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VA Benefits and Medicare

VA Benefits and Medicare

As a veteran, you’ve earned the right to have excellent healthcare, and we thank you for your service!

At the same time, when you approach the age of 65, you’ll also qualify for Medicare. You can carry both VA benefits and Medicare, but they don’t work together. Instead, some of your care will be covered by the VA and other medical needs by Medicare.

This guide will help you understand how to use both VA benefits and Medicare and when each coverage will apply. Let’s get started!

VA Benefits vs Medicare

Both VA Benefits and Medicare provide comprehensive medical coverage for a variety of needs. However, they work in different places.

If you go to a VA facility for your medical care, your VA medical benefits will apply. However, outside that system, you have to pay the full cost yourself, even in an emergency.

With Medicare coverage, if you get care outside the VA but at a Medicare-certified provider, you can use your Medicare benefits. As a result, Medicare can be a vital coverage if you don’t live close to a VA facility or if you travel frequently.

It’s important to keep in mind that VA care is based on your priority level. If you have a lower assigned priority level and VA funding drops, you may not be able to get VA medical benefits anymore. That’s why having Medicare if you’re eligible is an important backup.

How Do VA Benefits Work With Medicare?

You might be wondering “Does the VA bill Medicare?” or “Does the VA bill Medicare Advantage plans?” The answer in both cases is no, they do not work together.

Instead, your coverage will depend on what medical facility you go to. If you go to a VA facility, your VA benefits will take care of your needs. Any non-VA but Medicare-certified care will be covered by Medicare.

Sometimes the VA will authorize care at a non-VA facility. This generally means that they will cover the costs of those services, but if they don’t, Medicare may pay for the Medicare-eligible services left over.

Is Medicare Primary Over VA Benefits?

Medicare only applies to non-VA doctors. So in the VA, your VA benefits are primary. Everywhere else, Medicare is primary.

Are VA Benefits Better Than Medicare?

In general, you’ll get the same benefits from both Medicare and VA benefits, though your coverage amounts, copays, and other factors may differ. Your access to VA care, along with the out-of-pocket costs you have in the form of copayments, can vary depending on your priority level. If you have a lower priority number, you might have to wait for care at the VA or have to pay more for services or medications.

Medicare gives you another option that isn’t dependent on your VA priority. Instead, you can get non-VA care when you need it. You can also choose a Medicare Advantage plan that brings additional benefits, such as vision, dental, and other care. However, Medicare Advantage plans have a limited network, so you’ll have to see the approved providers.

Instead of thinking about which coverage is better, it’s best to consider the benefits of combining Medicare and VA benefits.

VA Medicare Eligibility

VA eligibility and Medicare eligibility are separate. To qualify for VA care, you need to be a veteran and meet the VA benefit requirements.

For Medicare, you need to be a U.S. resident or citizen who has lived in the country for at least five years, along with being 65 years of age or older, or having specific health conditions. You can qualify for VA but not Medicare, or you might qualify for both.

As we’ve mentioned, VA benefits are only applicable to VA medical centers. That’s why having Medicare as a secondary coverage can help.

Do I Have to Enroll in Medicare if I Have VA Benefits?

You don’t have to, but you may face penalties if you don’t enroll during your initial enrollment period but decide to sign up later.

Most Americans get Part A automatically and it’s free. For Medicare Part B, you might be automatically enrolled or you may have to sign up. There is a monthly fee for Medicare Part B, but it will be higher if you skip enrollment and then change your mind later on. We put a guide together that explains the difference between Medicare Part A and Part B in further detail.

We highly recommend signing up for Medicare when you are initially eligible. It expands your available medical options and can bring peace of mind if you have a lower VA priority level.

Do I Need Medicare If I Have VA Benefits?

Do VA patients need Medicare? It’s a common question. You might think it’s unnecessary to carry two forms of health coverage.

However, those with VA benefits can only go to VA medical centers. Anything else isn’t covered. With Medicare, you have a much wider range of care available, which can be essential if you’re traveling or live far from a VA center.

