Medicare Coverage – Your Key to Affordable Healthcare

Medicare is vital to Americans’ health care security with affordable premiums, copays, and deductibles.

Insurers must cover several preventive services without charging you anything extra.

Despite ACA-era protections and enhanced Marketplace subsidies, many uninsured adults still struggle to afford coverage. Many are American Indian and Alaska Native or Hispanic people in states that did not expand Medicaid or individuals in low-income families.

Medicare Part A

Medicare coverage is essential to millions of Americans’ healthcare access and financial security. Individuals aged 65 and older, those with specific disabilities, and those with end-stage renal disease require essential care. The significance of Medicare cannot be overstated as it provides healthcare access to those who might not be able to afford it otherwise. Medicare Part A covers semi-private rooms, meals, nursing care, and some medical supplies for hospital stays of up to 60 days. It also covers part of your stay in a skilled nursing facility, hospice or psychiatric facility, and some home health care services. Medicare doesn’t cover prescription drugs. Enrolling in a Medicare plan with drug coverage, such as Medicare Part D or Medicare Advantage, is possible.

Medicare Advantage plans are private insurance options that bundle Part A, Part B, and usually Part D into one plan. These plans follow the rules set by Medicare but can offer more benefits than Original Medicare, like vision and dental coverage.

Individuals who do not enroll in premium Part A during their IEP and choose to do so later may pay a penalty. This penalty is based on the number of months during which the individual could have signed up for Part A but didn’t.

Medicare Part B

Medicare Part B covers doctor visits, medical equipment and supplies, and certain preventive services. Typically, you must pay a monthly insurance premium that will be deducted from your Social Security or Railroad Retirement Board (RRB) benefits.

Individuals who missed their initial Part B enrollment period due to an illness or injury may enroll during a Special Enrollment Period. This SEP begins the month in which the individual is notified of their Medicare entitlement and ends six months after that date.

Individuals can also enroll during this SEP if they previously declined Part B coverage. They are now receiving Social Security or RRB benefits and haven’t signed up for a Medicare private health plan (Part D). They must sign up within eight months of their Medicare entitlement or pay a penalty for life. Individuals with Medicare Advantage or Group Health Plans are not eligible to use this SEP. However, they can enroll in premium Part B during the General Enrollment Period without a late penalty.

Medicare Part D

The Medicare Part D prescription drug benefit includes four coverage phases: the deductible phase, the initial coverage phase, the coverage gap phase, and the catastrophic coverage phase. A monthly premium is required. Each plan must offer a standard benefits package. Plans may also offer “enhanced” benefits that differ from but are actuarially equal to the standard benefit.

Most Part D plans have a list of drugs that they cover, known as a formulary. This list might change over time. When a plan changes its formulary, it must notify you. You can choose to stay on the same plan if you like.

Employers and unions may also sponsor their own Part D retiree plans. These MA-PD Plans must follow the same rules as commercial Part D plans.

The annual Open Enrollment Period for Part D and Medicare Advantage plans runs from October 15th to December 7th. Individuals can join, disenroll, or switch their current plans during this period. Individuals with dual eligibles or LIS may enroll or change plans anytime during the year using a Special Enrollment Period (SEP).

Medicare Advantage

Over half of all Medicare beneficiaries are enrolled in private Medicare Advantage plans. These are “all-in-one” alternatives to Original Medicare, bundling Parts A and B and often Part D into one plan. These plans can have lower premiums, copayments, or coinsurance than traditional Medicare and sometimes offer extra benefits.

Medicare Advantage Plans must adhere to Medicare’s regulations, but they can decide how to implement them. For example, they can choose whether or not you require a referral to see a specialist. The plans also determine their provider networks and may change premiums, copayments, and benefits from year to year.

In 2023, the weighted average maximum out-of-pocket cost for HMOs and PPOs was $7,550 and $11,300 for in-network and out-of-network services combined. Medicare Advantage plans may also limit your access to providers within their network.