Medicare health insurance

Medicare is a Health Insurance Program for individuals in the following categories:
People age 65 or older
People under age 65 with certain disabilities
People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)
Medicare is made up of two parts:

You can select different ways to receive the services covered by Medicare. Generally, when you begin receiving
Medicare, you are in Original Medicare. You may consider a Medicare Prescription Drug Plan that will provide
for drug coverage. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that
provides all of your Part A, Part B, and often Part D coverage. You make this selection when you are first
eligible for Medicare. You should review your health and prescription needs annually and select the plan that
most suits your needs in the fall. As long as you have both Part A and Part B, items covered by Part A and Part B
are covered whether you have Original Medicare or you belong to a Medicare Advantage Plan (like an HMO or
PPO).
Part A (Hospital Insurance)
Helps Pay For: Care in hospitals as an inpatient, critical access hospitals (small facilities that give limited
outpatient and inpatient services to people in rural areas), skilled nursing facilities (not custodial or
long-term care), hospice and some home health care.
Cost: Most people get Part A automatically when they turn age 65. They don’t have to pay a monthly
payment (called a premium) for Part A because they or a spouse paid Medicare taxes while they were
working.
If you don’t automatically receive premium-free Part A, you may be able to purchase it:
• If you (or your spouse) aren’t entitled to Social Security because you didn’t work or didn’t pay enough
Medicare taxes while you worked and you are age 65 or older, or
• If you are disabled but no longer get premium-free Part A because you returned to work.
If you have limited income and resources, the State of South Carolina may be able to help you pay for Part A
and/or Part B.
Part B (Medical Insurance)
Helps Pay For: Doctors services, outpatient hospital care, and some other medical services that Part A
doesn’t cover, such as the services of physical and occupational therapists, and some home health care.
Part B helps pay for these covered services and supplies when they are medically necessary.
Information about your coverage under Medicare Part B can be found in the Your Medicare Coverage
database.
Enrolling in Part B is a decision that you will have to make. You can sign up for Part B anytime during a 7-month
period that begins 3 months prior to your 65th birthday. Please call or visit the local U.S. Social Security Office
to sign up. If you choose to have Part B, the premium is usually taken out of your monthly Social Security, Railroad
Retirement Board, or Civil Service Retirement payment.
If you don’t get any of the above payments, Medicare sends you a bill for your Part B premium called a “Notice
of Medicare Premium Payment Due” (CMS-500). You should get your Medicare premium bill no later than the
10th of the month in which the bill is due.
Medicare Premiums for 2018:
Part A: (Hospital Insurance) Premium
Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of
Medicare-covered employment.
The Part A premium is $232.00 per month for people having 30-39 quarters of Medicare-covered employment.
The Part A premium is $422.00 per month for people who are not otherwise eligible for premium-free hospital
insurance and have less than 30 quarters of Medicare-covered employment.
Part B: (Medical Insurance) Premium
$134.00 per month*
*If your income is above $85,000 (single) or $170,000 (married couple), your Medicare Part B premium may
be higher than $134.00 per month.
Medicare Deductible and Coinsurance Amounts for 2018:
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care). For each benefit period
Medicare pays all covered costs except the Medicare Part A deductible ($1,340.00 in 2018) during the first
60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay the following amounts:
A total of $0 for a hospital stay of 1-60 days.
$335.00 per day for days 61-90 of a hospital stay.
$670.00 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
All costs for each day beyond 150 days.
Skilled Nursing Facility Coinsurance:
$167.50 per day for days 21-100 of the benefit period.
All costs for each day after day 100 of the benefit period.
Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services,
durable medical equipment) In 2018, the annual deductible is $183.00. You pay 20% of the Medicare-approved
amount for services after you meet the annual deductible.
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Who is eligible for Medicare?
Generally, you are eligible for Medicare if you or your spouse worked
for at least 10 years in Medicare-covered employment and you are 65
years or older and a citizen or permanent resident of the United
States. If you are not, you might also qualify for coverage if you have
a disability or have End-Stage Renal disease (permanent kidney failure
requiring dialysis or transplant). You will be eligible for Medicare
when you turn 65 even if you are not eligible for Social Security
retirement benefits.
