Navigating the Medicare Maze: Exploring Medicare, Medicare Advantage, and Medicare Supplement Plans

Navigating Medicare Part 1: Understanding Basics, Eligibility, and Key Terminology

*This blog post is for educational purposes. Each insurance is different and has different benefits. It is up to you to know your benefits. Roaming Rehab will verify insurance prior to seeing each person to know exactly what will be covered and the costs associated with services. If you have any questions on if services are covered under your plan, please call!* 

​Navigating the intricacies of Medicare and its various options can be overwhelming. This guide is designed to simplify the process, answering common questions about coverage, plans, and enrollment. Gain the confidence to make informed decisions about your Medicare options with clear and concise information.

Deciphering Medicare

Understand the fundamentals of Medicare, a pivotal federal health insurance program tailored for individuals aged 65 and above. Read more to learn about its components, including Parts A, B, C, and D, and determine your eligibility criteria. 

Eligibility Criteria

Determining eligibility for Medicare involves various factors, primarily age and citizenship status. Here's a breakdown:

• Age: Generally, individuals aged 65 and above are eligible for Medicare. Some exceptions may apply, such as individuals with certain disabilities or medical conditions who may qualify for Medicare before turning 65.
• Citizenship or Legal Residency: To be eligible for Medicare, you must be a U.S. citizen or legal resident who has lived in the U.S. for at least five continuous years.
• Work History: Many people become eligible for premium-free Part A based on their own or their spouse's work history. If you or your spouse worked and paid Medicare taxes for at least 10 years, you typically qualify for premium-free Part 

• End-Stage Renal Disease (ESRD) or Disability: Individuals with ESRD or certain disabilities may qualify for Medicare regardless of age.

Medicare Components

Medicare consists of four primary parts, each offering different types of coverage to address various healthcare needs. You do not need to have all 4 parts. Most people have either Part A, B, and D with a supplemental medigap plan OR Part C. They are separate areas of coverage:

• Part A (Hospital Insurance): Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services. It's often referred to as hospital insurance.
• Part B (Medical/Outpatient Insurance): Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. It helps pay for services and supplies that are medically necessary to treat a disease or condition.
• Part C (Medicare Advantage/Replacement): Part C, also known as Medicare Advantage, offers an alternative way to receive Medicare benefits through private insurance companies approved by Medicare. These plans often include coverage for Parts A and B, and sometimes prescription drug coverage (Part D), along with additional benefits like vision, dental, and hearing. *This REPLACES Part A and Part B*
• Part D (Prescription Drug Coverage): Part D provides prescription drug coverage, helping to lower the cost of prescription medications. It's available to everyone with Medicare through private insurance companies that contract with Medicare.

When you enroll into Medicare. You will enroll into traditional Medicare (also called original Medicare) which is Part A and Part B. With traditional Medicare, you can add a prescription drug coverage plan (Part D) or a supplemental coverage plan.

Important Insurance Terminology

Premium: This is the amount you pay each month for your insurance coverage. It's like a subscription fee that keeps your insurance policy active, regardless of whether you use any medical services.

Deductible: This is the amount you must pay out of pocket for covered services before your insurance starts to pay. For example, if you have a $1,000 deductible, you'll need to pay the first $1,000 of covered medical expenses before your insurance kicks in. 
*In 2024, each traditional medicare beneficiary had an annual deductible of $240.*

Out-of-pocket Maximum (or Limit): This is the most you'll have to pay for covered services in a plan year. Once you reach this limit, your insurance will cover 100% of covered services for the rest of the year. It includes deductibles, co-payments, and co-insurance, but typically excludes premiums. 
*Original Medicare does not have out of pocket limits*

Co-pay: This is a fixed amount you pay for covered healthcare services at the time of the visit. For example, you might have a $20 co-pay for a doctor's office visit or a $10 co-pay for prescription drugs. 
*Original Medicare does not have co-pays for therapy services*

Co-insurance: This is the percentage of costs you share with your insurance company after you've met your deductible. For example, if your insurance plan covers 80% of the cost of a covered service and you have a 20% co-insurance, you'll pay 20% of the cost, and your insurance will cover the remaining 80%.
*Original medicare has a 20% Co-insurance for therapy services. This is typically covered by a Medigap or supplemental plan*

In-Network: This refers to the group of healthcare providers, facilities, and pharmacies that have contracted with your insurance company to provide services at negotiated rates. Using providers within your network typically results in lower costs for you because these providers have agreed to accept the insurance company's payment terms. 
*All therapy providers (PT/OT/ST) are opted in with Original Medicare. There is no out of network. However, this does not apply to Medicare Advantage/Replacement plans*

Out-of-Network: These are healthcare providers, facilities, or pharmacies that do not have a contract with your insurance company. If you receive care from an out-of-network provider, you may have to pay higher costs, and your insurance company may cover less of the expense, or none at all, depending on your plan.

Superbill: A superbill is a detailed invoice or receipt that healthcare providers give to patients after a visit. It includes the services provided, the corresponding charges, and any diagnosis or procedure codes. Patients can use superbill to submit claims to their insurance company for reimbursement if the provider is out-of-network. This document helps ensure that insurance companies have the information they need to process claims accurately.