If you wait to enroll in Medicare Part B because you have VA benefits, you may have to pay a late-enrollment penalty when you do decide to sign up. VA benefits don’t give you a special enrollment period or an exemption from the late-enrollment fees.

Can You Have VA Benefits and Medicare Advantage?

Medicare Advantage, or Medicare Part C, is a full replacement for Original Medicare. Often you get additional benefits, such as discounts on health memberships, vision care, or dental coverage.

Does the VA Bill Medicare Advantage Plans?

It does not. Instead, you use the plan that applies to the medical provider you see.

If you are eligible for Medicare, you can sign up for Medicare Advantage, even if you have VA benefits. As we’ve noted, VA benefits only apply at a VA health center. Medicare Advantage can be used anywhere within the plan’s medical network.

Keep in mind that, unlike Original Medicare, a Medicare Advantage plan will have a limited network of providers, generally within a single geographical area. Make sure your non-VA doctors are part of the network and that the plan covers the prescriptions you need.

More Questions About Medicare for Veterans?

This guide has covered the most commonly asked questions that veterans have about Medicare coverage, but you might have additional concerns. That’s not a problem! We’re here to make it easy for you to understand your VA and Medicare options.

Often it helps to talk to a licensed insurance agent that can review your specific situation and help you find the coverage that works for you. If this is something you’d like to do, contact us today!

