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Medicare

Who Is Medicare Part D Eligible?

Medicare is a federal program designed to provide health care to people who are over the age of 65 and those who have certain disabilities. Several components make up Medicare, and its various sections are divided into parts. Understanding each of these parts can help you select the best Medicare coverage for your needs. Medicare Part D is one part.

What Is Medicare Part D Coverage?

Medicare Part D is the specific component of Medicare designed to provide drug coverage. This is the component of health insurance coverage that helps to pay for the prescription medications you need now, whether it is routine and ongoing prescriptions or a one-time treatment for an illness. Your prescription drug coverage is very important to get right. Otherwise, you may have to pay a substantial amount of money for the medications you need. Let’s take a closer look at how it all works.

Who Is Eligible for Medicare Part D?

To get prescription drug coverage through a Medicare plan, you need to:

Be eligible for Medicare, also called being a Medicare beneficiary
You can qualify for drug coverage if you sign up for Original Medicare or a Medicare Advantage Plan

Remember, Original Medicare only provides Part A and Part B coverage. That helps to pay for a hospital stay you may have and your routine doctor’s appointments. Original Medicare does not include any drug coverage.

If you choose Original Medicare, you can then compare several providers for prescription drug coverage and find one that works for you. You then add this coverage to your Original Medicare coverage.

The other option is to choose a Medicare Advantage Plan instead of Original Medicare. This gives you access to an affordable type of health insurance that will include drug coverage.

Why Do You Need Medicare Part D?

You may think you do not need Medicare Part D coverage. You may not be taking any prescription medications right now. You may be pretty healthy. Yet, a single illness may cause you to need antibiotics or ongoing prescription medication. That is when the costs get high.

Also important is that if you are eligible for Medicare and do not sign up for it, you may be charged a penalty for late enrollment. That can make getting the health coverage you need even more expensive.

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Who Can Qualify for Medicare Part D?

Being eligible for Medicare means you have met one of two main qualifies set by the federal government. Let’s explain.

You have reached the age of 65

Many people today are living far longer than 65, but that is the magical retirement age for many people. You become eligible to receive all your Medicare benefits when you reach this age. If you are retired, you may want to sign up right away because it helps to get your insurance in place quickly.

You can sign up for Medicare during a seven month window that begins three months before your 65th birthday and continues for three months after it. Medicare will let you know when you are eligible, in most cases, by sending you information.

You may be able to enroll in Medicare after this time. However, you may pay a penalty if you do so.

You have an eligible disability

Some people under the age of 65 qualify for Medicare. That means that you have met the requirements under federal laws that show you have a disability that prevents you from working. There are several steps in getting approved for disability coverage through Medicare. One of them is having a statement from your doctor that confirms that you meet the requirements.

You will need to formally apply for Medicare disability coverage. If you are awarded it, you are then eligible to receive Medicare benefits. That includes signing up for Medicare Part D coverage.

You have end stage renal disease

If you have end stage renal disease, a type of kidney disease in advanced stages, you may also qualify for Medicare coverage with that diagnosis. You will still need to apply to Medicare for coverage and receive approval in order to obtain Medicare Part D coverage. You can qualify for benefits like this between one and three months of receiving a diagnosis of this condition. If you receive a kidney transplant, you may be eligible for this coverage as well.

You have ALS

If you’ve been diagnosed with ALS, also known as Lou Gehrig’s disease, you may also qualify for Medicare even if you have not reached the age of 65. If you qualify for Medicare, you are then able to obtain Medicare Part D coverage. You will be eligible for this coverage as soon as you receive a diagnosis of ALS and it is accepted.

How Do You Get Prescription Drug Coverage with Medicare?

Prescription drug coverage becomes available as soon as you qualify for Medicare. However, just having Medicare prescription drug eligibility does not mean you automatically get it. You have to choose a policy for your drug coverage.

A standalone policy

One way to do this is to purchase a standalone prescription drug plan. If you have Original Medicare (Part A and Part B), this is the best route to getting prescription drug coverage. You will need to compare policies to determine which one fits your needs.

Medicare Advantage Plan

If you decide to choose a Medicare Advantage Plan instead of Original Medicare, you will likely obtain prescription drug coverage. Not all Medicare Advantage Plans include prescription drug coverage. You just need to purchase a plan that includes it.

What If You Qualify for Medicaid?

If you are enrolled in Medicaid health insurance, which is a type of need based health insurance policy, and you are eligible for Medicare, you will automatically receive a Medicare prescription drug plan. This will allow you to have coverage for most of your medications through the plan. Keep in mind that Medicaid is run by states and that sometimes means the requirements and eligibility is a bit different.

What Will Medicare Drug Insurance Cover?

One of the key things to remember about prescription drug coverage is that it is not a standard policy. That is, the drug coverage you obtain is dependent on the specific prescription drug plans you select. Policies will differ in various ways, not just by the actual cost of policies but also by what drugs are covered, what the initial coverage limit is, and even brand name drugs available.

When choosing prescription drug coverage for your needs, you will need to consider what type of medications you need. Then, choose a Medicare drug plan that covers those costs.

Even the least expensive Medicare drug plan will provide coverage for most generic and brand name drugs that people need. They are designed to ensure that most drugs, including insulin preparations, are covered by those who have prior authorization.

Also notable is that your prescription drug insurance must cover some or all of the costs associated with specific types of drugs. That includes:

All anticancer drugs, unless these medications fall under your Medicare Part B coverage
Most mental health drugs, including antidepressants
Antipsychotic medications
All treatments for HIV/AIDs
All immunosuppressant medications deemed necessary
Anticonvulsant medications for those who have seizure disorders

Total drug costs will vary by the insurance company. Keep in mind that you should do some research before choosing any type of policy and Part D plans. Compare plans to determine:

What type of coverage do they offer
Any quantity limitations
All out of pocket costs associated with your needs
What exclusions or limitations are presented by drug manufacturers
The total drug costs to you

If you need to obtain medications that are rare or your doctor is using them off plan, which means that they may not follow the plan’s formulary in terms of when they are prescribed or covered, it is very important to factor this into your medication costs. In some situations, this can add a significant amount of cost, or you may not be able to get coverage from the insurance company. Talk to your doctor about any concerns you have with Part D plans in these situations.

Considerations for vaccinations

Part D plans must also provide full coverage for vaccinations. This includes all recommended vaccinations for you. Some of these vaccines and medication costs may fall under Medicare Part B insurance, which is a part of Traditional Medicare. That is common if they are a type of preventative care service provided. Examples of these include your annual flu shot, COVID-19 vaccinations, and pneumococcal vaccinations.

What Drugs Are Not Covered Under Medicare Part D Plans?

There are some situations where the prescription drug insurance that you have does not cover some medications. That does not mean it is not credible drug coverage.

Some medications are simply not covered by all Medicare Part D plans. That could be due to the plan’s formulary, or it may be related to some type of quantity limit. There may be limitations based on medical necessity, safety, or cost.

You should know about these Medicare Part D restrictions and limitations

Many types of prescription drug insurance coverage will have limitations related to them. That is true for a Medicare Part D plan as well. In short, your Medicare Part D plan may require some of the following:

Prior authorization

In some situations, you may need prior authorization for the medication before it is covered under your Medicare Part D plan. For example, this is common when the medication is typically only approved for some conditions. They also want to be sure there is a prescription drug benefit – is this medication recommended and used for the conditions you are diagnosed with? If the medication is not medically necessary, it may not receive full coverage under the Medicare Part D policy.

Stepped up therapy

Many offer drug coverage for most medications, but you may need to work through several steps before you qualify for that specific coverage. For example, you may have to try lower costing generic drugs before you can obtain a brand name drug. If the cheaper medication does not fit your needs or achieve the desired result, then you may be able to step up to a more expensive option. The Part D plans do not always cover whatever your doctor prescribes.

Quantity limitations

Quantity limits are sometimes a factor for Medicare Part D plans and Medicaid services. You may be limited to a specific amount of the medication prescribed. This is often done to reduce costs but also because it may be unsafe or unproven to use a higher amount of the medication.

What If the Medications You Need Are Not Included in the Medical Part D Plan?

If your Part D plan does not cover the medication you need, there are a few things to consider.

First, if you are in the enrollment period now and trying to choose a Medicare supplement plan to meet your needs, be sure that you use the various tools provided to help you compare plans to find out if the medication you take is covered. When you reach Medicare Part D eligibility, you will be given access to information about just about any medication you need and whether the Medical supplement covers the cost.

Second, you may be able to appeal. For example, if generic drugs are not working for you, or your doctor believes you have a specific need for some reason, you can appeal the decision to not cover the drugs you need. For example, your doctor can submit a formal request to the Social Security Administration about the drug coverage rule. They can then help you to get the cost of medication covered to lower your out of pocket costs.

You can pay out of pocket costs for the medication. If you have the financial means to do so, you can decide to pay for the medications you need out of pocket when your D Plan does not cover it. That can be expensive, though, and does not fit most people’s needs.

When Can You Enroll in Medicare Part D Coverage?

There are several enrollment windows you should know about as Medicare beneficiaries. First, you know that you need to be approved for Medicare Part D plans based on your age, health, or disability. Then, you will receive information from Medicare about your ability to enroll in Medicare Part D. There are several times when you will need to consider your Medicare drug coverage and make decisions about which prescription drug plan and private insurance companies you want to work with for cost sharing.

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When Is the Medicare Initial Enrollment Period?

The initial enrollment period refers to the first time you qualify for Medicare Part D plans. This is a 7-month enrollment period. It is when you will first be eligible as a Medicare beneficiary, whether that is through a Medicare Advantage Plan or Traditional Medicare. This begins three months before your 65th birthday, including the month of your birthday, and then extends for three months after your birthday. During this time, you are eligible for Medicare most commonly (remember, there are other times when you may be able to get a Medicare Part D Prescription plan).

There are other times of the year when you can be eligible for Medicare. This is when you can switch to another Part D plan. This is beyond the initial enrollment period.

October 15 to December 7

This is the official open enrollment period that is available to all Medicare beneficiaries. During this time, you can join a new Medicare drug plan, which may mean switching to another Medicare Part D prescription plan that better fits your needs.

This open enrollment period is also when you can make the decision to switch from traditional Medicare to a Medicare Advantage Plan if you would like to do so. During the enrollment period, you are able to compare plans and choose which plan best fits your needs. Medicare Part D enrollment during this period of time allows your new Medicare Part D prescription policy to go into effect on January 1 of the following year.

Also note that, during this period, you are eligible to make a switch to another plan if your current plan does not have 5 stars. The 5 star rating for Medicare drug coverage plans helps to give you confidence that the policy meets your needs. If your plan does not have 5 stars and you want to switch, you can do so during Medicare Part D enrollment during this time.

January 1 to March 31

The next opportunity to update your Medicare Part D prescription plan is at the start of the year. This is the Medicare Advantage Open Enrollment period. This open enrollment period applies to those who are with a Medicare Advantage plan right now. If you want to leave that plan and enroll in a Medicare Part D plan with traditional Medicare, you can do that during this enrollment period. You may wish to do this if your monthly premium is too high or you want to choose drug plans that offer more of the coverage you need.

Special Enrollment Period

You may have heard about the special enrollment period. This is another time when you may be able to enroll in Medicare and drug plans in some situations. The Medicare Part D plan eligibility occurs when you enter a specific special enrollment period (SEP).

There are various times when you may receive Medicare Part D eligibility. For example, you may be moving. If you are moving outside of where the prescription drug benefit is available to you, that qualifies as a special enrollment period. Otherwise, your current Medicare Part D prescription drug coverage would not apply to your needs and cost sharing is eliminated. If you are moving, request this type of open enrollment option.

Another time when you may wish to consider a special enrollment period is when you are moving into a skilled nursing facility or nursing home. This may alter the type of care you need, and your existing drug plans may not meet your needs, but other Part D plans will. This special enrollment period is beyond the Medicare annual enrollment period. It can occur at any time of the year when you meet Medicare Part D eligibility due to a special circumstance.

December 8 through November 30 of the following year

The Social Security Administration does allow for some people to enroll in Medicare Part D after the Medicare annual enrollment period ends (which typically ends on December 7th each year). This is a one time 5-star SEP period. That means that you can enroll in Medicare Part D plans during this period of time if they are a 5-star rating plan from Medicare.

When you enroll in Medicare Part B, the goal is to ensure you do so when you are eligible. If you are unsure of when that is, be sure to reach out for help from the Social Security Administration about being eligible for Medicare or a Medicare prescription drug plan. Don’t assume you have coverage.

What Is the Late Enrollment Penalty for Medicare Part D?

You may be charged a late enrollment penalty if you do not sign up for Medicare Part D prescription drug coverage when you are eligible to do so. When you achieve Medicare Part D eligibility, and you do not have health insurance coverage from another location, Medicare expects you to sign up for coverage. If you do not enroll in Medicare, you may be faced with some concerns.

First, the late enrollment penalty applies to you if you do not have credible prescription drug coverage within 63 days of when your Medicare prescription drug eligibility period began.

The late enrollment penalty is based on the amount of time that you did not have the necessary prescription drug coverage.

This late enrollment penalty will remain in place throughout your lifetime. That is why it is so important to sign up for you to sign up for prescription drug coverage to cover your prescription drugs when you are eligible to do so for a Medicare Advantage plan or traditional Medicare prescription drug plans.

