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What is Medicare?
As a United States citizen who has reached the age of 65 or above, you have the opportunity to enroll in Medicare, the federally provided healthcare program. Medicare consists of Parts A and B, commonly known as Original Medicare, which provide coverage for fundamental hospital and doctor expenses.
However, Original Medicare leaves certain expenses uncovered, resulting in potential out-of-pocket expenses. To safeguard against these gaps in coverage, Medicare supplements or Medicare Advantage plans are available, offering additional protection. Our team has extensive experience assisting clients in comprehending the coverage provided by Original Medicare and identifying plan options that align with their individual circumstances. We are dedicated to helping individuals make informed decisions about their healthcare coverage.
Your Trusted Health Advisor
How Does Medicare Work?
Medicare is a federal health insurance program that provides coverage for eligible individuals, primarily those aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions.
It is divided into different parts, including Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), and Part D (Prescription Drug Coverage). Medicare enrollment occurs during specific periods, and there are costs involved such as deductibles and co-payments.
To choose the right coverage, individuals can consider options like Original Medicare, Medicare Advantage, or supplemental coverage like Medigap plans.
However, Original Medicare leaves certain expenses uncovered, resulting in potential out-of-pocket expenses. To safeguard against these gaps in coverage, Medicare supplements or Medicare Advantage plans are available, offering additional protection. Our team has extensive experience assisting clients in comprehending the coverage provided by Original Medicare and identifying plan options that align with their individual circumstances. We are dedicated to helping individuals make informed decisions about their healthcare coverage.
Medicare Basics
Medicare is not free
There are over 56 million
people on Medicare.
There are over 800,000
providers who accept
Medicare in the US.
In some cases, people
under the age of 65
can qualify based on
health conditions or
disability.
Your initial enrollment
period is 7 months long
and begins 3 months
before your turn 65.
There are some penalties
if you miss the enrollment
period and don’t have
any other credible health
coverage.
Enrollment Opportunities
Initial Election Period for Part C & D:
When you first turn 65 (or become eligible for Medicare prior to age 65 through special circumstance) and have enrolled in Part A & B of Medicare, you will have a 7-month window to enroll in a Medicare Advantage Plan (Part C) or Prescription Drug Plan (Part D).
This 7-month window is the 3 months prior to your Part A & B starting, the month they take effect, and the 3 months following that effective month.
Open Enrollment for Medigap:
If someone would like to purchase a Medigap Plan (Medicare Supplement) instead of a Medicare Advantage Plan, they have a 6 month “Open Enrollment window” starting the day their Part B takes effect where they can do so without being subjected to medical underwriting by an insurance carrier.
Medigap Plans can also be purchased at any time throughout the year, but they would be subject to underwriting if outside of the Open Enrollment.
Annual Enrollment Period (AEP) for
Part C & D:
For Medicare Recipients that have Medicare Part A and/or Part B they are eligible to enroll into or change their Medicare Prescription Drug Plan (Part D) between October 15th and December 7th and all those enrollments will take effect on January 1st.
For Medicare Recipients that have Medicare Part A and Part B they are eligible to enroll into or change their Medicare Prescription Drug Plan (Part D) or Medicare Advantage Plan (Part C) between October 15th and December 7th and all those enrollments will take effect on January 1st.
When are the Enrollment Periods?
AEP: Annual Enrollment Period:
The Medicare Annual Enrollment Period (AEP) is October 15th-December 7th and all plans will take effect January 1st. Medicare recipients can add, switch, or drop a plan. You are also allowed to enroll in as many plans as you want and typically the last enrollment completed during the enrollment period will be the one that goes into effect January 1st of the following year.
Open Enrollment for Medigap:
If someone would like to purchase a Medigap Plan (Medicare Supplement) instead of a Medicare Advantage Plan, they have a 6 month “Open Enrollment window” starting the day their Part B takes effect where they can do so without being subjected to medical underwriting by an insurance carrier. Medigap Plans can also be purchased at any time throughout the year, but they would be subject to underwriting if outside of the Open Enrollment.
