Medicare Medicare

Medicare Basics 101

 

There are many elements to Medicare health care plans and coverage.  Explore the basics of Medicare, the types of Medicare plans, enrollment and eligibility guidelines, and other key information about Medicare Advantage. 

What is Medicare?

Medicare is health insurance offered through the Federal Government and is available when:

  • You turn 65 years old
  • You are disabled
  • You have End Stage Renal Disease (ESRD)

You can choose different ways to receive the services covered by Original Medicare.  When you first enroll, you will be covered by Original Medicare.

Original Medicare is a fee-for-service plan that pays for many healthcare services and supplies, but it doesn’t pay all of your healthcare costs.  These are out of pocket costs, like coinsurance, copayments and deductibles.  These are called “gaps” in Medicare coverage.

To fill these gaps, you can choose to receive additional coverage through a Medicare Advantage plan (HMO, PPO, MSA) or Medigap supplemental insurance.

What is Original Medicare?

Original Medicare covers many services and supplies, but not everything, which is why there are additional options for Medicare health coverage.  Original Medicare includes:

  • Medicare Part A, which covers inpatient hospitalization, skilled nursing facilities, and hospice. Generally, you don’t pay a premium for Part A, but you will have deductibles and copayments or coinsurance.
  • Medicare Part B, which covers outpatient care and doctor services, such as a visit to your primary doctor or a specialist. Part B has a premium, deductible, and coinsurance.

What is Medicare Advantage?

Medicare Advantage plans cover the same services as Original Medicare and usually more.  What are the benefits of Medicare Advantage plans?

  • Medicare Advantage plans combine Part A, Part B, and sometimes Part D (drug coverage) into one plan.
  • With a Medicare Advantage plan, your costs will usually be lower than with Original Medicare.
  • These plans can include extra benefits, such as health and wellness programs, vision, and fitness.
  • You join a Medicare Advantage plan through a Medicare-approved private insurance company (like HealthNow).
  • There are different types of Medicare Advantage plans, giving you options to find the plan that’s the right fit for you.

Medicare Part A

Medicare Part A includes hospital insurance.  Most people do not pay a monthly Part A premium, because they or their spouses have 40 or more quarters of Medicare-covered employment.

What should you know about Medicare Part A?

Provides partial coverage for inpatient hospitalization and skilled nursing facility care.

  • Has deductibles and copayments for which you will be responsible for unless they are covered by a separate health insurance plan.
  • Part A is required to qualify for Medicare Advantage programs.

Medicare Part B

Medicare Part B includes medical insurance.  The monthly plan premium provides partial coverage for inpatient hospitalization and skilled nursing facility care and has deductibles and copayments for which you will be responsible for unless they are covered by a separate health insurance plan.

What should you know about Medicare Part B?

  • Provides partial coverage for doctor office visits and other medical services.
  • Has deductible and coinsurance
  • Although Part B is optional, there is a penalty if you sign up after your initial enrollment period
  • Part B is required to qualify for Medicare Advantage programs.

Medicare Part C

Medicare Part C includes Medicare Advantage Plans such as HMOs, PPOs, and MSAs.  


What should you know about Medicare Part C?

  • Combines your part A and Part B benefits.
  • Private insurance companies approved by Medicare provide this coverage.
  • Costs may be lower than in the Original Medicare Plan, and you may get extra benefits.

Medicare Part D

Medicare Part D includes prescription drug coverage.  Some prescription drug plans have separate premiums, while others do not.  The monthly premium will vary by plan. 


What should you know about Medicare Part D?

  • Sold by private insurance companies, some Part C plans include Part D
  • Part D is optional for most people, with a penalty for late enrollment
  • Part D plans can have a deductible
  • After your total yearly drug costs reach the initial coverage limit of $3,310, you enter the coverage gap (donut hole) where you receive a 45% discount on brand name drugs and pay 58% of the plan’s costs for all generic drugs until your yearly out-of-pocket drug costs reach $4,850.
  • After your yearly out-of-pocket drug costs reach $4,850 (catastrophic phase), you pay the greater of 5% coinsurance or $2.95 copay for generic (including brand drugs treated as generic), and a $7.40 copay for all other drugs.

What are star ratings?

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance.  Medicare Plan Ratings help you know how good a job our plan is doing.  For full details on Medicare Plan Ratings, please review the 2016 Medicare Plan Ratings.

 

ENROLLMENT TIME FRAME AND PROCESS

When you can enroll in a Medicare Advantage plan?

You may enroll in a Medicare Advantage plan only during specific times of the year:

  • When you first become eligible for Medicare, the seven month period  beginning three months before you turn 65, the month you turn 65 and three months after you turn 65.
  • If you get Medicare due to a disability.
  • During the Annual Enrollment Period from October 15, 2015 and December 7, 2015.

When you can join, drop or switch a Medicare Advantage plan?

In most cases, you must stay enrolled for the calendar year that starts the date your coverage begins.  In certain situations, however, you may be able to join, drop or switch a Medicare Advantage Plan, excluding MSA.