Prescription drug coverage can help to lower the costs of the medications you need. Medicare Advantage Plans and other Medicare prescription drug coverage are nearly always worthwhile. And, if you do not have creditable prescription drug coverage, that could mean you pay too much. Instead, be sure to learn about Medicare Part D eligibility and get into a plan that fits your needs.

Medicare

Medicare Part B: What It Covers, What It Costs

Medicare Parts A & B are known as the Original Medicare. Together they are said to serve as the foundation of an eligible individual's Medicare coverage.

In a separate blog post, we’ve walked you through the details of Part A, which covers most inpatient services in addition to hospital and home nursing care. Part B of the program looks after a very different side of an individual's healthcare needs, which is medical insurance that covers a broad range of services including outpatient care, doctor visits, x-rays, emergency care, ambulance transportation, IV medications, labs, MRI, other durable medical equipment. It also includes preventive services such as screenings and vaccines.

Yet the services and items covered are not the only things that differentiate Part B from A -- there are also major differences in costs to Medicare members. In this blog post -- the second in a series that seeks to explain the different parts of Medicare coverage -- we will walk you through all the details about Part B. But first, let us briefly recap the basics of Medicare.

What is Medicare and Who are Eligible for Medicare Enrollment?

Medicare is the federal health insurance program for people who are 65 or older, younger people with certain disabilities, and people with permanent kidney failure who requires dialysis or a transplant(a condition also known as end stage renal disease). The areas of coverage under the four parts of Medicare include the following:

Medicare Part A: Hospital Insurance -- covers all inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care
Medicare Part B: Medical Insurance -- covers some doctors' services, outpatient and preventive care, and medical supplies
Medicare Part C: Medicare Advantage Plan -- the private health insurance alternative to the original Medicare
Medicare Part D: Prescription drug coverage -- covers the cost of prescription drugs, recommended shots and vaccines.

The cost for Medicare coverage may vary depending on the kind of coverage and services you get, and also the medical service providers you visit.

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Medicare Premiums for Part B

The standard Medicare Part B monthly premium in 2023 is $164..90. This premium level may change every year, and you will have to pay the full premium each month even if you are not getting any services covered by Part B. If you have a higher income, you will pay an income related adjusted amount based on your IRS tax return from two years ago. You will pay higher premiums if your modified adjusted gross income is more than:

$97,000 in 2023, if you file an individual tax return or are married and file separately
$194,000 in 2023, if you are married and file a joint tax return

Th monthly premiums for Medicare Part B can go up to as high as $560.50 (for those with gross income of $500,000 and filing individually, and $750,000 if filing jointly).

Contact the Social Security office to find out if you have to pay a higher premium because of your income. You can also ask them to lower the additional amount you have to pay if you have had a life-changing event that reduced your household income. These events include marriage, divorce, death of a spouse, loss of income, and an employer settlement payment.

How is the Premium for Medicare Part A Compared with Part B?

As explained in the last blog, many people get Part A for free. The easiest way to qualify for free Part A Medicare is with age -- you are automatically eligible when you turn 65 and have paid Medicare taxes for a certain period of your working life. In fact, if you fail to enroll during the Initial Enrollment Period you face a penalty when you do eventually enroll.

Part A is also free for those who are recipients of retirement benefits through Social Security or the Railroad Retirement Board. If you want more detail, contact Social Security. If you do not qualify for free Part A, your monthly premium of $278 or $506 (2022 levels) is determined by how long you or your spouse had worked and paid Medicare taxes.

For most people, when they buy Part A, they must also get Part B. Yet Part B can be purchased independently of Part A, and some people who don't choose to get Part A can also buy Part B. A penalty maybe imposed on you if you don't get Part B when you are eligible, and the amount is about 10% extra for every 12-month period that you failed to sign up after you become eligible.

Medicare Part B Premiums for Members with Low Income

Unlike Part A, Part B is only free for those with low income and those who are enrolled in one of the Medicare Savings Programs for financial assistance. The eligibility for these programs for different for each state. Some states would make it easier to qualify by setting higher income limits or by eliminating the asset requirement.

What does Medicare Part B cover?

Two types of services are covered by Part B: medically necessary services and preventive services.

Medically Necessary Services:

These are services or supplies that are needed to diagnose or treat your condition which meet accepted standards of medical practice

Preventive Services

These are services to prevent illness (COVID, Flu) or detect them at early stages when treatment is most likely to work best.
The cost to you are normally zero if you are getting preventive services from a healthcare provider who accept assignment, which is an agreement between your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Some of the other services covered by Part B include the following:

Ambulance Services

Part B also covers ground ambulance transportation if your health may be endangered by traveling in any other vehicles and you need to obtain necessary care from a hospital or skilled nursing facility.

In fact, Medicare may even pay for emergency ambulance transportation in an airplane or helicopter if you need immediate and rapid transport that ground transportation can’t provide.

In some cases, Medicare may pay for limited, medically necessary but non-emergency ambulance transportation if you your doctor stated in written order that the transportation is medically necessary, such as if you have end stage renal disease and needs to be taken to a kidney dialysis facility.

Durable Medical Equipment (DME)

Part B covers medically necessary DME when a Medicare-enrolled doctor or healthcare provider order them to be used in your home. These equipment include but are not limited to blood sugar meters, and test strips, canes, commode chairs, crutches, hospital beds, infusion pumps & supplies, oxygen equipment and accessories, suction pumps, walkers, wheelchairs, and scooters.

Medicare pays for DMEs in different ways, and you may rent or buy the equipment depending on their types.

Mental Health Care

Part B pays for outpatient mental health services including depression screening, psychotherapy with doctors, family counseling, psychiatric evaluation, and certain prescription drugs as well as tests and partial hospitalization.

It also covers outpatient mental health services for substance abuse treatment. /

What's Not Covered

There are a few things that neither Part A nor Part B cover and they will have to be paid by yourself. The list include:

Long-Term Care (also called custodial care)
Most dental care
Eye exams (for prescription glasses)
Dentures
Cosmetic surgery
Massage therapy
Routine physical exams
Hearing aids and exams for fitting them
Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care)
Covered items or services you get from an opt-out doctor or other provider (except in the case of an emergency or urgent need)

To find out if Medicare covers what you need, talk to your doctor or other health care provider about why you need certain services or supplies. You can also ask them if Medicare will cover these items.

Sometimes, you may require services that's usually covered but your doctors may think that Medicare won't cover it. If that is the case, you will have to read and sign a notice that says that you may have to pay for the service, supply, or item out of your own wallet.

Medicare Part B Deductibles and Coinsurance

For most of the Part B-covered services mentioned above, you usually pay 20% of the Medicare-covered services or item after you meet your deductible. This amount is called your coinsurance

In 2023, the annual deductible for all Part B members is $226, which is down from the $233 in 2022.

