MEDICARE ABC & D's

Medicare is health insurance for individuals age 65+ as well as recipients of Social Security Disability Income for at least 2 years and people who have End Stage Renal Disease.  Medicare is administered by the federal government in conjunction with private insurance carriers.  Medicare is divided into four parts: A, B, C and D.

When one begins Medicare, there are two distinct ways to creating your health insurance future: 

Either enroll in a Medicare Advantage Plan OR keep Original Medicare.

• Part A covers inpatient hospital stays, skilled nursing facility (SNF) stays, limited home health visits, and hospice care due to diagnosis of a terminal illness. 
• Part A benefits are subject to a deductible ($1,676 per benefit period in 2025). 
• Part A also requires coinsurance for extended inpatient hospital and SNF stays. 
• To qualify for SNF stay, one must arrive after an inpatient stay for a minimum of three days. Neither observational status nor the day of discharge count toward the three day requirement.

• Part B covers medical care, some examples include: 
• Physician office visits 
• Diagnostic testing - MRI, CT Scans, etc.
• Preventive services -mammography, annual wellness visit, cancer screenings
• Outpatient hospital care and surgery 
• Durable medical equipment (wheelchair, oxygen, diabetic supplies) 
• Ambulance in life threatening emergency 
• Physical, occupational, and speech therapy   
• Medication and injections given in the doctor's office/outpatient hospital setting
• Most Part B benefits are subject to a deductible ($257 in 2025) and 20% coinsurance. 

• Part C is also known as Medicare Advantage (MA) and is a different way to get your Medicare benefits. 
• MA plans are network-based health insurance plans provided by private companies that contract with Medicare. 
• Beneficiaries enroll in a private health plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO). 
• MA plans include all Medicare-covered Part A and Part B benefits and typically also include Part D, prescription drug benefits.
• MA plans may offer coverage for routine vision, dental, hearing, health and wellness programs. 
• Referrals and prior-authorization may be necessary, depending on the plan. 
• Co-pays and cost sharing is a part of the structure of MA plans, with annual maximum financial out-of-pocket limits. 
• There are MA plans specifically created for beneficiaries who are dual-eligible for both Medicare and Medicaid or diagnosed with certain chronic-health conditions. 
• And while the MA plan IS your health insurance, you must be enrolled in Part A and Part B, and continue to pay the premium of Part B.

•  Part D covers outpatient prescription drugs through private plans that contract with Medicare. 
• Participation can be through a stand-alone prescription drug plan (PDP) or included within a Medicare Advantage plan (MA-PD). 
• The Part D benefit helps pay for enrollees’ drug costs and provides coverage to fill those medications. 
• All Part D plans have the same five-tier structure and can have different formulary, list of medications, it will cover. 
• Enrollees pay monthly premiums and cost sharing for prescriptions, with costs varying by plan. 
• Reviewing your Part D plan should be done on an annual basis, as plan premiums and formularies can change. The Annual Enrollment Period occurs each year between October 15 - December 7.
•  Additional financial assistance is available for beneficiaries with low incomes.  Contact Social Security to see if you qualify for extra help.