Are There Times I May Be Able to Enroll Outside the Enrollment Periods?
Low Income Subsidy or Medicaid
If you qualify for a low income subsidy or Medicaid, you may have opportunities to enroll in Medicare outside the regular enrollment periods.
Qualifying Chronic Condition:
If you have a chronic condition that meets the eligibility criteria,you may be able to enroll outside the enrollment periods.
Change of Residence
If you have moved to a new zip code, you may be eligible for a special enrollment period to enroll in or change your Medicare plan.
5-Star Rated Plans:
You may be able to enroll in a plan with a 5-star rating outside the enrollment periods, as these plans offer exceptional quality and performance.
Changes in Extra Help or Medicaid:
If you experience changes in your eligibility for extra help or Medicaid, you may have options to enroll or make changes to your Medicare coverage.
Leaving Group Coverage or Retirement Coverage
If you are leaving a group health insurance plan or retirement coverage, you may be eligible for a special enrollment period to enroll in Medicare.
Veterans Affairs (VA)
If you have VA, you may have flexibility in enrolling in or changing your Medicare coverage.
Moving into or out of Long-Term Care Facility
If you are moving into or out of a long-term care facility or skilled nursing facility, there may be opportunities to enroll or make changes to your Medicare plan.
It is essential to consult with a representative who can provide personalized guidance based on your specific circumstances and help you understand the options available for enrolling in or changing your Medicare coverage outside the regular enrollment periods.
Medicare
Supplement
VS.
Medicare
Advantage
Medicare Supplement Insurance Plans are also called Medigap Plans. These types of policies can help with the cost of your deductibles, copayments, coinsurance and excess charges depending on the coverage you choose, as there are several different Medigap options.
Medicare Supplements are more “pay up front” with a higher monthly paymet and very little cost as you use them.
Medicare Supplements follow the coverage and freedoms of Medicare, meaning they work the same everywhere in the US and are not a network-based type of coverage.
Certain Medigap policies provide coverage for services that are not covered by Original Medicare, such as medical care received when traveling outside of the United States. If you have Original Medicare and you choose to purchase a Medigap policy, the following occurs:
- Medicare Coverage: Medicare will first pay its portion of the Medicare-approved amount for the covered healthcare services you receive.
- Medigap Coverage: After Medicare has paid its share, your Medigap insurance company will then pay its portion of the remaining costs. This helps fill the gaps in coverage left by Original Medicare.
By combining Original Medicare with a Medigap policy, you can have more comprehensive coverage and potentially lower out-of-pocket expenses for healthcare services. The Medigap policy works alongside Original Medicare to provide additional financial protection and peace of mind.
Medicare Advantage Plans will minimize your overall risk, while keeping your monthly costs at a minimum due to being a network-based type of coverage.
Medicare Advantage plans are more “pay as you go” with little to no monthly payments, but have copays for most services and feature a cap on your maximum out-of-pocket expenses.
Who Qualifies for a Medigap Plan?
Individuals who are eligible for Medicare Parts A and B can qualify for a Medicare Supplement plan,
provided they are not enrolled in a Medicare Advantage plan and can pass underwriting.
However, there are circumstances where individuals may qualify for a Medicare Supplement plan
without undergoing underwriting:
Open Enrollment
Open Enrollment is a six-month period that begins in the first month someone is enrolled in Part B. During this period, there is no underwriting required to qualify for a Medicare Supplement plan. This means that pre-existing conditions do not disqualify individuals, and they can change their policy as many times as needed within this six-month window.
Guaranteed Issue
Guaranteed Issue applies to those who have involuntarily lost creditable coverage. This window allows for a period of 60 days before and 63 days after the end of coverage to qualify for certain Medicare Supplement plans without undergoing underwriting. Similar to Open Enrollment, individuals can change their policy as many times as necessary during this timeframe.
