kathy hope

Insurance Advisors


Individual, Child-Only, Family, Entrepreneur, Small Business, Group,  Medicare

Serving Northern and Southern California

Medicare Health Insurance Basics
Part A, Part B, Part C, Part D


Who Qualifies For Medicare Health Insurance?
People aged 65 or older.

People under 65 with certain disabilities.

Foreign born residents who have entered the U.S., legally and have lived here for at least 5 years. 

Do You Have To Sign-Up For Medicare?

If you are 65 and still working you will have to sign up for medicare. There are 3 ways you can sign up: 

1. Visiting a local social security office
2. Calling Social Security:  714-840-0047
3. Go online to website: www.socialsecurity.gov.
Part A and Part B - Original or Traditional Medicare 

Administered by the federal government and has two parts: 

Part A - Hospital Insurance

Covers, in part, care and services received during a hospital stay, at a skilled nursing facility or hospice and during home health care. Certain conditions do apply.  It is usually free because of previously paying for it via payroll taxes. If you don't sign up when first 65, penalties may be applied when you do unless you can use a special *enrollment period. 

Part B - Medical Insurance

Partially covers services like doctors' services, outpatient care, home health services and other medical services. Also covers some preventive services. There is a monthly premium averaging from $100 - $119 in CA. If you don't sign up when 65, is only available, without penalties, during special *enrollment periods.

Medicare Enrollment Periods 
Enrollment, changes, cancellation, additions to your Medicare A, B & D can only happen during certain periods of time during the year. The ability to enroll or un-enroll whenever you want is NOT an option.  In California there are 5 different enrollment periods.

Initial Enrollment Period (IEP)
General Enrollment Period (GEP)
Annual Election Period (AEP)  "Open Enrollment"
Special Enrollment Period (SEP) and Special Election Periods (SEPs)
Medicare Advantage Disenrollment Period (MADP)
Initial Enrollment Period 
You can sign up when you're first eligible for Part B. For example, if you're eligible for Part B when you turn 65, this is a 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you enroll in Part B during the first 3 months of your Initial Enrollment Period, your coverage start date is the 1st day of your birthday month. If your birthday is the first day of the month, your coverage begins on the 1st day of the prior month.
General Enrollment Period 
If you did not sign up for Part A and/or Part B (for which you pay monthly premiums) when you were first eligible, you can sign up between January 1 - �March 31 each year. Your coverage will begin July 1. You may have to pay a higher premium for late enrollment.
Annual Election Period - Open Enrollment 
The Annual Election Period is October 15 - December 7th of every year. During this time you may join, change or drop an MA or Part D plan. Changes are effective January 1st. Each year, Medicare health plans and Part D prescription drug plans can change their premiums, deductibles, cost-sharing and some benefits, or discontinue their coverage altogether. You need to be aware of how your plan may change, and prepare accordingly.
The California Birthday Rule!
California has an "open enrollment period" for MEDIGAP plans that occurs the 30 days prior and after your birthday.  Note that Medigap plans can be changed at any time, but if you use the "birthday rule" you don't have to answer any medical questions. You must already have a Medigap plan.  You can switch to another plan as long as it is of equal or lesser coverage. Contact me to find out more about this enrollment period. 
Special Enrollment Periods and Special Election Periods 
Special Enrollment Periods (SEP) exist for Part B and Special Election Periods (SEP) exist for MA and Part D plans. 
Special Enrollment Periods
If you did not sign up for Part B (for which you pay monthly premiums) when you were first eligible because you're covered under a group health plan based on current employment, you can sign up for Part B during the 8-month period that begins the month after the employment ends or the group health plan coverage ends, whichever happens first.
Special Election Periods: 
These may be available for MA and Part D plans depending upon the situation.  If you move might allow you to have a special period of time. Qualification for Medi-Cal benefits, coverage from an employer, etc. are some possible justifications. Contact me to discuss if this applies to you. 
Medicare Advantage Disenrollment Period
This period runs from January 1st - February 14th of each year.  It allows beneficiaries to un-enroll from their MA plan and return to original medicare. Because MA plans include prescription plans, when you un- enroll from a MA plan you will have a coordinating Special Election Period to enroll in a stand-alone Part D prescription plan.  You cannot switch from one MA to another MA during this period. 
Part C - Medicare Advantage Plans
These plans are offered by private insurance companies approved by Medicare. You must have both Part A and Part B to join one of these plans. The plans provide all of your Part A and Part B services and generally provide additional services. You usually pay a monthly premium, and co-payments that will likely be less than the coinsurance and deductibles under Original Medicare. In most cases, these plans also offer Part D prescription drug coverage. Costs and benefits vary by plan.
The different types of Medicare Advantage Plans are:

Health Maintenance Organization (HMO) Plans
A Medicare HMO Plan has a network of primary care doctors, specialists, hospitals and other providers that you must go to. Most plans require referrals to see specialists.

Preferred Provider Organization (PPO) Plans
 A Medicare PPO Plan has a network of primary care doctors, specialists, hospitals and other providers that you may go to. You have the flexibility to go to any doctors, specialists, or hospitals that are not on the plan’s list, but it will usually cost more.

Private Fee-for Service (PFFS) Plans
Generally, you get care from any Medicare-approved provider such as a doctor or hospital who, before treating you, agrees to accept the Medicare Private Fee-for-Service Plan's terms and conditions of payment. If your provider does not agree to the plan's terms and conditions of payment the provider should not provide services to you except for emergencies, and you will need to find another provider that will accept the plan.

Special Needs Plans (SNP)
Plans for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions).

HMO Point of Service (HMOPOS) Plans 
An HMO plan that sometimes allows you to go out-of-network for some services, but when you do it will cost more.

Medical Savings Account (MSA) Plans 
A plan that combines a high deductible health plan with a bank account. Deposits from Medicare will be made to an account you set up.  The amount of money is less than the deductible in most cases, and you use the money to pay for you health services as needed throughout the year. 
You can enroll in a Medicare Advantage Plan every year during the Annual Election Period (AEP) beginning on 10/15/2011 thru 12/7/2011. You can also enroll during your Initial Election Period (IEP) or if you qualify for a Special Election Period (SEP). To join a Medicare Advantage Plan, you must have Part A and Part B and live in the plan's service area.
Part D - Medicare Prescription Drug Plans
Prescription drug plans offered by private insurance companies and approved by Medicare. Drug coverage is available to everyone who has Medicare, regardless of income or health. Subscribers pay a monthly premium.

There are two types of Medicare Part D prescription drug coverage:

Stand-Alone Medicare Prescription Drug Plans (PDP's)
If you are enrolled in original / traditional medicare you may also enroll in a PDP. California has over 30 plans available. 
Medicare Advantage Prescription Drug Plans (MA-PD's)
You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. The availability of MA plans varies by CA county.  Plus not "all" MA plans have drug coverage. 

To join a Medicare Prescription Drug Plan, you must have Medicare Part A or Part B. You must also live in the service area of the Medicare drug plan you want to join.

Standard Benefits of Part D
- Deductible amount is $310 (may vary .. call us to inquire)
- Initial Coverage Limit is $2,840
- Out-of-Pocket Threshold is $4,550
- Coverage Gap (donut hole) begins when you pay total drug costs (what you pay + what the plan pays) of $2,840 and ends when you reach $4,550 in total drug costs. Part D enrollees will receive a 50% discount on the total cost of their brand name drugs while in the donut hole. The full retail cost of the drug will still apply to the catastrophic stage. Enrollees will receive a 7% discount on generic drugs while in the donut hole.
- Catastrophic Coverage - The enrollee pays the greater of 5% or $2.50 for generic drugs and the greater of 5% or $6.30 for all other drugs,
- Drug copays and coinsurance vary by plan.
Financial Prescription Drug Aid:
Extra help or low income subsidy (LIS) is a program that helps people with Medicare who have limited income and resources pay for Medicare prescription drug coverage. If you qualify for extra help, you will get help paying for your Medicare drug plan’s monthly premium, and for some of the costs you would normally pay for your prescriptions. The amount of extra help you get will be based on your income and resources. You can apply for extra help by calling Social Security at   or visiting www.socialsecurity.gov.      


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