What you should read next

Some Medicare beneficiaries have concerns about their out-of-pocket expenses. In particular, it can be intimidating to face 20% coinsurance after your deductible is met. That can get expensive. Both Medicare Advantage and Medicare Supplements can address these concerns, in different ways. Understanding the difference between Medicare Advantage vs Medicare Supplements can help you choose the right plan for your needs. This article will help you understand the differences between Original Medicare, Medicare Advantage, and Medigap Did you know Medicare has the highest rate of satisfaction among Medicare beneficiaries? In fact, they ranked both Original Medicare and Medicare Advantage highly according to a 2019 survey. Still, it can be a difficult task to pick the best Medicare plan for your needs. Let's simplify the process by looking at Original Medicare, then discussing how Medicare Part C (Medicare Advantage) plans and Medicare Supplement (Medigap plans) work and take a closer look at the difference between Medigap and Medicare Advantage. What Is Medicare? Medicare is health insurance with different parts for: People who are 65 and over.People under 65 years old who are disabled and have been receiving Social Security Disability benefits for at least 24 months.People suffering from End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease.Medicare Part A CostsOriginal Medicare is broken into two parts: Part A (for hospitalization) and Part B (for medical services). In most cases, there is no cost for Medicare Part A.But you would have to pay a $471 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $259.Medicare Part B CostsMedicare Part B premiums are determined by your modified adjusted gross income.If your income for 2021 was less than or equal to $87,000 for a single or $174,000 for a married couple filing jointly, you will pay the standard Medicare Part B rate, which is $148.50 a month in 2021. Part B premiums rise to a maximum of $504.90 a month if your income exceeds $500,000 for an individual or $750,000 for a couple filing jointly.Many people are automatically enrolled in Medicare Part A and Part B when they turn 65 and begin to receive Social Security retirement benefits.But you might be in a situation where you have other health insurance besides Medicare, like a plan through your employer. In this case, you can delay your enrollment in Part B without being penalized and save paying the monthly premium. However, you would have to pay a $458 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $252.How to Enroll in Original MedicareIf you don’t receive Social Security benefits at age 65, you need to sign up on your own. There are three ways to enroll:Go online to Social Security at 1-800-772-1213 (TTY 1-800-325-0778).Visit your local Social Security office in person.The seven-month Initial Enrollment Period (IEP) for Medicare begins three months before you turn 65, continues during your birthday month, and runs for three months after you turn 65. If you don’t enroll in Medicare during this timeframe, you could face penalties for not complying with Medicare rules.There’s also a Medicare annual enrollment period each year after your initial enrollment, which allows you to make changes to your coverage for the following year.What are the Different Types of Original Medicare Plans?Medicare Part A is hospital insurance. It helps cover inpatient care, skilled nursing facility care, hospice care, and home healthcare. In most cases, there is no cost for care, but there is a deductible of $1,484 in 2021.Medicare Part B is medical insurance. This plan helps cover doctor visits, outpatient care, home healthcare, durable medical equipment, and many preventive care services. Monthly premiums vary based on your income, and there is a deductible of $203 in 2021.Medicare Part C is Medicare Advantage. Medicare Advantage plans combine Medicare Part A and Part B into a health plan. Many Medicare Advantage plans may include prescription drug coverage and extra benefits. (More on this below).Medicare Part D is prescription drug coverage. Medicare Part D helps cover the cost of prescription drugs. The standard maximum deductible is $445 in 2021.Medicare plans A-N is Medicare Supplement coverage. Medicare Supplement, also known as Medigap, have several different plans, which help cover benefits that Original Medicare may not cover. Medigap prices vary by plan benefits, not income. Note that Plans C, E, F, H, I, and J are no longer sold to new enrollees.So, the big question is: Should you consider Medicare Advantage, or enroll in Original Medicare and get a Medicare Supplement instead? And the short answer is: It depends.You have to evaluate your healthcare needs and how much you can afford to pay out-of-pocket for health insurance.What is Medicare Advantage (Medicare Part C)?Medicare Advantage provides all of your Part A (hospital) and Part B (medical) coverage. A majority of Medicare Advantage plans offer extra coverage, such as vision (78%), hearing, dental care (67%) or wellness programs (72%). Most include Part D prescriptions drug coverage (90%).As a Medicare beneficiary, you have a choice between selecting Original Medicare or choosing a Medicare Advantage plan (also known as Part C), which is provided by private health insurance companies.How Much Does Medicare Advantage Cost?Medicare Part C premiums vary by the plan (many plans have $0 premiums). And each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get