Medicare

Understanding your Medicare plan options

MEDICARE 101

Who Is Eligible for Medicare?

Persons under 65 with certain disabilities. (Must receive Social Security Disability Insurance (SSDI) payments for more than 24 months.)

Persons of all ages with End Stage Renal Disease (ESRD).

If you are a U.S. citizen age 65 or older and you have been a permanent resident for five consecutive years.

Some beneficiaries are dual eligible. They qualify for Medicare and Medicaid. This program is designed for people with limited income and resources.

Eligible beneficiaries who have paid into Social Security for 40 quarters, pay no premium for Part A.

Fewer than 40 quarters and you could have a premium as high as$471 (for 2021 and premium based on number of quarters).

If you do not qualify on your own, then you may still be eligible based on your spouse’s work history when you turn 65.

Persons who have paid into Social Security for a minimum of 40 quarters (10 years)

Medicare Options

Medicare Part A and/or B+

Prescription Drug Coverage

Medicare Parts A and B+

Medicare Advantage Plan (MAPD)

Most plans include Part D

Medicare Parts A and B+

Medicare Supplement+

Prescription Drug Coverage

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Four Parts of Medicare

Original Medicare

PART AHospital Coverage (has deductibles and coinsurance)

PART BDoctors/Medical Coverage(Deductible, premium, and late enrollment penalty. Has deductible

and coinsurance. Includes preventive care.)

Offered by private insurance companies with an approved Medicare contract

PART CMedicare Advantage(Combines Parts A and B and usually includesprescription drugs)

PART D Prescription Drug Coverage

Items Not Covered by Original Medicare

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Deductibles

Coinsurance/Copays

Outpatient Prescription Drugs

Healthcare Outside the U.S.

Hearing Aids/Exams/Screenings

Routine Eye Exams and Most Glasses

MEDICARE 101

Part D Prescription Coverage

Drug coverage must be obtained through a Medicare Health Plan with drug coverage included or through a stand-alone prescription plan.

Prescription drug coverage is available to everyone with Medicare.

Each Part D Plan is different based on the cost and formulary of covered drugs.

MEDICARE 101

Part D Late Enrollment Penalty

If you choose not to enroll in Part D when you are first eligible,

then you will likely pay a late enrollment penalty for each month

that you do not have creditable coverage.

The penalty is 1% of the “national base beneficiary premium”

every month you could have had prescription drug coverage and

chose not to enroll.

Delayed enrollment is 63 continuous days without enrollment.

2021 “national base beneficiary premium” is $33.06 per month.

MEDICARE 101

Part D Terms to Remember

F O R M U L ARY – A List of prescription drugs, both generic and brand name, that are available through each health plan. Not all health plans cover the same drugs on their formulary.

T I E R – The groups in which drugs are categorized. Copayments are determined by the tier on which each medication is listed.

M AI L O R D E R - Some health plans offer a service in which drugs may be ordered through the mail. If used, discounts may be offered, such as receiving a three-month supply for the copayment of two months.

C O PAY - Your share of the cost of a prescription.The remaining cost is paid by the health plan.

S T E P T H E R AP Y – In some cases, health plans require a member to first try a more cost-effective alternate drug before covering another drug for that condition.

MEDICARE 101

Medication Therapy Management

If you take medications for different medical conditions, you may be eligible to volunteer to get services at no cost to you through a Medicare Therapy Management (MTM) program.

MTM helps you and your doctor monitor your health needs to make sure your medications are improving your health.

You will receive a comprehensive review of all of your medications.

This review will detail the full list of the prescriptions you are taking and why.

MEDICARE 101

Part D Important Information

If you have higher income, the law requires an adjustment to both Part B and your monthly prescription drug coverage premiums.

You must live in the service area of the plan you would like to join.

A network pharmacy may be required for some plans. Some plans offer preferred pharmacies, which can offer lower copays.

