Can I Get My Health Care From Any Doctor Other Health Care Provider Or Hospital
- Original Medicare
-
You can go to any doctor or hospital that takes Medicare, anywhere in the U.S.
In most cases, you don’t need a
referral
to see a specialist.
- Medicare Advantage
-
In many cases, youll need to only use doctors and other providers who are in the plans network . Some plans offer non-emergency coverage out of network, but typically at a higher cost.
You may need to get a
referral
-
You can join a separate Medicare drug plan to get Medicare drug coverage.
- Medicare Advantage
-
Medicare drug coverage is included in most plans. In most types of Medicare Advantage Plans, you cant join a separate Medicare drug plan. You can join a separate Medicare drug plan with certain types of plans that:
- Cant offer drug coverage
- Choose not to offer drug coverage
Youll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:
What Is Medicare Part B Medical Insurance
Medicare Part B provides outpatient/medical coverage. The list below provides a summary of Part B-covered services and coverage rules:
This list includes commonly covered services and items, but it is not a complete list. Keep in mind that Medicare does not usually pay the full cost of your care, and you will likely be responsible for some portion of the cost-sharing for Medicare-covered services.
The 2022 Part-B premium is $170.10 per month
When Can I Enroll In Medicare Part D
To be eligible for Medicare Part D prescription drug coverage, you must have either Medicare Part A or Part B, or both. You can sign up for Medicare Part D at the same time that you enroll in Medicare Part A and B.
As mentioned above, most people who select Medicare Advantage must receive their Part D prescription benefits as part of that same Medicare Advantage plan . Medicare Savings Account plans do not include Part D coverage, nor do some Private Fee-for-Service Medicare plans. If you have an MSA or a PFFS and it doesnt have Part D coverage included, youre allowed to purchase a stand-alone Part D plan to supplement it.
As with Part B, you are still eligible for Part D prescription drug coverage if you dont enroll when youre first eligible, but you may pay higher premiums if you enroll later on, unless you had during the time that you delayed enrollment in Part D.
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Consider Medicare Advantage For All
You can choose to sign up for traditional Medicare: Parts A, B and D, and a supplemental medigap policy. Or, you can go an alternative route by signing up for Medicare Advantage, which provides medical through private insurance companies. These plans also frequently include prescription drug coverage.
Also called Part C, Medicare Advantage has a monthly cost, in addition to the Part B premium, that varies depending on which plan you choose. For 2022, the average monthly premium for Advantage plans is $19.
Like traditional Medicare, you’ll also be subject to co-payments, deductibles and other out-of-pocket costs. In many cases, Advantage policies charge lower premiums than medigap plans but have higher cost-sharing. Your choice of providers may be more limited with Medicare Advantage than with traditional Medicare, and recent research has found that sicker enrollees often dump Medicare Advantage in favor of original Medicare.
Who Is Eligible For Medicare
Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease . Medicare has two parts, Part A and Part B . You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:
- You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
- You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
- You or your spouse had Medicare-covered government employment.
To find out if you are eligible and your expected premium, go the Medicare.gov eligibility tool.
If you did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A. If you are under age 65, you can get Part A without having to pay premiums if:
- You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months.
- You are a kidney dialysis or kidney transplant patient.
While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.
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Why Do I Need To Buy A Private Health Plan
Private Medicare health plans like Medicare Advantage or Medicare Cost plans cover everything Original Medicare does, and usually include more coverage for services you might need. Plus, they can include extra perks and benefits.
Find out more in the article, 4 reasons to buy a private health plan.
Carriers Are The Hub Of Original Medicare
Amazingly, in 2020 alone Part A and Part B carriers processed more than $400 billion in claims, bills, disputes, and appeals for the Medicare Fee-For-Service program.
As well as handling the ins-and-outs of medical claims, Medicare Administrative Carriers educate providers to develop improvements for claims standards.