medical services.For example, most insurance companies require Medicare Advantage plan participants to get pre-approved before they can have a procedure done, but another insurance company might not have that requirement.Do Medicare Advantage Plans Cover Pre-existing Conditions?Yes, your acceptance is guaranteed and you're not required to complete any medical history forms. This includes coverage for people with End State Renal Disease (ESRD), which is a 2021 change to Medicare.What is a Medicare Supplement (Medigap) Plan?Medicare supplement plans (Medigap) plans provide extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t pay. These plans can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits.It’s important to note that you can’t have more than one Medicare supplement plan. And though Medicare supplement plans may have higher monthly premiums than Medicare Advantage plans, you may want to consider buying a Medicare supplement insurance plan if:You’re likely to have numerous hospital stays during a year.You have regular doctor visits and/or medical services.You live in different places during the year and cannot be confined to a local network.You frequently travel outside the U.S. and want insurance coverage for emergency medical care overseas, which Medicare Part A and Medicare Part B may not provide. Note: Some Medicare supplement plans provide international travel coverage.A Medicare supplement plan may also be a good fit if you want to visit a specific top-tier medical facility like the Mayo Clinic. You wouldn’t qualify for an in-network check-up with a Medicare Advantage plan, but you’d have the ability to see a Mayo Clinic doctor with a Medicare supplement plan, with coverage for a large chunk of your services.How Much Do Medigap Plans Cost?Pricing for Medicare Supplement plans are based on the plan you select (high/low benefits), your age at time of enrollment, your state of residence, and the health insurance company you select. That’s why it is important to compare when you shop from plan to plan or even between the same company’s plan differences before choosing a Medicare supplement plan.What's the Difference Between Medicare Advantage vs Medicare Supplements?Medicare Advantage offers more choice and covers more medical services than Medicare, while still following all of Medicare’s rules. One of the biggest differences between the two is the difference in cost. Medigap plans generally have a higher premiums than Medicare Advantage plans, but in some cases, Medicare Advantage can cover less expenses than Medigap. This means that despite a lower initial cost, you may end up paying more in out-of-pocket expenses with Medicare Advantage than with a medicare supplement. Remember: Medicare Advantage acts as an alternative to original Medicare, while Medicare Supplement plans are additions to Original Medicare coverage.Do I Need a Original Medicare with a Supplement or Medicare Advantage?Choosing between a Medicare Advantage plan or adding a Medicare Supplement plan on to your Original Medicare coverage depends on your situation.To start, ask yourself these types of questions:Do I travel outside of the United States regularly? Do I live in a different state for a portion of the year? Do I want to see any doctor and not be limited to a network? Is my budget more important than my health benefits? Are extra benefits like dental and vision coverage important to me?Answering these questions will help you determine if Medigap or Medicare Advantage is a better fit for you.Can You Switch From Medicare Advantage to Medigap?Switching from Medicare Advantage to Medigap means you need to go back to Original Medicare. Instead of having coverage under Medicare Part C (Medicare Advantage), you’ll have coverage under Medicare Part A and Part B, with Medigap added on.This can only be done during open enrollment periods. The Annual Election Period is between October 15th and December 7th of each year. The Medicare Advantage Open Enrollment Period is between January 1st and March 31st each year.Keep in mind that usually if you switch from Medicare Advantage to Original Medicare with Medigap, you may pay a higher price for your Medigap plan because you won’t have guaranteed issue rights. Guaranteed issue rights give you the ability to buy any Medigap plan without paying more due to your health status.To switch from Medicare Advantage to Medigap with guaranteed issue, you need to:Have purchased your Medicare Advantage plan when you were first eligible, but decided within the first year to switch.Lose your Medicare Advantage plan because you moved out of the service area or the plan stopped operating in your area.These temporary guaranteed issue opportunities may not include all Medigap plans — it will depend on the rules in your state.Compare Medigap and Medicare AdvantageThe chart below offers a side-by-side comparison of costs and coverage to help you understand the difference between Medigap and Medicare Advantage.   Medicare AdvantageMedicare SupplementCoverageIn most cases, copayments (a fixed amount of money you pay) are required.In most cases, it can cover deductibles, copayments, and coinsurance that isn’t covered by Part A and Part B.CostMany times $0 or a low monthly cost.Higher monthly cost based on state, gender, and age.TravelMany plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay.Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay.Prescription DrugsTypically included with coverage.Not covered. You must enroll in a Part D plan for drug coverage.Routine dental, vision, hearing coverageMay be covered depending on the plan selected.Not covered.Copayments and coinsuranceUsually have copayments and/or coinsurance.Typically pays for copayments and coinsurance.NetworkMedicare Advantage plans have different networks: HMO, PFFS, and PPO. It’s important to understand the rules about going out of network for your healthcare.No network. See almost any doctor or medical facility that accepts Medicare.Medicare Advantage and Medigap plans may provide benefits for the following services (but check your plan details for specific benefits):Hospitalization: Medicare limits the number of days you can spend in the hospital. If you pass the maximum number of days, supplemental insurance pays the copayment that Medicare does not cover.Skilled Nursing Facility: Depending on the plan you select, Medicare supplement covers skilled nursing services that Medicare does not cover.Blood: If you need blood, Medigap coverage could pick up the tab on a few pints.Hospice care: Medicare pays for everything but copayment and coinsurance. Medicare supplement could pay the copayment and coinsurance.Inpatient or outpatient hospital medical expenses: Medicare generally pays 80% of all expenses, and a Medigap plan generally pays the remaining 20%.Note: Medicare supplement plan benefits are subject to state rules and regulations. Benefits described here encompass common Medigap plans available in the marketplace. Other services may be covered based on the supplemental plan you pick. Please check your insurance policy documents or talk to a customer service representative for more information.Find & Compare Medicare Advantage and Medigap PlansBut you don’t have to go it alone: We can answer your questions about Medicare and help you find the best Medicare quotes for your needs. Just try our Medicare Advantage plan comparison tool to get Medicare quotes online, or call 800-620-4519 to get help from a licensed insurance agent.
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Medicare, as a federal health coverage program, is intended to help provide access to healthcare for those who may not get it through an employer. Often, this means retirement age, which in the United States is age 65. Once you turn 65, you have aged into Medicare eligibility. If you’re approaching your 65th birthday, it’s important to understand what Medicare options are available to you. While you may be automatically enrolled in Medicare, it’s possible that the default options are not the coverage that’s best for your situation. This guide will answer common questions and help you choose the Medicare plan that’s right for you or your family member. Medicare is for the nation's elderly and certain individuals with qualifying disabilities However this article will focus on those aging into Medicare. Are you or someone you care about turning 65? Turns out, you’ll be joined by thousands of birthday buddies. In fact, 10,000 Americans turn 65 every day - a real cause for celebration, whether it’s the milestone of retirement or your journey to the right Medicare coverage. Still, many Americans are confused by Medicare: how to enroll, when their enrollment period is and what plan to even enroll in. But the process doesn’t need to be so complex. In this guide, we’ll help you understand what you should do when you’re aging into Medicare. Remember that while age is one trigger for being eligible for Medicare, it’s not the only one. Aging into Medicare: what you need to know Approaching age 65 may bring a lot of changes into your life. As you look at your Medicare options, you may have some of the questions we address below. At What Age Should I Start Looking Into Medicare?Because Medicare can be a complex subject, it pays to start learning early. There’s nothing wrong with beginning to review Medicare rules in your state, along with the available options, in your early 60’s. By the time you turn 64, it’s a good idea to start looking into specific plans.Your initial enrollment period will start three months before your 65th birthday, include your birthday month, and extend three months afterward. You’ll have unique options in your initial enrollment period that will not happen again, like guaranteed acceptance into a Medigap plan, so it’s important to make the right Medicare plan choices from the very beginning.Is It Mandatory to Go on Medicare at Age 65?Many people who turn 65 will be automatically enrolled in Medicare if they are already receiving social security retirement benefits or other retirement payments. It is not mandatory to enroll in Medicare at age 65, but you might pay a financial penalty if you delay your enrollment.Medicare Part A is premium-free for most people, so there’s no harm in enrolling in that coverage immediately. Medicare Part B, which covers outpatient care, doctor’s visits, and more, does have a monthly premium. If you defer enrollment in Part B because you have a qualifying employer coverage through your job or a spouse, you won’t have to pay a late enrollment penalty when you do sign up for Medicare Part B.If you do not sign up for Medicare Part B during your initial enrollment and you don’t have qualifying coverage, when you do decide to enroll in Part B you will need to pay a late-enrollment penalty.Enrollment PeriodsAs you approach age 65, you’ll want to make a note of the different enrollment periods that affect Medicare recipients. AEP stands for Annual Enrollment Period. You can