Q: What is Medicare?

According to CMS.gov , Medicare started in 1965 (over 50 years) when President Lyndon Johnson with U.S Congress enacted the Medicare bill (Title XVIII) of the Social Security Act providing health coverage for U.S. senior citizens (65 years and older). Medicare is a federal, “pay-as-you-go” program, which means; Social Security taxes today fund benefits today and any extra funds are held in a futures account. Part of the tax pays for OASDI (old age, survivor and disability) benefits and the other fund goes directly to Medicare. Medicare offers seniors two options Original Medicare (Part A and Part B) and Medicare Advantage (Part C).

Q: What doesn't Medicare cover?

Medicare may not cover the following items; Deductibles Coinsurances Co-payments Long Term Care / Custodial Care Prescription Drug Coverage (unless Part C) Dental, Vision and Hearing insurance Critical Illness Coverage Cosmetic Surgery Always check your health plan carefully or have a licensed Agent help assist you.

Question 1

What is Medicare?

Accepted Answer

According to CMS.gov, Medicare started in 1965 (over 50 years) when President Lyndon Johnson with U.S Congress enacted the Medicare bill (Title XVIII) of the Social Security Act providing health coverage for U.S. senior citizens (65 years and older). Medicare is a federal, “pay-as-you-go” program, which means; Social Security taxes today fund benefits today and any extra funds are held in a futures account. Part of the tax pays for OASDI (old age, survivor and disability) benefits and the other fund goes directly to Medicare. Medicare offers seniors two options Original Medicare (Part A and Part B) and Medicare Advantage (Part C).

Question 2

What are the main differences between Medicare and Medicare Advantage?

Accepted Answer

The main differences between Medicare and Medicare Advantage go beyond just coverage, availability, and price. It comes down to trust. Since Original Medicare is funded by taxpayers, the idea of foregoing its management from the U.S government to for-profit, private insurance may have some more concerned than others. Another big difference is based on freedom. Original Medicare operates like a Preferred Provider Organization (PPO) whereas Advantage is similar to a Health Maintenance Organization (HMO). For example, PPO's often give people freedom to choose doctors unlike HMO's that can limit people to networks within states or even zip codes! For more information on Medicare, Medicare Advantage and Medicare Supplements follow us on The Medicare Journey and escape the Medicare Maze.

Question 3

What does Medicare cover?

Accepted Answer

According to Medicare.gov, Medicare may cover many things depending on what path one takes. The question you should really be asking is, what does Medicare consist of? The answer: Medicare is made up of Four (4) Letter 'Parts' NOT 'Plans'. When dealing with Medicare, there is a big difference between the two terms 'Parts' and 'Plans' because they represent entirely different insurances as you will see. Plans represent Medigap Plans which are private insurance plans that help cover the costs that Medicare doesn't pay for. By keeping these terms separate in your mind, you will understand Medicare more easily as this can be a major source of confusion for many. Medicare consists of of the following parts;

Medigap Plans also cover;

Hospital Insurance (Part A).
Medical Insurance (Part B).
Medicare Part A Coinsurance.
Medicare Part B Coinsurance.
First Three (3) Pints of Blood.
Part A Hospice Coinsurance.
Skilled Nursing Facility Care Coinsurance.
Part A Deductible.
Part B Deductible.
Part B Excess Charges.
Part B Co-payments
Foreign Travel Emergency Insurance.
Gym memberships and other perks.

Question 4

What doesn't Medicare cover?

Accepted Answer

Medicare may not cover the following items;

Always check your health plan carefully or have a licensed Agent help assist you.

Question 5

How does Medicare enrollment work?

Accepted Answer

Enrolling in Medicare is automatic, upon turning age 65 years old or after applying for Social Security benefits. According to SSA, if a recipient earned their full, 40 Social Security credits, they are entitled to free, Medicare Part A not Part B. If they didn't receive full credit, this coverage is paid for out of their Social Security income. Read more about Social Security Benefits and Medicare Enrollment Periods.

