Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS). There are some minor differences from state to state, but the vast majority of Medicare is the same everywhere in the United States, so the coverage Pennsylvania residents receive is much like Medicare coverage throughout the nation.
More than 2.7 million Pennsylvania residents are enrolled in Medicare or approximately 21% of the state's population. Of these, about 45% have coverage under Medicare Advantage plans and more than 700,000 people have Medigap plans. The state remains one of the most robust Advantage markets in the country. Every county has at least 24 plans available as of 2020, meaning that choices are plentiful and competitive.
Two groups of people are eligible for Medicare:
Medicare has four parts. At a high level, these parts provide the following coverage:
Part A and Part B are also referred to as Original Medicare. Part C is commonly called Medicare Advantage. Note that dental, hearing, and vision are usually not covered by Original Medicare, and most times, you'll need to get coverage by purchasing an additional policy.
Medicare coverage extends to all 50 states, Washington, D.C., the Northern Mariana Islands, American Samoa, Guam, or the U.S. Virgin Islands.
Medicare coverage pays for various tests and services, sometimes depending on where you live. However, other items and services are covered no matter where you live.
To see a complete list of tests, items, and services covered by Medicare no matter where you live, go here.
Let's take a closer look at each part of Medicare.
Part A is also known as Medicare hospital insurance, and coverage typically includes inpatient hospital care, skilled nursing facility care, hospice, and certain types of eligible home health care. Medically necessary services and equipment (e.g., nursing services, a semi-private room, prescription drugs, etc.) are also generally covered if part of a beneficiary's inpatient treatment.
Coverage also includes hospice care if a beneficiary is diagnosed as terminally ill and has six months or less to live. Doctor/nursing services, hospice aide services, physical/occupational therapy, prescription drugs, and respite care for caregivers are included.
Part A does not cover long-term nursing home or care facility benefits. Coverage only includes facilities where help with personal care, such as eating and bathing, is not the only assistance a beneficiary receives.
You are automatically enrolled in free Part A coverage at age 65 if you paid Medicare taxes while working for at least 10 years (40 quarters). If your spouse qualifies for Part A benefits without a premium, then you may also be eligible for premium-free benefits.
You can also qualify for free benefits if you or your spouse receive or you're eligible to receive Social Security benefits or Railroad Retirement Benefits (RRB). This benefit is available even if the spouse is deceased or divorced from the person seeking coverage.
If you don't meet work requirements, you can still sign up for Part A, but you must pay a monthly premium.
If you're under age 65, you can qualify for Medicare Part A benefits if:
If you already get Social Security or Railroad Retirement Board benefits, then most of the time you will automatically get Part A and Part B coverage starting the first day of the month you turn 65 years old.
If you're under 65 and disabled, you'll automatically get Part A and Part B after receiving disability benefits from Social Security or the Railroad Retirement Board for 24 months.
In both cases, you'll get a "Welcome to Medicare" package with your Medicare card and complete information about how Medicare works.
If you don't meet these requirements, you can sign up for Medicare during your Initial Enrollment Period (IEP). Your IEP is the 7-month period that begins three months before you turn 65 and ends three months after the month you turn 65.
After your IEP ends, you can sign up for Part A and Part B during a Special Enrollment Period if you qualify. You can also sign up during the Medicare General Enrollment Period (January 1 through March 31 annually), but you may face higher premiums and delayed coverage if you choose this option.
Part A coverage is free if you qualify, other than some deductibles for hospital stays.
If you don't qualify for free Part A coverage, you can still enroll and pay a premium under the following requirements:
Premium costs will vary depending on how long you have worked and how close you are to meeting the minimum of 40 Social Security credits.
In most cases, if you enroll and pay for Medicare Part A, you must also enroll and pay a separate premium for Medicare Part B.
Part B covers doctor's services, outpatient care, labs and clinics, and preventative services. This bundle of services is often collectively referred to as outpatient care.
Part B also covers ambulance services to the nearest appropriate medical facility, but Medicare only helps pay for ambulance services when other transportation could put your health at risk. Medicare may also cover emergency air transportation when serious health dangers are present, and you can't be safely transported by ground.
