Residents of Clinton, NC with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage Plan. Here's a look at the differences between these two options.
The traditional program offered directly through the federal government includes Part A (inpatient/hospital coverage) and Part B (outpatient/medical coverage).
You will receive a red, white, and blue card to show to your providers when receiving care. Most doctors in the country take your insurance.
Additionally, Medicare limits how much you can be charged if you visit participating or non participating providers.
Private plans that contract with the federal government to pro-vide Medicare benefits are also known as Medicare private health plans or Part C. Some of the most common types of plans are:
• Health maintenance Organizations (HMOs)• Preferred provider Organizations (PPOs)• Private Fee-For-Service (PFFS)
If you join a Medicare Advantage Plan, you will not use the red, white, and blue card when you go to the doctor or hospital. Instead, you will use the membership card your plan sends you to get health services covered. Plans must provide the same benefits offered by Original Medicare, but they may apply different rules, costs, and restrictions. They also may offer certain benefits that Medicare does not cover.
If you sign up for Original Medicare and later decide you would like to try a Medicare Advantage Plan-or vice versa-be aware that there are certain enrollment periods when you are allowed to make changes.
The table compares Original Medicare and Medicare Advantage. Remember that there are several different kinds of Medicare Advantage Plan.
If you are interested in joining a plan, speak to a plan representative for more information
The monthly fee you pay to have Medicare.
What you must pay out of pocket before Medicare starts paying for your care.
The amount you pay for each service.
Provider accepts Medicare's approved amount as full payment.
Doctors, hospitals and medical facilities that contract with a plan to provide services.
Medigap is Medicare Supplement Insurance that helps fill "gaps" in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like:
Note: Medigap plans sold to people new to Medicare can no longer cover the Part B deductible. Because of this, Plans C and F are no longer available to people new to Medicare on or after January 1, 2020. However, if you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans that cover the Part B deductible (Plan C or F). If you already have or were covered by Plan C or F (or the Plan F high deductible version) before January 1, 2020, you can keep your plan.
Medigap policies generally don't cover:
Some types of insurance aren't Medigap plans, they include:
You may want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage). Or, you might decide to switch to a Medicare Advantage Plan that offers prescription drug coverage.
If you decide to drop your entire Medigap policy, you need to be careful about the timing. When you join a new Medicare drug plan, you pay a late enrollment penalty if one of these applies:
Medicare is health insurance that exists because of Federal Laws that were passed to create it. Initially, as created in 1965, it consisted of Part A (hospital benefits) and Part B (medical benefits) and reflected the restrictions and limitations of most health insurance at that time. Additions have been made over time, including prescription drug coverage through Part D. The federal law that created Medicare benefits has specific provisions that exclude coverage for certain things, like dental care and routine vision services. Other services that are not covered by Medicare, like certain long-term care services, are excluded because they do not meet the definition of health care service in the law. Just because something is not covered by Medicare does not mean that it is not needed. As we talk about types of care that Medicare doesn't cover, we will include some resources and information about other ways of accessing or paying for these services.
Dental care is excluded from Medicare coverage. Medicare does not cover dental services that you need primarily for the health of your teeth, including but not limited to:
If you receive dental services, you will be responsible for the full cost of your care unless you have private dental coverage or are utilizing a low-cost dental resource (see question 4). Medicare will not pay for or reimburse you for almost any dental services.
Note: Some Medicare Advantage Plans cover routine dental services, such as checkups or cleanings (see question 6). If you have a Medicare Advantage Plan, contact your plan to learn about dental services that may be covered.
While Medicare does not pay for dental care needed primarily for the health of your teeth, it does offer very limited coverage for dental care needed to protect your general health in certain ways, or for dental care needed in order for another Medicare-covered health service to be successful.
