Medicare Coverage
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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.
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 copayments.
To choose the right coverage, individuals can consider options like Original Medicare, Medicare Advantage, or supplemental coverage like Medigap plans.
Parts of Medicare
Medicare is divided into different parts that provide specific coverage.
Part A (Hospital Insurance)
Covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services. Most people don’t have to pay for Part A if they or their spouse paid Medicare taxes while working.
Part B (Medical Insurance)
Covers outpatient medical services, including doctor visits, preventive care, diagnostic tests, durable medical equipment, and some outpatient treatments. Part B requires a monthly payment.
Part C (Medicare Advantage)
Offers an alternative way to receive Medicare through private insurance companies approved by Medicare. Medicare Advantage plans often combine coverage for Parts A and B. These plans have their own price and rules.
Part D (Prescription Drug Coverage)
Provides coverage for prescription drugs. Part D plans are offered by private insurance companies and can be added to Original Medicare or included in Medicare Advantage plans. Part D plans have their own copayments and formularies (lists of covered drugs).
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
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?
Discuss the following scenarios with a representative:
- Qualifying Chronic Condition: If you have a chronic condition that meets the eligibility criteria, you 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.
- 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.
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.
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.
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.
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. This situation typically arises when moving to a new service area or experiencing changes to existing coverage.
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
- Not very common, but can be seen from specialists, surgeons, etc.
- Not allowed in CT, MA, MN, NY, OH, PA, RI, VT
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Factors to Consider When Shopping for Medicare
There are many factors to consider when shopping for Medicare. Here are some of the most important ones:
- Your health: If you have chronic health conditions, you will need a plan that covers those conditions. You should also consider your expected future health needs.
- Your budget: Medicare plans vary in cost, so you need to find a plan that fits your budget. You should also consider your out-of-pocket costs, such as deductibles, copays, and coinsurance.
- Your prescription drugs: If you take prescription drugs, you need to find a plan that covers the drugs you need. You should also consider the cost of prescription drugs, both with and without insurance.
- Your provider network: You need to make sure that your doctors and other providers are in the network of the plan you choose. You can check the plan’s provider directory to see if your providers are in the network.
- Your coverage needs: You need to consider what type of coverage you need. Do you need coverage for hospital stays, doctor visits, prescription drugs, or all of the above?
- Your state: Medicare plans vary from state to state. You need to make sure that you choose a plan that is available in your state.
Once you have considered these factors, you can start shopping for Medicare plans. There are many resources available to help you compare plans, such as the Medicare Plan Finder tool on the Medicare website.
Here are some additional tips for shopping for Medicare:
- Start early: It is important to start shopping for Medicare early, so you have enough time to compare plans and choose the right one for you.
- Get help from a professional: If you need help choosing a Medicare plan, you can get help from a Medicare counselor or insurance agent.
- Read the fine print: Before you choose a Medicare plan, be sure to read the fine print and understand all of the terms and conditions.
Shopping for Medicare can be a daunting task, but it is important to take the time to do your research and choose a plan that is right for you. By considering your needs and budget, and using the resources available to you, you can find a plan that will help you afford the care you need.
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 a plan tailored to your needs. Connect with us today by completing our convenient contact form.
Apollo Insurance Group
Official Health Insurance Brokers
What states are Apollo licensed for Medicare?
Apollo is licensed in 35 states to help find a medicare plan that meets your needs and is able to aid in the enrollment process. These states include: AL, AR, AZ, CA, CO, FL, GA, IA, IL, IN, KS, KY, LA , MD, MI, MN, MO, MS, MT, NC, NE, NJ, NM, NV, OH, OK, PA, SC, TN, TX, UT, VA, WA, WI, WY.
FAQ on Medicare
I'm about to turn 65 - WHAT DO I DO?
If you are currently collecting Social Security Income (SSI) congratulations you will be automatically enrolled in Original Medicare—parts A & B.
If not then you will need to actively sign up by the following:
- Calling the social security office
- Going to www.socialsecurity.gov and applying online
- Visiting your local social security office in person
How much will I pay for this coverage?
For most Americans, Medicare Part A will have no monthly premium—If you’ve worked 40 quarters paying into medicare OR you were married for 10 years to a spouse that worked and paid in during 40 quarters even if you are not currently married to them.
Medicare Part B for most Americans will be around $170.10 per month. If you are drawing Social Security already, the premium can be taken out automatically before you receive your Social Security Check.