Durable medical supplies for use in your home are also covered under Part B. Some examples of these types of supplies include wheelchairs, hospital beds, walkers, oxygen equipment, CPAP devices, infusion pumps, and commode chairs.
Part B also covers outpatient mental health services, including visits to psychiatrists, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician's assistants. Treatment for alcohol and drug abuse is also covered, as well as depression screenings, psychiatric evaluations, psychotherapy, medication management, and other similar services.
If you're eligible to enroll in Part A at no cost, you are eligible to enroll in Part B by paying a monthly premium.
Suppose you don't qualify for Part A at no cost. In that case, you can qualify for Part B if you're 65 years or older and a U.S. citizen or legal permanent resident who has lived in the United States continuously for five years immediately preceding the month you apply for Part B.
Part B enrollment typically occurs during an IEP when a person also signs up for Part A. You're automatically enrolled in Medicare Part B if you already receive benefits from Social Security or the Railroad Retirement Board.
But if you don't enroll in Part B at that time, you can enroll during a General Enrollment Period between January 1 and March 31 each year. One drawback if you sign up during this period is that your Part B coverage will not begin until July 1, and you may have a coverage gap.
Also, if you don't sign up for Part B when you're first eligible, then you could end up paying more for coverage as well as a late enrollment penalty.
Medicare beneficiaries also can review their existing coverage for all Parts and make changes during an Annual Open Enrollment Period from October 15 through December 7.
You will have to pay a monthly premium for Part B coverage. Premiums are often taken directly out of Social Security or Railroad Retirement benefit checks, so most people don't need to worry about paying a monthly bill.
If your adjusted gross income is above a certain threshold, you may be required to pay a larger premium.
If you initially decide not to enroll in Part B coverage, then the monthly premium will increase by 10% for each 12-month period you're eligible when you finally do enroll. That penalty is permanent, and you'll pay it for as long as you have Part B coverage.
Also, after you meet your Part B deductible, you'll pay 20% for all approved Medicare services as your cost-sharing portion.
Part C is interchangeable with the term Medicare Advantage plans. These policies are optional plans sold by Medicare-approved private insurance companies.
Part C plans offer added benefits above what Part A and Part B offer. This might include vision, dental, or hearing coverage. Most Part C plans also provide prescription drug services as well.
By law, Medicare Advantage plans must provide at least the same level of coverage as Original Medicare but can do so with differing costs and restrictions. Several types of coverage are offered by HMOs, PPOs, PFFSs, and Special Needs Plans.
If you have Medicare Part A and Part B coverage, you can enroll in a Part C plan. The only qualification is that you must make sure you live in an area where you're eligible to enroll in Part C. Also, even after enrolling in a Part C plan, you must keep paying your Part B premium.
In most cases, people with end-stage renal disease (ESRD) can't join a Medicare Advantage Plan, although there are a few exceptions.
You can enroll in a Part C plan during your Initial Enrollment Period.
You can only enroll in Medicare Advantage plans or make changes to your existing coverage at certain times of the year. Those periods include:
If you no longer want Part C coverage, you can opt out during the Medicare Advantage Disenrollment Period between January 1 and February 14 each year. You can only switch to Medicare Part A and Part B if you opt-out, but not a new Medicare Advantage Plan.
While plan providers agree to follow Medicare's rules regarding care and coverage, they can provide those services differently and use different fee structures for expenses.
Part C costs vary depending on what services are covered and the plan's level of copayments and coinsurance. For example, some beneficiaries may pay more per month for a smaller deductible for services or cheaper copayments for doctor visits.
When shopping for a plan, pay close attention to how well the company is reviewed, and a good track record of customer service.
As part of their agreement with Medicare, providers can only change plan costs once a year, beginning January 1.
It's also worth noting that Medicare Advantage Plans have annual out-of-pocket maximums, but Original Medicare does not. There are no charges for covered services after a Part C maximum amount is reached.
Part D provides enhanced drug coverage to go with the coverage provided with Medicare Part A, and Part B. Part D plans are available through private insurance companies that Medicare has approved. Typically, Part D plans offer higher degrees of coverage and a lower limit on out-of-pocket expenses.
Any person eligible for Part A or Part B can purchase a Part D plan, regardless of income or health status.