Initial Enrollment Period (IEP)

Similar to Part A, Part B's Enrollments are handled by the Social Security Administration. You can sign up at your local social security office or online at SSA.gov. Bear in mind that there may be penalty if you fail to enroll in Medicare on time.

The first sign up window is when you turn 65. The initial enrollment period lasts for seven months -- it starts three months before your birthday month and ends three months after that. So if your birthday is on March 10, you initial enrollment period is from December 1st until June 30th. For Part B, the coverage starts based on the month you sign up.

If you miss this window, you can only sign up for Part B and premium-Part A during one of the other enrollment period. For example, you will get another chance that's known as the general enrollment period. And this lasts from January 1st to March 31st of each year. So while Part A is still premium-free, since you have missed the first enrollment period, you will likely have to pay higher monthly premium for Part B.

Special Enrollment Period (SEP)

There are certain situations when you can sign up for Part B (and Premium-Part A) during a Special Enrollment Period (SEP) without paying a late enrollment penalty. For example, if you have been impacted by a disaster or an emergency,

An SEP is only available for a limited time. If you don’t sign up during your SEP, you’ll have to wait for the next General Enrollment Period and you might have to pay a monthly late enrollment penalty.

If you want to sign up for one of these SEP, fill out Form CMS-10797 (Application for Medicare Part A and Part B Special Enrollment Period). Send the completed form to your local Social Security office by fax or mail.

Medicare Part B Late Enrollment Penalty

As mentioned above, if you fail to sign up for Medicare coverage during your Initial Enrollment Period, you may have to pay an extra amount called a late enrollment penalty. The only exception is if you have other coverage that's similar in value to Medicare, such as an employment-linked health coverage.

Late enrollment penalties are not a one-time late fee and may be added to your monthly premium. This means they are are usually charged for as long as you have the coverage. The amount also increase the longer you wait to sign up for Medicare.

How Medicare Works with Other Coverage

If you are concerned about the cost of deductibles and copayments, you need not worry. Many insurance providers offer plans that either help reduce your out-of-pocket expenses under Medicare or expand coverage to services that are not covered by the program.

EASY Insurance Plans, is dedicated to finding the right Medicare plan for you. Our experts are available to provide answers and will not rest until your health care needs have been met. Best of all? Our services come at no cost to you! Let us help make sure that you get the coverage that best fits your situation - contact us today!

Medicare

A Guide to Understanding a Medicare Broker vs Agent

Medicare is a complex program, and it can be difficult to know which type of representative you need to help you navigate it. There are Medicare agents and Medicare brokers, but what is the difference?

In this article, we will explain the key differences between these two types of Medicare broker vs agent, as well as what is the most important thing to look for when choosing one. Let's get started!

Is There A Difference Between a Medicare Insurance Broker and an Agent?

Different companies use different terms to describe a broker or agent. Some companies will say a broker is independent and an agent works for only one insurance company.

Others say brokers can't sign you up for policies and agents can.

Lastly, they also say the difference between a Medicare insurance broker and an agent is that brokers have access to multiple plans from different companies while agents represent just one company.

So which one is right?

If you search different sites the terms are interchangeable. So what to do?

Ask the agent or broker one simple question...

Do You or Your Agency Represent One Insurance Carrier or Many?

If they represent one insurance carrier they are called a captive agent or licensed only agent. A captive agent represents numerous plans but they are limited to being from only one carrier. If that carrier does not offer a plan that fits your needs this agent is unable to suggest plans from other carriers in your area.

If they represent multiple carriers, they are independent agents or agency.

And neither type is better or worse than the other.

That's it. All the different terms people use and saying one is better than the other is just marketing spin.

So what is the MOST important thing about a Medicare Broker or Agent?

Does You Medicare Agent or Broker Put YOUR Needs First?

Your agent or broker should be an advocate for you, not just trying to make a sale.

They need to be licensed to access Medicare health plans. You can search for your agent online and confirm their license status.

Look for an agent or broker who takes the time to understand your needs and goals. One that knows all the Medicare options available and will explain each one so you can make an informed decision.

Not All Plans are Offered in Your Area

Different insurance companies offer different plans depending on your area. An independent broker or agent can help you compare plan options in your area and find the best fit for you. They can quickly research for you if your preferred doctor is on covered on each plan as well as which of your prescriptions will be covered on each of the plans.

This is one benefit of working with independent agents vs. searching for plans yourself or the limited options offered by captive agents.

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888-212-7991

Do You Have to Pay Your Medicare Insurance Agent or Broker?

No. Insurance agents and brokers are paid from the insurance company that offers the Medicare plan chosen by you.

Good Independent agents are not selling policies (in any case, you don't pay them). Their responsibility is to help determine which Medicare plans best fit your three core needs.

Health Coverage

Does your Medicare coverage offer the best health coverage for your specific needs?

Costs

Can you afford the premiums, co-pays and deductibles for your Medicare plan? Are your prescription drugs covered and what will be the out of pocket costs? Do you qualify for any zero premium plans?

Convenience

Are doctors and hospitals near you in-network on your Medicare plan? Do the covered services fit with your lifestyle and budget?

Can you save money by going directly to the Insurance Company?

No, you will still pay the same amount if you enroll for coverage directly with the insurance company.

However, you may not choose the best plan for yourself without access to the different tools and research a knowledgeable agent can provide you.

Do I need to pay the agent for help if I choose to use a different insurance agent?

No.

You are not required to use the same agent and you do not have to pay for help in finding a Medicare plan. Be careful of agents asking for fees - it’s illegal for Medicare agents or brokers to charge you a fee.

What if You Qualify for Medicaid Services?

An insurance agent can be a valuable resource for Medicare beneficiaries who also qualify for Medicaid. These individuals are often referred to as "dual eligible," and they may be eligible for additional benefits beyond what traditional Medicare offers. An insurance agent can help dual eligible understand their coverage options, including Medicare Advantage plans and Special Needs Plans (SNPs).

They can also help these individuals enroll in programs that provide assistance with prescription drug costs and other healthcare expenses.

Additionally, an insurance agent can assist with the enrollment process, ensuring that dual eligible are enrolled in the most appropriate plan for their needs. By working with an experienced insurance agent, you can make informed decisions about their healthcare coverage and receive the support you need to manage your health effectively.

Get a personalized Health Insurance quote now.

Click to speak with a licensed Insurance Agent

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888-212-7991

Medicare Beneficiaries - Get the Plan That Is Best For You

There are many different insurance companies, agents and brokers offering Medicare policies.

If you are looking for an experienced Medicare agent that has your best interest in mind, our team of licensed agents at EASY Insurance Plans will be happy to take the time and discuss your Medicare options.

