Ashford Insurance

Basics of Medicare

Medicare Made Easy

 Medicare is a federal health insurance program that pays most of the health care costs for people who are 65 or older.  It will also pay for health care for some people under age 65 who have disabilities.


These are the basics of Medicare:


Medicare doesn’t pay 100% of your health care costs. Your out-of-pocket costs may include deductibles, co-insurance, and co-pays. You must also pay the Part B monthly premium (and the Part A premium if you owe it).

Part B (medical insurance) generally pays 80% of the Medicare-approved amount for outpatient services, such as doctor visits, after you meet the annual deductible. You are responsible for the remaining 20%. With Part A (hospital insurance) you are responsible for deductibles, co-insurance, and co-pays when you receive covered inpatient services.

Original Medicare has co-pays, coinsurances, deductibles, and a Part B premium for which you would be responsible and does not include an annual out-of-pocket maximum.  A Medicare supplement insurance plan or a Medicare Advantage plan may help keep out-of-pocket costs down. But they do it in different ways, and you have to choose. You can’t use both of these plans together.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). If you or your spouse have worked full time for 10 or more years over a lifetime, you are probably eligible to receive Medicare Part A for free. If you have to buy Part A, you’ll pay up to $471 each month.

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. What Medicare covers is based upon, Federal and state laws, National coverage decisions made by Medicare about whether something is covered, local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Medicare Part B is available at a monthly rate set annually by Congress ($148.50 in 2021 for incomes of $85000.00 or less for an individual). Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Some seniors are eligible to receive the medical insurance portion (Part B) free as well, depending on their income and asset levels. For more information, inquire about the Qualified Medicare Beneficiary (QMB), Special Low Income Medicare Beneficiary (SLMB), and Qualifying Individual programs through your county social services office.

Remember, in most cases, if you don’t sign up for Part B when you are first eligible, you will have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn’t sign up for it. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B, and coverage will start July 1 of that year. Usually, you don’t pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period.

Medicare Part C (Medicare Advantage Plans) are a type of Medicare health plan offered by a private insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), Private Fee-for-Service Plans (PFFS’s), Special Needs Plans (SNP’s), and Medicare Medical Savings Account Plans (MSA’s). If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and are not paid for under Original Medicare. Most Medicare Advantage Plans have prescription drug coverage included.

Medicare Part D (prescription drug coverage) adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare.

Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. Keep in mind, you may owe a late enrollment penalty if you go without a Medicare Prescription Drug Plan (Part D), or without a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage, or without creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over.

You can make a decision about how to receive your Medicare coverage during certain periods. When you first become eligible for Medicare you may choose between Original Medicare and a Medicare Advantage Plan and may choose a Medicare Advantage Plan three months prior, the month of, and three months after you turn 65. During the Annual Election Period (October 15th – December 7th), you may move from Original Medicare to a Medicare Advantage Plan or a Medicare Advantage Plan to Original Medicare or you can switch from one Medicare Advantage Plan to another. During the Medicare Advantage Open Enrollment Period (January 1st – March 31st), you can make one move from a Medicare Advantage Plan back to Original Medicare or from one Medicare Advantage Plan to another Medicare Advantage Plan. In most cases, you are locked into your choice for the calendar year; however, some people qualify for a Special Election Period and can make a change during the lock-in period; this may include a move in or out of a service area, qualification for Low Income Subsidy, or losing group coverage.

re you new to Medicare?  Not sure what plan to choose at the Annual Open Enrollment?  Ashford Insurance is dedicated to helping you find a supplement, advantage plan, or drug plan that is right for you.

Whether an “all-in-one” Medicare Advantage plan or a standalone Part D plan suits you, Ashford Insurance can help. Get a quote for prescription drug plans online now at now cost to you. Or, let one of our licensed agents review your options and find the best drug insurance plan for your unique needs. Just give us a call today at 817-952-3153.

Next, learn: How Medicare Works

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* A licensed sales agent may call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance.