The Following Medicare Detail should answer many of your questions.

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                           INDEX                                    

A. Medicare Part A
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM

4. INPATIENT HOSPITAL STAY (WHAT YOU PAY IN 2023)
a) Deductible
b) Coinsurance
c) Medicare Covers:
d) Benefit Period for In-Hospital Stay

5. SKILLED NURSING INSURANCE
a) ENROLLMENT

B. Medicare Part B
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM for Part B
4. DEDUCTIBLE
5. COINSURANCE
6. EXCESS CHARGES
7. ENROLLMENT

A. Medicare Part C (Medicare Advantage)
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE
4. PLAN RESTRICTIONS
5. ENROLLMENT

B. Medicare Part D (Medicare Prescription Drug Plan)
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE
4. ENROLLMENT
5. PRESCRIPTION DRUG PLAN STAGES

A. Medicare Part A

• Medicare Part A.is the Hospital Insurance portion of Original Medicare. Original Medicare allows you to use ANY doctor, specialist, or hospital that accepts Medicare. There are no “networks” of hospitals to you must adhere to; as long as the provider accepts Medicare, you can use that provider or facility.  You do not need a referral.

1. ELIGIBILITY

You are eligible for Medicare if:

• you are 65 years or older, and
• you are a citizen or permanent resident of the United States who has lived in US for at least 5 years.
• If you are not yet 65, you might also qualify for coverage if you have a disability or End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant). You are entitled for Medicare after you get disability benefits from Social Security for 24 months.
• Your age is the main determining factor. You do NOT need to retire or receive Social Security benefits in order to be eligible for Medicare.
• Some Medicare beneficiaries are dual-eligible, i.e. they are qualified for both Medicare and Medicaid.

2. BENEFITS

• Inpatient hospital care (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
• Inpatient care in a skilled nursing facility (not custodial or long-term care)
• Hospice care services
• Home health care services

3. PREMIUM

• Most people age 65 or older don’t have to pay a monthly payment (called premium) for Part A because they or their spouses paid Medicare taxes while they were working 40 or more quarters of Medicare covered employment.

4. INPATIENT HOSPITAL STAY (WHAT YOU PAY IN 2023

a) DEDUCTIBLE

$1,600 each benefit period

b) COINSURANCE

$400 per day for days 61-90 of a hospital stay

$800 per day for days 91 and beyond of a hospital stay up to 60 days over Lifetime Reserve Days

All costs for each day beyond reserve days

c) Medicare covers:

 Up to 90 days of inpatient hospital services in each benefit period

An additional 60 lifetime reserve days

d) Benefit Period for in-hospital stay

A benefit period begins when you are admitted to the hospital and ends when you have been out of the hospital for 60 days or have not received Medicare-covered care in a skilled nursing facility (SNF) or hospital for 60 consecutive days from your day of discharge.

Medicare provides 60 lifetime reserve days of inpatient hospital coverage following a 90-day stay in the hospital. These lifetime reserve days can only be used once. If you use all 60 lifetime days, Medicare will not renew them. Very few people remain in a hospital for 150 consecutive days. In the rare event this does occur, most Medicare Supplement policies would cover additional days

5. SKILLED NURSING INSURANCE

• $0 for days 1 through 20
• $200.00 per day for days 21 through 100 each benefit period.
• All costs for each day after day 100 in each benefit period

a) ENROLLMENT

• If you already get Social Security Benefits, then you’ll be automatically enrolled in Medicare Parts A and B effective the first day of the month you turn age 65. Your Medicare Card will be mailed to you about 3 months before your 65th birthday. Enrollment in Part B is optional.
• If you are under 65 and disabled, you’ll be automatically enrolled after you get disability benefits from Social Security for 24 months. You will get your Medicare card in the mail 3 months before your 25th month of disability.
• If you do NOT yet get the Social Security benefits, then you’ll need to apply for Medicare through Social Security three months before you turn 65– at the start of Initial Enrollment Period.  An Initial Enrollment Period is a 7-month period that begins 3 months before you turn 65, or, in the case of disability, 3 months before your 25th month of disability.  You can sign up anytime during the Initial Enrollment Period.  However, by waiting until you are 65 or later, your Medicare coverage will be delayed.  Enrollment in Part B is optional.

