Medicare Overview

Original Medicare

Original Medicare, which is sometimes referred to as "Medicare Fee-for-Service", is coverage managed by the federal government. Generally, there's a cost for each service.

With original Medicare, beneficiaries can go to any doctor, health care provider, hospital, or facility that is enrolled in Medicare and accepting new Medicare patients. The beneficiary does not have to select a primary care provider (PCP) nor get a referral to see a specialist.

Beneficiaries generally pay a set amount for their health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and the beneficiary pays their share (coinsurance/copayment) for covered services and supplies. There's no yearly limit to the amount of out-of-pocket costs the beneficiary is responsible to pay. Additionally, the beneficiary usually pays a monthly premium for their Part B coverage.

Insight

Original Medicare gives the beneficiary the freedom to chose their providers and to direct their own care. However, out of pocket expenses may be cost prohibitive to those who are on a fixed income and/or have no supplemental coverage, such as Medi-Cal or MediGap.

Medicare Advantage (MA) Plan -Medicare Part C

Medicare Advantage (MA) Plans, also referred to as Medicare Part C, are a type of Medicare health plan offered by a private company that contracts with MA Plans to provide all Part A and Part B benefits, excluding hospice*. MA Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If a beneficiary is enrolled in an MA Plan, most Medicare services are covered through the plan and aren’t paid for by Original Medicare. Most MA Plans offer prescription drug coverage.

*Once hospice benefit starts, Original Medicare will cover everything related to the terminal illness. Original Medicare covers these services even if the beneficiary remains in an MA Plan or other Medicare health plan. If the beneficiary is in an MA Plan before starting hospice care, s/he can stay in that plan, as long as the beneficiary continues to pay their monthly premiums.

If the beneficiary stays in the MA Plan, s/he can choose to get services not related to the terminal illness from either providers in the MA Plan’s network or other Medicare providers.

A Few Words About MA Plans

Monthly premiums, deductibles, copayments, and coinsurance are generally less costly than original Medicare. Additionally, most MA Plans offer extra benefits to their enrollees, such as dental care, eyeglasses, and hearing aids.

However, a beneficiary who enrolls in an MA Plan will usually need to select a primary care provider. S/he will also need to obtain medically needed services and prescriptions (if Part D enrollment is with the same MA Plan) through the Plan's provider network.

The 3 Parts of Medicare & What is Covered

Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

In general, Part A covers:

Covers certain doctors' services, outpatient care, medical supplies, and preventive services.

Part B covers 2 types of services

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

Part B covers services like:

Helps cover the cost of prescription drugs (including many recommended shots or vaccines)

There are 2 ways to get Prescription Drug Coverage:

1. Enroll in a Medicare drug plan. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some private Fee‑for‑Service plans, and Medical Savings Account plans.

The enrollee must have Medicare Part A and/or Part B to be eligible for a separate Medicare drug plan.

2. Enroll in a Medicare Advantage (MA) Plan (aka: Medicare Part C) or other Medicare health plan with drug coverage. The enrollee can get all of Part A, Part B, and drug coverage, through these plans.

The enrollee must have Part A and Part B to join an MA Plan. Not all MA Plans offer drug coverage.

All Plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A Plan’s list of covered drugs is called a “formulary”. Each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost less than a drug in a higher tier.

Medicare

What is Medicare?

Please Note

Original Medicare

Insight

Medicare Advantage (MA) Plan -Medicare Part C

A Few Words About MA Plans

The 3 Parts of Medicare & What is Covered

Medicare

What is Medicare?

Please Note

Original Medicare

Insight

Medicare Advantage (MA) Plan -Medicare Part C

A Few Words About MA Plans

The 3 Parts of Medicare & What is Covered

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