The insurance company determines what to charge for the Medicare Advantage plan premium. Insurers also set the guidelines for your deductible, coinsurance and copays if applicable.
6. Are prescription drugs covered by Medicare?
There are 2 ways to get prescription drug coverage through Medicare. You can either choose a Medicare Advantage plan that includes drug coverage, or enroll in Part D if you have Original Medicare. Part D plans are offered by insurance companies approved by Medicare.
Your out-of-pocket costs for deductibles, copays, and coinsurance vary from plan to plan. Keep in mind that not all drugs are covered under Part D.
7. What is supplemental Medicare coverage?
Medicare Supplement insurance, or Medigap, is designed to help fill the cracks in coverage for those with Original Medicare. Medigap plans are sold by private insurers and they're meant to help cover things like your deductibles, coinsurance and copays. You'll pay a monthly premium for a Medicare Supplement plan in addition to your Part B premiums.
8. Can I get Medicare with a pre-existing condition?
A pre-existing health condition won't bar you from enrolling in Original Medicare as long as you sign up for coverage during your initial enrollment period. This is the 7-month window that extends from the 3 months before your birth month through the 3 months after your birth month.
The same is true for Medicare Advantage plans, with one exception. You can't enroll in one of these plans if you have end-stage renal disease. With Medicare Supplement plans, the insurer may impose a waiting period before your coverage takes effect for any pre-existing issues.
9. Will I be able to choose my doctor?
With Original Medicare, you can choose a primary care doctor, although it's not required. With a Medicare Advantage plan, your choice of doctor depends on whether you select a health maintenance organization (HMO) or preferred provider organization (PPO) plan.
With an HMO plan, you need to choose a primary care physician from within your plan's network. If you opt for a PPO plan, choosing a primary care doctor is optional.
10. Do all doctors and healthcare facilities accept Medicare?
Medicare is widely accepted but it's not universal. When reviewing plan options, pay close attention to which providers in your area accept Medicare to ensure that you have access to care when you need it.
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