If you have Medicare Part A and Part B coverage, you're eligible for Part D.
The other requirement is to live in the service area of the Part D plan you choose.
You can enroll in Part D through a Medicare-approved private insurance company during your IEP, the Annual Election Period from October 15 to December 7, and immediately following the General Enrollment Period between April 1 to June 30.
You can also enroll at any time you qualify for the Extra Help program.
Part D costs vary from plan to plan because different providers offer various types of coverage.
You'll pay a monthly premium and a yearly deductible with a Part D plan. In addition, you'll also have to pay some copayments or coinsurance after meeting your annual deductible. You may also have some small costs if you're enrolled in Extra Help, but often your costs are zero.
You may pay an enrollment penalty if you enroll in Part D late.
The good news is that if a person enrolls in a Medicare Advantage Plan, drug coverage is usually included as part of the policy.
You will have a cap on your yearly out-of-pocket expenses, and once you reach this amount, catastrophic coverage kicks in, and you'll pay only a small copayment or coinsurance for the balance of the year.
Because there are so many cost variables for Part D plans, it's essential to shop around for an affordable plan that best meets your needs.
Most people get Medicare Part A for free by working and paying taxes over an extended period.
You earn Social Security credits by paying Social Security and Medicare payroll taxes while working. You earn one credit for each quarter year you work, and for free Part A Medicare, you must earn 40 credits (10 years of work) to qualify.
You must meet income minimums for each quarter as well. In 2021, that amount is $1,470 per quarter. This amount can change annually, so you may want to verify the minimum if this has the potential to impact you.
You can only earn a maximum of four credits per year, and if you accrue more than 40 credits over your working life, these do not provide you with any added benefits.
You may also qualify for Medicare if you have been a government employee who has paid Medicare payroll taxes while working.
If you didn't enroll in Medicare during your Initial Enrollment Period (IEP) Medicare has several other enrollment opportunities throughout the year for those who meet qualifying conditions.
Your IEP is seven months beginning three months before the month you turn 65 and ending three months after your 65th birthday. You can sign up for coverage during your IEP even if you don't plan on retiring when you turn 65. If you're already getting Social Security or Railroad Retirement benefits you'll be contacted three months before you turn 65.
You can also apply for Medicare before age 65 if you meet one or more of the following conditions:
Annual Enrollment Period (AEP). This begins every year in mid-October and runs through the first week in December. If you missed your IEP, you could enroll during this special timeframe, but you may have to pay a penalty in some cases if you didn't enroll during your IEP. Any changes to coverage go into effect on January 1 of the following year.
General Annual Open Enrollment Period. People who did not sign up for Part B at the required time can use January 1 to March 31 each year to sign up. If you choose this option, your Part B coverage will start on July 1, and you may have to pay a penalty for late enrollment.
Part B Special Enrollment Period (SEP). You can enroll in Part B without penalty after 65 if you can show you or your spouse had group health coverage from an employer after turning 65. This SEP runs eight months from the time you or your spouse stopped working.
Part D Special Enrollment Period. You can delay enrolling in Part D drug coverage beyond age 65 if you have creditable drug coverage from another provider. Creditable is defined as having prescription drug coverage equal to or exceeding what you can get with Part D.
Annual Disenrollment Period. People enrolled in Medicare Advantage Plans and who want to change to Original Medicare or enroll in Part D coverage can do so between January 1 and February 14. New coverage begins the first day of the month after you make your changes.
Several other Special Enrollment Periods are available in specific circumstances related to Medicare Advantage and Part D plans. Check with Medicare to see if you qualify for one of these SEPs.
Two of the most extensive healthcare programs administered by the federal government are Medicaid and Medicare. Although they sound alike and are sometimes confused with each other, they are distinctly different.
Medicare is a health insurance program primarily for people 65 and older administered by the federal government.
Medicaid is an assistance program that serves low-income people of all ages and is administered jointly by federal and state governments.
Medicare is primarily for people who are 65 and older or who have qualifying conditions if they're under 65. Medicaid has no age restrictions, is based strictly on need, and provides benefits if a person falls below designated income and asset levels. Most Medicaid services are provided at no cost, with a few exceptions.
Per federal regulations, there are core benefits states are required to provide under Medicaid and optional benefits offered at the discretion of each state.