make any change or update to your Medicare plan each year between October 15 and December 7th. Coverage changes go into effect on January 1. Learn more about annual enrollment periods.The OEP is the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year. During this time you can make changes to your Medicare Advantage plan or go back to Original Medicare. You can learn more about Medicare enrollment periodshere.Special Enrollment periods happen due to specific life events. For example, if you move out of a plan’s service area, have a chance to get other coverage, or lose current coverage, you may get a special enrollment period. This guide gives more information about special enrollment periods.What Happens if You Don’t Enroll in Medicare in Time?If you don’t sign up for Medicare during your initial enrollment period, you may be penalized with higher premium if you do decide to enroll later. Every year, you may enroll in Part A or Part B during the General Enrollment Period from January - March.6 Steps for Aging Into MedicareNow that you know the eligibility requirements and when to enroll, follow these tips to prepare for Medicare enrollment.1. Make Sure You Qualify For Premium-Free Medicare Part AMost people qualify for Medicare Part A because of their work history. If you’re a U.S. citizen or permanent legal resident, you qualify for premium-free Part A as long as you have paid payroll taxes for at least 10 years.Call your local Social Security Office to see if you’re eligible for Medicare Part A. You may receive a paper statement from SSA [sample here] as a reference, or you can create an account online at If You Didn’t Work Enough?You may still qualify for Medicare Part A through your spouse if you don’t (or won’t) have 40 quarters of work history. You’re eligible if your spouse qualifies for premium-free Part A, and:You have been married for at least one year and your spouse is eligible for Social Security benefits.You're divorced and your former spouse is eligible for Social Security benefits. You must have been married at least 10 years, and you must be single now.You’re widowed, but were married for at least nine months, and you are currently single.If you don’t meet any of these criteria, you can either continue working until you’ve logged 40 quarters, or pay for Part A. For 2022, the Part A premium is $499 per month, but this amount may be reduced if you have some work history.2. Decide When Need You Medicare Part BIf you are currently employed and you are covered by an employer health plan, and your employer has more than 20 employees, you don’t have to sign up for Part B until you retire and give up your employer-based health coverage.Many people can’t take full Social Security benefits until age 66, so it’s common to delay retirement by a year. You can delay Part B as long as your employer coverage meets Medicare’s minimum requirements.But if you work for a small company with less than 20 employees, you’ll probably need to enroll in Part B when you’re first eligible. Be sure to talk about this with your employer before your 65th birthday. There’s no reason to pay the Part B premium until you’ll actually need Medicare.3. Decide When You’re Taking Social SecurityThere are a few nuances to receiving Social Security and how it impacts when you can enroll in Medicare Parts A and B:If you take Social Security at age 65, your enrollment in Medicare will be automatic.If you pass on Social Security at age 65, but want to sign up for Medicare, you’ll have to apply for it separately.You can use to enroll if you choose to enroll before your 65th birthday.If you wait until after you’re 65, you’ll have to visit a Social Security office to sign up for Medicare.4. Know Which Doctors You Want To See When You Have MedicareMake sure the doctors you see, or want to see, accept Medicare. Finding out ahead of time can help you avoid surprises.If you plan to move during your retirement, it’s wise to get recommendations for doctors in your new hometown and see if they accept Medicare patients.5. Get A Firm Understanding Of Your MedicationsWhen it comes to medications and aging into Medicare, there are 3 steps to take:You should always know your medications and their doses.Talk to your doctor about generic versions of your prescriptions to reduce costs.Find out if your doctor thinks you might need a new or different medication in the future.6. Understand The Gaps In Original MedicareMedicare doesn’t cover 100% of your health care costs. Instead, you’ll pay a portion out of your own pocket. The costs you pay for Part A differ from what you’ll pay for Part B.Gaps In Medicare Part APart A will cover you for inpatient type of events, like:Hospital staysHome health careHospiceSkilled nursing facilitiesWhen you have a hospital stay, you’ll have to pay the Part A deductible. For 2022, the deductible is $1,556. You’ll pay this inpatient hospital deductible each time you are admitted to the hospital, provided you haven’t received hospital or skilled nursing facility services within the previous 60-day benefit period.Gaps In Medicare Part BPart B of Original Medicare covers the services you’d receive in an outpatient setting, including:Doctors and therapy appointmentsLab work and diagnostic imagingOutpatient surgeriesMedical equipment like oxygen machinesSome cancer treatments like chemotherapyWhen you use Part B coverage, you can expect to pay out of pocket for each service. Your share of cost can include:Part B deductible: $233 for 2022 (you only pay