Medicare is a federal insurance program, which benefits people 65 years of age or older. Also known as Aseguranza or Original Medicare.
A person is eligible to enroll in Medicare from 3 months before his or her 65th birthday and up to 3 months after his or her 65th birthday.
You can offer coverage to people under 65 years of age, who present the following situations:
When you are close to enrolling in Medicare, it is important to understand the process, scope and coverage to choose from. This is why we must familiarize ourselves with each part of Medicare.
With the original Medicare enrollment, you receive a blue, red and white card that includes Part A and Part B, additional and supplemental Medigap, Medicare Advantage or Part C and Part D drug coverage.
Part A is hospital insurance. It covers hospitalization, as well as nursing facility care, hospice care and home health care.
Among the services covered by the care centers are:
Medicare Part B: Medical insurance.
Coverage is conditioned on certain physician services, outpatient care, medical supplies and preventive services.
Medical care includes:
Part C or Medicare Advantage: an alternative to original Medicare (Part A and B).
These are private health plans authorized by Medicare. It is the second coverage option when you are of Medicare enrollment age, and provides hospital, doctor, drug and supplemental benefits all on one card.
The benefits of Medicare Advantage plans can vary from one plan to another, there are plans that, for example, also cover:
Medicare Part D: Medicare Part D is drug coverage.
This coverage includes medicines prescribed for the treatment of chronic illnesses, such as heart disease. It also covers medicines that must be taken for short periods of time, such as antibiotics.
In the health market there are several concepts that help to identify processes, conditions, coverage and/or limits of the different benefits for each insurance plan.
It is important to become familiar with all of them, because each one explains or describes the implications at the level of payment commitments, both for the insurance company and for each of the beneficiaries.
The Pirma is the monthly payment to Medicare or a private insurance plan.
In the case of Medicare, it establishes premiums based on income limits according to individual or joint declarations. Determining the adjusted premium amounts for Medicare Part B and Part D premiums.
This monthly payment does not respond to a fixed amount, it may vary each year according to the adjustments of the income limits.
Before choosing a health plan, it is important to be able to project annual disposable income for out-of-pocket medical expenses vs. average annual health care expenses.
There are health plans with low premiums, however, they do not necessarily offer coverage until a significant portion of out-of-pocket medical expenses have been paid. On the other hand, there are plans with higher premiums, but with higher medical expense coverage.
The deductible means that you will pay the cost of the service before the benefit begins. In the health care market, it may refer to the amount you pay for medical services or drugs before the insurance plan begins to share in the value of covered services.
For example, if your deductible is $300 and the doctor’s visit costs $300, you will have to spend those dollars to meet the deductible.
In other words, you are responsible for the cost of the medical or hospital service up to this deductible, the amount of money you have to spend out of pocket before your benefits, discounts or anything else the insurance offers you.
In other words, basically the deductible is going to determine how much money you’re going to have to spend before the benefits of your policy or your insurance start, whether you have health marketplace insurance, whether you have Medicare insurance, whether you have drug plan insurance, usually Medicare plans, not all Medicare plans, have a $0 deductible, which is totally different.
This is the dollar cost of the service, such as, for example, what you pay to see a doctor or for a medical examination.
A fixed amount you pay for a covered medical service, after you have paid your deductible.
The amounts to be paid for co-payment may vary according to the service; the co-payment for medicines is not the same as the co-payment for laboratory services.
Plans with higher co-payments are usually those with lower premiums and vice versa, those with higher premiums have lower co-payments.
Coinsurance refers to the cost of the service as a percentage, as opposed to Copayment which refers to a fixed amount.
After the deductible has been paid, scenarios may arise in which Medicare pays 80% of the hospitalization expenses, and the user pays 20%, i.e., the Copayment is the percentage of a benefit that must be paid.
Maximum out of pocket, which is equal to the annual spending limit before insurance benefits begin.
Most Medicare Advantage plans have a spending cap, which is the maximum amount you will spend on health care in a given year after which the plan will pay 100% of your health care benefits until the start of the next plan year.
Because Medicare Advantage plans are administered by private companies, each company can set its own costs and each plan will be subject to a cap.
company can set its own costs and each plan will be subject to a so-called maximum spending limit.
maximum spending limit.
The MOOP is unique to Medicare Advantage plans. Original Medicare does not have this type of limit: you will always pay copayments and coinsurance if you only have Medicare Parts A and B.
It brings together several private health plans, offered by Medicare-approved insurance companies, to present an alternative to Original Medicare.
Medicare Advantage plans include Part A, Part B and usually Part D. They may offer additional benefits not covered by Original Medicare.
While traditional Medicare beneficiaries can see any doctor who accepts Medicare, beneficiaries in Medicare Advantage plans must be restricted to a network of doctors and/or health care providers.
Medicare Advantage, also known as Medicare Part C, covers plans that offer additional benefits not covered by Original Medicare, such as vision, hearing and dental care.
It is private health insurance that supplements Original Medicare (A and B), which helps cover costs that Medicare does not cover.
These plans are designed to supplement Medicare coverage and help beneficiaries pay out-of-pocket expenses, such as deductibles and co-payments.
Medicare Supplement Insurance is different from Medicare Advantage. You can have either a Medicare Advantage Plan or a Medicare Supplement Plan, but not both at the same time.