Medicaid core benefits are like those offered by Medicare. They include inpatient and outpatient hospital services, nursing and home health care services, labs and x-rays, pediatric and family nurse practitioner services, transportation to medical centers, and other related benefits.
Optional Medicaid benefits include prescriptions, physical and occupational therapy, respiratory care, dental and vision services, chiropractic services, private nursing, hospice, psychiatric care for people under 21, and mental health institutional care for people over 65.
If you meet qualifying circumstances under both programs, you can get assistance from Medicare and Medicaid. People eligible to receive both benefits are known as "dual eligible."
This includes beneficiaries enrolled in Medicare Part A and/or Part B and getting full Medicaid benefits and/or assistance with Medicare premiums or cost-sharing through the Medicare Savings Program.
Medicare pays covered dual-eligible beneficiaries' services first because Medicaid is generally the payer of last resort. Also, Medicaid may cover medical costs Medicare doesn't cover or only partially covers.
Dual eligible coverage and terms vary by state. If you need help with Medicaid, call 1-800-692-7462 between 8:30 a.m. and 4:45 p.m., Monday through Friday. If you are hearing impaired, call TTY/TTD at 1-800-451-5886.
You can contact or visit your local county assistance office (CAO).
If you are not eligible for Medicaid, your child may still be eligible for the Children's Health Insurance Program. For questions about eligibility or benefits, go to CHIP Covers PA Kids.
What to Know About Medigap Policies in Pennsylvania
Some Medicare beneficiaries in Pennsylvania may find out that Original Medicare does not cover some of their healthcare costs, including copayments, coinsurance, deductibles, and other similar out-of-pocket expenses.
If this is the case, you may want to consider a Medigap policy. These are also often referred to as Medicare Supplement policies.
Medigap policies are different from Medicare Advantage Part C plans. Medigap policy bridges the coverage gap to help pay for services not fully covered by Part A, Part B, or at all.
Medicare Part B covers 80% of costs after the Part B deductible is met. This means Medicare beneficiaries are responsible for the remaining 20%. Depending on the policy and coverage, beneficiaries with some Medigap plans would have the cost-sharing covered completely, creating a potentially significant benefit for a policyholder.
One important thing to note is that you can't purchase a Medigap policy if you have a Medicare Part C Plan.
Pennsylvania offers several standardized Medigap plans to eligible beneficiaries. Each of these plans is designated by a specific letter (A, B, C, D, F, G, K, L, M, and N).
The plans are not standardized, and the monthly premium you'll pay for a Medigap policy depends on the types of benefits in the policy and what individual companies charge for coverage.
Speak with an experienced agent if you decide that a Medigap policy is a good option for you.
Some companies may offer premium discounts for such things as multiple policies in the same household, automatic premium deductions, and so forth. Also, Medigap policies only cover one person. If you and your spouse both want Medigap coverage, you will have to buy separate policies.
The best time to sign up for a Medigap policy is during your Medigap Open Enrollment Period (OEP). Your OEP is the six-month period that begins the month you turn 65 or older and enrolled in Medicare Part B. During your OEP, you can enroll without the need to submit a medical background or history and without any fear of being denied coverage. However, once your OEP has expired, you can still enroll, but your rates may be higher, and you may be subject to medical underwriting or even denial of coverage based on pre-existing conditions.
If you miss your OEP, you can also buy a Medigap policy when you have a guaranteed issue right. If you're 65 or older, you have a guaranteed issue right within 63 days of when you lose or end certain kinds of health coverage.
If you meet specific qualifications, you may be able to get assistance to help you pay for Medicare and Medicaid services in Pennsylvania.
Medicaid for the aged, blind, and disabled can pay for Medicare cost-sharing expenses and cover some services not covered by Medicare Part A and Part B. Beneficiaries whose incomes and assets make them eligible for Medicaid can receive coverage for those additional services if they're enrolled in Medicaid for the Aged, Blind and Disabled (ABD).
If an individual's income is over the eligibility limit for Medicaid ABD, but their assets are below the resource limit, they can enroll in the Medicaid spend-down, which is also called the "Medically Needy Program." Enrollees must submit medical bills equal to this amount to activate their coverage. After approval, Medicaid calculates the amount of income higher than the spend-down income limit.