the Part B deductible once each year).Part B coinsurance: 20% of the cost for each service or procedure.Part B excess charges: Up to 15% of the Medicare-approved charge if your doctor does not accept the Medicare-approved amount for a service (known as Medicare assignment).The biggest Part B expense is the 20% coinsurance, which you’ll pay throughout the year. There are other costs you can expect to pay out of pocket with Original Medicare, including things like dental care, eye exams, hearing aids, and more.Keep in mind that there is no cap on how much you can spend out of pocket with Original Medicare.How To Find The Right Medicare Plan For YouMake sure any Medicare plan you consider:Covers the doctors you want to seeCovers the medications you needHas a premium you can affordYou can also narrow your choices down further by asking yourself:Do I intend to split my time between two or more States?Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re comfortable with a particular HMO-type medical group and plan to live in one place, then Medicare Advantage could be right for you.Your Options Beyond Original MedicareThere are Medicare plans available that help close the coverage gap of what Original Medicare doesn’t cover. They include:Medicare AdvantageMedicare Part D (Prescription Drug Plans)Medicare Supplement (Medigap)Medicare Advantage PlansMedicare Advantage plans, also known as Medicare Part C, is a contract between a private insurer and Medicare. These plans must cover everything that Original Medicare covers.Medicare Advantage plans work like traditional private health insurance, so you may see certain out-of-pocket costs with Medicare Advantage, including:Monthly premium: Many Part C plans don’t have a monthly premium.Annual deductible: Most plans don’t have a deductible.Copayments or coinsurance for services and procedures.Medicare Advantage plans also offer a number of added benefits, which vary by state and health plan. Some benefits include:Fitness programs like Silver Sneakers or free memberships to local gyms.Vision coverage for exams, lenses, and sometimes frames.Hearing coverage for exams and discounted hearing aids.Dental coverage for basic dental services.Transportation to and from medical appointmentsPrescription drug coverage (some plans)Medicare Advantage plans can also provide emergency coverage outside the United States. With the international coverage, out of pocket maximum protection, and a wide range of extra benefits, you can see why many people choose Medicare Advantage plans.Prescription Drug PlansPrescription Drug plans (PDPs or Medicare Part D) help with the cost of prescription drugs. Each company creates their PDPs differently, but you can expect to pay these costs for coverage:Monthly premium, which varies based on incomeAnnual deductible (although many plans don’t have a deductible)Copayment or coinsurance per filled prescriptionThe copayments and coinsurance costs increase as the total amount your plan pays rises above certain thresholds, also known as coverage stages:Coverage Stage 1 – Deductible Stage: You pay full price until you’ve spent $480 (for 2022).Coverage Stage 2 – Initial Coverage Stage: You pay small copayments or coinsurance for each prescription.Coverage Stage 3 – Coverage Gap Stage: Also known as the Medicare “Donut Hole.” Once your total drug costs (what you’ve paid plus what your plan has paid) exceed $4,020, you hit the coverage gap. You’d then pay 25% of the cost of prescriptions.Coverage Stage 4 – Catastrophic Stage: Once your total drug costs (excluding what your plan has paid) exceed $6,350, you pay no more than 5% for medicationsThese coverage stages reset on January 1 each year. But it’s important to know that there is no out-of-pocket cap on drug costs under Part D.Click the link if you want to more about the phases of Medicare Part D.Medicare Supplement InsuranceMedicare Supplement Insurance, also known as Medigap, is designed to fill the gaps in Original Medicare. Medigap supplements Original Medicare by paying some or all of the expenses that you’d normally have to pay out of pocket.Medigap policies are issued in 10 standardized plans: A, B, C, D, F, G, K, L, M, and N. Each of these plans cover a slightly different portion of the Original Medicare gaps.Plan G is a popular Medigap option that covers every gap except for the Part B deductible. If you have Plan G, you can expect to pay for the first $198 in Part B expenses (like doctor’s visits). Plan G will then cover every penny of any Medicare-approved service or procedure.Several Medicare supplements provide some international coverage, including plans C, D, F, G, M, and N.Medigap plans also give you maximum flexibility, so you can see any doctor or use any facility that accepts Medicare patients, anywhere in the United States. You’re not bound to a network, or reliant upon referrals.Medicare Supplement Insurance plans don’t cover prescription drugs, so you’ll need to enroll in a stand alone Prescription Drug plan to get drug coverage.Considerations Before Choosing A PlanMake sure any Medicare plan you consider:Covers the doctors you want to seeCovers the medications you needHas a premium you can affordYou can also narrow your choices down further by asking yourself:Do I intend to split my time between two or more States?Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re fine with HMO-type medical groups and plan to live in one place, then Medicare Advantage could be right for you.As you approach age 65, it’s important to start your research sooner rather than later. Make sure you know what plans your doctors will accept, and which plans cover your medications.Comparing Medicare plan features and costs doesn’t have to be complicated though. You can get Medicare quotes through our site. Or you can call 800-620-4519 to reach one of our licensed Medicare agents who can guide you through your Medicare plan options.