It is important to note that Medigap is only compatible with Original Medicare (Parts A and B). It cannot be combined with Medicare Advantage (Part C). In order to purchase a Medigap plan, you generally must be enrolled in Medicare Part B.
Medicare Supplement or Medigap Plans
They are standardized and identified by letters, Plan A through Plan N. Each plan offers a specific set of benefits, and all insurance companies must offer the same benefits for each specific plan. However, costs may vary among insurance companies.
It is important to note that the availability of these plans may vary by state and insurance companies. In addition, some Medigap plans may not be available to new beneficiaries due to changes in legislation.
It is advisable to research and compare the plans available in your area before choosing the one that best suits your needs.
Obamacare, Medicare and Social Security are three health insurance programs in the United States, each with different characteristics and objectives. Here are the differences between them:
Obamacare (Affordable Care Act or ACA):
Obamacare is a health care reform law implemented in 2010. Its main goal is to expand access to health care and improve the quality of care. Obamacare established the Health Insurance Marketplaces (also known as exchanges) where individuals can purchase private health insurance plans.
It also provides subsidies and tax credits to help low- and moderate-income individuals and families pay their insurance premiums. In addition, the law prohibits insurance companies from denying coverage or increasing premiums because of pre-existing medical conditions.
Medicare:
Medicare is a health insurance program administered by the federal government that provides coverage for people over age 65, some people under age 65 with disabilities, and people with end-stage renal disease. Medicare is divided into several parts:
Social Security:
Social Security is a social insurance program in the United States that provides financial benefits to eligible individuals, including retirement, disability, and survivor benefits.
Social Security is funded through workers’ payroll taxes and is used to provide income to eligible beneficiaries when they reach retirement age, become disabled, or in the event of the death of a spouse or parent who has worked and contributed to the program.
In short, Obamacare is a health care reform law that establishes health insurance exchanges and subsidies to help people obtain coverage, while Medicare is a health insurance program for the elderly and disabled administered by the federal government.
Social Security, on the other hand, is a social insurance program that provides financial benefits to eligible individuals, including retirement, disability and survivor benefits.
Health Maintenance Organization Plans.
An HMO is one of the Medicare Advantage plans that generally provides health care services by doctors, other health care providers, or hospitals within the plan's network, except in emergency or urgent care situations.
Network refers to the group of doctors, hospitals and other health care providers or facilities that contract with a plan to provide services.
Generally, this plan requires the beneficiary to obtain a referral from his or her primary care physician for special care or treatment.
If the beneficiary requires drug coverage, he/she must evaluate among the alternatives and choose the plan that provides the medicines he/she needs.
HMO plan with a Point-of-Service option.
This type of plan may allow for extended out-of-network coverage, that is, you may receive care from doctors outside the established network, paying a higher Copayment or Coinsurance.
The coverage allows for a combination of in-network and out-of-network types of care in exchange for a higher premium than an HMO Plan.
Preferred Provider Organization Plans.
These are Medicare Advantage plans that offer a network of doctors and hospitals, however, beneficiaries can also be seen by doctors or providers that are not within the network.
This type of plan has a higher cost and covers emergency care as well as drugs as long as you choose the plan that offers the required drugs.
Beneficiaries of this plan are not conditioned to be referred for specialist care.
Private Fee-for-Service Plans.
These plans allow care from any Medicare-approved doctor or provider, as well as any hospital that accepts payment from this plan. Generally, PFFS plans have a network of doctors and/or health care providers, however, they allow beneficiaries to be seen by those outside of that network in exchange for paying a higher premium.
Not all PFFS plans cover prescription drugs, so it is important to consider enrolling in Medicare Part D if the plan you have chosen does not include drugs.
It is up to the discretion of doctors, hospitals and out-of-network providers whether or not to provide the service, even though they were already patients. Also, there are network providers who may accept or provide the service even if they were not previously a patient.
This plan also covers emergency or urgent care cases.
Special Needs Plans.
These are types of Medicare Advantage plans created to address specific health needs, such as for people who have some type of medical condition that requires certain specialized medical care. Medicaid beneficiaries also fall into this group.
These plans generally tailor benefits, providers and drug formularies to meet special needs.
They are types of HMO, PPO or HMOPOS plans and cover the same benefits as Medicare Part A and Part B, however, they may also cover additional services for special groups with serious or chronic illnesses. They also cover the drug part (Medicare Part D).
There are 3 types of SNPs:
Chronic Condition SNP (or C-SNP).
Institutional SNP (or I-SNP)
Dual Eligible SNP (or D-SNP)
Medicare Medical Savings Account.
MSA plans, which do not necessarily have a network of physicians or health care providers, are those that combine a high deductible insurance plan with a medical savings account that the beneficiary uses to pay for medical care.
If an MSA plan is chosen, it should be noted that it does not cover drugs, so it is appropriate to enroll in the prescription drug plan.
There are 2 parts:
High Deductible Health Plan: this is a special form of a high deductible Medicare Advantage plan.
Medical Savings Account: the special form of a savings account.
More Options
We do not offer every plan available in your area. Currently we represent at least 4 organizations which offer at least 10 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
Plans are insured or covered by a Medicare Advantage organization with a Medicare contract and/or a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.
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