NOTE: If you didn’t sign up for Medicare Part A or Part B during the Initial Enrollment Period, you may sign up during the next General Enrollment Period.  This period runs from January 1 through March 31 of each year.  The coverage will start on July 1 of the year you sign up.  If you aren’t eligible for premium-free Part A and didn’t buy Part A when you were first eligible, your monthly premium may go up 10%.  You will have to pay the higher premium for twice the number of years you could have had Part A but didn’t join.  You’ll have to pay a higher Medicare Part B premium because you could have had Medicare Part B and didn’t take it.  Actual increase is 10% for each full 12-month period that you were entitled for the Part B, and the penalty is as long as you have Part B.  You may avoid paying higher premium, if you are entitled for a Special Enrollment Period.

B. Medicare Part B

• Medicare Part B is a Medical Insurance portion (as compared to Part A being a Hospital Insurance portion) of Original Medicare and is optional. Original Medicare Part B allows you to use any doctor, specialist, or hospital that accepts Medicare. NOTE: Even though most do, not all doctors or hospitals accept Medicare. There is no network of doctors that you have to use, and you never need a referral.  You are paying a separate amount for each service – fee for service.

1. ELIGIBILITY – You are eligible for Medicare if:

• You are 65 years or older, and
• You are a citizen or permanent resident of the United States who has lived in US for at least 5 years
• If you are not yet 65, you might also qualify for coverage if you have a disability or End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant). You are entitled for Medicare after you get disability benefits from Social Security for 24 months.
• Your age is the main determining factor. You do not need to retire or receive Social Security benefits in order to be eligible for Medicare.
• Many Medicare beneficiaries are dual-eligible, i.e. they are qualified for both Medicare and Medicaid.

2. BENEFITS

Medicare Part B covers a portion of:

• Doctor & Specialist services
• Outpatient hospital care
• Laboratory tests
• Outpatient physical therapy
• Outpatient speech therapy
• Certain home health care
• Certain ambulance services
• Certain medical equipment and supplies

3. PREMIUM for Part B

4.  

   Part B (Medical Insurance) IRMAA costs

    

   1. Monthly premium:  2023 Payments

      The standard Part B premium amount in 2023 is $164.90 Most people pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount. IRMAA is an extra charge added to your premium.

      If your yearly income in 2021 (for what you pay in 2023) was			You pay each month (in 2023)
      File individual tax return	File joint tax return	File married & separate tax return
      $97,000 or less	$194,000 or less	$97,000 or less	$164.90
      above $97,000 up to $123,000	above $194,000 up to $246,000	Not applicable	$230.80
      above $123,000 up to $153,000	above $246,000 up to $306,000	Not applicable	$329.70
      above $153,000 up to $183,000	above $306,000 up to $366,000	Not applicable	$428.60
      above $183,000 and less than $500,000	above $366,000 and less than $750,000	above $97,000 and less than $403,000	$527.50
      $500,000 or above	$750,000 and above	$403,000 and above	$560.00

      DEDUCTIBLE

$226 calendar year

5. COINSURANCE

• You pay 20% of the Medicare approved amount for doctors’ visits after you meet the Deductible.  There is no limit in your spending.

6. EXCESS CHARGES

• For services rendered by non-participating providers, a physician may charge a maximum of 115% of the Medicare approved amount.  This 15% overcharge is known as Excess Charges, and you are responsible for them

7. ENROLLMENT

• If you already get Social Security Benefits, then you will be automatically enrolled in Medicare Part A and B effective the first day of the month you turn age 65. Your Medicare Card will be mailed to you about 3 months before your 65th birthday. Enrollment in Part B is optional.

• If you are under 65 and disabled, you’ll be automatically enrolled after you get disability benefits from Social Security for 24 months. You will get your Medicare card in the mail 3 months before your 25th month of disability.
• If you do NOT yet get Social Security benefits, then you will need to apply for Medicare through Social Security beginning three months before you turn 65 at the start of Initial Enrollment Period.  The Initial Enrollment Period is a 7-month period that begins 3 months before you turn 65, or, in the case of disability, 3 months before your 25th month of disability.  You can sign up anytime during the Initial Enrollment Period.  However, by waiting until you are 65 or later, your Medicare coverage will be delayed.  Enrollment in Part B is optional.
• If you didn’t sign up for Medicare Part A or Part B during the Initial Enrollment Period, you may sign up during the next General Enrollment Period.  This period runs from January 1 through March 31 of each year.  The coverage will start on July 1 of the year you sign up.  If you aren’t eligible for premium-free Part A and didn’t buy Part A when you were first eligible, your monthly premium may go up 10%. You will have to pay the higher premium for twice the number of years you could have had Part A but didn’t join.  You will have to pay a higher Medicare Part B premium because you could have Medicare Part B and didn’t take it.  Actual increase is 10% for each full 12-month period that you were entitled for the Part B, and the penalty is as long as you have Part B.  You may avoid paying higher premium if you are entitled for Special Enrollment Period.

