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This is a presentation by Soraya Ghebleh that explains the major components of Medicare and the associated terms an individual would need to know to navigate the vast amount of information available on Medicare.
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Soraya Ghebleh
¡ Medicare is a federal health insurance program
¡ It covers people over the age of 65, people with disabilities, and people with end stage renal disease
¡ Medicare does not cover all health care needs but does cover most medically necessary services
¡ Medicare is divided into four parts: Part A, Part B, Part C, and Part D
¡ Part A is for hospital insurance, paying for most inpatient hospital care and some inpatient skilled nursing facilities
¡ Individuals are automatically enrolled in Part A when they join Medicare
¡ If you automatically qualify for Medicare, you do not have to pay a monthly premium
¡ Part B pays for doctors’ services, outpatient hospital care, outpatient physical and speech therapy, some home health care, ambulance services, and some medical equipment and supplies
¡ Part B is voluntary and the monthly premium is automatically deducted from monthly Social Security checks
¡ If you do not receive Social Security, you will be billed for Part B
¡ Part C combines A, B, and D into an HMO or a PPO with a private insurer
¡ Part C governs the way Medicare benefits are provided by companies that contract with the Medicare program
¡ Individuals enrolled in a Medicare Advantage plan receive all of their medical savings through that plan
¡ HMOs and PPOs contract with Medicare to provide Medicare benefits in a managed care setting
¡ You must pay the Part B premium in order to qualify for a Medicare Advantage Plan
¡ Part D refers to Medicare prescription drug coverage and can often be a stand-‐alone plan with a private insurer
¡ Part D coverage is voluntary and the monthly premium depends on how much coverage an individual has
¡ Medigap is also known as supplemental insurance
¡ Generally individuals who buy a Medigap policy also have Medicare Part A and Part B and the Part B premium must be paid
¡ Medigap policies are health insurance sold by private insurance companies to fill the “gaps” in the original Medicare Plan coverage
¡ Costly, but often very useful
An agreement with a doctor to be paid directly by Medicare, accept the payment amount Medicare approves for the service, and not bill you anything other than the Medicare deductible and coinsurance.
The amount you have to pay for medical services after paying any deductibles. Coinsurance is usually a percentage of the service. So if you have a $10,000 doctor bill after deductibles and a 20 percent coinsurance rate, Medicare would pay $8,000 and you would pay $2,000.
The amount you have to pay for a medical service or supply, for example, a doctor’s visit or a prescription. A co-‐payment is usually a set amount, such as $10 or $20.
The amount you have to pay for health care or prescriptions before Original Medicare, your prescription drug plan, or other insurance kicks in.
The amount over the approved Medicare payment that some doctors and other health-‐care providers can charge you under Original Medicare.
Also called “Medigap Protections.” Means that Medigap plans can’t deny you a Medigap policy, refuse to cover preexisting conditions, or charge you more for the policy based on your age or medical status if you buy the policy within six months of signing on for Medicare Part B.
Insurance companies can’t cancel your Medigap policy unless you lie on your application, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.
A joint federal and state health insurance program for those who meet certain financial requirements.
The maximum amount that doctors who accept a Medicare assignment can be paid for a service. In other words, they can’t bill you any extra.
A Medicare Advantage plan that combines a high deductible with a medical savings account. The plan deposits money each year into your account. You do not pay any taxes on the money or the interest it earns as long as you use it for health-‐care costs, including those that aren’t covered by Medicare. Any money left in the account at the end of the year can still be used for medical costs in future years. Unlike non-‐Medicare medical savings accounts, you cannot deposit any money into this account.
A type of Medicare Advantage (Part C) plan in which you can see the same doctors and use the same hospitals as someone with Original Medicare. However, because the plan determines how much it will pay doctors and hospitals and how much you must pay when you receive care, you may pay more (or less) for Medicare-‐covered benefits than if you had Original Medicare.
A type of Medigap policy that may require you to use hospitals and, in some cases, doctors, within its network to be eligible for full benefits.
A health problem you had or have before a new insurance policy starts.
A monthly fee paid to Medicare, an insurance company, or a health-‐care plan to maintain your insurance coverage.
Health care to prevent illness or detect illness at an early stage. Screening mammograms, flu and pneumonia vaccines, and Pap tests are examples of preventive services.
Someone entitled to Medicare Part A, whose income is not higher than the Federal Poverty Level, and whose resources (i.e., a house, car, etc.) do not exceed twice the Supplemental Security Income level. These people are eligible to have their state Medicaid system pay their Medicare premiums, deductibles, coinsurance and co-‐payment amounts (except for Part D).
State programs that provide free local health insurance counseling to people with Medicare. The federal government funds these programs.
¡ http://www.rd.com/health/healthcare/medicare-‐alphabet-‐soup-‐a-‐glossary/
¡ http://www.youtube.com/watch?v=slVO3p83_S0
