Understanding Medicare

  • Summer 2023
Clipboard on an blue with white stars background with a piece of paper clipped to it hat reads Medicare, Part A, Pat B, Part C, D

If you are puzzled by Medicare and the many choices you have as a Medicare beneficiary, you’re not alone. Our chart below helps to compare the differences between original, traditional Medicare and the Medicare Advantage plans.

In addition to our chart, you can find more information at Medicare.gov as well as Senior Health Information & Insurance Education (SHIINE) and Minnesota Senior Linkage Line.

 

ORIGINAL/TRADITIONAL MEDICARE

MEDICARE ADVANTAGE PLANS

PLAN COMPONENTS

Part A: Hospital care, including hospital stays, short-term skilled nursing care, hospice, and home health.

Part B: Clinic and outpatient care with doctors and other health care providers.

Part D: Prescription drug coverage

Medigap: optional Part A & B supplemental insurance to pay for out-of-pocket costs. Offered by commercial insurers.

Part C: Combines Parts A & B of Original Medicare

Part D: Prescription drug coverage

Other: some Medicare Advantage plans include additional coverage, such as vision, dental or travel expenses.

PLAN MANAGER

Government-managed single-payer system.

Government contracts with a private insurer to provide coverage for Medicare eligible individuals.

HOSPITAL CARE

Freedom to choose any hospital that accepts Medicare. No restrictions on networks.

Able to be seen at any hospital that accepts Medicare. Low out-of-pocket options are only hospitals that are in-network with the specific plan. Using of out-of-network hospitals may have additional out-of-pocket costs.

CLINIC CARE

Freedom to choose any medical provider that accepts Medicare. No referral required to see specialists.

Able to be seen by any medical provider that accepts Medicare. Low out-of-pocket options are only those providers or medical suppliers that are in-network with the specific plan. Referral required to see a specialist. Out-of-network providers may have additional out-of-pocket costs.

PREMIUMS

Part A: $0 if the person/spouse paid Medicare taxes during employment over the course of 40 quarters.

Part B: $164.90 - $560.50/month, depending on income. Premiums withdrawn from monthly Social Security Income.

Part D: different levels of coverage depending on plan. Can range from $7 - $110+/month.

Medigap: different levels of coverage depending on plan. Can range $75 - $400+/month.

Part C: depends on the plan chosen. Can range from $0 - $400+ per month. Lower premiums equal higher deductibles and coinsurance amounts. Higher premiums equal lower deductible and coinsurance amounts.

Part D: some Part C plans include Part D coverage. If it does not, separate coverage can be purchased. Different levels of coverage depending on plan. Can range from $7 - $110+/month.

2023 OUT-OF-POCKET EXPENSES

Part A:

  • Deductible: $1,600.00
  • Coinsurance: per days in hospital per year
    • Days 0 – 60: $0
    • Days 61 – 90: $400/day
    • Days 91+: $800/day
  • Home Health: $0
  • Skilled Nursing Facility: $200/day
  • Durable Medical Equipment: 20% of Medicare approved amount
  • Hospice: $0

Part B:

  • Deductible: $226
  • Coinsurance: 20% of Medicare approved amount

Part D:

  • Deductible and Coinsurance both depend on plan selected

Medigap: will pick up some or all of Part A and Part B coinsurance and copay out-of-pocket costs depending on selected plan.

Part C:

  • Deductible: varies depending on the specific plan.
  • Copayment: usually begins on day 1 of hospitalization. Varies depending on the specific plan.
  • Part A & B In-Network Maximum Out-of-Pocket Limit: $8,300
  • Part A & B Out-of-Network Maximum Out-of-Pocket Limit: $12,450
  • Part D Maximum Out-of-Pocket Limit: $7,050

HOSPITAL COVERAGE

Inpatient: Semi-private room, meals, nursing services, drugs, supplies, etc. Includes care provided in critical access facilities and mental health facilities.

Skilled Nursing: Covered after a 3-day qualifying hospital stay. Covers room and meals, nursing services, rehab services, and medication. Maximum 100 days per stay.

Home Health: Covers care if ordered by physician. Can include skilled nursing, home health aides, durable medical equipment and medical supplies.

Hospice: Covers those with a terminal illness and less than 6 months to live. Can include drug and symptom relief, medical services, support services like pastoral care and grief counseling, and some inpatient care if the family caregiver needs a rest.

Must provide at least the same coverage as Traditional Medicare, but may have different rules, costs and restrictions as determined by the specific plan.

CLINIC & OUTPATIENT COVERAGE

Physician Visits

Outpatient Services

Other services not covered by Part A: anesthesia, radiology, labs, etc.

Must provide at least the same coverage as Traditional Medicare but may have different rules, costs and restrictions as determined by the specific plan.

PRE-AUTHORIZATION FOR SERVICES

Does not generally require prior authorization for services with the exception of durable medical equipment, medications given in outpatient setting like chemotherapy, some pain injections, cosmetic procedures, and skilled nursing stays.

Required by most Medicare Advantage plans for most services, including durable medical equipment, medications given in an outpatient setting like chemotherapy, skilled nursing stays, inpatient hospital stays, diagnostic procedures, labs, tests, partial hospitalization programs and home health services.

Are you a Medicare beneficiary who would like a better understanding of how Medicare works? Save the date and attend the free Understanding Medicare seminar at Brookings Health System on either Sept. 13 or Sept. 27.