Question 6

How do I compare Medicare and Medicare Advantage?

Accepted Answer

When comparing between Original Medicare and Medicare Advantage Plans, one needs a Complete Health Plan Perspective before settling. Seniors are often bombarded with information and sales calls to make quick decisions which may impact their entire life. Still many make decisions in haste based off pushy sales agents, poor information or price alone. Switching between plans is not as easy as some expect. There are rules. The Complete Health Plan Perspective looks at Medicare as a whole and helps seniors evaluate their options.

Question 7

How is Medicare paid for?

Accepted Answer

Every employed or self-employed American pays for Medicare in the form of payroll taxes called the Federal Insurance Contributions Act (FICA). FICA Infographic.

Question 8

How does Medicare billing, claims and appeals work?

Accepted Answer

According to CMS, Medicare billing is handled by Medicare and private insurance carriers. Every three (3) months, those enrolled into Medicare, will receive a Medical Summary Notice (MSN), also known as an Explanation of Medicare Benefits (EOMB) which denotes all the specific medical costs and supplies billed to Medicare on behalf of the beneficiary from the previous quarter. Any excess charges (ie: the 20% left over costs) are coordinated with private Medigap Insurance, Medicare Advantage or paid out-of-pocket.

If a recipient was under or over-charged, they can make a claim to the Medicare claims processor. In the case of Medicare claims, every enrollee has the right to appeal the following:

An application that was denied for a Medicare program.
If an enrollee received a service or line-item that is not covered by the plan and he or she believes it should be.
A service or item was denied and the enrollee believes it should be paid for.
The amount that Medicare actually paid for a service or item.
If Medicare or the enrollee’s plan provider (Carrier) stops providing or paying for all or part of a healthcare service, supply, item or prescription drug that the enrollee believes he or she still needs.

When appealing, an enrollee can self-file or appoint a representative to help with the process. A representative can be any of the following: family member, friend, attorney, doctor or anyone an enrollee chooses. After filing an appeal against a Medicare decision or expense, there are five levels of appeals an enrollee can go through (NIS, 2018);

A redetermination by the company that manages claims for Medicare.
A reconsideration from a Qualified Independent Contractor (QIC).
A hearing before a Administrative Law Judge (ALJ).
A review by Medicare Appeals Council (Appeals Council).
A Judicial review by a federal district court.

Click Here to Make an Appeal. Here is an article we found that explains Medicare spending for stats.

Question 9

Who manages Medicare?

Accepted Answer

Medicare eligibility and the processing of premiums go through the Social Security Administration (SSA) but Medicare laws and Medicare administration are not managed by the SSA. The Centers for Medicare and Medicaid Services (CMS) further administer the program by providing ‘enrollees’ with over 1.5 million healthcare providers and suppliers, that are contracted with the Federal Government.

Question 10

What if I don't accept Medicare?

Accepted Answer

Although seniors are not forced to accept Medicare, it would be unwise not to accept it because Medicare is the foundation for health care. Even if one is covered by a group plan, Medicare is still a secondary safety net. Any claims beyond the group coverage fall on Medicare to cover the costs. You could be putting yourself in a compromising situation without basic Medicare coverage and could pay a penalty for choosing not to enroll on-time.

The Medicare Journey™

Medicare Insurance

60 Seconds

Medicare is so confusing & seniors are making ill-informed decisions that can have lasting consequences!

Where are you now?

New to Medicare

On Medicare

The Complete Health Plan Perspective™

Who will you choose?

Medicare Broker

Insurance Carrier

Independent Agent

*As a Broker, Bridge only makes a commission if you like the plans we offer & only when decide to purchase. Save your time, money & energy, just ask Bridge.

Medigap Plans

Find the Right Drug Plan Nearest You

Medicare Parts Explained

Medicare Advantage

Medicare Enrollment Periods for 2020

Find a Medicare Plan to Fit Your Needs with Bridge!

Anti-Fraud Committment

FAQ’s

How much does Medicare cost?

Switching from Advantage to Medicare

I need to buy a Part D separately?