San Antonio Medicare supplement insurance guide

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.

You can buy Medicare supplement insurance to help pay some of your out-of-pocket costs that Medicare won’t pay. Because it helps cover some of the “gaps” in Medicare coverage, Medicare supplement insurance is often called Medigap insurance.

Do you need Medicare supplement?

Not everyone needs a Medicare supplement policy. If you have other health coverage, the gaps might already be covered. You probably don’t need Medicare supplement insurance if:

• You have group health insurance through an employer or former employer, including government or military retiree plans.
• You have a Medicare Advantage plan.
• Medicaid or the Qualified Medicare Beneficiary (QMB) Program pays your Medicare premiums and other out-of-pocket costs. QMB is a Medicare savings program that helps pay Medicare premiums, deductibles, copayments, and coinsurance.

If you have other health insurance, ask your insurance company or agent how it works with Medicare.

Medicare basics

Original Medicare has two parts. Part A covers hospital services and Part B covers other types of medical expenses. You may go to any doctor or hospital that accepts Medicare. Medicare supplement policies only work with original Medicare.

Medicare Part A (hospital coverage) pays for:

• care in a hospital.
• care at a skilled nursing facility after a hospital stay.
• home health care.
• hospice care.
• all but the first three pints of blood each calendar year.

Medicare Part B (medical coverage) pays for

• doctor visits.
• home health care.
• lab services.
• outpatient hospital care.
• durable medical equipment and supplies.
• preventive health services, like exams, health screenings, and shots.

Medicare Part D (prescription drug coverage) pays for generic and brand-name prescription drugs. You can get prescription drug coverage by joining a stand-alone prescription drug plan or by buying a Medicare Advantage plan that includes drug coverage. If you have group health insurance, your health plan might already cover prescriptions. Ask your plan’s sponsor whether the plan has prescription drug coverage that is comparable to Medicare Part D.

Insurance companies approved by Medicare offer Part D coverage.

The Centers for Medicare and Medicaid Services (CMS) publishes the Medicare & You handbook that describes Medicare coverages and health plan options. CMS mails the handbook to Medicare beneficiaries each year. You can also get a book by calling 800-MEDICARE (800-633-4227).

Learn more: How to pick the right Medicare plan | Watch: How to understand Medicare plans

Services Medicare doesn’t cover

• Most long-term care. Medicare only pays for medically necessary care provided in a nursing home.
• Custodial care, if it’s the only kind of care you need. Custodial care can include help with walking, getting in and out of bed, dressing, bathing, toileting, shopping, eating, and taking medicine.
• More than 100 days of skilled nursing home care during a benefit period following a hospital stay. The Medicare Part A benefit period begins the first day you receive a Medicare-covered service and ends when you have been out of the hospital or a skilled nursing home for 60 days in a row.
• Homemaker services.
• Private-duty nursing care.
• Most dental care and dentures.
• Health care while traveling outside the United States, except under limited circumstances.
• Cosmetic surgery and routine foot care.
• Routine eye care, eyeglasses (except after cataract surgery), and hearing aids.

What you pay with original Medicare

For Medicare parts A and B, you will usually must pay monthly premiums, and deductibles, copays, and coinsurance. You also pay the full cost of any services that Medicare doesn’t cover.

• Premiums are amounts you pay to keep your Medicare coverage. Most people don’t have to pay a Part A premium, but everyone must pay the Part B premium. The premium amounts may change each year in January.
• A deductible is the amount you must pay for medical expenses before Medicare begins to pay.
• A copayment is a set dollar amount you usually have to pay each time you see a doctor or go to the hospital.
• Coinsurance is the percentage of the cost of a service that you pay after Medicare pays its portion of the cost. This means that if Medicare pays for 80% of the cost of a service, you’ll pay the remaining 20%.

Ask if your doctor ‘accepts assignment’

Assignment is an agreement between doctors and other health care providers and Medicare. Doctors who “accept assignment” charge only what Medicare will pay them for a service. You must pay any deductibles, coinsurance, and copayments that you owe.

Doctors who don’t accept assignment may charge more than the Medicare-approved amount. You are responsible for the higher charges. You also might have to pay the full cost of the service at the doctor’s office, and then wait to be reimbursed by Medicare.

Use your Medicare Summary Notice to review the charges. You get a Medicare Summary Notice each quarter. If you were overcharged and weren’t reimbursed, follow the instructions on the notice to report the overcharge to Medicare. The notice will also show you any deadlines to complain or appeal charges and denied services. If you are in original Medicare, you can also look at your Medicare claims online at MyMedicare.gov.

Medicare has a directory of doctors, hospitals, and suppliers that work with Medicare. The Physician Compare directory also shows which providers accepted assignment on Medicare claims.