Frequently Asked Questions

When it comes to Medicare, we know just how overwhelming it can be. Your friends at Arizona Medicare Store have put together a quick list of Frequently Asked Questions below. Not finding the answer to your question?

What is Medicare?

Medicare is the federal health insurance program for:

  • People who are 65 or older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

The different parts of Medicare help cover specific services:

Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)

Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Medicare Part C (Medicare Advantage)

Medicare Advantage (also known as Part C) is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D.

Medicare Part D (prescription drug coverage)

Part D adds prescription drug coverage to:

  • Original Medicare
  • Some Medicare Cost Plans
  • Some Medicare Private-Fee-for-Service Plans
  • Medicare Medical Savings Account Plans

These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

What is NOT covered by Part A & Part B?

Medicare doesn’t cover everything. Some of the items and services Medicare doesn’t cover include:

  • Long-term care (also called custodial care )
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and exams for fitting them
  • Routine foot care

Find out if Medicare covers a test, item, or service you need.

If you need services Medicare doesn’t cover, you’ll have to pay for them yourself unless you have other insurance or a Medicare health plan that covers them.

What does Part B cover?

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 servicesHealth 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.

*Note: If you’re in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers things like:

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.

What does Part A cover?

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

*Note: If you’re in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

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.

What happens if Medicare’s contractor decides the penalty is correct?

If Medicare’s contractor decides that your late enrollment penalty is correct, the Medicare contractor will send you a letter explaining the decision, and you must pay the penalty.

What happens if Medicare’s contractor decides the penalty is wrong?

If Medicare’s contractor decides that all or part of your late enrollment penalty is wrong, the Medicare contractor will send you and your drug plan a letter explaining its decision. Your Medicare drug plan will remove or reduce your late enrollment penalty. The plan will send you a letter that shows the correct premium amount and explains whether you’ll get a refund.

How soon will I get a reconsideration decision?

In general, Medicare’s contractor makes reconsideration decisions within 90 days. The contractor will try to make a decision as quickly as possible. However, you may request an extension. Or, for good cause, Medicare’s contractor may take an additional 14 days to resolve your case.

Do I have to pay the penalty even if I don’t agree with it?

By law, the late enrollment penalty is part of the premium, so you must pay the penalty with the premium. You must also pay the penalty even if you’ve asked for a reconsideration. Medicare drug plans can disenroll members who don’t pay their premiums, including the late enrollment penalty portion of the premium.

What if I don’t agree with the late enrollment penalty?

You may be able to ask for a “reconsideration.” Your drug plan will send information about how to request a reconsideration.

Complete the form, and return it to the address or fax number listed on the form.  You must do this within 60 days from the date on the letter telling you that you owe a late enrollment penalty. Also send any proof that supports your case, like a copy of your notice of creditable prescription drug coverage from an employer or union plan.

How do I know if I owe a Part D Prescription Drug penalty?

After you join a Medicare drug plan, the plan will tell you if you owe a penalty and what your premium will be. In general, you’ll have to pay this penalty for as long as you have a Medicare drug plan.

How much is the Part D penalty?

The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.

Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($32.74 in 2020*) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.

The national base beneficiary premium may change each year, so your penalty amount may also change each year. You can read more by clicking here.

 

*The Part D penalty is subject to change

Do I have to enroll in Part D – Prescription Drug Coverage?

If you join a Medicare Drug Plan when you’re first eligible, you won’t have to pay a Part D late enrollment penalty, even if you’ve never had prescription drug coverage before. If you delay enrolling, you will have a late enrollment penalty. The late enrollment penalty is an amount added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without one of these:

  • A Medicare Prescription Drug Plan (Part D)
  • A Medicare Advantage Plan (Part C) (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage
  • Creditable prescription drug coverage

Note: If you get “Extra Help”, you don’t pay the late enrollment penalty. You can apply for Extra Help by clicking here.

What is Medigap?

Since there are many copays and deductibles, private insurers sell Medicare Supplemental Insurance Plans, or Medigap plans. There are different varieties of Medigap plans, depending on the coverage you want. While Medigap plans are standardized in terms of the coverage they provide, costs can vary significantly.

How much does Medicare cost?

Medicare Part A is free for the vast majority of American seniors, but has a deductible of $1,408* per benefit period, as well as coinsurance requirements if your hospital stay lasts more than 60 days or if your skilled nursing stay extends beyond 20 days.Part A is free if you or your spouse has worked and paid taxes to Medicare for at least 40 quarters (10 years). If you do not have enough working quarters, you will have to pay a premium for Part A. If you buy Part A, you’ll pay up to $458* each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $458. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $252. Click here for more information about Part A costs.

Medicare Part B has a monthly premium. The standard Part B premium amount in 2020 is $144.60*. Most people pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA).
Part B deductible and coinsurance costs is $198. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment (dme)

IRMAA is an extra charge added to your premium. Click Here to read more about Medicare Part B costs and premiums.

