Skip to content
ePro Associates
ePro LOGO Dark

GUIDE TO MEDICARE

Watch our seminar for more details

  • What is Medicare?
  • How to apply for Medicare?
  • What is the Original Medicare cover?
  • What is the difference between Medicare and other insurance?
  • What is Part D?
  • What is the Supplement Plan?
  • What is the Advantage Plan(Part C)?
Medicare_card_new

Medicare is the nation’s medical health insurance program for eligible people 65 years of age or younger. Certain people under the age of 65 are also eligible for Medicare, including people with disabilities, permanent kidney failure, and amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Generally, you can qualify if you meet the following requirements.

First, you are 65 years of age or older; second, you are a U.S. citizen or a green card holder who has lived in the U.S. for more than five years; and third, you have been filing tax returns legally for 10 years or have earned 40 work quarters. If you do not have a job, you can rely on your spouse to meet the 40-point requirement. However, you must also be 65 years old and have legal status to qualify.

What parts are included in MEDICARE? What coverage is covered?

Medicare (also known as the “Red and Blue Card”) consists of 2 parts.

1. Medicare Part A (Part A)

2. Medicare Part B (Part B)

People with Medicare have a blue card and a red card, commonly known as the “red and blue card”.

Original Medicare

  • Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).
  • You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
  • You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
  • To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also shop for and buy supplemental coverage.
Medicare Part A and Medicare Part B are called traditional plans.

In general, Part A covers:

  • Inpatient care in a hospital
  • Skilled nursing facility care
  • Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
  • Hospice care
  • Home health care

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something that's usually covered but your provider thinks that Medicare won't cover it in your situation. If so, you'll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
  2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Part B covers 2 types of services

  • Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Part B covers things like:

  • Clinical research  
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
    • Inpatient
    • Outpatient
    • Partial hospitalization
    • Intensive outpatient program services (starting January 1, 2024)
  • Limited outpatient prescription drugs
With a medicare card, what else do you need?

Medicare Card traditional plans do not include prescription drug coverage. In 2003, Congress passed a new law that added a plan specifically to reimburse prescription drugs called Part D. If you need to take special medications, you will pay a higher premium. “Medicare Part D” has one more point: delaying applications for the plan results in a lifetime late application penalty!

Do I need a supplemental plan?
Traditional plans (Medicare Parts A and B) reimburse you for 80% of your expenses and Part D reimburses you for prescription drugs. This leaves an uncapped 20% uncovered portion that can be a concern for your quality retirement. But don’t worry, you can buy a supplemental plan! Supplemental Plan G (Medigap Plan G) will reimburse the remaining 20% of your Part A deductible, including travel abroad for medical emergencies (80%). The supplemental plan is approximately $150-$180 per month. It is the same as the Red and Blue Card: no network restrictions, coverage throughout the U.S., no prior authorization required, no referrals needed for specialty visits.
One key point: the government requires that as long as you apply for a Supplemental Plan within 6 months of the Red and Blue Card’s effective date, the insurance company must offer you the lowest price and cannot deny you coverage. If this period is exceeded, the insurance company will investigate your health status and has the right to increase or even deny your coverage based on your health status. So, make sure you pay attention to the application deadline for the Supplemental Plan and try not to miss it!
Part C (aka Advantage Plan)

Part C, the discount plan, is offered by a licensed private health insurance company and covers all the medical services that are covered under Part A and Part B, so it can be used in place of the Red and Blue cards. Unlike Supplemental Plans, many Part C plans do not require premium payment. Unfortunately, however, the network coverage is small and you will have to pay a registration fee for each doctor’s visit. Discount plans even include services not covered by traditional plans, such as dental, vision and hearing aids, as well as other benefits and services, gym memberships, transportation, and over-the-counter drug programs. In addition to network restrictions, Part C requires a portion of the medical costs to be shared.
Customers who choose a Part C discount plan have the option to add, change, cancel or switch their existing plan between October 15 and December 7 of each year. For example, if you switch from a traditional plan to a Part C discount plan, switch from a Part C to a traditional plan, convert from one Part C plan to another Part C plan, move from a Part D prescription drug plan to another Part D plan, or if you are eligible for the first time and did not purchase one, you can apply during this period and the changes made will be effective January 1 of next year. If you miss this period, you will need to wait until this time next year to make another change or application.

Choose any one you like

To recap, there are different plan options for seniors insurance. If you choose only the traditional plan with 80% reimbursement plus a Part D prescription drug plan, you will pay an average monthly premium of $174.70. If you want to add a supplemental plan to cover the remaining 20%. If you want the lowest price for your coverage, you can choose a Part C discount plan with no monthly fee, but this plan has network limitations and requires pre-approval status. Whatever you decide, you can contact us. We can work out a plan that suits your individual situation.

The following is an example of a Advantage Plan: 

Screenshot 2023-10-18 at 12.47.59 PM