Kara Peltier Insurance Agency Billings, Montana

RESOURCES

Medicare & You 2022

The official U.S. government Medicare handbook

Original Medicare vs. Medicare Advantage

Original Medicare Medicare Advantage
You can go to any doctor or hospital that takes Medicare, anywhere in the U.S.
In many cases, you’ll need to only use doctors and other providers who are in the plan’s network (for non-emergency care). Some plans offer non-emergency coverage out of network, but typically at a higher cost.
In most cases, you don’t need a referral to see a specialist.
You may need to get a referral to see a specialist
Original Medicare Medicare Advantage
For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This is called your coinsurance.
Out-of-pocket costs vary—plans may have different out-of-pocket costs for certain services.
You pay a premium (monthly payment) for Part B. If you choose to join a Medicare drug plan, you’ll pay a separate premium for your Medicare drug coverage (Part D).
You pay the monthly Part B premium and may also have to pay the plan’s premium. Plans may have a $0 premium and may help pay all or part of your Part B premium. Most plans include Medicare drug coverage (Part D).
There’s no yearly limit on what you pay out of pocket, unless you have supplemental coverage—like Medicare Supplement Insurance (Medigap).
Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and Part B covers. Once you reach your plan’s limit, you’ll pay nothing for services Part A and Part B covers for the rest of the year.
You can get Medigap to help pay your remaining out-of-pocket costs (like your 20% coinsurance). Or, you can use coverage from a former employer or union, or Medicaid.
You can’t buy and don’t need Medigap.
Original Medicare Medicare Advantage
Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams.
Plans must cover all of the medically necessary services that Original Medicare covers. Most plans offer some extra benefits that Original Medicare doesn’t cover—like some routine exams and vision, hearing, and dental services.
You can join a separate Medicare drug plan to get Medicare drug coverage
Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, you can’t join a separate Medicare drug plan.
In most cases, you don’t have to get a service or supply approved ahead of time for Original Medicare to cover it.
In some cases, you have to get a service or supply approved ahead of time for the plan to cover it.
Original Medicare Medicare Advantage
Original Medicare generally doesn’t cover care outside the U.S. You may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care outside the U.S.
Plans generally don’t cover care outside the U.S. Some plans may offer a supplemental benefit that covers emergency and urgently needed services when traveling outside the U.S.

How does my other insurance work with Medicare?

When you have other insurance (like group health plan, retiree health, or Medicaid coverage) and Medicare, there are rules for whether Medicare or your other coverage pays first.

If you have retiree health coverage (like insurance from your or your spouse’s former employment)… Table Header
If you have retiree health coverage (like insurance from your or your spouse’s former employment)…
Medicare pays first.
If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees…
Your group health plan pays first.
If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has fewer than 20 employees…
Medicare pays first.
If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees…
Your group health plan pays first.
If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees…
Medicare pays first.
If you have group health plan coverage based on your or a family member’s employment or former employment, and you’re eligible for Medicare because of End-Stage Renal Disease (ESRD)…
Your group health plan pays first for the first 30 months after you become eligible to enroll in Medicare. Medicare pays first after this 30-month period.
If you have Medicaid...
Medicare pays first.

If you’re still working and have employer coverage through work, contact your employer to find out how your employer’s coverage works with Medicare.

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