Part C, also known as Medicare Advantage. These are plans offered by private companies to provide Medicare benefits. The monthly premium varies by plan. If you decide on a Medicare Advantage — or MA — plan, you’ll still have to enroll in parts A and B and pay the Part B premium. Then, in addition, you will have to choose a Medicare Advantage plan and sign with a private insurer. The federal government requires these plans to cover everything that original Medicare covers, and some plans pay for services that original Medicare does not, including dental and vision care. In addition in recent years, the Centers for Medicare and Medicaid Services, which sets the rules for Medicare, has allowed Medicare Advantage plans to cover such extras as wheelchair ramps and shower grips for your home, meal delivery and transportation to and from doctors’ offices. Most Medicare Advantage plans also fold in prescription drug coverage. Not all of these plans cover the same extra benefits, so make sure to read the plan descriptions carefully. Medicare Advantage plans generally are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs). In HMOs you typically choose a primary care doctor who will then direct your care and usually will have to give you a referral to see a specialist. PPOs have networks of doctors that you can see and facilities you can use, often without the need of a referral. If you go to a provider who is not in the plan’s network, you likely will pay more. You generally cannot enroll in both a Medicare Advantage plan and a Medigap plan at the same time.

Part D monthly premium varies by plan (higher-income consumers may pay more).

For more information on Medicare costs, premiums and deductibles, click here for Medicare Costs At A Glance.

*Deductibles are subject to change and may change annually*

What is Medicaid?

Medicaid is a joint federal and state government program that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies depending on the state and the type of Medicaid you have. What you pay for covered services may depend on your level of Medicaid eligibility. Some people with Medicaid get help paying for their Medicare premiums and other costs. Other people may also get coverage for additional services and drugs that are covered under Medicaid but not by Medicare.

The following information explains your healthcare options and the Medicaid portion of dual eligibility. Medicaid benefits are valuable because the state provides additional healthcare coverage and financial support based on your Medicare Savings Program (MSP) aid level as described below:

Full-Benefit Dual Eligible (FBDE): Medicaid will pay for your Medicare Part A & B premiums, deductibles, co-insurances, and co-payments. Eligible beneficiaries also receive full Medicaid benefits.

Qualified Medicare Beneficiary (QMB): Medicaid will pay for your Medicare Part A & B premiums, deductibles, co-insurances, and co-payments. (Some people with QMB are also eligible for full Medicaid benefits (QMB+))

 Specified Low-Income Medicare Beneficiary (SLMB): Medicaid will absorb the cost of your Medicare Part B Premiums. Some people with SLMB are also eligible for full Medicaid benefits (SLMB+)

Qualified Individual (QI): Medicaid will pay costs associated with Medicare Part B
Qualified Disabled Working Individual (QDWI): Medicaid will pay costs associated with Medicare Part A

Note: Some MSP Levels automatically qualify for “Extra Help” for Medicare prescription drug coverage assistance.

How will I determine my drug costs?

If your plan offers a drug benefit, you will generally have to use one of our network pharmacies to fill your prescriptions covered by Part D. You will need to use our plan’s formulary (list of covered drugs) to locate what tier your drug is on to determine how much it will cost you. Each medication will be grouped into one of the five tiers. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached.

Travel Coverage and Medicare Supplement: What will Original Medicare Cover and what will the Medicare Supplement Cover?

Although Medicare usually doesn’t cover health care while you’re traveling outside the U.S., there are some exceptions. Click Here for more information

What Is “Extra Help”?

A Low Income Subsidy (LIS), also referred to as “Extra Help,” may be available to help you with Part D out-of-pocket expenses such as premiums, deductibles, co-insurance or co-pays. Many people qualify for the “Extra Help” Program and don’t even know it. Keep in mind that assistance may also depend on your Medicare Savings Program (MSP) level and your dual eligible status. “

If you have questions about your Medicaid eligibility and what benefits you are entitled to, call: 1-833-444-9089 (TTY users should call 711). You can also click here visit the Social Security Administration website for more information or to apply for “Extra Help”.

What if I Need Extra Help Paying for my Part D Prescription Drugs?

Anyone who has Medicare can get Medicare prescription drug coverage. Some people with limited resources and income may also be able to get Extra Help to pay for the costs — monthly premiums, annual deductibles, and prescription co-payments — related to a Medicare prescription drug plan. Click Here for more information

What if I need extra help with my Medicare Costs?

You can get help from your state paying your Medicare premiums. In some cases, Medicare Savings Programs may also pay Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments if you meet certain conditions.Click Here for more information 

How much is my Part B premium going to be?

On November 8, 2019 the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. Click Here for 2020 Medicare Parts A & B Premiums and Deductibles