It’s important to note that these eligibility criteria and enrollment periods may vary, so it’s advisable
to consult with a Medicare representative or insurance provider for specific details
and guidance based on individual circumstances.
Most Common Medigap Plans
Plan F:
Covers 100% of cost not covered by Part B – no copayments or coinsurance ever!
Covers 100% of Part B Deductible
Only pay Part B and Plan F
Can go to any doctor or hospital in the US as long as they accept Original Medicare
Plan is no longer available to people who were not eligible for Medicare before January 1, 2020
Plan G:
Most comprehensive plan available to those eligible for Medicare after January 1, 2020
Covers 100% of costs associated with Part B aside from Part B deductible – no copayments or coinsurance ever!
Great option for saving money due to increasing Plan F rates
Plan N:
Covers most Part B copayments and coinsurance
Up to $50 ER visits
Up to $20 doctor visits
Does not cover Part B Excess Charges – could be responsible for up to 15% above what Medicare allows for billing in certain states
What are the Parts (A)
and (B) Referenced in
Medicare?
Part A: Hospital Insurance
- Covers inpatient care, including stays at
hospitals and skilled nursing facilities. - Provides coverage for hospice care, which
focuses on providing comfort and support
to individuals with terminal illnesses.
Part B: Medical Insurance
Under Part B, Medicare provides insurance coverage for a range of medical services, which include but are not limited to:
• Doctor Services (excluding routine physicals)
• Outpatient Surgeries
• Diagnostic Tests
• Emergency Room (ER) Visits
• Ambulatory Services
• Durable Medical Equipment (such as wheelchairs, walkers, and hospital beds)
• Outpatient Mental Health Services
• Outpatient Physical and Occupational Therapy
• Speech and Language Therapy
What is Medigap?
Medigap, also known as Medicare Supplement Insurance, is a private insurance coverage that assists in filling the gaps left by Original Medicare. While Original Medicare covers a substantial portion of the expenses for healthcare services and supplies, it does not cover everything. By obtaining a Medigap policy, you can alleviate some of the remaining healthcare costs, such as copayments, coinsurance, and deductibles. Moreover, certain Medigap policies provide coverage for services that are not included in Original Medicare, such as medical care during international travel. If you have Original Medicare and decide to purchase a Medigap policy, the following process occurs:
Medicare will cover its portion of the Medicare-Approved Amount for the healthcare costs that are eligible.
Afterward, your Medigap insurance company will cover its portion of the expenses.
Medigap Policies Don’t Cover Everything
Typically, Medigap policies do not provide coverage for the following:
Long-term care: This refers to non-skilled care received in a nursing home or assisted living facility.
Vision or dental services: Medigap does not cover routine vision or dental care, such as eye exams, eyeglasses, or dental procedures.
Hearing aids: The cost of hearing aids is generally not covered by Medigap policies.
Eyeglasses: Medigap does not cover the expenses related to purchasing or replacing eyeglasses.
Private-duty nursing: Medigap policies do not typically cover the costs associated with private-duty nursing services, which involve hiring a nurse for in-home care.
It’s important to note that while Medigap policies do not cover these services, you may be able to obtain separate insurance or coverage for them, such as standalone dental or vision insurance plans.
Apollo Will Find The Right
Plan For You
Operating since 2010, Apollo Insurance Group is a prominent health insurance brokerage serving Lee’s Summit, Missouri, and Chicago, Illinois. Our core purpose revolves around making a positive impact on people’s lives. Through our relentless commitment, we strive to unearth the optimal solutions for our valued clients, foster meaningful connections with our employees, and actively contribute to our communities. With a specialization in Medicare, life insurance, dental, and vision coverage, Apollo boasts a team of knowledgeable agents well-versed in individual health insurance. Allow us to assist you in finding the perfect plan tailored to your needs. Connect with us today by completing our convenient contact form.
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