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A Guide to Understanding Your Healthcare Insurance Benefits

Appendix C: Medicare

SUMMARY OF MEDICARE STRUCTURE
Part Description
Part A

Institutional insurance program which covers:

  • Hospital inpatient
  • Skilled nursing facility
  • Hospice
  • Home health care
Part B Medical insurance program which covers:
  • Physician care
  • Hospital outpatient
  • Laboratory tests
  • Medical supplies
  • Home health
Part C Managed care plans that provide Part A and B benefits to those members that opt to enroll. Known as Medicare Advantage.
Part D (available in 2006) Drug discount cards available in 2004 to help members save on prescription drugs.

New prescription drug benefit will be effective in 2006. All members will be able to enroll in plans that cover prescription drugs.

  • Members will select the drug plan and pay a premium monthly.
  • Members will be responsible for a $250 deductible.
  • Medicare will then pay 75 percent of costs between $250-$2,250 in prescription spending and the beneficiary will be responsible for 25 percent.
  • Members will be responsible for 100 percent of prescription costs above $2,250 until they have reached $3,600 in out of pocked spending.
  • Once members have exceeded the $3,600 out of pocket, Medicare will pay 95 percent of prescription drug costs.
MEDIGAP

There are currently 10 Medigap plans that Medicare members can select from. Each plan must cover the basic benefits that are listed below:
Basic Benefit Comments
Medicare Part A coinsurance and hospital benefits

Medigap policies will pay:

  • $219 per day for days 61-90 of a hospital stay
  • $438 per day for days 91-150 of a hospital stay
  • Up to 365 more days of a hospital stay during your lifetime after you exhaust all Medicare hospital benefits
Medicare Part B coinsurance or copayment Covered after beneficiary has met their annual Medicare deductible.
Blood First three pints of blood or equal amounts of packed red blood cells per calendar year, unless your or someone else donates blood to replace what you use.
Part D (available in 2006) Drug discount cards available in 2004 to help members save on prescription drugs.

New prescription drug benefit will be effective in 2006. All members will be able to enroll in plans that cover prescription drugs.

  • Members will select the drug plan and pay a premium monthly.
  • Members will be responsible for a $250 deductible.
  • Medicare will then pay 75 percent of costs between $250-$2,250 in prescription spending and the beneficiary will be responsible for 25 percent.
  • Members will be responsible for 100 percent of prescription costs above $2,250 until they have reached $3,600 in out of pocked spending.
  • Once members have exceeded the $3,600 out of pocket, Medicare will pay 95 percent of prescription drug costs.
The following chart provides more information on each of the Medigap plans.
 
A
B
C
D
E
F
G
H
I
J
Basic Benefits
  • Covers Part A coinsurance and cost of some extra days of hospital care after Medicare coverage ends
  • Part B coinsurance or co-payment amount which may vary according to service
  • First 3 pints of blood per year
x
x
x
x
x
x
x
x
x
x
Part A Inpatient Hospital Deductible
-
x
x
x
x
x
x
x
x
x
Part B Annual Deductible ($100)
-
-
x
x
x
x
x
x
x
x
Part A Skilled Nursing Facility Coinsurance
-
-
x
-
x
x
x
x
x
Foreign Travel Emergency
-
-
x
x
x
x
x
x
x
x
At-Home Recovery
-
-
-
x
-
-
x
-
x
x
Part B Excess Charges
-
-
-
-
-
100%
80%
-
100%
100%
Preventive Care
-
-
-
-
x
-
-
-
-
x
Prescription Drugs (subject to cap)
-
-
-
-
-
-
-
x ($1,250)
x ($1,250)
x ($3,000)

This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.

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