Medicare Basics 101

 

Understanding Medicare

Medicare is health insurance offered through the Federal Government.  It is available when:

  • You turn 65 years old
  • You are disabled
  • You have End Stage Renal Disease (ESRD)

When you first enroll, you will be covered by Original Medicare.  You can choose different ways to receive the services covered by Original Medicare.  Original Medicare is a fee-for-service plan that pays for many health care services and supplies, but it doesn’t pay all of your health care costs.  These are out of pocket costs, like coinsurance, copayments and deductibles.  These are called “gaps” in Medicare coverage.

To fill these gaps, you can choose to receive additional coverage through a Medicare Advantage plan (HMO, PPO, MSA) or Medigap supplemental insurance.

 

Original Medicare covers many services and supplies, but not everything, which is why there are additional options for Medicare health coverage.  Original Medicare includes:

  • Medicare Part A, which covers inpatient hospitalization, skilled nursing facilities, and hospice. Generally, you don’t pay a premium for Part A, but you will have deductibles and copayments or coinsurance.
  • Medicare Part B, which covers outpatient care and doctor services, such as a visit to your primary doctor or a specialist. Part B has a premium, deductible, and coinsurance.

Medicare Advantage plans cover the same services as Original Medicare and usually more.  What are the benefits of Medicare Advantage plans?

  • Medicare Advantage plans combine Part A, Part B, and sometimes Part D (drug coverage) into one plan.
  • With a Medicare Advantage plan, your costs will usually be lower than with Original Medicare.
  • These plans can include extra benefits, such as health and wellness programs, vision, and fitness.
  • You join a Medicare Advantage plan through a Medicare-approved private insurance company (like BlueShield).
  • There are different types of Medicare Advantage plans, giving you options to find the plan that’s the right fit for you.

Medicare Part A includes hospital insurance.  Most people do not pay a monthly Part A premium, because they or their spouses have 40 or more quarters of Medicare-covered employment. 

What should you know about Medicare Part A?

  • Provides partial coverage for inpatient hospitalization and skilled nursing facility care.
  • Has deductibles and copayments for which you will be responsible for unless they are covered by a separate health insurance plan.
  • Part A is required to qualify for Medicare Advantage programs.

Medicare Part B includes medical insurance.  The monthly plan premium provides partial coverage for inpatient hospitalization and skilled nursing facility care and has deductibles and copayments for which you will be responsible for unless they are covered by a separate health insurance plan. 

What should you know about Medicare Part B?

  • Provides partial coverage for doctor office visits and other medical services.
  • Has deductible and coinsurance
  • Although Part B is optional, there is a penalty if you sign up after your initial enrollment period
  • Part B is required to qualify for Medicare Advantage programs.

Medicare Part C includes Medicare Advantage Plans such as HMOs, and PPOs.

What should you know about Medicare Part C?

  • Combines your part A and Part B benefits.
  • Private insurance companies approved by Medicare provide this coverage.
  • Costs may be lower than in the Original Medicare Plan, and you may get extra benefits.

Medicare Part D includes prescription drug coverage.  Some prescription drug plans have separate premiums, while others do not.  The monthly premium will vary by plan. 

What should you know about Medicare Part D?

  • Sold by private insurance companies, some Part C plans include Part D
  • Part D is optional for most people, with a penalty for late enrollment
  • Part D plans can have a deductible
  • After your total yearly drug costs reach the initial coverage limit of $3,750, you enter the coverage gap (donut hole) where you pay 35% of the plan's cost for brand name drugs and pay 44% of the plan’s costs for all generic drugs until your yearly out-of-pocket drug costs reach $5,000, which is the end of the coverage gap. 
  • After your yearly out-of-pocket drug costs reach $5,000 (catastrophic phase), you pay the greater of 5% coinsurance or $3.35 copay for generic (including brand drugs treated as generic), and a $8.35 copay for all other drugs

The Medicare program rates all health and prescription drug plans each year based on a plan’s quality and performance.  Medicare Plan Ratings help you know how good a job our plan is doing.  For full details on Medicare Plan Ratings, please review the Medicare Plan Ratings.

 

Enrollment Time Frame and Process

You may enroll in a Medicare Advantage plan only during specific times of the year:

  • When you first become eligible for Medicare, the seven month period  beginning three months before you turn 65, the month you turn 65 and three months after you turn 65
  • If you receive Medicare due to a disability
  • During the Annual Enrollment Period from October 15, 2017 and December 7, 2017

In most cases, you must stay enrolled for the calendar year that starts the date your coverage begins.  In certain situations, however, you may be able to  join, drop or switch a Medicare Advantage Plan, excluding MSA plans.

