Consumer Resources

A: Medicare Part A, often referred to as hospital insurance, covers several essential healthcare services.

These services include:

- Inpatient care in a hospital: This covers semi-private rooms, meals, general nursing, and certain hospital services and supplies.

- Skilled nursing facility care: This is covered following a qualifying hospital stay and is not for custodial or long-term care. It includes services like rehabilitation and medically necessary skilled nursing care.

- Inpatient care in a skilled nursing facility: Similar to skilled nursing facility care, this excludes long-term custodial care and focuses on short-term, intensive rehabilitation or medical treatment.

- Hospice care: This includes care for terminally ill patients with a life expectancy of six months or less, covering medical services aimed at comfort and quality of life.

- Home health care: Services here include part-time or intermittent skilled nursing care, physical therapy, and speech-language pathology services.

To be eligible for premium-free Medicare Part A at age 65, you must meet one of the following criteria:

- You already receive retirement benefits from Social Security or the Railroad Retirement Board. - You are eligible to receive these benefits but have not yet filed for them.

- You or your spouse had Medicare-covered government employment.

For more detailed information, or to discuss your specific needs, please visit ISMHealth.net. Our specialists are here to help you understand your Medicare options and ensure you get the coverage you need.

A: Medicare Part B provides critical coverage for both medically necessary services and preventive services.

- Medically necessary services include services or supplies required to diagnose or treat your medical condition that adhere to accepted standards of medical practice.

- Preventive services aim to prevent illnesses (such as the flu) or detect them early when treatment is most effective.

At ISMHealth.net, we specialize in helping you navigate your Medicare options, ensuring you understand and maximize your benefits under Medicare Part B. Our dedicated team will provide personalized assistance to ensure you receive the medical attention you need without unnecessary out-of-pocket expenses. Contact us today to learn more about how we can support your healthcare requirements.

MEDICARE PART C covers:

A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:

• Health Maintenance Organizations

• Preferred Provider Organizations

• Special Needs Plans

If you’re enrolled in a Medicare Advantage Plan:

• Most Medicare services are covered through the plan

• Medicare services aren’t paid for by Original Medicare

Most Medicare Advantage Plans offer prescription drug coverage.

HEALTH MAINTENANCE ORGANIZATION (HMO)

In most HMO Plans, you generally must get your care and services from providers in your plan’s network, like:

• Doctors

• Other health care providers

• Hospitals

You may also need to get a referral from your primary care doctor. Find and compare HMO Plans in your area.

In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:

• Emergency care

• Out-of-area urgent care

• Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.

What else do I need to know about this type of plan?

• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.

• If you get health care outside the plan’s network , you may have to pay the full cost.

• It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

PREFERRED PROVIDER ORGANIZATION (PPO)

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.

Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.

Prescription drugs are covered in PPO Plans. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).

In most cases, you don’t have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

• A PPO Plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.

• PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

SPECIAL NEEDS PLAN

How Medicare SNPs work

Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Find out who can join a Medicare SNP.

Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:

• Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away

• If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis

Special Needs Plans have:

• Specialists in the diseases or conditions that affect their members.

• Medicare prescription drug coverage.

• SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.

Generally, you need a referral to see a specialist in SNPs. Certain services don’t require a referral, like these:

• Yearly screening mammograms

• An in-network pap test and pelvic exam (covered at least every other year)

Other considerations and limitation on Special Needs Plans

• A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.

• Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.

• If you have Medicare and Medicaid , your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.

For additional questions/information, please visit www.medicare.gov, www.ssa.gov, or call Medicare at 1-800-MEDICARE (1-800-633-4227), or Social Security Administration at 1-800-772-1213.