Overall, the carriers responsibilities include the following tasks:
- Process claims for Original Medicare
- Make Medicare payments and reimbursements
- Account for Medicare payments
- Recruit doctors and facilities for Original Medicare
- Review claim appeals for individuals denied coverage
- Review medical records as needed for claims
- Establish Local Coverage Determinations to include more procedures as medicinal innovations grow
- Handle inquiries from service providers, like doctors
- Coordinate with CMS and the other administrative contractors under CMS
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Ask Rusty I Have Medicare Advantage
Dear Rusty: My wife and I have a Medicare Advantage Plan, and we do not use Medicare for our claims. However, we still have the Medicare premium deducted from our Social Security checks. Is this correct? Signed: Wondering
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Dear Wondering: If, after age 65, you choose to take Medicare outpatient coverage of any kind you must pay that Part B premium, even if you decide to acquire a Medicare Advantage plan instead of using original Medicare to administer your healthcare claims.
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Medicare Advantage plans are healthcare plans offered by private insurers who will administer your healthcare claims instead of the Federal Government. But you cannot get a Medicare Advantage plan without first being enrolled in Medicare Part A and Part B and paying any associated Part B premium.
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So, when you see or hear a Medicare Advantage provider advertising no cost or very low cost coverage, recognize that they can offer that only because the government pays them a fixed amount for your care from the Medicare Part B premium taken from your Social Security. The Part B premium you are paying from your Social Security benefit is why your Medicare Advantage plan premium is as low as it is.
From The Centers For Medicare And Medicaid Services: Benefit Design For Simplified Determination Of Creditable Coverage Status
If an entity is not an employer or union that is applying for the retiree drug subsidy, it can determine that its prescription drug plans coverage is creditable if the plan design meets all four of the following standards. However, the standards listed under 4 and 4 may not be used if the entitys plan has prescription drug benefits that are integrated with benefits other than prescription drug coverage . Integrated plans must satisfy the standard in 4.The 2022 Medicare Part D Model Plan Parameters
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Medicare Offers More Free Preventive Services
Medicare beneficiaries can receive a number of free preventive services. You get an annual free “wellness” visit to develop or update a personalized prevention plan. Beneficiaries also get a free cardiovascular screening every five years, annual mammograms, annual flu shots, and screenings for cervical, prostate and colorectal cancers.
Get Information Online By Phone Or Mail
The federal and state governments have taken a lot of steps to make information about Medicare available to everyone. The best advice for someone approaching the age of 65 is to make a study of the benefits and requirements for Medicare. Eligibility, application procedures, and timing matter the outcomes can be better or worse depending on the actions you take. You can also get information online, call Medicare or Social Security, or write.
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There’s Medicare Part A Part B Part D Medigap Plans Medicare Advantage Plans And So On We Sort Out The Confusion About Signing Up For Medicare
Heading into retirement brings a slew of new topics to grapple with, and one of the most maddening may be Medicare. Figuring out when to enroll in Medicare and which parts to enroll in can be daunting even for the savviest retirees. There’s Part A, Part B, Part D, medigap plans, Medicare Advantage plans and so on. And what the heck is a doughnut hole, anyway?
To help you wade into the waters of this complicated federal health insurance program for retirement-age Americans, here are 11 essential things you must know about Medicare.
Am I Eligible For Medicare Part A
Generally, youre eligible for Medicare Part A if youre 65 years old and have been a legal resident of the U.S. for at least five years. In fact, the government will automatically enroll you in Medicare Part A at no cost when you reach 65 as long as youre already collecting Social Security or Railroad Retirement benefits.
If youre already receiving Social Security or Railroad Retirement benefits, all you need to do is check your mail for your Medicare card, which should automatically arrive in the mail about three months prior to your 65th birthday . The card will arrive with the option to opt-out of Part B , but opting out of Part B is only a good idea if youre still working and have employer-sponsored coverage that provides the same or better coverage, or if your spouse is still working and you have coverage under their plan.
If youre not already receiving Social Security or Railroad Retirement benefits, youll need to enroll in Medicare during a seven-month open enrollment window that includes the three months before the month you turn 65, the month you turn 65, and the three following months. If you enroll before the month you turn 65, your benefits will start the month you turn 65 . If you enroll in the three months after you turn 65, your coverage could have a delayed effective date.
In addition to turning 65, people can become eligible for Medicare due to a disability , or due to end-stage renal disease or amyotrophic lateral sclerosis .
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Already Enrolled In Medicare
If you have Medicare, you can get information and services online. Find out how to .
If you are enrolled in Medicare Part A and you want to enroll in Part B, please complete form CMS-40B, Application for Enrollment in Medicare Part B . If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete form CMS-L564, Request for Employment Information.
