Veteran Medicare Basics

Veteran Medicare Basics

Medicare is a health insurance program run by the federal government. It provides coverage for people who are:

• Age 65 and older
• Under age 65 with certain disabilities
• Of all ages with end-stage renal disease

Medicare is made up of parts that handle different types of coverage:

• Parts A and B, also known as Original Medicare
• Medicare Advantage (Part C)
• Part D (Prescription Drug Plans)

There is also a product that isn’t a part of Medicare that provides additional coverage, called Medicare Supplement or Medigap. Medicare Supplement plans are a supplement to Medicare and are available through private insurance companies such as Aetna, Humana, AARP and UnitedHealthCare.

Medicare is different than Medicaid. If you are interested in Medicaid, please visit medicaid.gov

Who’s Eligible for Medicare?

To be considered eligible for Medicare:

• You’re a United States citizen or a legal resident who has lived in the U.S. for at least five consecutive years.
• You’re 65 and have worked at least 10 years in a job that is considered Medicare-covered or you have a disability or end-stage renal disease.

When Do I Enroll If I’m Turning 65?

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Medicare Parts

Parts A and B (Original Medicare)

Parts A and B (also known as Original Medicare) are run by the federal government. With these parts, the government pays the doctors and hospitals you visit directly for your health care.

Part A covers:

• Hospital inpatient care services
• Inpatient care for nursing homes or other skilled nursing facilities
• Hospice care

Part A pays most hospital costs for stays that last up to 60 days annually. After 60 days, you pay a daily copayment for each additional day. If you’re hospitalized for more than 90 days, you may have to pay for all of your care.

Part B covers:

• Doctor visits
• Outpatient care (including preventive services)
• Physical or occupational therapy
• Home health care services that are medically required

Part B doesn’t limit how many covered medical services you can get, as long as the services are medically necessary to treat a medical illness or condition. Some services, such as preventive care and screenings, may be limited.

Medicare Advantage (Part C)

With Medicare Advantage plans, the government pays a set fee to your plan for your health care and then your plan pays the doctors and hospitals.

Medicare Advantage plans include:

• The same coverage and services as Medicare Parts A and B, plus additional benefits (such as vision and dental)
• Part A benefits, including hospital visits, skilled nursing care and home health care
• Part B benefits, including doctor visits, outpatient care, screenings, shots, lab tests, etc.
• Prescription drug coverage, if Part D coverage is included in the Medicare Advantage plan

Some Medicare Advantage plans may also include coverage for other services, including fitness programs or hearing and vision care.

Medicare Supplement Insurance Plan (Medigap)

Parts A and B (also known as Original Medicare) pay for many, but not all, health care services and supplies. That’s where Medicare Supplement plans come in: they help pay for those things Parts A and B don’t cover, such as Medicare deductibles, which are the amounts you owe for health care services before your insurance plan begins to pay.

Medicare Supplement Insurance plans are run by private insurance companies. These plans are state-regulated and not offered by the Federal Government.

Some Medicare Supplement Insurance plans provide additional coverage for services when traveling outside the United States.

Part D (Prescription Drug Plans)

Part D Prescription Drug plans help pay for prescription drugs, as well as brand name and generic medications.

Part D Prescription Drug plans have:

• Formularies, which are lists of the drugs covered under a plan
• Different levels of cost-sharing, which means you pay different amounts for your prescription drugs, depending on the level
• A network of available pharmacies for you to choose from and mail order pharmacy services

If you’re considering prescription drug coverage, sign up as soon as you’re eligible — otherwise, you may have to pay a penalty fee for late enrollment.

Available for Purchase

Your three options for purchasing additional Medicare coverage are shown below.

Please keep in mind that you’ll want to compare the monthly premium cost as well as the cost to use the plan. For example, if you visit your primary care doctor frequently, a plan that costs you $0 a month in premiums and requires you to pay $35 every time that you visit your doctor may end up costing you more out of pocket than a plan that costs $39 a month in premiums but only requires you to pay $15 per visit.

Please remember that the Medicare Advantage Plan can only be purchased as a single plan, which includes drug coverage options. Only Medicare Supplement Insurance Plan and Medicare Part D Prescription Drug plan can be purchased together as a combination.

Medicare Advantage (Part C)

• Everything is packaged together, so it works like insurance plans you used before Medicare
• The carriers maintain a network of doctors for you ^{1, 2}
• Plans have an out-of-pocket maximum, which helps protect you financially
• The cost of the plan is NOT based on your age or health
• Preventive care is covered at 100% ³
• You must have both Parts A and B (Original Medicare)
• You cannot also purchase a Medicare Supplement or Part D plan

Medicare Supplement (Medigap)

• Offers coverage for the costs Medicare doesn’t cover ^9,14
• Prescription drug coverage is not included, but you can purchase a Part D
• Prescription plan in addition to a Medicare Supplement Insurance
• You can go to any doctor that accepts Medicare, which can be helpful if you travel out of NC ¹⁰
• The cost of the plan is based on your age ¹¹
• You must have both Parts A and B (Original Medicare)
• You cannot also purchase a Medicare Advantage plan

Medicare Part D Rx (Part D)

• Medical coverage is not included, but you can purchase a Medicare Supplement plan in addition to a Part D plan
• Uses a pharmacy network that includes most national chains ¹
• You have the option of getting prescriptions mailed to you
• Helps with costs during the coverage gap stage, which is also known as the “donut hole”
• You must have either Parts A or B (Original Medicare)
• You cannot also purchase a Medicare Advantage plan

Medicare Supplement Disclaimer: MILOPS Insurance Services℠ nor its agents are endorsed by or affiliated with the United States Government or the Federal Medicare program.

Footnotes

1. Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
2. A formulary applies for all plans that include Medicare prescription drug coverage.
3. Preventive care is covered at 100% with your primary care provider, at a county health clinic.
4. You must use the plan’s providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor (VIC) will be responsible for the costs.
5. Beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
6. Mail order is available; please see Summary of Benefits for more details.
7. With the exception of emergency or urgent care, member liability PPO may be greater for services received out-of-network than services received in-network. Many out-of- network services are subject to coinsurance, which are based on the Medicare allowed amount and not on the potentially lower in-network contract amount.
8. You must continue to pay the Medicare Part B premium in addition to your plan premium.
9. Caution: Policy benefits are limited to those approved by Medicare for payment.
10. If you go to a physician not participating in Medicare you may be responsible for the difference in the approved Medicare charge and the billed amount. Private contracts between you and a provider are excluded from Medicare and Medicare Supplemental Insurance Plan payments.
11. When you enroll in an attained-age plan, your rates will increase as you age. The rates will only increase due to age when you move from one age band to the next. In addition, rate adjustments will also be due to medical inflation or overall claims experience. Rates are subject to change June 1 of each year and are guaranteed for 12 months. Any change in rate will be preceded by a 30-day notice. Members will not be singled out for premium increases based on their individual health. Medicare policies that are attained-age should be compared to issue-age rated policies. Premiums for issue-age policies do not increase due to age as the insured ages.
12. This is only a summary of benefits describing the policies’ most important features. The policy is the insurance contract. You must read the policy itself to understand all the rights and duties of both you and your insurance company. These policies may not fully cover all of your medical costs..
13. If you enroll within 30 days following your 65th birthday, or if you have 6 months of continuous prior coverage, the 6-month waiting period for pre-existing conditions will be waived. Pre-existing conditions are conditions for which medical advice was given, or treatment was recommended by or received from a physician within six months before the effective date of coverage. If you wait until after the deadline to enroll, you may have a waiting period for pre-existing conditions and may have to complete a medical questionnaire.