C. Medicare Part C (Medicare Advantage)

• Instead of enrolling or using the Original Medicare, you may decide to enroll into a Medicare Part C – Medicare Advantage Plan. These plans are offered by private insurance companies and must be approved by Medicare.  It is not a ‘fee for service’ as is Original Medicare.  Instead, Medicare pays a fixed amount every month to insurance companies for the enrolled members regardless whether or not the services were used by members.

1. ELIGIBILITY

• You are eligible for Medicare Part C if:
• You have both Part A and Part B

• You live in the service area of the plan

2. BENEFITS

• Plans must enroll anyone who is eligible. The same minimum benefits are offered to all members, no matter what age or health status.  Consequently, pre-existing health conditions cannot be taken into account as enrollment cannot be denied, and the premium cannot be increased because of the health conditions.
• Covers all services that Original Medicare covers (Part A and Part B), except hospice care. (Original Medicare covers hospice care even if you are in Medicare Advantage Plan).
• May offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs
• Can come with or without Prescription Drug Coverage (MA-PD)
• There are several types of plans available: HMO, PPO, PFFS, MSA, and SNP
• Plans have different rules for how you get services.  Some plans you must stay “in-network” and sum you must get referrals from your primary care physician.  Emergencies are exceptions as no referrals are necessary, and services are available anywhere in the U.S.
• You are still a part of the Medicare system.  With a Medicare Advantage plan private insurance is administering the plan and paying for your services.  If the private insurance company fails, you are guaranteed acceptance back into Original Medicare.

3. PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE

• Each plan typically charges a monthly premium in addition to the Part B premium (although, some plans actually pay the Part B premium). There are additional charges for Prescription Drug Coverage (if applicable), and for Extra coverage (if applicable). The total cost may be higher or lower than you’ll pay under Original Medicare.
• Each plan can charge different out-of-pocket costs.  You normally pay co-payments for each visit or service.  The plan may also charge you yearly deductible or any additional deductibles.
• Most Medicare Advantage Plans will offer a maximum out-of-pocket maximum (a yearly limit to your health care covered expenses).

4. PLAN RESTRICTIONS

• Medicare places restriction as to when you can enter or leave a plan, i.e. for another Medicare Advantage Plan.  These restrictions change on a yearly basis, and changes can be made during Annual Enrollment Periods.

5. ENROLLMENT

You can join, switch, or drop a Medicare Advantage Plan during:

• Initial Enrollment Period – a 7-month period that begins 3 months before you turn 65, or 3 months before your 25th month of disability.  The period includes the 3 months before, the month of, and the 3 months after the triggering event, such as ‘turning 65’.
• Annual Enrollment Period – between October 15 and December 7.  Your coverage will begin on January 1 of the following year.  You have the option of switching to another plan:
  •  Between Medicare Advantage plans,
  • From a Medicare Advantage plan to Original Medicare, or
  • From Original Medicare to Medicare Advantage plan.

Be careful when changing plans as your Prescription Plan may be affected. It’s important when making any change that you are careful that the change is best for you as to coverage and cost.  This is where you should contact MyHealthcareSeach@gmail.com agent for assistance.

• Medicare Advantage Disenrollment Period – between January 1 and March30.  You can dis-enroll from your current Medicare Advantage plan, but then only return to Original Medicare.  You can also select a Part D Prescription Drug Coverage if your Medicare Advantage plan included prescription coverage.
• Special Election Period (SEP) – In certain situations you may be eligible for a Special Election that allows you to make changes in your coverage outside of enrollment periods described above. Examples of SEP are – you’ve moved out of service area, you are qualified for Extra Help, you have both Medicare and Medicaid, etc.
• People who either have Medicare and Medicaid or qualify for Extra Help can switch plans every month.
• Normally enrollment is on calendar year basis, starting the date your coverage begins.

Also note that Part C plans have a contract with Medicare that govern minimum provisions.

