Hospital Coverage

What does Medicare Part A cover?

• Inpatient hospital stays
• Care in a skilled nursing facility
• Hospice care
• Some home health care

For most people it is FREE!

Most of the time Medicare Part A does not cost you anything in the way of a monthly premium as long as you paid 40 quarters into the Medicare system through your taxes while you were working. Remember FICA taxes? Now it is finally paying off.

There is a Gotcha . . .

Let's say you ended up in the hospital. There is a large deductible ($1600+) that needs to be met before Part A starts paying benefits.

You will be covered for the 1st 60 days, after which you start to realize copays and coinsurance. Once your deductible is met, Medicare Part A will pay 100%.

NOTE: To avoid this large deductible, most people get on a secondary plan: Either a MediGap plan or a Medicare Part C plan, called a Medicare Advantage plan. These secondary plans pay that whopping Part A deductible (and the 20% that Medicare Part B will not pay).

Medical Services

What does Medicare Part B cover?

• Outpatient Services
• Dr. visits, Physician Services
• Diagnostic Testing
• Emergency Room
• Urgent Care
• Radiology
• Ambulance
• Durable Medical Equipment, ie wheel chairs

Note: Part B will pay the bill up to 80%. You are responsible for the 20% balance. Read the side bar to the right on how to remedy this. ===>

How much does Medicare Part B cost?

Medicare Part B is NOT FREE. Most people will pay $185 per month, in 2025.

However, the IRS looks back 2 years to 2023, to see what your Adjusted Gross Income (AGI) was and if it is more than a certain amount, you will pay a higher premium. In 2023, if your yearly income as an individual was over $106,000 and up to $133,000, then you pay $259 per month to be on Part B. Some people with AGI's higher than $500,000 pay $628.90 per month in 2025.

The premium rates go up each year and typically get announced in October.

This is called, IRMAA, and it is not named after your Aunt. It stands for Income-Related Monthly Adjustment Amount.

Most premiums are automatically deducted from your Social Security Benefits each month. However, if you are delaying Social Security, you can have it automatically deducted from your bank or you can be billed.

What if my income is low?

If your income is low, you may qualify for Medicaid which will pay for most or all of your services including your Part B premium.

Or, you may not qualify for Medicaid, but you may qualify for the "Medicare Savings Program". If so, you can have your Medicare Part B premium paid for you on your behalf.

This is one of the reasons it is so important to work with a broker. Give us a call. We would love to help. That is why we named our company, "Help You Insurance".

Each state calls Medicaid by their chosen name:

• Medicaid in Arizona = AHCCCS. People pronounce it "Access".
• Medicaid in California = Medi-Cal.
• Medicaid in Texas = State of Texas Access Reform (STAR).
• Medicaid in Florida = Statewide Medicaid Managed Care (SMMC), pronounced, "smack"

Medicare Advantage

Yup . . . Part C is called "Medicare Advantage" and is one of the roads that you will need to choose from in order to supplement your Original Medicare, Part A and Part B. So, this means to be eligible, you MUST have Medicare Part A and Part B.

What does Medicare Advantage Cover?

These plans are run by private insurance companies and use networks called HMOs and PPOs. These are an alternative to Original Medicare.

They are all-in-one, "bundled plans" that include:

• Medicare Part A & Part B. (Our Federal Government subsidizes the private company to run Medicare Part A & Part B for them.)

• Prescription Drugs: some have an option to drop the prescription drug part of the plan. For instance, you may be a Vet getting your drugs from the VA, instead.

• Dental, Vision, and Hearing.

• Plus, other benefits like gym membership, over-the-counter money, etc.

Note: some may even offer a "Give Back" benefit where they pay some of your monthly Medicare Part B premium.

For more details, click the button:

Medicare Advantage Plan Details

How much do Medicare Advantage plans cost?

Many Medicare Advantage plans offer $0 premium per month.

How can they do this?

Our Federal Government subsidizes these companies to run Medicare Part A & Part B for them, so that they don't have to. For each member who signs up for a Medicare Advantage plan, our government gives a monthly subsidy. The subsidy is substantial enough that the insurance companies can offer these plans at a ZERO monthly rate.

So, then, do I have to pay for anything else?

Yes. You may have to pay a medical deductible and a drug deductible depending on the plan. You also have to pay for copays and coinsurance each time you get a service, depending on your service.

There is a cap or "stop loss" on how much you pay out of your pocket each year, however. This is called a MOOP or Maximum Out of Pocket.

