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Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B (Medical Insurance)
Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
Medicare Part D (Prescription Drug Coverage)
Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
There are only certain times when people can enroll in Medicare. Depending on the situation, some people may get Medicare automatically, and others need to apply for Medicare. The first time you can enroll is called your Initial Enrollment Period. Your 7-month Initial Enrollment Period usually:
Begins 3 months before the month you turn 65
Includes the month you turn 65
Ends 3 months after the month you turn 65
Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost.
A drug in a lower tier will generally cost you less than a drug in a higher tier. Sometimes, if your prescriber thinks you need a drug that’s on a higher tier, you or your prescriber can ask your plan for an exception to get a lower copayment.
A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:
Provide written notice to you at least 60 days prior to the date the change becomes effective
At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.
Medicare drug plans may have these coverage rules:
Prior authorization: You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
Quantity limits: Limits on how much medication you can get at a time.
Step therapy: You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.Before your prescriptions are filled, your Medicare drug plan will also perform additional safety checks, like checking for unsafe amounts of opioid pain medications.
Part D vaccine coverage
Except for vaccines covered under Medicare Part B (Medical Insurance), Medicare drug plans must cover all commercially available vaccines (like the shingles vaccine) when medically necessary to prevent illness.
Drugs You Get In Hospital Outpatient Settings
In most cases, the prescription drugs you get in a hospital outpatient setting, like an emergency department or during observation services, aren’t covered by Part B. These are sometimes called “self-administered drugs” that you would normally take on your own. Your Medicare drug plan may cover these drugs under certain circumstances.
You’ll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Or, if you get a bill for self-administered drugs you got in a doctor’s office, call your Medicare drug plan for more information. Get your plan’s contact information from a Personalized Search (under General Search), or search by plan name.
Automatic-Refill Mail-Order Service For Prescription Drugs
Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription drugs when you’re about to run out. Some prescription drug plans weren’t making sure that some customers still wanted or needed a prescription drug and this created waste and unnecessary additional costs for people with Medicare and Part D.
Now, there’s a new policy for mail-order prescriptions. Plans have to get your approval to deliver a prescription (new or refill) unless you ask for the refill or request the new prescription. Some plans may ask you for your approval every year so that they can send you all new prescriptions without asking you before each delivery. Other plans may ask you before each delivery.
This new policy won’t affect refill reminder programs where you go in person to pick up the prescription, and it won’t apply to long-term care pharmacies that give out and deliver prescription drugs. Giving your approval may be a change for you if you’ve always used mail-order in the past and haven’t had the opportunity to confirm that you still need refills.
If you have Medicare and other health insurance or coverage, each type of coverage is called a “payer.” When there’s more than one payer, “coordination of benefits” rules decide which one pays first. The “primary payer” pays what it owes on your bills first, and then sends the rest to the “secondary payer” to pay. In some cases, there may also be a third payer.
The insurance that pays first (primary payer) pays up to the limits of its coverage.
The one that pays second (secondary payer) only pays if there are costs the primary insurer didn’t cover.
The secondary payer (which may be Medicare) may not pay all the uncovered costs.
If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay.
If the insurance company doesn’t pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should’ve made.
A Medicare Supplement Insurance (Medigap) policy, sold by private companies, can help pay some of the health care costs that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles.
Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share.
A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
8 things to know about Medigap policies
1. You must have Medicare Part A and Part B.
2. If you have a Medicare Advantage Plan, you can apply for a Medigap policy, but make sure you can leave the Medicare Advantage Plan before your Medigap policy begins.
3. You pay the private insurance company a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare.
4. A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.
5. You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one.
6. Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
7. Some Medigap policies sold in the past cover prescription drugs, but Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
8. It’s illegal for anyone to sell you a Medigap policy if you have a Medicare Medical Savings Account (MSA) Plan.
Medigap policies generally don’t cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.
Insurance Plans That Aren’t Medigap
Some types of insurance aren't Medigap plans, they include:
Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)
Medicare Prescription Drug Plans
Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP)
Long-term care insurance policies
Indian Health Service, Tribal, and Urban Indian Health plans
Dropping Your Entire Medigap Policy (Not Just The Drug Coverage)
If you decide to drop your entire Medigap policy, you need to be careful about the timing. For example, you may want a completely different Medigap policy—not just your old Medigap policy without the prescription drug coverage. Or you might decide to switch to a Medicare Advantage Plan that offers prescription drug coverage.
You have to pay a late enrollment penalty when you join a new Medicare drug plan if:
You drop your entire Medigap policy and the drug coverage wasn’t creditable prescription drug coverage, or
You go 63 days or more in a row before your new Medicare drug coverage begins
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