Unit 20 Life and Health - Medicare

Medicare Eligibility

Age 65+, end-stage renal disease, or 24+ months of Social Security disability

Medicare Part A

Hospital insurance; automatic for those 65+ eligible for Social Security; funded by payroll taxes

Part A Hospital Coverage

90 days per benefit period plus 60 lifetime reserve days; deductible then 100% for first 60 days, co-pay for days 61-90

Part A Skilled Nursing Facility (SNF)

Covers up to 100 days following a 3+ day hospital stay; 100% for days 1-20, daily co-pay for days 21-100

Part A Home Health

Covers in-home health care (not sitting services) 100%; 80% of durable medical equipment

Part A Hospice

Comfort care for the terminally ill, in home or approved facility

Part A Exclusions

First three pints of blood, private duty nursing, non-medical services, intermediate care, custodial care

Medicare Part B

Optional; monthly premium increases with income; covers doctors, outpatient services, and home health not covered by Part A

Part B Initial Enrollment Period

3 months before, the month of, and 3 months after turning 65

Part B General Enrollment Period

January 1 - March 31 annually; coverage starts the following month

Part B Coverage Details

Calendar year deductible, 80/20 coinsurance after deductible, no stop loss

Medicare Exclusions

Routine physical/foot/vision/dental/hearing care, most immunizations and prescription drugs, private-duty nursing, cosmetic surgery, most care outside the US, war-related expenses

Medicare Part C (Advantage)

Private companies contract with Medicare to pay medical expenses; requires enrollment in Parts A & B

Medicare Managed Care Plan (Part C)

HMO or POS with a gatekeeper; care from network providers only

Medicare PPO (Part C)

No gatekeeper; higher cost for out-of-network care

Private Fee-for-Service (PFFS)

A Part C plan where the plan negotiates provider fees

Medicare Specialty Plan

A Part C plan for special needs, such as kidney failure

Medicare Part D

Private prescription drug plan; Medicare pays the private company; has premium, deductible, and 25% co-pay

Group Health & Medicare (Under 20 Employees)

Medicare is primary

Group Health & Medicare (20+ Employees)

Group plan is primary for employees; Medicare is primary for retirees

Medigap (Medicare Supplement)

Private insurance that fills Medicare coverage gaps; can't be sold to Medicare Advantage enrollees

Medigap Plan A (Core Benefits)

Covers hospital co-pays for days 61-90, additional 365 lifetime days at 100%, and Part B coinsurance

Medigap Regulations

Requires NAIC Buyer's Guide, 30-day free look, guaranteed renewal, guaranteed acceptance within 6 months of Part B enrollment

Medicaid

Health coverage for the poor, regardless of age; funded by state and federal government; can be combined with Medicare