Not turning 65 but looking for an independent agent to help determine what the best coverage health plans are available for you and your family?

We can compare your current health insurance coverage with other plans in your area to help you find the best fit.

Health Insurance

Getting Medical Insurance for Green Card Holders

Let's face it, the U.S. medical system is tough to navigate. Even those of us who have lived our entire lives in this country can easily get confused by some of the terminologies used by medical service and health insurance providers. Adding to that is the maze of government agencies and legislation governing different social healthcare benefits.

Now think about how much more difficult it can be for someone who has just emigrated to the U.S.A. Take health insurance as an example. In many countries, basic medical services are provided by the public sector and the vast majority of population may never have had to deal with getting medical coverage by themselves. That explains why that to many new immigrants, terms like "pre existing condition" and "deductible options" are nothing but alien terms -- even if you try explain to them in their native languages.

If you like many other permanent residents, also known as green card holders, who are having trouble understand how medical insurance in the U.S. works and how to get them, we are here to help. In this blog post, we will run you through some key information for immigrants trying to get health insurance coverage for themselves and their families.

Can a Green Card Holder Get Medical Insurance?

The answer to this question is a simple "Yes". You don't need to be a U.S. citizen in order to buy medical insurance in the country. All you need is a social security number and a valid photo-ID.

The same goes for many government assistance, though there are some medical coverage benefits that are only available to citizens or permanent residents who have been residing in the U.S. for a period of time.

In fact, as long as you are legally residing in the U.S., whether you are a lawful permanent resident (green card holder) or are here on an employment or student visa, you will be eligible for some government benefits that can help lower medical insurance costs.

How can Green Card Holders Get Health Coverage?

Just like U.S. citizens, new immigrants can get medical insurance through a few different sources. The most common ones are

Health insurance plans sponsored by employers;
Private health insurance that they buy in the market;
Medical insurance plans tailored specifically for immigrants

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What is the Health Insurance Marketplace?

If this is your first time buying insurance, or if you do not have a preferred insurance provider and are unsure what health benefits are available to you, one good place to start is the federal Health Insurance Market.

Sometimes called the "Marketplace" or "Exchange," it is the website where you can browse and compare various health care plan available under the Affordable Care Act (ACA). After choosing the right plan, you can complete the enrolment procedure there.

The federal government runs the Marketplace for most states at HealthCare.gov, while some states run their own Marketplaces. The service is also available for small business owners who are providing coverage for their employees through the Small Business Health Options Program Marketplace.

When you apply for individual and family coverage through the Marketplace, you will be asked to provide income and household information. You’ll find out if you qualify for:

Premium tax credits and other savings that make insurance more affordable
Coverage through the Medicaid and Children’s Health Insurance Program (CHIP) in your state

What is the Affordable Care Act?

You might have noticed that we mentioned the term Affordable Care Act above (ACA) above So what exactly is it?

Enacted in 2010, the ACA is a law that seeks to extend access to health insurance to more uninsured people in the U.S., as long as they are lawfully residing in the country. It was introduced by then President Barack Obama with the aim of reforming the health insurance market.

With the ACA, also known as Obamacare, there are now more people who are eligible for subsidies when buying health insurance, provided that their income fall within the range set by the government and that their employers don't provide any sponsored plan.

Currently, the subsidies under the ACA are available to applicants whose income is at least 100% of the federal poverty line (FPL), as those who fall below this threshold are covered by Medicaid, which is a joint federal and state program that offers health coverage to people with limited income and resources.

Can New Immigrants Benefit from the ACA?

When it comes to the ACA, what's even better for new immigrants is that the income threshold that normally applies to U.S. citizens and long-term immigrants would not apply to them.

The reason behind this is because that in most states, Medicaid isn't available to new immigrants until they've been lawfully resided in the U.S. for five years. In order to ensure that immigrants have access to affordable medical insurance, the U.S. Congress has passed a law to allow recent immigrants to receive subsidies when they purchase health insurance in the Marketplace. regardless of how low their income-levels are.

Can Undocumented Immigrants Receive Benefits from ACA coverage?

While the ACA benefits are extended to lawfully-present immigrants, it does not provide any direct benefits for undocumented immigrants.

The ACA prevents those who are not lawful residents of the U.S. from enrolling in insurance plans through the Marketplace. Undocumented immigrants are also not eligible for Medicaid under federal guidelines.

Some states have implemented programs to cover undocumented immigrants, particularly low-income children or those who are pregnant. We will give more details on that later.

Medical Insurance for Green Card Holders Over 65

Besides Medicaid, another term that may require some explaining for new immigrants is Medicare, which is the federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions.

Most Americans become eligible for Medicare when they turn 65, and no longer require individual-market coverage. But for recent immigrants, the restrictions are higher -- they are not eligible to buy into the Medicare program unless they have been lawfully residing in the U.S. for five years.

In the past, this used to cause problems for some new immigrants as most insurance providers generally don't offer health plans to anyone over the age of 64 in the individual market. But as a result of the ACA, policies in the individual market are available on a guarantee-issued basis, regardless of age. And if they buy the plan in the Marketplace, they will be eligible for the subsidies that are available to younger applicants, though they are subjected to the same income threshold.

And even if their income is too high to qualify the subsidies, the ACA still offers them some form of protection by capping the premiums that providers can charge older applicants at three times the premiums they charge for younger applicants.

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State-funded Health Insurance for Immigrants

Beside the Federal Government, medical insurance benefits is the U.S. may also come from other levels of the government. Some states have expanded fully state-funded coverage for either income-eligible children or pregnant women (or both) irrespective of their immigration status. These states are:

California
DC
Illinois
Maine
New York
Oregon
Rhode Island
Vermont
Washington
Massachusetts
Connecticut
New Jersey
Colorado

Each state set up different agencies to run their state-funded program. You can refer to the websites of these agencies for more details.

Health Insurance for Immigrants Waiting for their Green Cards

While you may not be eligible for ACA benefits if you are still waiting to get your green card in the U.S., you can still get health insurance plans from private providers.

Many US insurance providers offer visitor health insurance. There are numerous visitor medical insurance plans in the market that can cover you during your stay or waiting period for your green card.

These plans typically cover medical-related benefits like eligible medical expenses, hospitalization charges, urgent care, doctor visits, prescriptions and drugs, emergency medical evacuation, repatriation, and more. Some of these plans also offer travel-related benefits similar to travel insurance, such as trip delay, trip interruption, baggage, personal loss, etc, at extra charges.

Are Pre-Existing Conditions Covered by Health Insurance for Immigrants?

Under ACA, health insurance companies can't refuse to cover you or charge you more just because of a health problem you had before the date that new health coverage starts. This provision also applies to new immigrants who are covered by the ACA.

Need Help Sorting Out Your Health Insurance Need?