Additional help may be available to lower drug costs and protect against higher out-of-pocket expenses.

MEDICARE 101

Part D Initial Coverage Limit

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Initial deductible (not to exceed $445 in 2021.

The amount paid by the beneficiary after the initial deductible is a copayment or coinsurance.

All Part D plans cover the first $4,130 in 2021.

This includes your copays andcoinsurance, plus what your drug plan pays.

Once you have reached the initial coverage limit (combined copays/ coinsurance with the total cost of the drug), you will fall into the coverage gap.

MEDICARE 101

Part D Coverage Gap

You will receive a discount on the brand-name drugs and generally pay no more than 25% forbrand-name drugs and generic drugs until your yearly out-of-pocket drug costs reach $6,550 in 2021.

MEDICARE 101

Part D Catastrophic Coverage

Not everyone will fall into the coverage gap.

Once you have spent $6,550 (for 2021) True Out-of-Pocket (TROOP) for the year, you are out of the coverage gap and will then automatically move into Catastrophic Coverage.

Once in Catastrophic Coverage, beneficiaries will be charged $3.70 for those generic or preferred multisource drugs with a retail price under $74 and 5% for those with a retail price greater than $74.

For brand-name drugs, beneficiaries would pay $9.20 for those drugs with a retail price under $184 and 5% for those with a retail price over $184.

MEDICARE 101

Part D Extra Help is Available

Additional help paying for your prescriptions may be available. You may qualify for a Low-Income Subsidy (LIS) if your yearly

income and resources are below certain limits

MEDICARE 101

Medicare Supplement Plans

Beneficiary has the freedom to go to any provider who accepts Medicare anywhere in the U.S.

Direct access to specialty doctors; no more referrals.

Monthly premiums are based on age and zip code. Rates will increase over time.

Enrollment is based on underwriting (certain guaranteed issue options may be available).

Some copays are associated withOriginal Medicare (based on planselection).

Beneficiary must purchase a stand-alone prescription drug plan for drug coverage.

Limited value-added services. Must purchase dental and vision plans separately.

If foreign travel coverage is needed, beneficiary must purchase a Med Supp with that coverage.

Plans Available to All ApplicantsMedicare first eligible

before 2020 only

Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2020

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MEDICARE 101

Medicare Advantage Plans

Guaranteed issue (except for End Stage Renal Disease).

Must select a primary care physician and stay within network.

May need a referral to see a specialist.

Low or $0 premiums may be available and not based on any criteria.

Drug benefits are included, in most cases.

Many plans offer value-added benefits with no or lowpremiums such as vision, dental, and hearing.

Emergency foreign travel coverage is included.

MEDICARE 101

Enrollment Periods

Initial Election Period (IEP): The seven-month election period begins three months before your 65th birthday, includes the month you turn 65 and ends three months later.

Annual Enrollment Period (AEP): October 15th through December 7th.

Open Enrollment Period (OEP): January 1st through March 31st.

Special Election Period (SEP): Certain beneficiaries can change their benefits due to a specific life change.

Lock-In: Those with a Medicare Advantage plan can only change plans during AEP, unless they qualify for a special election period.

Medicare Supplement Open Enrollment: The six-month period begins the first day of your 65th birthday month if you are enrolled in Part B. If you apply after this period, there is no guarantee that you will be accepted and you may have to undergo medical underwriting.

MEDICARE 101

Star Ratings

Medicare uses information from member satisfaction surveys, plans, and providers and assigns each plan a star rating.

Medicare measures how well health and prescription drug plans perform on more than 50 key factors.

A plan can be rated from one to five stars. The higher quality plans have higher star ratings.

Medicare health plans are rated in five different categories: Staying healthy, managing chronic conditions, member experience, and customer service.

Additional information is available on Medicare.Gov.

Ready to enroll or have more questions?

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(856) 371-7149Jimmy Dzaman

License #9716319Email: dzaman3@verizon.net