D. Medicare Part D (Medicare Prescription Drug Plan)

There are two types of Medicare Part D plans.

• If you are using Original Medicare (or Medicare Advantage Plan of PFFS/ MSA types), you may use a stand-alone Medicare Prescription Drug Plan (PDP). Using a prescription drug plan is optional. These prescription drug plans are operated by private insurance companies than have been approved by Medicare.
• Alternatively, if you are enrolled into a Medicare Advantage Plan that does not have coverage for prescriptions, you may enroll in a Medicare Advantage Prescription Drug Plan (MA-PD).

1. ELIGIBILITY

You are eligible for Medicare Prescription Drug Plan if you are enrolled in Medicare Part A and/or Part B.

2. BENEFITS

Covers most types of prescription drugs (both generic and brand-names) with few exceptions.

• Part D adds drug coverage to Original Medicare, HMO and PPO Plans, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
• Unlike Original Medicare, the Part D coverage is not standardized.  All plans must provide at least a standard level of coverage set by Medicare, but each plan can vary in cost and drugs covered.  Insurance companies decide which drugs they cover, at what level (tier), and whether or not to cover some of them at all.

3. PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE

Each plan can vary in cost and drugs covered.  The cost includes monthly premium, yearly deductible and copayment or coinsurance.

• Most Medicare Drug plans have a coverage gap (sometimes called the ‘donut hole’). It means that after you and your plan spend a certain amount on prescriptions, you’ll need to pay higher out-of-pocket cost for all drug costs up to a specified limit. After this limit is reached, you will enter the catastrophic coverage level which will reduce your prescription cost. Each year the prescription plans start over.

4. ENROLLMENT

You can join, switch, or drop a Medicare Prescription Drug Plan (PDP):

• At Initial Enrollment Period – a 7-month period that begins 3 months before you turn 65, or 3 months before your 25th month of disability.  The period includes the 3 months before, the month of, and the 3 months after the triggering event, such as ‘turning 65’.
• At Annual Enrollment Period – between October 15 and December 7.  Your coverage will begin on January 1 of the following year.
• In certain situations, you may be eligible for a Special Election Period (SEP that allows you to make changes in your coverage outside of enrollment periods described above. Examples of SEP are – you’ve moved out of service area, you are enrolled into PACE plan, you’ve lost creditable prescription coverage, you have both Medicare and Medicaid, etc.   SEP length is dependent on the event that triggered it.   For example, people who qualify for Extra Help have continuous SEP – they can change plans once a month.
• When switching to a PDP, you don’t need to cancel the old plan. It will end automatically when the new plan begins.
• Normally enrollment is on calendar year basis, starting the date your coverage begins.
• If you didn’t enroll in a Prescription Drug Plan when you were first eligible and you go without Creditable Prescription Drug Coverage for 63 continuous days or more, you may have to pay a penalty if you’ll decide to join later.  The penalty is 1% for each month you could have been enrolled but were not assuming you didn’t have the creditable coverage.  (Creditable Prescription Drug Coverage is prescription drug coverage that is at least ‘as good’ as standard Medicare Prescription Drug Coverage).
• Each PDP plan is required to provide to its members the Annual Notice of Change every year.  Changes may include changes in drug tier structure as well as cost sharing.

5. PRESCRIPTION DRUG PLAN STAGES

There are four stages in PDP.  Coverage vary significantly from various carriers  

• Yearly Deductible – some pans have a deductible that you pay before plan starts to pay.
• Copayment/Coinsurance – For each covered there may be an amount you have to pay to receive the prescription.
• Coverage Gap (donut hole) – Once the total costs of prescriptions (paid by you and your plan) has reached a level that is determined each year, you will pay a higher price for your prescriptions until you reach the Catastrophic Coverage area.
• Catastrophic Coverage – After you exit the “donut hole” you will enter the Catastrophic Coverage area. Here you will pay less for your prescriptions as the manufacture and insurance company will offset the major cost of the drugs.

Part D (Medicare prescription drug coverage)

• Monthly premium: The Part D monthly premium varies by plan (higher-income consumers may pay more).

Part D premiums by income

The chart below shows your estimated prescription drug plan monthly premium based on your income as reported on your IRS tax return. If your income is above a certain limit, you’ll pay an income-related monthly adjustment amount in addition to your plan premium. 

Income bracket premium adjustments for 2023 Medicare Part D IRMAA

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