For instance, Medicare may cover:
It is important to know that while Medicare may cover these limited dental services, Medicare will not pay for any follow-up dental care after the underlying health condition has been treated. For example, if you were in a car accident and needed a tooth extraction as part of surgery to repair a facial injury, Medicare may cover your tooth extraction-but it will not pay for any other dental care you may need later because you had the tooth removed.
Medicare also covers some dental-related hospitalizations. For example, Medicare may cover:
In these cases, Medicare will cover the costs of hospitalization (including room and board, anesthesia, and x-rays). It will not cover the dentist fee for treatment or fees for other physicians, such as radiologists or anesthesiologists. Further, while Medicare may cover inpatient hospital care in these cases, it never covers dental services specifically excluded from Original Medicare (like dentures), even if you are in the hospital. If you need dental care, look into resources or other forms of insurance that may help pay for dental services. You can also use FAIR Health's consumer cost lookup tool to get an estimate for the amounts dental professionals usually charge in your area for different services.
If you need dental coverage, you may be able to get assistance through the programs listed below.
Routine eye care services, such as regular eye exams, are excluded from Medicare coverage. However, Medicare does cover certain eye care services if you have a chronic eye condition, such as cataracts or glaucoma. Medicare covers:
Medicare only covers routine eye care in the following circumstances:
You are considered to be at high risk if you:
Medicare Advantage Plans can cover dental and vision services as supplemental benefits. A supplemental benefit is an item or service covered by a Medicare Advantage Plan that is not covered by Original Medicare. These benefits do not need to be provided by Medicare providers or at Medicare-certified facilities. Instead, to receive these items or services, you need to follow your plan's rules. Some commonly offered supplemental benefits are dental care, vision care, hearing aids, and gym memberships.
Most supplemental benefits must be primarily health-related.* These benefits can either be:
Before joining a Medicare Advantage Plan for its supplemental dental or vision benefits, make sure you fully understand what services are covered and what rules you must follow to receive coverage. Also make sure the plan fits your other health needs.
*Medicare Advantage Plans can also offer coverage of supplemental benefits that are not primarily health-related for beneficiaries who have chronic illnesses.
Long-term care (LTC), also called long-term services and supports (LTSS), refers to a range of services that help you perform everyday activities. LTC can be provided in a nursing home, assisted living facility, or other setting, and may include medical care, therapy, 24-hour care, personal care, and custodial care (homemaker services). Medicare usually does not cover non-medical LTC services.
However, if you need this assistance, there are other organizations and forms of insurance you can try:
In certain areas, you can dial 2-1-1 to ask for referrals to community services. You can also contact your State Health Insurance Assistance Program (SHIP) for assistance and counseling. You can find your local SHIP by going to www.shiphelp.orgor calling 877-839-2675. If you are unsure what kind of care you need, you may want to start by asking your provider.
Medicare Part A covers up to 100 days of skilled nursing facility (SNF) care in certain circumstances. Medicare will not cover the cost of your stay if you need additional days in a SNF or LTC in a different kind of facility (such as an assisted living facility). If you have significant LTC needs, you may want to explore other kinds of insurance that may provide you with more comprehensive coverage:
Medicare covers home health care through its home health benefit if you meet the eligibility requirements. You must need skilled nursing or therapy care to qualify for Medicare's home health benefit. If you are eligible, Medicare may also cover other services, such as personal care, that are provided along with your skilled nursing or therapy services.
If you need home health care and/or personal care services but do not need what Medicare defines as skilled care, Medicare will not pay for those services. If you are not eligible for Medicare-covered home care, you may want to consider other options, such as the following:
You can also contact your SHIP for assistance and counseling. Find your local SHIP at www. shiphelp.org or by calling 877-839-2675. You may want to consider speaking to a home health agency to learn more about costs if you must pay out of pocket.
Medicare only covers respite care (care that allows your caregiver to rest while you temporarily stay in a hospital or other facility) under the hospice benefit. If you are not eligible for Medicare-covered respite care through hospice, you may want to consider other options, such as the following: