If you are getting ready to turn 65, are on Medicare disability, or if even if you are 65 already, you may have questions about Medicare and the different options that are available to you. I have provided explanations of different Medicare options and downloadable informational booklets detailing Original Medicare, Medicare Advantage plans, Medicare Supplement (Medigap) plans, Part D prescription drug coverage, and L.I.S. assistance.

Original Medicare - Parts A and B
The Original Medicare Plan is a fee-for-service plan managed by the Federal Government.

With Original Medicare:
Eligibility is usually at at age 65 or can be under the age of 65 if you have qualified for Medicare disability benefits. You will receive a red, white, and blue Medicare card when you are eligible for Medicare. You can go to any doctor, hospital or other facility or supplier that accepts Medicare and is accepting new Medicare patients. You pay a set amount for your health care (an annual deductible for each of Medicare A and B) before Medicare pays its part. Medicare pays its share and then you pay your co-insurance or co-payment share for Medicare covered services and supplies. If you have a a Medicare Supplement (Medigap) policy or other supplemental coverage, they may pay deductibles, co-insurance, or other costs that arenít covered by the Original Medicare parts A and B.

Medicare Advantage Plans - Part C
Medicare Advantage Plans are health plan options that are approved by Medicare but are run by private companies. They are part of the Medicare Program, and are sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare.
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. Some of the plans (generally HMO's) require referrals to see specialists. They generally offer extra benefits and many include (Part D) prescription drug coverage. In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans. If you decide to enroll in a Medicare Advantage plan, you do not need to purchase a Medicare Supplement or a stand alone Part D prescription drug plan.

Plans include:

Health Maintenance Organization (HMO)

Preferred Provider Organization (PPO)

Point of Service (POS)

Special Needs Plans (SNP)

**Under the Medicare Modernization Act of 2003 (Section 231),Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. "Special Needs Individuals" (SNP) were identified by Congress as: 1) institutionalized; 2) dual eligible; (D-SNP) and/or 3) individuals with severe or disabling chronic conditions, (C-SNP).

Note: Medicare Advantage plans often re-evaluate benefit packages each year. Any changes in plan design and benefits are generally released in October of each year for the upcoming years coverage. Check with your plan for any changes in benefits or costs for the new year.

PPO and HMO Quick Comparison

HMO (Health Maintenance Organization)
It is an organization of healthcare providers that have contracted with an insurance company to offer their services at a fixed price.

HMO plans are generally more restrictive than PPO's and HMO-POS plans. You will be required to select a primary care physician, who manages all aspects of your healthcare. The primary care physician must be a member of the HMO, so you may need to switch doctors if the one you are currently seeing is not in the network. If you need to see a specialist, you will be required to see your primary care physician first to obtain a referral.

The major advantage of an HMO is generally the cost. Premiums (if there is one) co-payments, or co-insurances are also typically very low, or cost free and are also generally lower when compared to other types of plans.

HMO-POS (Health Maintenance Organization-Point of Service)
A Point-of-Service (POS) plan is an HMO plan that gives you the option to receive some services from doctors or hospitals that are not in the plan's network, usually at a higher cost. POS plans (in most cases) will offer the advantages of HMO plans, including prescription drug coverage in some plans. Because there is the flexibility to see non-network providers, services may cost more than a standard Medicare Advantage HMO plan. Always check your plan for details.

PPO (Preferred Provider Organization)
These organizations also have contractual relationships with insurance companies. PPO's are more loosely organized and are not as restrictive as HMOs.

If you have a PPO, you can see whatever doctor you like, but if you choose an out-of-network physician, you will have to pay more out-of-pocket. You will not need a referral to see a specialist.

PPO's in general, cost more than HMOs, but many people choose them because they are less restrictive. You will generally have more control over your own healthcare decisions than you would have under an HMO.


Whichever of these insurance models you choose, ultimately
you will have to make the decision that best fits your needs based
on your age, health status, flexibility, and financial limitations.


Medicare Supplemental Insurance

Medigap policies are health insurance policies sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage.

With a Medigap policy:
You get help paying for some of the health care costs that the Original Medicare Plan doesnít cover. You also get benefits not covered by Original Medicare, like emergency health care outside the United States. You pay a monthly premium to the private health insurance company that sells you the policy. Medicare and the Medigap policy both pay their shares of covered health care costs.

By law, companies will offer 10 Modernized Medigap insurance plans beginning June 1st 2010. (A,B,C,D,F,G,K,L,M,N). Each plan has a different set of benefits. You will want to study all the Medigap plans before deciding which is best for you. No matter which insurance company offers a particular plan, all plans with the same letter cover the same benefits. For instance, all Plan C policies have the same benefits no matter which company sells the plan, however, the premiums will likely vary.

Modernized Medigap plans do not cover:

-Long-term care to help you bathe, dress, eat or use the bathroom

-Vision or dental care

-Hearing aids

-Private-duty nursing

-Prescription drugs

Medicare Prescription Drug Plans / Part D
Medicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Medicare.

With a Medicare Prescription Drug Plan:
Generally, you pay co-pays for your prescriptions. You will get a plan member card after you enroll. You use this card when you go to the pharmacy to get your prescriptions filled. You will pay the co-payment and/or deductible, if any. If you have limited income and resources, you may get extra help (thru L.I.S. assistance) to pay for your Medicare drug plan costs.