You can get Part A at age 65 without having to pay premiums under the following conditions:
If you already receive retirement benefits from Social Security or the Railroad Retirement Board.
If you are eligible to get Social Security or Railroad Retirement Board benefits but haven’t yet filed for them.
If you or your spouse had Medicare-covered government employment.
Before age 65, you can get Part A without having to pay premiums:
If you have received Social Security or Railroad Retirement Board disability benefits for 24 months.
If you have End-Stage Renal disease and meet certain requirements.
You can get your Medicare benefits through Original Medicare or a Medicare Advantage Plan (like an HMO or
PPO). If you have Original Medicare, the government pays for Medicare benefits when you get them. Medicare
Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private insurance companies approved
by Medicare. Medicare pays these companies to cover your Medicare benefits. If you join a Medicare Advantage
Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical
Insurance) coverage.
General Enrollment
If you didn’t sign up for Medicare Part B when you first became eligible, you may be able to sign up during the
General Enrollment Period. This period runs from January 1 through March 31 of each year. During this time, you
can sign up for Medicare part B at your local Social Security office. If you receive benefits from the Railroad
Retirement Board, call your local RRB office. Your Medicare Part B coverage will begin on July 1 of the year that
you sign up.
The cost of Medicare Part B will go up 10% for each full 12 month period that you could have received Medicare
Part B but selected not t
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Question Traditional Medicare A & B
+ Medigap Policy
Medicare Advantage Plan
What health care benefits are
covered?
All Medicare A and B benefits,
Medigap policy benefits depend on
the plan purchased. Refer to each
policy for details
All the Medicare A and B benefits
and perhaps others, depending on
the plan. Some plans may offer
other coverage. Refer to the plan
for details.
Are outpatient prescription drugs
covered?
No It depends on the plan. See each
plan for any drug coverage.
Can I go to any doctor or hospital? You can go to any doctor, specialist
or hospital that accepts Medicare.
You may go to any doctor,
specialist or hospital that has a
contract with the plan.
Does the policy/plan let doctors or
hospitals charge more than
Medicare’s deductibles, coinsurance
and copayments?
Not for hospitals, but possibly for
doctors. Doctors who do not
accept Medicare assignments may
charge up to 15% more than Medicare’s
approved amount. (Part B
excess charges are covered under
plans F and G.)
Medicare Advantage sets the rates
for deductibles, coinsurance and
copayments for the plan. Refer to
the plan for details
How are claims paid? The provider sends the claim to
Medicare. Medicare approves the
amount of the claim and pays its
portion. Medicare or the provider
forwards the claim to the Medigap
policy which, according to the
policy requirements, may or may
not pay the remaining balance.
Prior to receiving care, the plan
member pays a copayment/
deductible amount. The provider
sends the claim to the Medicare
Advantage plan. The plan
approves the claim amount and
pays its share. The member pays
any remaining share – such as a
deductible, coinsurance or copayment
– if the plan allows balance
billing. Refer to plan details.
Medicare with Medigap vs. Medicare Advantage Comparison
Medigap or Medicare Supplement Insurance
Medicare supplement insurance (often called Medigap insurance) fills in the gaps between what Medicare
pays and what you must pay out-of-pocket for deductibles, coinsurance and copayments. Medigap policies
only pay for services that Medicare deems medically necessary, and payments are generally based on the
Medicare- approved charge. Some plans offer benefits that Medicare doesn’t, such as emergency care while
in a foreign country.
There are 10 standardized Medigap plans, labeled A through L. All companies that sell Medigap insurance
must offer Plan A, but do not have to offer the other 9 plans. If you bought a Medigap policy before
standardized plans were first introduced in 1992, you may keep your existing policy. You do not have to
switch to one of the 10 standardized plans.
Medigap policies are sold by private insurance companies that are licensed and regulated by the South
Carolina Department of Insurance but the benefits, however, are set by the federal government. Medigap
policies are automatically renewed each year.
