back to top

The Medicare Basics: Types of Coverage & Plans

To qualify for Medicare, you must be an American citizen or a long-term legal resident (at least five years in a row) who is at least 65 years old or have a disability or certain medical conditions, such as end-stage renal disease or amyotrophic lateral sclerosis.

Original Medicare refers to the hospital insurance provided by Part A and the prescription drug coverage provided by Part B of the Medicare program as a whole (medical insurance).

Under the Affordable Care Act, no one may be denied coverage during the Open Enrollment Period for medical grounds, including pre-existing conditions. Certain procedures and treatments are also required in all medical plans, regardless of where you purchase the plan or which insurance company provides it.

  1. Medicare Advantage (MA) plans

These are government-administered supplemental health insurance plans with low monthly premiums that cover all services covered by Original Medicare (hospital insurance, medical insurance and some prescription drug coverage) says expert from Clearmatch Medicare.

They provide you with all of a single type of medical plan but with greater flexibility and lower out-of-pocket expenses. MA plans can also provide extensive preventative health care. There are two types of MA plans; Advantage Private Fee-for-Service (PFFS) plans and Advantage HMO (health maintenance organization).

Advantage PFFS plans allow you to go to any doctor or receive any service you want, provided the provider accepts Medicare. On the other hand, Advantage HMO plans require you to receive your health care services from doctors and hospitals within the plan’s network.

  1. Prescription Drug Plans (PDP)

These Medicare Part D plans provide prescription drug coverage for those eligible for Original Medicare. You can enroll in a PDP plan if you are dually eligible for Medicare and Medicaid.

There are three types of Part D prescription drug plans: Preferred Drug Plans (PDPs), Standard Drug Plans (PDPs) and Special Need Drug Plans (SNPs).

All Medicare Part D plans must cover certain types of prescription drugs and medical supplies (such as syringes and needles) and provide information to help you make informed coverage decisions.

If you decide to enroll in this plan, you must choose one of the prescription drug plans offered by Medicare. This plan provides coverage for medically necessary drugs, as determined by the plan.

Generally, prescription drugs are only covered if they are prescribed by a doctor (or other health care professional) licensed to practice in the United States. Your plan may have different or additional coverages.

  1. Stand-alone Drug Plans (also called MA-EPDs)

This plan is designed specifically for people who have very high drug costs and are therefore at risk of losing their health insurance coverage because of the high costs. The plan is offered by a few insurance companies and the United States government and allows people to get their prescription drugs at a reduced cost.

This plan may be available to you if you are enrolled in Medicare and have very high prescription drug costs (more than $2,200 a year). The plan offers reduced-cost prescription drugs to people whose health insurance is at risk of being or has been terminated because of the high costs of prescription drugs.

Special enrollment periods exist for those who are also dually eligible for Medicare and Medicaid and do not have access to a PDP. These special enrollment periods occur when there is a significant change in your health status, such as an end-stage disease diagnosis, or when you move to a new service area.

  1. Part D prescription drug plans

Part D medical plans give you medical coverage for prescription drugs. You should consider joining a Part D plan if you are not currently receiving prescription drug coverage through another health insurance plan. Part D plans are administered by private insurance companies participating in Medicare.

These plans provide coverage only for prescription drugs. Suppose you have medical coverage under Medicare Parts A and B. In that case, you will have to have a separate medical plan to cover medical services such as doctor visits, inpatient hospital care and outpatient medical services such as laboratory tests, X-rays and surgery.

There are eight types of Part D prescription drug plans: Basic, Preferred, Enhanced, Special Needs, Combination, Medigap and Employer Group Waiver. Although there are many differences between the eight types of plans, one thing they all have in common is that they all must provide prescription drug coverage.

  1. Medicare Supplement Insurance (also called Medigap)

These private, standardized health insurance policies provide supplemental coverage to the Original Medicare plan. Medigap policies are regulated by state law and are standardized across the country.

Each state has its own approved list of Medigap insurance providers and there is a specific list of coverage each policy will cover. For the plan to provide complete coverage, it must contain at least the eight standards “fully-covered” benefits.

Medigap plans cover the out-of-pocket expenses you are responsible for under Original Medicare, such as coinsurance and copayments, deductibles and other expenses not covered under Original Medicare.

When considering a Medigap plan, you’ll want to examine the following factors:

  • Premium amounts: The monthly premium amount is based on your health and risk level and the type of service area in which you live.
    • Deductibles, copayments and coinsurance: The amounts you must pay out of pocket when you receive services.

What each coverage and plan provides and what you should look for when deciding which plan you need to best meet your health care needs are all important factors in deciding which plan to enroll in.

While Medicare is an important component of a complete health care health plan, it is important to know all the available types of coverage and plans and how the different options protect health care expenses.

Latest Articles

- Advertisement -Fox Radio CBS Sports Radio Advertisement

Latest Articles

- Advertisement -Fox Radio CBS Sports Radio Advertisement

Related Articles