Medicare separately offers four types of Savings Programs for eligible individuals:
Qualified Medicare Beneficiary (QMB) Program. QMB pays for Part A and Part B premiums and cost-sharing expenses. You must be eligible or currently enrolled in Medicare Part A to qualify for this program.
Specified Low-Income Medicare Beneficiary (SLMB) Program. If you earn slightly more than the QMB program's maximum, you may qualify for this program instead, which helps with Medicare Part B premiums.
Qualifying Individual (Q.I.) Program. If you don't qualify for QMB or the SLMB program, you may consider applying for the Q.I. program. It helps with Part B premiums and automatically qualifies you for the Extra Help program.
Qualified Disabled and Working Individuals (QDWI) Program. This only pays for Medicare Part A premiums.
State Medicaid agencies run these programs, so program qualifications may differ from state to state, but all are based on assets and income.
When you're eligible for a Medicare Savings Program, you're automatically qualified for participation in the Extra Help program as well.
Extra Help means Medicare pays for your Part D prescription drug plan premium and any yearly deductible, coinsurance, and copayments.
Some people with higher incomes get partial Extra Help, paying reduced premiums, deductibles, and copayments. Those who qualify for partial Extra Help pay no more than 15% of the costs of drugs on a plan's formulary (drug list) until reaching an out-of-pocket limit.
If you don't qualify for Extra Help, you may still be able to seek relief at the state level for drug prices. Many states provide State Pharmacy Assistance Programs (SPAP) to help low-income individuals with a disability or a medical condition pay for prescription drugs.
You're sure to have questions, and the best way to get answers is to work with an experienced Medicare agent. The market is dynamic, and there's a lot to understand, so going this route will likely save you time and money.
If you prefer, Medicare has a search function on its website that allows people to determine what providers offer Part C and Part D plans in Pennsylvania. To access the Medicare Plan Finder tool, go here.
You may have many questions about options, costs, coverage, and other related issues if you're new to Medicare. There are several resources you can tap into for answers.
APPRISE, Pennsylvania's State Health Insurance Assistance Program (SHIP), is a great place to start for questions related to Medicare coverage in Pennsylvania. Effective July 1, 2021, APPRISE became Pennsylvania Medicare Education and Decision Insight, PA MEDI.
You can get assistance with comparing plans, filing claims, reviewing your Medicare Summary Notice, submitting appeals, and applying for financial assistance. Visit the SHIP website or call 1-800-783-7067, 9 a.m. to 4 p.m., Monday to Friday.
Medicare coverage is regulated by both federal and state agencies, depending on the type of coverage. The Pennsylvania Insurance Department regulates Medigap plans in the state and brokers and agents who sell Medicare coverage. Although the department can't recommend specific plans, their Consumer Service Bureau can assist with insurance-related questions and help resolve issues or complaints with an insurance provider in the state.
Another source of outstanding information is the Medicare Rights Center. This website provides helpful information geared to Medicare beneficiaries, caregivers, and professionals.
For Medicare beneficiaries with limited income and assets, Pennsylvania Medicaid may make care more affordable. Contact the Pennsylvania Department of Human Services website for more information or call 1-866-550-4355.
Pennsylvania Health Law Project (PHLP) is a nonprofit law firm that helps residents having difficulty getting or keeping Medical Assistance health care coverage. Legal assistance is free and available throughout the state by contacting their helpline at 800-274-3258
If you are a veteran and have a question or concern about veterans' health care benefits, get assistance from the US Department of Veterans Affairs. Call (877) 222-VETS (8387) or go to
https://www.va.gov/health-care/
For questions about your health insurance not covered by the above resources, call the Health Insurance Assistance Team of the U.S. Center for Consumer Information and Insurance Oversight at (888) 393-2789.
DISCLAIMER: Medi-Solutions Insurance Agency, LLC is not affiliated or endorsed with the Social Security Administration or the Federal Medicare Program. Information is for educational purposes only and should not be construed as an offer of insurance, advice, or recommendation. The information provided is not intended as tax, financial, investment, or legal advice. Please consult legal or tax professionals for specific information regarding your individual situation.
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