Karpinski & Associates

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.

Medicare coverage is based on 3 main factors. 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 Fast Fact: If you sign up for Medicare Part B when you’re first eligible, you can avoid a penalty.

In Medicare Advantage in many cases, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs. Some plans won’t cover services from providers outside the plan’s network and service area.

Preventive Services mean routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Getting prior authorization means, getting approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

What is a non-preferred provider? A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers.

Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care settings. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams.

Original Medicare generally doesn’t cover care outside the U.S. You may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers care outside the U.S.

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees Your group health plan pays first.

How is the Hospital Plan different from a traditional medical plan? Medical insurance reimburses the insured, or provider, for covered and approved medical services, procedures, equipment, and prescription drugs. The Hospital Plan pays a lump-sum payment directly to the insured for a covered hospital confinement, outpatient surgery, and emergency injury or sickness.

Out of Network Coinsurance is the percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

Fast Fact: Since 2010, the Affordable Care Act has prohibited insurance companies from denying coverage to patients with pre-existing conditions and has allowed children to remain on their parents' insurance plan until they reached the age of 26.

Medicare covers some but not all of your health care costs. Depending on which plan you choose, you may have to share in the cost of your care by paying premiums, deductibles, copayments and coinsurance. The amount of some of these payments can change from year to year.

Feeling overwhelmed by upcoming Medicare decisions? Make sure to contact us today for a no cost consultation.

True or False: Medicare Part B Is Free? False: Medicare Part B is not free. You may pay premiums, deductibles, copays and coinsurance out of pocket, just like with any health insurance plan.

Medicare Myth: Medicare Costs the Same for Everyone. Nope. The exact amount you will pay for Medicare depends on the specific Medicare coverage you have, the health services and items you use each year and whether or not you have financial assistance for Medicare.

A Medicare Savings Account (MSA Plan) combines a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible.

If you have a Supplement policy, Medicare will first pay its share of your medical expenses. Then your policy will step in and pay its share. This is usually the remainder of your bill. However, it depends on which policy you choose from the standard offered plans.

Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage plan that provides coordinated care to beneficiaries with specific needs or situation. Like all Advantage plans, Special Needs Plans will have a network, usually either an HMO or a PPO.

Active employer coverage means you are still actively working, not retired. In this scenario, you have the right to remain on your employer’s group health insurance plan if you choose. Your Medicare benefits can coordinate with that coverage. HOW it coordinates depends on the size of your employer.

A Medicare Advantage plan is a private health insurance plan approved by Medicare. You may opt to get your Part A, B and D benefits from a Medicare Advantage plan instead of traditional Medicare. These Medicare private insurance plans usually have an HMO or PPO network of doctors.

Medicare AEP will end on December 7th, 2020. Please make sure to contact us with any questions you might have.

Medicare Part A is hospital insurance. Part A covers inpatient hospital care, limited time in a skilled nursing care facility, limited home health care services, and hospice care.