While we hope that this article will serve as a good starting point in your journey to secure health insurance coverage in your new home, we understand that along the way, you will have many more more questions that needs to be answered.

The truth is, even if you already know the kind of benefits available to you under the ACA, chances are you will be able to pick the insurance provider and plans that best suit you -- namely your financial situation and medical conditions -- if you work with a reliable insurance agent.

At EASY Insurance Plans, we specialize in helping new immigrants like you with your health insurance needs. Our experts are here to answer any questions that you may have, and we will not rest until we find the right health plan for you and your family. And last but not least, our services are free of charge.

Medicare

What Is Medicare and What Does It Cover?

Do you qualify for Medicare? If so, you may be able to obtain healthcare coverage for many of your needs.

What Is Medicare?

Medicare is a type of national health care program in the United States. It is available to certain people who reach the age of 65 as well as those who qualify due to a disability. It also provides coverage to people who have amyotrophic lateral sclerosis and end stage renal disease. It provides health insurance to those who qualify.

Medicare isn’t a new program. It’s been present in the U.S. since 1966, but it has changed and continues to change. That’s why it’s so important to know what your rights are when considering this investment. The Centers for Medicare and Medicaid Services oversees the program.

If you qualify for it, it may provide you with the medical insurance you need. Medicare coverage isn’t a simple policy, though. Here is what you need to know.

When Can You Sign Up for Medicare?

Typically, a person can sign up for Medicare when they reach retirement age, which is turning 65. However, if you are still working at that point and have health insurance from your employer, it may be better to maintain that policy longer and enroll in Medicare later.

When you begin to approach retirement age, you’ll learn more about open enrollment. That is the period of time that starts three months before you turn 65. It will end 7 months after your birthday. That means you need to be able to act within that timeframe.

If you become disabled or qualify for Medicare due to other health conditions, you can apply for Medicare directly at any time. You’ll need to meet the government’s requirements for qualifying based on your health condition.

Understanding Medicare’s Plans

The federal health insurance program gets confusing when you start looking at the various “plans” available. Let’s break down the details.

Original Medicare

The term “original Medicare” refers to the basic form. Under this policy, you will receive coverage for parts A and B.

Part A Medicare coverage is hospital insurance. That means this part of the policy covers some of the costs you pay when you are admitted to the hospital for medical care. Part A may cover the following:

Inpatient care at the hospital
Hospice care at the end of life
Skilled nursing facility care
Home health care, with limitations

Part B Medicare coverage is designed to provide you with medical insurance. It helps you cover costs related to going to the doctor and receiving the preventative screenings you need. Part B includes:

Outpatient care at your doctor’s office
Home health care, in some cases
Doctor care at a facility when you do not stay overnight
Durable medical equipment, such as lifting equipment, wheelchairs, and hospital beds, you may need at home
Preventative health care and screenings

When you sign up for this type of policy, it is very important to see the limitations. Parts A and B do not provide coverage for prescription drugs. They also do not cover dental and vision care. It does not cover any coinsurance, deductibles, or copayments that you have to pay for service either.

Remember, Part A covers the costs of your stay in the hospital, while Part B medical insurance covers preventative care, like when you see your doctor for a checkup. That’s where additional policy options are available that are not included in Original Medicare.

Many people who have Original Medicare will purchase a Medigap plan or go with Medicare Advantage Plan options. These are different types of services that could help to extend our coverage beyond what Original Medicare does.

Part D Prescription Drug Coverage

Prescription drugs are a big part of the out of pocket costs most people have over time. To get coverage for your medications, you will need to purchase Prescription Drug Coverage, also known as Part D. Private insurance companies provide Part D coverage. It does not come from the federal government.

Part D prescription drug coverage is regulated by the federal government. That means many plans are similar to each other. However, it’s still wise to compare policies to find the best one for your needs.

What Is Medigap Coverage?

When choosing health coverage, it is very important to choose a policy that gives you ample protection against the cost of medical care. Medicare coverage does not do that. It does not provide for all of the costs you are likely to need.

This is where choosing additional coverage that goes above and beyond what the federal government offers is very important. While you can purchase private insurance, most private insurance policies are very expensive, and that makes them difficult to access as you get older. However, Medigap can offer some protection.

Medigap coverage is also known as Medicare Supplement Insurance. This is one option that you can select to help fill in some of the gaps left by Original Medicare. It can help to cover things like copayments, coinsurance, and deductibles. Here’s how it works.

You sign up for Original Medicare and Medigap coverage. Medigap is a separate supplement insurance that is sold by private insurance companies.
When you file a claim, Original Medical care will pay for some of those costs – usually 80% of most covered needs.
Medigap then fills in the rest, paying the rest of your cases.

Medigap has limitations. For example, it does not provide you with prescription drug coverage. You still have to purchase prescription drug coverage separately. This is a big drawback for many people since medications can be a large part of the out of pocket costs you pay for your medical needs.

What Is a Medicare Advantage Plan?

An alternative for purchasing Medicare supplement insurance is to invest in a Medicare Advantage plan. Medicare Advantage Plans are sometimes called Part C Medicare or MA Plans. These policies come from private insurance companies that must follow specific rules and regulations set up by the federal government to protect policyholders.

Medicare Advantage plans often include drug coverage, Part D. That means that, instead of purchasing Original Medicare, Medicare Medigap Plans, and Part D, you can purchase Medicare Advantage plans that include all components of your coverage.

In these plans, you will receive health coverage for many of your needs. You will likely have to choose a medical provider that is within the plan’s network. There is then a limit to the amount of money you have to pay in out of pocket costs for your care.

What healthcare services do Medicare Advantage plans include?

In addition to providing Medicare Part A and B benefits, Medicare Advantage can go further than this. These plans often include the following:

Emergency medical care
Urgent medical care
Preventative services like wellness checkups
Home health services
All medically necessary services that are provided under Original Medicare
Hospice care
Some plans include vision, dental, and cash cards to help you with additional costs
Some plans cover things like fitness programs, like a gym membership or discounts.
Some may cover transportation to doctor’s visits.
Some plans cover over-the-counter medications that Part D insurance does not cover that help to support health and wellness

When choosing these plans, you will need to compare their details carefully. There are several options, and not all are the same. This lets you choose coverage that is a good fit for your specific needs, though, and that can be well worth it.

There are some exclusions to all of these health coverage options. For example, your doctor visits are covered if they are in network, and some providers will cover some out-of-network doctor visits. However, this type of policy typically does not cover cosmetic surgery or non-health-based care. It is important that you know what the policy offers to ensure you receive ongoing coverage that meets your needs.

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Common Questions About Original Medicare and Medicare Advantage

There’s a lot to think about and plan for when it comes to getting the medical health insurance you need. It’s best to take some time to really explore what your options are. To help you, consider these common questions.

What Does Original Medicare Mean?

If you have Original Medicare, that means you have Parts A and B, which are a part of your Social Security benefits. Part A hospital insurance will help pay for the costs of your medical care when you are admitted into the hospital for a qualified need. The services covered in the hospital include most testing, your care, procedures you have to have, and other needs for inpatient hospital care.

Part B medical insurance helps provide for your routine medical appointments. It may also help cover the costs you have for specific concerns like end stage renal disease when you have permanent kidney failure, Lou Gehrig’s disease, skilled nursing facility care, and outpatient medical care.

How Do I Get Drug Coverage?

If you meet the requirements of the general enrollment period right now, you can sign up for Original Medicare along with Part D drug coverage. This is a separate fee from a private insurance provider. Medicare Part D prescription coverage is an additional cost for your care but can cover most of the cost of your medications as a component of your Medicare benefits.

An alternative to this is to use Medical Advantage Plans. This will cover your Medicare Part B medical, Medicare Part A hospitalization, and Medicare Part D coverage. This means you will have hospital care, medical care for your health care costs, and drug coverage.

Do You Need Supplement Coverage if You Have an Advantage Plan?

No, If you decide to choose a Medicare Advantage Plan, you cannot have supplemental coverage through Medigap.

What Is the Cost of Medicare?

One of the difficult components of getting the medical care you need is understanding the costs Medicare charges.

The cost of Medicare will change each year. During the general enrollment period, you will be able to see the costs so you can choose what works best for you.

Here is a look at some of the costs you can expect for 2023:

Cost for Part A Medicare

Typically, this is $0 if you have paid into Medicare taxes while you were working. Most of the time that means you paid it for at least 10 years. If you do not qualify for premium-free Medicare, you may be able to purchase it at a cost.

There is a $1,600 deductible for Part A that is applied every time you are admitted to the hospital during the benefit period. You must pay this amount before Original Medicare will cover your health costs.

There is a copayment cost that is dependent on the length of your stay. There is no copayment for the first 60 days. From Day 61 to day 90, this is $400 each day. From Days 91 to 150, you pay $8000 in copayments using your 60 lifetime reserve days. After 150 days, you pay all costs.

Costs for Part B Medical Insurance

With Original Medicare, you will pay a monthly premium for your Part B medical insurance. For 2023, this was $164.90 each month but could be higher if you earn more than the limit. This amount will change each year. Even if you do not use any services covered by Part B, you still have to pay this fee to remain enrolled in coverage.

Also, you may pay a penalty if you do not sign up for Part B when you are first eligible for coverage. This is a late enrollment penalty that could be as much as 10% for each year you could have signed up but did not do so. If you learn you do not have creditable drug coverage because you did not sign up for coverage when you earned Medicare eligibility, you may have to pay this fee.

Costs for Part D Drug Coverage

When you purchase health insurance, the cost of prescription drugs is nearly always a big factor. However, since Part D is separate from Original Medicare, Parts A and B, you will pay additionally for this plan on top of the costs for Part A and B. However, these costs range widely between providers. The monthly premiums will be provided to you when you begin to compare your options, but know that the costs will vary significantly from one person to the next.

Medicare Part D coverage is one of the most important parts of Medicare for many people. Be sure that you consider the value of having this as a component of your Medicare plan.

Costs for Supplemental Coverage and Medicare Advantage

As you consider the options to enroll in Medicare, carefully consider the costs associated with supplemental coverage and Medicare Advantage plans. Both of these policies are premiums you will pay monthly to gain access to the Medicare Plan. There’s a difference though:

Medigap supplemental coverage is an additional cost on top of Part A and B and drug coverage.
Medicare Advantage is not an additional cost but rather a single cost you pay that will cover services.

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How Does Social Security Disability Insurance Apply?

Some people become injured and cannot work as a result of that. Social Security Disability insurance may help you to cover your costs. That is, if you qualify for disability through Social Security, you may be then able to receive Medicare. In this situation, you do not have to wait until you reach the age of 65, nor do you have to wait until you have an open enrollment period. You will qualify based on your disability.

However, there is a 24-month qualifying period. That means that when you begin to receive Social Security Disability Insurance benefits, you will receive Medicare after 24 months passes. This waiting period means that you will not have health insurance through Medicare during that time.

If you need health insurance prior to this, you may be able to qualify for Medicaid services. Medicaid services are based on your income and are not the same as Medicare, but they can provide you with some of the coverage you need while you wait for disability benefits to become available to you to cover your healthcare needs.

How Do I Know When My Enrollment Period Begins?

If you are getting older, you may want to start planning for coverage. Your initial enrollment period begins three months prior to your 65th birthday. You typically do not have to do anything, but Medicare will alert you to your ability to qualify. You will likely receive a great deal of information at that time about Medicare Part A and B, as well as when you need to sign up for coverage within your enrollment period.

You will also get information about all of your options, including Medicare supplemental insurance and Medicare Advantage Plans.

How Can You Get The Coverage You Need?

From skilled nursing care to help with physical and occupational therapy after an in hospital stay, there are a lot of times when you may need medical care. Medicare is a government program that may help you cover services and costs, but understanding your options and the parts of Medicare is critical. That is why it is so important for you to seek out some help as you compare private insurers and health care providers.

If you paid Medicare taxes, you may have the ability to get benefits and let Medicare pay your medical bills. Let our team help you.

Medicare

Everything You Need to Know About Medicare Part A

Healthcare is one of the top issues facing the American society today. Businesses, different social groups and non-governmental organizations (NGOs), and government agencies on both the federal and state levels all play important roles in the running of our medical system. But for you as an individual, your top concern should be make sure that you and your family have comprehensive health insurance coverage.

With an aging population -- about one in five Americans will be age 65 or above by 2040 -- it is important that there is affordable healthcare available for senior and individuals who are in need. Luckily, our government has long recognized this problem. Since 1965, the Medicare program has been providing health coverage for older Americans who are not served by the individual and employer-linked insurance markets.

But despite the program's many benefits, the working of Medicare can be complicated and confusing, making it difficult for users to navigate. And this is especially so for the elderlies. To make it easier for both beneficiaries and their families to sort through, the program has been split into four main parts (A,B, C, and D), with each focusing on providing coverage in one or several specific areas, ranging from emergency care to preventive services to hospital care to prescription drugs.

This blog post is the first in a series of articles that aim to help you understand what each parts of Medicare is about. While we will be focusing on Part A this time, before we go into the details, let us give you a brief and general introduction about the Medicare program itself.

What is Medicare and Who is Eligible for Medicare Enrollment?

Medicare Part A: Hospital Insurance -- covers all inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care
Medicare Part B: Medical Insurance -- covers some doctors' services, outpatient and preventive care, and medical supplies
Medicare Part C: Medicare Advantage Plan -- the private health insurance alternative to the original Medicare
Medicare Part D: Prescription drug coverage -- covers the cost of prescription drugs, recommended shots and vaccines.

The cost for Medicare coverage may vary depending on the kind of coverage and services you get, and also the medical service providers you visit.

Medicare Part A Based on Age for People Who Must Pay a Premium

While not everything about Medicare is free, the good news is that most people don't usually have to pay a monthly premium to get coverage for Part A. This is also called the premium free Medicare part A.

You won't have to pay a premium for Part A if you belong to one of the following groups:

Have qualified for or are already getting retirement or disability benefits from social security
Get Medicare earlier than age 65
65 years old or older and have paid Medicare taxes while working working for a certain amount of time (usually 10 years). This applies as long as either you or your spouse (former or current) have been paying the taxes.

If you are unsure whether you have paid Medicare taxes long enough to qualify for Part A, you can either contact your employer, check your W2s forms when you file taxes, or login to the My Social Security account.

If you are a U.S. citizen or permanent resident (also known as green card holder) but haven't worked long enough to qualify for Medicare, you may able to buy into the program and enjoy the coverage by paying a Part A premium.

As of 2023, the premium for individuals who fall under this category is either $278 or $506, depending on how long they or their spouses worked and paid Medicare taxes.

How and When Do I Enroll in Medicare?

Enrollments are handled by the Social Security Administration. You can sign up at your local social security office or online at SSA.gov. Bear in mind that there may be penalty if you fail to enroll in Medicare on time.

The first sign up window is when you turn 65. The initial enrollment period lasts for seven months -- it starts three months before your birthday month and ends three months after that. So if your birthday is on March 10, you initial enrollment period is from December 1st until June 30th.

If you miss this window, you will get another chance that's known as the general enrollment period. And this lasts from January 1st to March 31st of each year. So while Part A is still premium-free, since you have missed the first enrollment period, you will likely have to pay higher monthly premium for Medicare Part B (doctor visits and other outpatient services).

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What if I Start Receiving Social Security Benefits Early

If you started receiving social security benefits before 65, you will automatically be enrolled in Part A and Part B when you turn 65. Your monthly premium will be deducted from your monthly social security payment.

You can still qualify for Medicare if you are under 65 and are receiving certain disability benefits or are suffering from specific condition, such as end stage renal disease or amyotrophic lateral sclerosis (also known as Lou Gehrig's disease).

Are There Any Exceptions?

Even if you are turning 65, there are some circumstances under which you may be able to delay enrollment in Medicare without any late penalties. For example, if you are still working and have comprehensive health coverage through your company, or that your spouse is working and the insurance also covers you.

However, sometimes your employer may still require you to enroll in Medicare Part A and B so that your employment-based insurance only acts as a secondary program to fill gaps in Medicare coverage.

Bear in mind that for you will have to sign up for Medicare once turning 65 even if you already have health coverage. For example, if you are getting your coverage through the Affor Affordable Care Act’s (ACA) health insurance marketplace, you must transition to Medicare once you turn 65.

But the bottom line is, since the vast majority of enrollees won’t have to pay premiums for Part A, enrolling will get you into the system and may make it easier for you to sign up for Part B in future. So even if you already have comprehensive health insurance and are not required to sign up for Medicare at 65, it's best for you to still enroll in Part A.

What Does Medicare Part A Covers?

You are automatically enrolled in Part A as soon as you apply for Medicare. Part A covers most inpatient services: hospital stays, hospice care, and some skilled nursing care that you may require after suffering from more severe conditions such as stroke, or if you are recovering from a major injury that require rehabilitation in a nursing facility.

Medicare pays for virtually all hospital services for the first 60 days you’re in the hospital, though there are some exceptions — it won’t pay for a private room, for example. Here are more details on the coverage provided under Part A:

Inpatient Hospital Care

Part A covers the hospital care if a patient is admitted after an official doctor's order to treat an illness or injury and that the hospital accepts Medicare. One thing to note is that the physicians at the hospital may recommend you to get services more than what Medicare covers or those that aren't covered by Medicare at all. If this is the case, you may have to bear some or all of the costs. Hospital are now required to published standard charges of all their services and items.

Some of the items that are covered include semi-private rooms, meals, general nursing, and drugs. Those that aren't covered are private-duty nursing, private rooms (unless medically necessary), and personal care items such as razors.

Skilled Nursing Facility Care

Part A covers skilled nursing facility care for a limited time if the patients have days left in their benefit period to use and a qualifying inpatient hospital stay. In addition, their doctors will have to decide that they need to be cared by skilled nursing or therapy staff and the facility has to be Medicare-certified.

The items covered include semi-private rooms, meals, skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services, medications, ambulance transportation, and dietary counselling.

Long Term Hospital Care

Long-term care hospitals treats patients with more than one serious medical condition and who are hospitalized for 25 days or more. They may improve with time and care, and eventually return home. The services offered under this include respiratory therapy, head trauma treatment, comprehensive rehabilitation, and pain management.

After you are discharged from the long-term care hospital, some people may get care in a skilled nursing facility or custodial care in a long-term care facility.

Hospice Care

You qualify for hospice care under Part A if you meet all of these conditions: your doctors certify that you're terminally ill with a life expectancy of 6 months or less; you accept comfort care instead of care to cure your illness; and you sign a statement choosing hospice care instead of other treatment for your terminal condition.

Hospice care is usually given in your home or in the facility where you live, such as nursing homes. Once you choose this service, your benefit will usually cover everything you need. You are normally charged nothing for hospice care.

Home Health Services

You are eligible for this services if you doctor decides that you require skilled nursing care or treatment such as physical therapy or speech-language pathology, and that you must be homebound. Usually the services are coordinated by a home health care agency based on what your doctor orders for you.

But Part A Isn't Totally Free

As mentioned earlier, even for those who don't have to pay the premium, Part A isn't completely free. The Medicare program charges a substantial deductible when you are admitted to the hospital. As of 2023, the deductible for each inpatient hospital benefit period is $1,600.

A hospital benefit period starts on the day you are admitted as an inpatient, and ends when you haven't gotten any inpatient hospital care for 60 days in a row. The same calculation method applies to skilled nursing facility.

If you are admitted to a hospital or nursing facility after a benefit period has ended, a new benefit period begins. There is no limit to the number of benefit period you can have in a given year.

In addition to the deductibles, there are also copayments that comes with inpatient stays and skilled nursing facility stay, as well as home health care and hospice benefits. For a complete list of these cost, you can refer to the chart in this link.

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How Medicare Works with Other Coverage

If you are concerned about the cost of deductibles and copayments, you need not worry.
Many insurance providers offer plans that either help reduce your out-of-pocket expenses under Medicare or expand coverage to services that are not covered by the program.

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