Some of these situations include the following:

  • During the Medicare Advantage Disenrollment Period, between January 1 and February 14, you may drop your Medicare Advantage Plan
    and return to Original Medicare (does NOT apply to the MSA plans)
  • If you move out of the plan’s service area
  • If you have both Medicare and Medicaid
  • If you qualify for extra help to pay for your prescription drugs
  • If you live in an institution

How to Enroll

Becoming a member of SelectSaver HMO-POS or SmartSaver PDP Value is easy. You can print off, complete and mail in the paper application.

 

Medicare beneficiaries may also enroll in SelectSaver HMO-POS through the CMS Medicare Online Enrollment Center located www.medicare.gov

 

SelectSaver HMO-POS Paper Application

 

SmartSaver RX PDP Value Paper Application

 

Who to Contact with Questions

If you have any questions, please call Customer Service at 1-888-989-9905, TTY: 711

We are open:

October 1 - February 14

8 a.m. to 8 p.m., 7 days a week

February 15 - September 30

8 a.m. to 8 p.m., Monday-Friday


During non-business hours, your call will be answered by our automated phone system.  A Customer Service Representative will return your call on the next business day. You may also chat online with a representative in a secure online chat room.  We also welcome any suggestions you may have for improving our plan or to make recommendations regarding the Member Rights and Responsibilities Policy (Please see the Member Rights and Responsibilities section of your Evidence of Coverage for more information).

Medicare Eligibility Requirements

When you turn 65, you’ll be eligible for Medicare, and you’ll need to make some important decisions about how you receive your health care.  Beginning three months before your 65th birthday, you will be eligible to enroll in Medicare.  Your eligibility will last for seven months - including the three months before your birthday month, your birthday month, and the three months after.  Before or during those seven months, you will need to decide:

  • What healthcare benefits are most important to you
  • How you want to get Medicare coverage:
  • Original Medicare alone
  • A Medicare Advantage Plan, like SelectSaver HMO-POS.
  • Original Medicare plus a supplemental insurance policy (Medigap)
  • Whether you need prescription drug coverage

 

You must live in one of the following counties to be eligible for enrollment in the specified HealthNow New York Medicare Advantage Plan:

SelectSaver HMO-POS

Monroe, and Wayne Counties, NY.

SmartSaver Rx PDP

Live in New York State

 

 

TYPES OF MEDICARE PLANS

To fill the gaps in Medicare coverage you can select from different types of Medicare plans. 
Medicare plans offered by HealthNow New York include:

Health Maintenance Organization

A Health Maintenance Organization (HMO) is a type of Medicare Advantage plan that takes the place of Original Medicare (Medicare Advantage Plan is primary).  With an HMO plan, you must receive care from doctors and hospitals in the plan’s network, except for emergency or urgent care.  Prescription drug coverage is included with some plans.

Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is a type of Medicare Advantage plan that takes the place of Original Medicare (Medicare Advantage Plan is primary).  With a PPO plan, you can receive care within a network of doctors and hospitals or use out-of-network doctors and hospitals for covered services, usually for a higher cost.  Prescription drug coverage is included with some plans.

Medigap Supplemental Insurance

Medigap Supplemental Insurance works with Original Medicare (Medicare is primary).  It covers some of the health care costs that the Original Medicare Plan does not.  Plans are standard between companies and you can receive care from any doctor or hospital that accepts Medicare assignment nationwide.  Medigap plans don’t cover prescription drugs. Therefore, if you join a Medigap plan, you can also join a Medicare prescription drug plan to receive drug coverage.

 

HOW MEDICARE ADVANTAGE DRUG COVERAGE (PART D) WORKS:

Step 1: Yearly Deductible

This amount is the amount you must pay before your drug plan begins to pay its share of your covered drugs. Some drug plans don't have a deductible

Step 2: Initial Coverage

You pay a copay or coinsurance.  HealthNow pays the remaining cost.  You start in the initial coverage stage and generally stay in this payment stage until your year-to-date total drug costs (what you pay plus what HealthNow pays) reach $3,310. After you reach $3,310 you will enter the "coverage gap" or "donut hole"

Step 3: Coverage Gap (Donut Hole)

When you are in the coverage gap (donut hole):

  • You pay 58% of HealthNow's cost for all covered generic medications. The cost you pay at the pharmacy applies toward your out-of-pocket costs.
  • You pay no more than 45% of HealthNow's cost for covered brand name medications.* The total cost of the medication (before the discount) applies toward your out-of-pocket costs.
  • The discounts are automatically applied at the point of sale.
  • You generally stay in this stage until your year-to-date out-of-pocket costs reach $4,850.

Step 4: Catastrophic Coverage

After you reach $4,850, you enter the catastrophic coverage stage.  In this stage, you pay the greater of 5% coinsurance or $2.95 for generic medications and $7.40 for all other medications.  HealthNow pays the remaining cost.   Once you are in this payment stage, you will remain in it for the rest of the calendar year (through December 31).

* As defined by the Centers for Medicare and Medicaid Services (CMS), a dispensing fee will apply.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year.  The Formulary, pharmacy network, and/or provider network may change at any time.  You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

 

HealthNow New York Inc.  is a Medicare Advantage and stand-alone PDP plan with a Medicare contract. Enrollment in HealthNow New York Inc. depends on contract renewal. 

 

Y0086_MRK1600 Approved 

Content Last Updated January 19, 2016