Some of these situations include the following:

  • During the Medicare Advantage Disenrollment Period, between January 1 and February 14, you may drop your Medicare Advantage Plan and return to Original Medicare (does NOT apply to MSA plans)
  • If you move out of the plan’s service area
  • If you have both Medicare and Medicaid
  • If you qualify for extra help to pay for your prescription drugs
  • If you live in an institution

 

Becoming a member of Senior Blue HMO or Forever Blue Medicare PPO from BlueShield is easy. You can use our online application or print off, complete and mail in the paper-based application. Use the links below to make your choice.

Medicare beneficiaries may also enroll in Senior Blue HMO, Forever Blue Medicare PPO through the CMS Medicare Online Enrollment Center located at: http://www.medicare.gov.

 

If you have any questions, please call Customer Service at 1-800-329-2792, TTY: 711.

We are open:

October 1 - February 14

8 a.m. to 8 p.m., 7 days a week

February 15 - September 30

8 a.m. to 8 p.m., Monday-Friday


During non-business hours, your call will be answered by our automated phone system.  A Customer Service Representative will return your call on the next business day.

You may also chat online with a representative in a secure online chat room. 

We also welcome any suggestions you may have for improving our plan or to make recommendations regarding the Member Rights and Responsibilities Policy (Please see the Member Rights and Responsibilities section of your Evidence of Coverage for more information). 

 

Medicare Advantage Plans

When you turn 65, you’ll be eligible for Medicare, and you’ll need to make some important decisions about how you receive your health care. Beginning three months before your 65th birthday, you will be eligible to enroll in Medicare. Your eligibility will last for seven months - including the three months before your birthday month, your birthday month, and the three months after. Before or during those seven months, you will need to decide:

  • What healthcare benefits are most important to you
  • How you want to get Medicare coverage:

            - Original Medicare alone

            - A Medicare Advantage Plan, like Senior Blue HMO, or Forever Blue Medicare PPO.

            - Original Medicare plus a supplemental insurance policy (Medigap)

  • Whether you need prescription drug coverage

You must live in one of the following Northeastern New York counties to be eligible for enrollment in one of BlueShield’s Medicare Advantage plans:

  • Albany
  • Columbia
  • Fulton
  • Greene
  • Montgomery
  • Rensselaer
  • Saratoga
  • Schenectady
  • Warren
  • Washington

To fill the gaps in Medicare coverage you can select from different types of Medicare plans.  Medicare plans offered by BlueShield include:

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Medigap Supplemental Insurance

A Health Maintenance Organization (HMO) is a type of Medicare Advantage plan that takes the place of Original Medicare (Medicare Advantage Plan is primary).  With an HMO plan, you must receive care from doctors and hospitals within the plan’s network, except for emergency or urgent care. Prescription drug coverage is included with some plans.

A Preferred Provider Organization (PPO) is a type of Medicare Advantage plan that takes the place of Original Medicare (Medicare Advantage Plan is primary).  With a PPO plan, you can receive care within a network of doctors and hospitals or use out-of-network doctors and hospitals for covered services, usually for a higher cost.  Prescription drug coverage is included with some plans.

Medigap Supplemental Insurance works with Original Medicare (Medicare is primary).  It covers some of the health care costs that the Original Medicare Plan does not.  Plans are standard between companies and you can receive care from any doctor or hospital that accepts Medicare assignment nationwide.  Medigap plans don’t cover prescription drugs. Therefore, if you join a Medigap plan, you can also join a Medicare prescription drug plan to receive drug coverage.

 

How Medicare Advantage Drug Coverage (Part D) Works

You pay a copay or coinsurance. BlueShield pays the remaining cost. You start in the initial coverage stage and generally stay in this payment stage until your year-to-date total drug costs (what you pay plus what BlueShield pays) reach $3,750. After you reach $3,750, you will enter the “coverage gap” or “donut hole”. 

When you are in the coverage gap (donut hole):

  • Some of our plans cover tier 1 generics through the coverage gap. Otherwise, you will pay 44% of BlueShield’s cost for all covered generic medications. The cost you pay at the pharmacy applies toward your out-of-pocket costs.
  • You pay no more than 35% of BlueShield’s cost for covered brand name medications*. The total cost of the medication (before the discount) applies toward your out-of-pocket costs.
  • The discounts are automatically applied at the point of sale.

    You generally stay in this stage until your year-to-date out-of-pocket costs reach $5,000.

    *As defined by the Centers for Medicare and Medicaid Services (CMS), a dispensing fee will apply.

After you reach $5,000, you enter the catastrophic coverage stage. In this stage, you pay the greater of 5% coinsurance or $3.35 for generic medications and $8.35 for all other medications. BlueShield pays the remaining cost. Once you are in this payment stage, you will remain in it for the rest of the calendar year (through December 31).

 

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

Out-of-network/non-contracted providers are under no obligation to treat BlueShield of Northeastern New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

A division of HealthNow New York Inc., and independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-329-2792 (TTY 711). BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-329-2792 (TTY: 711).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-800-329-2792 (TTY: 711).

Y0086_MRK1962 Approved
Content Last Updated October 1, 2017