Some Americans may elect to defer getting Part B if they are still covered under an employer (or Spouse’s employer) group health plan. Employer Group Health Plans are not always the right fit for clients so we can help you ensure you are not over spending.
If you do not elect to get Part B when you are first eligible, and you are not covered on an Employer Group Health Plan you may incur a late enrollment penalty when you do elect to get Part B.
I received my Medicare card. Is it important?
Yes!
Your Medicare number is what allows someone to determine your current plan and enroll you into any additional plans. Up until 2018 it was your social security number.
If you are looking at one with your social security number on it then that number has changed…you will want to find one that is a combination of letters and numbers.
I've got original Medicare A&B - does this mean I don't need to pay attention anymore?
Unfortunately, while original medicare is cheap to have your out-of-pocket expenses are substantial. Generally speaking you are covering 20% of costs.
More often than not, top carriers may offer plans that are low cost or no cost plan with more applicable benefits.
Why should I talk to a sales agent?
First and foremost the services of the sales agents are ABSOLUTELY FREE.
Your sales agent will have access to dozens of top rated carriers to find that plan that suits you. This can all be done over the phone in the convenience of your house.
There will be no need to spend hours filling out paperwork and everything you need to get started can be sent right to your doorstep.
Medicare Definitions
Premium
A regular payment, typically on a monthly basis, made to an insurance plan in exchange for receiving coverage.
Deductible
The specific amount that you are responsible for paying towards your healthcare expenses before your insurance provider starts covering the costs.
Co-insurance
A fixed percentage, known as a copayment or coinsurance, is paid by the beneficiary for the services received. This amount is a portion of the total cost of the services, and the remaining portion is typically covered by the insurance provider.
Copayment
A fixed dollar amount, known as a copayment, is paid by the beneficiary for the services received. This amount remains consistent regardless of the total cost of the services and is typically predetermined by the insurance plan.
Apollo Fights For You
OUR GOAL
Navigating the complexities of Medicare can be challenging, and we understand the need for reliable and accurate information.
Our primary goal is to serve as your dedicated advocates for comprehensive health care solutions. We are committed to guiding you through the entire process of transitioning to Medicare, from answering eligibility questions to helping you find the most suitable coverage.
Whether it’s for yourself or a family member, we are here to ensure that you receive the best possible coverage tailored to your specific needs.
HOW WE HELP
At Apollo, we understand what family means to you, and we do everything possible to help you plan for the best and worst case scenarios of your future. We want to get to know you, your story, and your family.
Medicare can be confusing and overwhelming. We are here to make it simple for you and your family.
We are a solution hub for everything Medicare and strive to meet the unique needs of each member of the Apollo family.
Apollo Will Find the Right Plan for You
Apollo Insurance Group is a health insurance brokerage located in Lee’s Summit, Missouri and Chicago, Illinois. We have been around since 2010, and our mission is to positively impact people’s lives. We do this by fighting to find the best option for our clients, create relationships with our employees, and give back to our communities. Apollo also specializes in Medicare, life insurance, dental, and vision plans. We have sales associate that are experts on health insurance and are ready to help you find the right plan or answer any questions you have. Fill out our contact form to get in touch with a sales associate for a free consultation.
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Contact Us
(816) 608-4333
-CALLING THE NUMBER ABOVE WILL DIRECT YOU TO A LICENSED INSURANCE AGENT.
By completing the form above, I understand that a Licensed Insurance Agent from Apollo Insurance Group may contact me via phone, email or mail to discuss Medicare insurance options. Calls may be made by auto dialer, text, or robocall and are for marketing purposes. Cellular carrier charges may apply. Providing permission does not impact eligibility to enroll or the provision of services. You can change permission preferences at any time by contacting (816) 608-4333. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Apollo Insurance Group is not affiliated with the federal Medicare program or the government. This is a solicitation for insurance.
Schedule Your Free Consultation To Get Personalized Help with Medicare Plan Options (No Obligation to Enroll)
What To Expect On Your Call With A Licensed Health Insurance Sales Agent:
- Enroll correctly to avoid penalties and ensure coverage.
- Understand your coverage so you aren't surprised by unexpected out-of-pocket expenses.
- Avoid selecting a plan that does not suit your needs.
- Be confident in your decision of selecting a plan that has coverage for what is important to you.
- Save time with our simplified process so you can spend more time doing what you enjoy.
- Our licensed health insurance sales agents work for you and with you to shop plan options available to find what suits your needs, and if requested may advocate on clients' behalf for issues with claims as well.