Consumer Resources

MEDICARE PART A covers: Inpatient care in a hospital Skilled nursing facility care Inpatient care in a skilled nursing facility (not custodial or long-term care) Hospice care Home health care MEDICARE PART A eligibility: You can get premium-free Part A at 65 if: You already get retirement benefitsfrom Social Security or the Railroad Retirement Board. You’re eligible to get Social Security or Railroad benefits but haven’t filed for them yet. You or your spouse had Medicare-covered government employment. If you’re under 65, you can get premium-free Part A if: You got Social Security or Railroad Retirement Board disability benefits for 24 months. You have End-Stage Renal Disease (ESRD)and meet certain requirements. If you have worked and filed taxes for at least 10 years or 40 credits, typically Medicare Part A is premium-free at age 65. MEDICARE PART A premiums If you buy Part A, you’ll pay up to $437 each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $437. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $240. In most cases, if you choose to buy Part A, you must also: Have Medicare Part B (Medical Insurance) Pay monthly premiums for both Part A and Part B 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.

MEDICARE PART B covers: Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment. Part B covers things like: Clinical research Ambulance services Durable medical equipment (DME) Mental health Inpatient Outpatient Partial hospitalization Getting a second opinion before surgery Limited outpatient prescription drugs MEDICARE PART B premiums You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these: Social Security Railroad Retirement Board Office of Personnel Management If you don’t get these benefit payments, you’ll get a bill. Most people will pay the standard premium amount. If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago. This is the most recent tax return information provided to Social Security by the IRS. The standard Part B premium amount in 2019 is $135.50. Most people will pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium. Part B deductible & coinsurance You pay $185 per year in 2019 for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for these: Most doctor services (including most doctor services while you’re a hospital inpatient) Outpatient therapy Durable medical equipment (DME) 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.

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.