You can use one of the following options to submit your enrollment request under the Special Enrollment Period:
Note: When completing the forms CMS-40B and CMS-L564
- State I want Part B coverage to begin in the remarks section of the CMS-40B form or online application.
- If possible, your employer should complete Section B.
- If your employer is unable to complete Section B, please complete that portion as best as you can on behalf of your employer without your employers signature and submit one of the following forms of secondary evidence:
- Income tax form that shows health insurance premiums paid.
- W-2s reflecting pre-tax medical contributions.
- Pay stubs that reflect health insurance premium deductions.
- Health insurance cards with a policy effective date.
- Explanations of benefits paid by the GHP or LGHP.
- Statements or receipts that reflect payment of health insurance premiums.
Some people with limited resources and income may also be able to get .
D: Prescription Drug Coverage
Original Medicare and Medigap plans do not provide prescription drug coverage, which means you may want to purchase a Part D plan or a Medicare Advantage plan that includes prescription drug coverage. Enrolling in a Part D plan is not required. However, if you don’t enroll in a Part D plan when you first become eligible you may wind up getting penalized financially should you enroll later.
Regardless of the coverage you choose for prescription drugs, it’s important to consider the ones that cover the medications you need, how often you need them, and where you purchase them.
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How To Apply Online For Just Medicare
If you are within three months of turning age 65 or older and not ready to start your monthly Social Security benefits yet, you can use our online retirement application to sign up just for Medicare and wait to apply for your retirement or spouses benefits later. It takes less than 10 minutes, and there are no forms to sign and usually no documentation is required.
To find out what documents and information you need to apply, go to the .
Medicare Offers Easy Enrollment
The best way to find out if one has Medicare is to apply. The main websites for Medicare and Social Security have short and simple online application pages. One can apply and get an official answer very quickly. The sites state the qualifications needed, and they process moves quickly for most applicants.
The Medicare system requires choices. One must choose the all-in-one plans of Medicare Advantage or the Original Medicare with Prescription drug and Medigap benefits added.
Comparison shopping is the ideal tool for making selections of private health, prescription drug, and gap insurance plans.
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What Does Medicare Part A Cost
When you work, your employer takes out money for Medicare taxes. As long as you or your spouse works for 10 years paying Medicare taxes, you get Medicare Part A without a premium when youre 65 years old.
Thats not to say that you or a loved one can walk into a hospital and receive free care. Medical Part A requires you pay a deductible toward your inpatient care. For 2022, this is $1,556 for each benefit period.
If you dont automatically qualify for free Part A, you can still buy Part A. For 2022, the monthly premium for Part A is $499 if youve worked less than 30 quarters. If you paid Medicare taxes for 30 to 39 quarters, you would pay $274.
Medicare Expands Telehealth Offerings
Although most Medicare Advantage plans have been covering telehealth for years, traditional Medicare used to restrict the service only to certain devices and practitioners, and patients had to be at a Medicare facility. When the coronavirus pandemic hit, telehealth was expanded so that patients could use smartphones in their own homes to consult with a broader range of medical professionals, a feature that could become permanent.
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The Importance Of Local Coverage Determinations
Collectively, Medicare A and B serves a diverse population of millions of older Americans and persons with disabilities.
Of course, these varied groups of Americans have tremendously more varied health needs.
Importantly, hundreds of millions of determinations of coverage each year means maintaining consistency of coverage standards from state to state and region to region.
Local coverage determinations help the system work consistently by providing peer guidance to the process of review and approval of billings and procedures.
In summary, Medicare Administrative Contractors that handle Part A and Part B claims and payments can grant local coverage determinations for medical situations or procedures for which no national rule yet exists.
As one state advances a new determination for medical procedures, every other carrier gets the information and can apply it.
Supplies Covered By Medicaid
The following medical supplies could be covered by Medicaid, depending on the state and the individual plan:
Bladder control pads, pull-on underwear, adult briefs, & more.
Catheters, insertion kits, lubricant, condom catheters, & more.
Test strips, blood glucose monitors, lancets, test solution, & more.
Skin barriers, 2 piece pouch systems, drainage bags, & more.
Bandages, foam dressings, tape, gauze, hydrogels, & more.
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