What are the different parts of Medicare?
When it comes to enrolling in Medicare benefits, seniors have many choices. It can be confusing to know the difference between Medicare Supplement Plans, Medicare Replacement Plans and Medigap Policies. These increasingly popular plans can help you cover costs that Traditional Medicare doesn’t, including co-insurance, co-pays, deductibles and more. In this section we highlight each option.
Medicare Part A – Helps pay for inpatient hospital care, skilled nursing facility care, home health, and hospice care.
Medicare Part B – Helps pay for physician services, medical services, lab tests, medical supplies and outpatient hospital services. Most people will pay a monthly fee for coverage, as well as an annual deductible.
Together, Part A and Part B are called Traditional Medicare. You may be eligible for premium-free Medicare if you are a U.S. citizen or permanent legal resident that has paid Social Security for at least 10 years, and meet at least one of the following criteria:
- You are age 65 or over and receiving Social Security retirement benefits
- You are permanently disabled and received Social Security disability for 24 months
- You have Lou Gehrig’s Disease
- You have End Stage Renal Disease (ESRD)
With Traditional Medicare, you do not need to get prior authorization from Medicare or your primary doctor. Enrollment in Part A and Part B is not automatic. To apply for Traditional Medicare benefits, you must contact Social Security.
Medicare Part C – Also called Medicare Advantage Plans, contract with various health care organizations to offer health insurance plans to Medicare beneficiaries. Each Medicare Advantage Plan must at least provide the same benefits as the Original Medicare Plan provides under Parts A and B. Medicare Advantage organizations are also permitted to offer additional benefits such as dental and vision care. It is important to remember that Medicare Advantage Plans may have network restrictions, meaning you will be more limited in your choice of doctors and hospitals.
Medicare Part D – Provides prescription drug benefits through various private insurance companies.
What is not covered by Traditional Medicare?
Medicare Part A and B do not cover all expenses, leaving you responsible for the following:
- Hearing aids and devices
- Vision and dental care services
- Deductibles, co-pays and co-insurance
- Non-emergency transportation
- Private rooms (unless medically necessary)
- Part B premiums
Medicare Advantage vs Medicare Supplement Plans
A supplement policy will pay AFTER Medicare. Depending on the plan that has been chosen, it will pay the Part A Deductible (for the hospital) and possibly the Part B Deductible (for the doctor). It may then pay the 20% that Medicare does not pay, and even possibly the extra 15% (Part B Excess Charges), if the doctor does not accept “Assignment” (the allowable charge by Medicare). When you have a Supplement, you can see any doctor or hospital that accepts Medicare.
Medicare Replacement / Advantage Plans
An Advantage Plan is a contract that Medicare has with a private insurance company to administer benefits. It does not pay after Medicare, it pays INSTEAD of Medicare. The premiums associated with Advantage Plans are generally lower than that of a Supplement; however, when you go see a doctor or go to the hospital, you will have co-payments. Not every doctor or hospital that accepts Medicare will accept an Advantage Plan. If a patient goes to a doctor or hospital that does not accept their Advantage Plan, they will be responsible for the entire bill. Medicare will not pay anything.
Medigap Insurance Policies
Medigap policies are not part of Medicare. These are private insurance plans that pay for health expenses – treatments, supplements, or co-payments – that Medicare does not cover. Medigap policies are run by outside insurance companies and have additional costs. The exact coverage and costs depend on the plan you choose.
2019 Medicare Part A Coverage
Hospital / Acute Care Hospital (per benefit period)
DAYS 1 THROUGH 60
DAYS 60 THROUGH 90
AFTER 90 DAYS
Skilled Nursing Facility (per benefit period)
While Medicare covers up to 100 days of skilled nursing care if you continue to meet Medicare’s daily skilled need requirements, our goal is always to help you return to your highest level of independence as soon as possible.
DAYS 1 THROUGH 20
DAYS 21 THROUGH 100
AFTER 100 DAYS
***2019 Medicare Costs. Please consult with the Admissions Coordinator for your co-pay amount, which is subject to change each year. If you have a Medigap policy with the original Medicare plan or are in a Medicare managed care plan, your cost may be different, or you may have additional coverage. Check your plan.
Understanding the Medicare 30-day Window
If you experience any health concerns within the first 30 days of discharging from the hospital or other care provider, you can still activate your Skilled Nursing benefits without an additional three-midnight hospital stay.
To qualify for the 30-Day Medicare Window you must:
- Have received Medicare Part A benefits in an acute hospital or skilled nursing facility within the last 30 days.
- Require daily skilled nursing care or rehabilitative services.
- Have days remaining in your original Skilled Nursing Part A 100-day benefit period.
- Be readmitted under physician orders.
We want to help you achieve your highest quality of life possible. If you get home and realize that you need additional rehabilitation or assistance, we are at your service.
Common Medicare Terms
Benefit Period – Starts the day the subscriber is admitted to a hospital or SNF and ends when the subscriber has not received hospital inpatient or SNF care for 60 consecutive days.
Hospital Lifetime Reserve Days – Each Subscriber has 60 hospital lifetime reserve days. These days are not renewable and therefore may be used only once.
Co-Insurance – The percent of the approved charge that the subscriber must pay (1) after the Part A deductible is paid and (2) after the Part B deductible is paid.
Deductible – The amount the subscriber must pay (1) for each benefit period for the Part A and/or (2) each year for Part B before Medicare begins to pay.
The information contained on this page is intended for general information purposes only, and should not be construed as legal or professional advice.
When a family member is unable to provide the necessary care for a loved one, the responsible decision is to choose a setting where that individual’s unique needs can be met. Learn more about the benefits and admission requirements for a skilled nursing stay. Read More ›