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A CDC study conducted over the span between 2017 and 2020 reports that 42.5% of Americans are obese. Because long-term weight loss is so challenging and often puts people on a cycle of losing and gaining weight repeatedly, many obese Americans research weight loss surgery as an alternative. If you’re currently on Medicare and are struggling with your weight, you might wonder, “Does Medicare cover weight loss surgery?” You may also wonder if you can get coverage for skin removal after a significant weight loss due to surgery. This guide will help you understand what coverage you can receive through Medicare and Medicare Advantage. We’ll answer the most common questions about this topic, but feel free to contact us if you’d like to talk about your specific situation. Let’s get started! Does Medicare Pay for Weight Loss Surgery? Original Medicare may cover certain bariatric surgeries if you meet specific criteria. Generally, this is to ensure that the surgery is medically necessary rather than simply cosmetic. In order to qualify for coverage, you’ll need to have: A BMI of 35 or higherA health condition related to your obesity, such as sleep apnea, diabetes, etc.A letter from your doctor recommending the surgery as medically necessaryBlood and psychological testingMedical records showing you’ve been obese for at least five yearsRecords that you’ve tried at least one weight loss program that was medically supervisedIf the surgery will be an inpatient process and coverage is approved under Medicare, it will generally be covered under Medicare Part A, which will change your costs compared to an outpatient procedure covered under Medicare Part B. Be sure you talk to your doctor to fully understand what kind of procedure is being recommended..Medicare Advantage plans are required to offer at least as much coverage as Original Medicare, but they might have different requirements and costs for covering the surgery. You may also get additional benefits. You’ll want to talk to your Advantage provider to get a clear understanding of what’s covered.Does Medicare Pay for Weight Loss Revision Surgery?Some patients continue to gain weight after bariatric surgery. The first step if this happens is to work with your doctor to explore lifestyle factors, mental health needs, and other behaviors that might be a primary cause of this weight gain.If those are ruled out, your doctor might recommend a revision surgery to ensure that the surgery was successful or to fix problems that have been found. If you’ve already qualified for the original bariatric surgery, you’ll likely have coverage for the revision as long as it’s proven to be medically necessary.That means that you may have to pass additional psychological assessments and physical testing to show that there’s no other cause for the failure to lose weight. Does Medicare Cover Skin Removal After Weight Loss Surgery?Medicare coverage focuses on medically-necessary care. However, excess skin after significant weight loss can often cause medical problems, so you may be able to get coverage for skin removal after successful weight loss. To qualify for skin removal surgery, you’ll need to meet the following conditions:You’ve maintained a stable weight for at least six monthsThe excess skin is causing a skin condition that threatens your healthThe excess skin impacts your daily movementYou’ve dropped at least 5 BMI points as a result of your weight lossIf you have excess skin to do significant weight loss and it’s making your life difficult, talk to your doctor about how to get coverage for skin removal surgery. Is Weight Loss Management Covered by Medicare?If you’re in a position where you want to focus on weight loss but aren’t interested in (or don’t qualify for) bariatric surgery, there’s good news. Medicare offers coverage for a variety of other weight management strategies.If you have a BMI of 30 or more, your Part B coverage may help pay for behavioral counseling and obesity screening to help you lose weight through diet and exercise. Medicare offers coverage if your primary care doctor or another qualified practitioner offers the counseling in a primary care setting like the doctor’s office. Your personalized plan will be coordinated with your other medical care. If you work with a doctor that accepts assignments from Medicare, your costs will fall under Part B coverage rules.   If you have Medicare Advantage, there may be different out-of-pocket costs, so be sure to check with your insurer.Contact Us to Learn More About Medicare and Weight Loss SurgeryStruggling with your weight can be frustrating and is often a lifelong struggle. Weight loss surgery can help some people radically change their eating habits so that they can finally lose the weight that’s threatening their health.If you have questions about how Medicare covers weight loss surgery, or you’re interested in comparing Medicare plans to get the best coverage for your needs, we’re here to help. Contact us today for more information!
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