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Medicare Select
Medicare Select is a type of Medigap policy. A Medicare Select policy is basically the same as a standard Medigap
policy in nearly all respects because you are purchasing one of the ten standard Medicare supplement plans (A
through N). The only difference is that each insurer under Medicare Select generally requires you to use doctors
and providers in the plan’s network for your routine care. If you use out-of-network providers, you’ll have to pay
more of the costs though benefits are not usually payable if you do not use preferred providers for non-emergency
situations. Medicare, however, will pay its share of approved charges regardless of the provider you select.
Premiums are generally lower under these policies due to the preferred provider arrangements. At any time, you
may opt to return to a standard Medicare Supplement (Medigap) policy. If you currently have a Medicare Select
plan, you also have the right to switch, at any time, to any regular Medigap policy being sold by the same company.
The Medigap policy you select must have equal or less coverage than the Medicare Select policy you currently have.
Open Enrollment for Medicare Supplement Insurance
Beginning on the first day of the month in which you are 65 years or older and enrolled in Medicare Part B, you will
have a six month open enrollment period for purchasing Medicare supplement insurance. During this time, you
may not be turned down for Medicare supplement insurance because of your health. The insurer may, however,
exclude a pre-existing health condition for up to six months. Because of the limited open enrollment period, it is
very important that you understand it and take advantage of it when available.
If you apply for Medigap coverage after your open enrollment period, there is no guarantee that an insurance company
will sell you a Medigap policy if you don’t meet the medical underwriting requirements.
Medigap Rights and Protections (Guaranteed Issue Rights), See Appendix, Rights and Protections
In some situations, you may have the right to purchase a Medigap policy outside of your Medigap open enrollment
period. These rights are called “Medigap protections.” They are also called guaranteed issue rights because federal
law requires insurance companies to make Medigap policies available to you.
In these instances, an insurance company must comply with the following requireme
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In many cases, these rights also apply when your health care coverage changes in some way, such as when you
lose or drop your other health care coverage. Remember, it is best not to wait until your current health coverage
has almost ended before you apply for a Medigap policy. You can apply for a Medigap policy early (for example,
while you are still in your health care plan) and choose to start your Medigap coverage the day after your health
care coverage ends. This will prevent gaps in your health coverage.
In many of these instances, you have the right to purchase Medigap plans A, B, C, F, K or L from any insurance
company that sells Medigap policies in South Carolina (If you are under age 65, you may only purchase a policy
from a company that sells Medigap policies to persons under 65 and on Medicare). You can purchase the policy
at the best premium price available, with no review of your medical records even if you have health problems.
Issue Age or Attained Age Premium
There are two types of premium schedules which insurers generally use. Under an issue age schedule, the insurer
charges a premium based on your age when your policy was first issued. Although, your premium will likely
increase due to inflation and changes in benefits provided by Medicare (and therefore changes in benefits of the
Medicare supplement), the insurer cannot increase your premium simply because you have gotten older.
Under an attained age schedule, the insurer charges a premium based on your age on each premium renewal
date. With this type of schedule, your premium is not only likely to increase due to inflation and changes in
benefits provided by Medicare but also because you have gotten older.
Guaranteed Medigap Coverage
South Carolina has two guaranteed issue Medigap policies for persons under the age of 65 and on Medicare due
to disability. The coverage is through the South Carolina Health Insurance Pool (SCHIP).
The plans and costs for all ages, effective January 1, 2018, are as follows:
Plan A — $932.75 monthly
Plan C — $1,185.38 monthly
For additional information on SCHIP, please call 803-788-0222 or 800-868-2500, ext. 46401. You will reach a
BlueCross BlueShield representative but please know that SCHIP is not a BlueCross BlueShield of SC policy. SCHIP
is a state program administered by BlueCross BlueShield of SC. You will get a Medigap open enrollment period
when you reach age 65 and you will be able to buy any Medigap policy sold in the state.
Basic Benefits
These benefits pay for the patient’s share of Medicare’s approved amount for physician services (generally 20%)
after the annual deductible, the patient’s cost for a long hospital stay, and charges for the first three pints of
blood not covered by Medicare.
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High Deductible Option
Insurance companies may offer a high deductible on Plan F. If you choose this option, you must pay an
annual deductible before the plan pays anything. If you still have a Plan J (no longer available), the
deductible matches the annual deductible for Plan F. For 2018, the deductible for Plans F or J is $2,240.
