Welcome to “Help with Health Care,” a online series designed to help you better understand health care and health insurance. We know health care and health insurance can be confusing. We're always here to help. If you have any questions about health insurance, speak with a Medicare Benefit Consultant today.
Help with Health Care: Understanding Medicare
ABCD's of Medicare
Medicare helps cover the cost of health care and is made up of four parts, Parts A, B, C and D that all offer different types of coverage.
Part A - Hospital
Part B - Medical
Part C - Medicare Advantage
Part D - Prescription Drug
Part A: Benefit Period
We'll explain Medicare Part A benefit periods, how they work, and ways to help cover some of the associated costs.
What’s a benefit period?
A benefit period begins the day you’re admitted to a hospital or skilled nursing facility. The benefit period ends when you haven’t received inpatient hospital care or care in a skilled nursing facility for 60 days in a row.
What are the costs associated with your part A inpatient hospital care?
With Original Medicare, you’re responsible for part A hospital inpatient deductibles and coinsurances. You pay a deductible or out-of-pocket amount, for each benefit period. After 60 days, you pay additional per day coinsurances
Original Medicare Part A hospital stay costs can add up, but there are options available to help alleviate some of the burden.
Medigap, or Medicare Supplemental plans, can help you avoid paying high costs for your Part A hospital stays. With a Medigap plan, your Original Medicare pays first and the Medigap plan pays second. Most Medigap plans will cover the Part A deductible and associated coinsurance amounts.
Another option, Medicare Advantage, this plan becomes your primary insurance instead of Medicare. Most Medicare advantage plans have a per-day hospital copay for inpatient stays. Medicare Advantage plans also have a yearly out-of-pocket maximum, so there’s a limit on how much you pay in a plan year for covered services.
Part B: In the Know
We’re going to talk about Medicare Part B, how it works, and when you need to apply for it. Medicare Part B is the medical insurance of your “Original Medicare.” You must meet an annual deductible before Medicare begins to pay for your Part B benefits.
Not every Medicare beneficiary is required to take Part B when they turn 65. If you choose to continue working, you’re still eligible for Medicare, but now you can decide how and when you want to take Medicare Part B.
Once you decide to retire or you decide to leave work, then you’re entitled to a special enrollment period which is also known as an S-E-P. You have eight months to use this special enrollment period to avoid any Part B late enrollment penalty.
You must contact the Social Security Administration to apply for Part B by phone or by downloading the application from their website at ssa.gov. We recommend starting this process 30 to 60 days before your retirement or loss of coverage date to avoid any lapse in your insurance coverage.
Part D: Deductible and First Copay
A deductible is an amount that you need to pay out of pocket, before your plan benefits begin.
If you are in a plan that has a drug deductible, you must pay the full cost of your drugs until you satisfy the deductible amount. Once you have reached this amount and satisfied the deductible, your plan benefits would begin and the insurance carrier would begin sharing the cost of your drugs.
If the actual cost of your prescription is higher than the deductible amount, you will be responsible to pay the deductible amount plus the regular tier copay for that drug the very first time you fill this prescription. The next time you went to fill the prescription, your plan benefits would begin and you would only pay the tier copay for the drug.
It’s important to note that Not all Medicare plans have a drug deductible and not all prescriptions may be subjected to the deductible—even if there is a deductible on the planIf the actual cost of your prescription is higher than the deductible amount, you will be responsible to pay the deductible amount plus the regular tier copay for that drug the very first time you fill this prescription. The next time you went to fill the prescription, your plan benefits would begin and you would only pay the tier copay for the drug.
Part D: Late Enrollment Penalty
We know that medications can be very expensive. The good news is that costs can be reduced by picking up a stand alone Part D Prescription Drug plan along with your Original Medicare A and B Plan, or by enrolling in a Blue Shield Medicare Advantage Plan that includes prescription drug coverage.
Maybe you don't have medications. Learn about the Late Enrollment Penalty and how you can save money now by enrolling in a Part D plan now.
The Four Stages of Part D Drug Coverage
It’s important to know that your total drug costs are being calculated throughout the year. You may not end up in the coverage gap each year, but you should still be aware of how it works.
Before the beginning of each plan year, Medicare announces the amount of money Part D beneficiaries spend to move through each coverage stage. This is standard on all Medicare Part D plans. Medicare may adjust these limits each year.
There are four stages to your Part D Drug Coverage which are the deductible, initial coverage, coverage gap, and catastrophic coverage.
- Stage 1 or the deductible stage. You must pay the full cost of your drugs until you satisfy the deductible amount. The drug deductible may not pertain to all tier levels. So once you satisfy the drug deductible, you will move on to the next coverage stage or the initial coverage.
- Initial coverage stage, you pay your regular tier copay or coinsurance for your prescriptions. You’ll remain in the initial coverage stage until your total retail drug costs reaches a certain dollar amount, set by Medicare each year. This includes the amount that both you and your plan pay.
- The coverage gap or donut hole, you will begin paying a certain percentage of the cost of your prescriptions. You’ll stay in the coverage gap until your total out-of-pocket costs reaches the amount that Medicare set for the year. This includes what you have paid during stages one, two, and three, as well as the costs that your plan or other agency paid on your behalf while in the donut hole.
- Catastrophic coverage, you’ll now you pay a smaller amount for your prescriptions. You’ll pay the greater of either a coinsurance of the cost of the drug, or the Medicare set copay amount.
All Medicare Advantage plans cover the same diabetic supplies and medications that Original Medicare covers, like glucose monitors, insulin, insulin pumps, and test strips. Our Medicare Advantage plans go above and beyond this coverage and give you more opportunities to save and better manage your diabetes.
We want to help you lead the healthiest life possible. That’s why we offer programs and one-on-one phone counseling to help you better manage your diabetes. Our care management team can work with you and your doctor… all at no cost.
Highmark Blue Shield of Northeastern New York wants to help you manage your diabetes. That's why we've partnered with Livongo®, a technology tool with coaching support, offered at no cost to Medicare Advantage members. Livongo provides an easy and convenient way to keep track of your health with a smart glucose meter, unlimited testing supplies, and health coaching — all through your cell phone.
Losing Employer Coverage
If you’re within three months of your 65th birthday, are over 65, or have certain qualifying disabilities or conditions, there’s good news.
You will need both Original Medicare Part A, hospital coverage, and Part B, medical coverage. In addition, you have Medicare Advantage Part C plan options. These plans generally cover hospital, medical, and prescription drug coverage, as well as other added benefits like dental, vision, hearing, gym memberships, and more.
If you’re under 65, you still have a few options.
- COBRA gives workers and their families who lose their health benefits a choice to continue group health benefits provided by their group health plan for limited periods of time.
- Individual and Family plans can either be purchased through the New York State of Health exchange at nystateofhealth.ny.gov, or through one of our representatives.
- You and your children may also be eligible for Medicaid, the Essential Heath Plan, or Child Health Plus. Based on your household size, income, and other factors, you may qualify for one of these low or no-cost health options.
Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BSNENY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BSNENY 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 1-833-735-4515 (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 1-833-735-4515 (TTY 711)
Content Last Updated: October 1, 2021