NOTE:  Medicare Part B is a separate payment from Medicare Advantage, even though the Medicare Advantage plan has Part B bundled inside it. So, you are still responsible for making your Part B monthly premium each month.  In 2024, that amount is $174.70 per month.

If you are getting your Social Security Benefit each month, the amount will be automatically deducted from your Benefit. You do not have to worry about physcially making that monthly payment.

Just to reiterate . . .

If you have a Medicare Advantage plan then this becomes your Primary insurance and Original Medicare gets set aside but you will still need to continue paying your Medicare Part B monthly premium.

Prescription Drug Plan (PDP)

What does a Prescription Drug Plan cover?

They are run by privately held companies and all plans have to have:

Formularies: These are a list of covered drugs

Tiers: Covered drugs are grouped into different cost-sharing levels within the formulary

All Drug Plans: All plans cover at least 2 drugs in each category of drugs, so you are not left high and dry.

Vaccines: All plans must cover all commercially available vaccines.

How do you get a PDP plan?

They are bundled inside a Medicare Advantage plan

They can be purchased as a "standalone" plan to accompany a MediGap plan, formerly called Medicare Supplement, along with your Original Medicare: Part A (Hospital) and Part B (Medical).

NOTE: You cannot enroll in a Medicare Advantage plan with a drug plan bundled in it AND enroll in a standalone drug plan at the same time. One will cancel out the other one.

How much do Drug Plans Cost?

Nationwide the average cost for a drug plan in 2024 is around $34 for the monthly premium. It is widely thought that, in 2025, that price will go up significantly. This is because the drug companies, Pharmacy Benefit Managers (PBMs), and insurance companies are incurring a higher cost burden due to the Inflation Reduction Act (IRA).

The IRA lowered the cost of insulin down to $35, got rid of having to pay for catastrophic coverage, and in 2025 will get rid of the infamous "Donut Hole" where a portion of our population paid a whopping 25% of the retail cost of their drugs.

Besides paying a premium, some plans will charge a deductible, or at least a deductible on their more expensive Tiered drugs.

In 2025, there will be two stages of drug coverage:

Which Medicare Road
Should I Go Down?

<--- Did you read about Medicare Part A and Part B? Then you know that you will need to come up with a HUGE deductible if you end up in a hospital before the plan pays. And with Medicare Part B, you have to pay 20% of the bills!

Who wants to do that? No one does. So, that is why you need a supplement plan that pays the 20% that you would otherwise be responsible for. AND, it pays that obscene hospital deductible.

But there are two types of supplements. You can go down the MediGap road OR you can go down the Medicare Advantage road.

Let's be clear. One road is not better than the other. It all depends on your circumstances. However, if you make the wrong choice it could have lifetime ramifications.

That is why it is important to work with a broker.

To learn more about these two roads to supplement your Original Medicare Part A and Part B click on these links:

Road 1: MediGap Road 2: Medicare Advantage

Medicare

To Qualify for Medicare, you must be 65 years old, be a U.S. citizen & resident at least 5 consecutive years, or have a disability for at least 24 months. Eligibility also includes those with certain medical conditions like ESRD or ALS.

Hospital Coverage

What does Medicare Part A cover?

For most people it is FREE!

There is a Gotcha . . .

Medical Services

What does Medicare Part B cover?

How much does Medicare Part B cost?

What if my income is low?

Medicare Advantage

What does Medicare Advantage Cover?

How much do Medicare Advantage plans cost?

Just to reiterate . . .

Prescription Drug Plan (PDP)

What does a Prescription Drug Plan cover?

How do you get a PDP plan?

How much do Drug Plans Cost?

Which Medicare Road
Should I Go Down?

Follow Us On

Important Links

Contact

Medicare

To Qualify for Medicare, you must be 65 years old, be a U.S. citizen & resident at least 5 consecutive years, or have a disability for at least 24 months. Eligibility also includes those with certain medical conditions like ESRD or ALS.

Hospital Coverage

What does Medicare Part A cover?

For most people it is FREE!

There is a Gotcha . . .

Medical Services

What does Medicare Part B cover?

How much does Medicare Part B cost?

What if my income is low?

Medicare Advantage

What does Medicare Advantage Cover?

How much do Medicare Advantage plans cost?

Just to reiterate . . .

Prescription Drug Plan (PDP)

What does a Prescription Drug Plan cover?

How do you get a PDP plan?

How much do Drug Plans Cost?

Which Medicare Road Should I Go Down?

Follow Us On

Important Links

Contact

Which Medicare Road
Should I Go Down?