Medicare Advantage
Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare. (see Medicare Part C) With Medicare Advantage Plans:
• Some of the plans require referrals to see specialists.
• In many cases, the premiums or the costs of services (co-pays and deductibles ) can be lower than they are in the Original Medicare Plan or the Original Medicare Plan with a Medigap policy. Medicare Health Plans charge different premiums and have different costs of services, so it is important to check with the plan before you join.
• The plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services.
• They often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.
• They generally offer extra benefits, and many include prescription drug coverage.
• In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans.
• Some of the plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you.
• You don't need to buy a Medigap policy.
• Some of the plans require referrals to see specialists.
• In many cases, the premiums or the costs of services (co-pays and deductibles ) can be lower than they are in the Original Medicare Plan or the Original Medicare Plan with a Medigap policy. Medicare Health Plans charge different premiums and have different costs of services, so it is important to check with the plan before you join.
• The plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services.
• They often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.
• They generally offer extra benefits, and many include prescription drug coverage.
• In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans.
• Some of the plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you.
• You don't need to buy a Medigap policy.
Medicare Health Plans include:
• Health Maintenance Organization (HMO),
• Preferred Provider Organization (PPO),
• Private Fee-for-Service (PFFS) Plans,
• Medicare Medical Savings Account (MSA) Plans,
Medicare Special Needs Plans.
• Preferred Provider Organization (PPO),
• Private Fee-for-Service (PFFS) Plans,
• Medicare Medical Savings Account (MSA) Plans,
Medicare Special Needs Plans.
When you are hospitalized for
1-60 Days
1-90 Days
91-150 Days
151 days or more
Skilled Nursing Confinement: When you are hospitalized for at least 3 days and enter a Medicare Approved skilled nursing facility within 30 days after a hospital discharge and are receiving skilled nursing care.
1-90 Days
91-150 Days
151 days or more
Skilled Nursing Confinement: When you are hospitalized for at least 3 days and enter a Medicare Approved skilled nursing facility within 30 days after a hospital discharge and are receiving skilled nursing care.
Medicare Covers
1-60 Days
Most confinement costs after the required Medicare Deductible
All eligible expenses, after the patient pays a per-day copayment
All eligible expenses, after patient pays per-day copayment. (These Are Liftetime Reserve Days Which may never be used again.)
Nothing
All eligible expenses for the first 20 days; then all eligible expenses, (if you qualify), for days 21-100, after patient pays a per day copayment.
Most confinement costs after the required Medicare Deductible
All eligible expenses, after the patient pays a per-day copayment
All eligible expenses, after patient pays per-day copayment. (These Are Liftetime Reserve Days Which may never be used again.)
Nothing
All eligible expenses for the first 20 days; then all eligible expenses, (if you qualify), for days 21-100, after patient pays a per day copayment.
You Pay
$1,364 Part A Deductible
$341/Day
$682/Day
You Pay All Cost
After 20 days $170.50/Day
$341/Day
$682/Day
You Pay All Cost
After 20 days $170.50/Day
Medicare Part B (2021)
Part B is Medical Insurance and covers physicians services, outpatient care, test, and supplies. (see Medicare Part B)
On Expenses incurred for
Medical Expenses: Physicians services, inpatient, outpatient medical/surgical services, physical/speech therapy, diagnostic test.
Clinical Laboratory Services
Blood Test, Urinalysis
Home Health Care Part-time or intermittent skilled care, home health aide services, durable medical supplies and other services
Outpatient Hospital Treatment Services for the diagnosis or treatment of an illness or injury
Blood
On all Medicare-covered expenses, a doctor or other health care provider may agree to accept Medicare "assignment." This means the patient will not be required to pay any expense in excess of Medicare's "approved" charge. The patient pays only 20% of the "approved" charge not paid by Medicare. Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge for covered services.
Clinical Laboratory Services
Blood Test, Urinalysis
Home Health Care Part-time or intermittent skilled care, home health aide services, durable medical supplies and other services
Outpatient Hospital Treatment Services for the diagnosis or treatment of an illness or injury
Blood
On all Medicare-covered expenses, a doctor or other health care provider may agree to accept Medicare "assignment." This means the patient will not be required to pay any expense in excess of Medicare's "approved" charge. The patient pays only 20% of the "approved" charge not paid by Medicare. Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge for covered services.
Medicare Covers
80% of approved amount
Generally <
100% of approved amount
100% of approved amount; 80% of approved amount for durable medical equipment
Medicare payment to hospital based on hospital cost
After first 3 pints of blood, 80% of approved amount
Generally <
100% of approved amount
100% of approved amount; 80% of approved amount for durable medical equipment
Medicare payment to hospital based on hospital cost
After first 3 pints of blood, 80% of approved amount
You Pay $203 Annual Part B Deductible PLUS
20% of approved amount
Nothing for
Services
Nothing for Services; 20% of approved amount for durable medical equipment
20% of Billed Amount
First 3 pints plus 20% of approved amount for additional pints
Nothing for
Services
Nothing for Services; 20% of approved amount for durable medical equipment
20% of Billed Amount
First 3 pints plus 20% of approved amount for additional pints
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For questions or comments please contact iba@ibatx.net
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