The monthly premium for Medigap Plan F with a high deductible option will generally be less than the
monthly premium for Plan F without a high deductible option. However, your out-of-pocket costs for
services may be higher if you need to see your doctor or go to the hospital. In addition to the annual
deductible that you must pay for the high deductible option on Plan F, you must pay a deductible for foreign
travel emergency ($250 per year for high deductible Plan F).
Find and Compare Medicare Plans
Visit the U.S. Government website for those with Medicare, https://www.medicare.gov/ to find and
compare Medicare health plans. Additional Medicare information can be obtained by calling 1-800-Medicare
(1-800-633-4227), (TTY 1-877-486-2048).
Medicare Supplement Plan Shopping Tips
√ Shop for benefits and price
□ Check the benefits in each of the 10 plans. Every
company must
use the same letters (A through N) to label its policies.
□ Plan A is always a company’s lowest-priced Medigap policy. It
contains basic benefits and must be sold by every company.
□ Plans B through N add other benefits to fill different gaps in your Medicare coverage. Options K and L
provide a product for those who can afford a higher deductible and are healthy. Few companies sell
all policies.
√ Research the insurance company
□ Find contact information, consumer complaint data, and more using the SCDOI’s online company database
at www.doi.sc.gov/CoSearch.
□ Review financial information and complaint data from all state DOIs through the National Association
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Medigap Plan Comparison
The chart below shows basic information about the different benefits Medigap policies cover.
*Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up
to the deductible amount of $2,240 in 2018 before your Medigap plan pays anything.
** After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered
services for the rest of the calendar year.
*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50
copayment for emergency room visits that don’t result in inpatient admission.
NOTE: Upcoming changes — Plans C & F will be discontinued by the year 2020.
Medigap Benefits A B C D F* G K L M N***
Part A coinsurance and hospital
costs up to an additional
365 days after Medicare benefits
are used up
Part B coinsurance or copayment
50% 75%
Blood (first 3 pints) 50% 75%
Part A hospice care coinsurance
or copayment
50% 75%
Skilled nursing facility care
coinsurance
No No 50% 75%
Part A deductible No 50% 75% 50%
Part B deductible No No No No No No No No
Part B excess charges No No No No No No No No
Foreign travel exchange (up to
plan limits)
No No 80% 80% 80% 80% No No 80% 80%
Out-of-pocket limit** N/A N/A N/A N/A N/A N/A $5,240 $2,620 N/A N/A
= the plan covers 100% of this benefit % = the plan covers that percentage of this benefit
No = the policy doesn’t cover the benefit N/A = not applicable
Make sure you compare plans before enrolling. Factors such as where you live, your gender, whether you smoke or if
the policy is for an individual or a group may affect your rates.
An individual Medigap policy is a contract between you and the insurer. It provides the maximum number of consumer
protections. These policies are either “guaranteed renewable” or “non-cancelable.”
Group Insurance: Group Medigap insurance is a contract between the insurer and a group master policyholder such as
AARP or an employer. You receive a certificate rather than a policy. The group negotiates the terms of the insurance
and has the option to terminate the policy or change insurance carriers. Some insurance policies will require you to join
a group or association.
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Dos and don’ts of buying Medicare Supplement Plans
What to do:
Ask questions of friends and family.
Know what you are buying. Ask for an outline of the coverage.
Choose the benefits you want and need.
Benefits are standardized in Medicare supplement policies.
Compare benefits for different policies before buying. Consider family and
medical history.
Check company’s consumer complaint history.
Keep proof of prior coverage.
Keep agent’s name and contact information for later reference.
What not to do:
Don’t feel pressured to buy immediately. There is a six-month open enrollment period.
Don’t drop a current insurance policy until you have your new coverage.
Don’t buy more than one Medicare Supplement policy.
Never pay cash. Always use a check made out to the insurance company and not the agent.
Don’t buy a Medicare Supplement policy if you have a Medicare Advantage Plan. They will not work together.
Call Medicare
If you have questions
about who pays first or if
your insurance changes,
call: 800-MEDICARE
(800-633-4227)
Ask for a Medicare
coordination of benefits
contractor.
Who pays first?
If you have Medicare and other health insurance coverage,
each type of coverage is called a “payer.” When there is
more than one payer, there are “coordination of benefits”
rules that decide which one pays first. The primary payer
pays what it owes on your bills and then sends them to the
second payer. There may be a third payer as well.
Whether Medicare pays first depends on several factors, including those listed in the chart on page 18. This
chart does not cover every situation. Make sure to tell your doctor and other health care providers if you
have coverage besides Medicare. This will help them send your bills to the correct payer and avoid delays.
Appendix
Rights and Protections for Everyone with Medicare
An insurance company cannot refuse to sell you a Medigap policy under the following situations:
Guaranteed Issue Concerns
You are in a Medicare Advantage Plan, and your plan is leaving Medicare or stops giving care in your
area, or you move out of the plan’s service area.
• You can purchase Medigap Plan A, B, C, F, K, or L that is sold by any insurer writing this coverage in SC.
• This option is only available if you switch to Original Medicare rather than joining another Medicare
Advantage Plan.
• The earliest you may apply for a Medigap policy is 60 days before the date your health care coverage
ends but no later than 63 calendar days after your health care coverage ends. Medigap coverage
cannot begin until the Medicare Advantage Plan coverage ends.
You have Original Medicare and an employer group health plan (including retiree or COBRA coverage)
or union coverage that pays after Medicare pays and that plan is ending.
• In this situation, you may have additional rights under state law.
Medigap Plan A, B, C, F, K, or L that is sold by any insurer writing this coverage in SC.
• If you have COBRA coverage, you can either buy a Medigap policy right away or wait until COBRA
coverage ends.
• You may apply for a Medigap policy no later than 63 calendar days after the latest of these 3 dates:
Date the coverage ends, date on the notice you get telling you that coverage is ending (if
you get one), date on a claim denial, if this is the only way you know that your coverage
ended.
If you have Original Medicare and Medicare Select policy, you will move out of the Medicare Select
policy’s service area and the following applies:
• You may keep your Medigap policy, or you may want to select another Medigap policy.
• You can purchase Medigap Plan A, B, C, F, K or L that is sold by any insurer writing this coverage in SC.
• You may apply for a Medigap policy as early as 60 calendar days prior to the date your health care
coverage will end, but no later than 63 calendar days after your health care coverage ends.
(Trial Right) You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly
(PACE) when you were first eligible for Medicare Part A at age 65, and within the first year of joining,
you have decided that you want to change and select Original Medicare.
• Any Medigap policy that is sold by any insurer writing this coverage in SC.
• You may apply for a Medigap policy as early as 60 calendar days before the date your coverage will end
but no later than 63 calendar days after your coverage ends.
Note: Your rights and protections may extend for an additional 12 months under certain circumstances.
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(Trial Right) You dropped a Medigap policy to join a Medicare Advantage Plan or switch to a Medicare
Select policy for the first time; you have been in the plan less than a year and you want to switch back.
• The Medigap policy you had before you joined the Medicare Advantage Plan or Medicare Select policy, if
the same insurance company you had still offers it.
• If your former Medigap policy isn’t available, you can purchase a Medigap Plan A, B, C, F, K, or L that is
sold by an insurer writing this coverage in SC.
• You may purchase a Medigap policy as early as 60 calendar days before the date of your coverage will
end, but no later than 63 calendar days after your coverage ends.
Note: Your rights and protections may extend for an additional 12 months under certain circumstances.
Your Medigap insurance company goes bankrupt and you lose your coverage or your Medigap policy
coverage otherwise ends through no fault of your own.
• You can purchase Medigap Plan A, B, C, F, K or L that is sold by any insurer writing this coverage in SC.
• You may purchase a Medigap policy no later than 63 calendar days from the date your coverage ends.
You leave a Medicare Advantage Plan or drop a Medigap policy because the company has not followed
the rules, or it misled you.
• You may purchase Medigap Plan A, B, C, F, K, or L that is sold by an insurer writing this coverage in SC.
• You may purchase a Medigap policy no later than 63 calendar days from the date your coverage ends.