The options for Medicare plans and program offerings can be overwhelming. We're here to help!
Medicare 101
Types of Medicare Coverage
Medicare is the federal health insurance program for:
People who are 65+
Certain people with disabilities
People with End-Stage Renal Disease (ESRD)
Medicare Part A (Hospital)
Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home healthcare services.
Medicare Part B (Medical)
Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
Medicare Part C (Medicare Advantage)
Also called Medicare Part C, these plans combine the benefits of Original Medicare (Part A and Part B) into a single plan with additional coverage, like dental, vision, hearing, wellness, and more.
Medicare Supplement
Medicare Supplement, or Medigap, bridges the coverage gap left by Original Medicare (Part A and Part B) and covers costs like deductibles, copayments, and coinsurance.
Medicare Part D (Drug Coverage)
Medicare Part D Prescription Drug Plans (PDP) work in tandem with Original Medicare (Part A and Part B) and Medicare Advantage plans to provide prescription drug coverage.
Medicare Dental & Vision Plans
Dental and vision plans are additional ancillary products beneficiaries can purchase (as standalone or part of Medicare Advantage) since they are not included in Original Medicare (Part A and Part B) coverage.
Original Medicare
Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital) and Part B (Medical). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
Medicare Part A (Hospital) Senior Wellness Programs
Medicare Part A primarily covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home healthcare services. While it doesn’t directly cover wellness programs, it does include some aspects of care that can impact overall wellness, such as:
Home Healthcare: Covers in-home skilled nursing care and physical therapy if you’re homebound.
Inpatient Mental Health Services:
Inpatient Psychiatric Hospital Stays: Covers hospital stays for mental health conditions in a psychiatric hospital, including treatment for severe mental health disorders requiring hospitalization.
Skilled Nursing Facility Care: Covers mental health care in a skilled nursing facility under certain conditions, typically following a hospital stay.
Medicare Part B (Medical) Senior Wellness Programs
Medicare Part B covers a range of outpatient services that are crucial for senior wellness, including:
Annual Wellness Visits: Medicare Part B covers annual wellness appointments with providers.
Preventive Services: Medicare Part B covers various preventive services:
Depression Screening: Covers annual depression screenings in a primary care setting, including further diagnostic testing and treatment.
Mental Health Counseling and Psychotherapy: Covers outpatient mental health services, including counseling and psychotherapy sessions provided by licensed professionals such as psychologists, clinical social workers, and psychiatric nurse practitioners.
Obesity Counseling: Covers counseling to help manage obesity, including diet and exercise counseling.
Screenings: Covers screenings for conditions like diabetes, cardiovascular diseases, and certain cancers, which are critical for early detection and management.
Smoking Cessation Counseling: Covers services to help seniors quit smoking, which is a crucial aspect of preventive health.
Medicare Part C (Medicare Advantage) Senior Wellness Programs
Medicare Advantage plans are offered by private insurance companies and often include additional benefits beyond those covered by Original Medicare (Part A and Part B). Many Medicare Advantage plans provide:
Extended Mental Health Coverage: Covers expanded mental health services, such as more extensive therapy options, additional counseling sessions, and sometimes holistic approaches to mental wellness.
Fitness Programs: Covers memberships to gyms, fitness centers, and group fitness classes like yoga or water aerobics.
Vision and Dental Coverage: Covers routine vision and dental care.
Wellness Programs: Covers additional wellness services such as nutrition counseling, weight management programs, and even home safety evaluations.
When to Enroll in Senior Wellness Programs
The plan you choose will dictate when you can enroll in the different wellness programs. These are the main enrollment periods throughout the year:
Annual Enrollment Period (AEP): The main enrollment period runs annually from October 15th to December 7th.
Initial Enrollment Period (IEP): This is the seven-month window around your 65th birthday when you first become eligible for Medicare. It starts three months before your 65th birthday, includes your birthday month, and extends three months after.
Open Enrollment Period for Medicare Advantage Plans (OEP): If you're enrolled in a Medicare Advantage plan, you can switch to a different plan or return to Original Medicare from January 1st to March 31st each year.
Special Enrollment Periods (SEPs): Certain life events may qualify you for a Special Enrollment Period. Consult with your agent to determine if you are eligible for this.
Medicare Cost Plan
A type of Medicare health plan available in some service areas. If a member receives services outside of the plan's provider network without prior authorization or a referral, their Medicare-covered services will be reimbursed according to the Original Medicare fee schedule. The Cost Plan will cover emergency services or urgent care needs.
Medicare Health Maintenance Organization (HMO) Plan
With most HMO-based Medicare Advantage plans, enrollees generally receive covered healthcare services from medical providers who are members of the plan's network, except in emergency situations. Additionally, many HMO plans require an enrollee to obtain a referral from their designated primary care physician prior to receiving specialty or hospital-based care. These types of HMO-based Medicare Advantage plans are offered in select areas.
Medicare Medical Savings Account (MSA) Plan
Medicare Savings Account (MSA) plans pair a high-deductible Medicare Advantage insurance plan with a dedicated financial account. Medicare deposits funds into this account to help cover medical costs. Enrollees can access this money to pay for healthcare expenses, though only costs pertaining to Medicare-covered services will accumulate toward satisfying the plan deductible.
Medicare Preferred Provider Organization (PPO) Plan
Some areas of the United States offer a Medicare Advantage plan where members pay lower costs when utilizing healthcare services from physicians, facilities, and providers within the plan's covered network. While out-of-network care is also available, members would be subject to additional expenses when receiving care outside of the preferred network.
Medicare Private Fee-For-Service (PFFS) Plan
A Private Fee-For-Service plan is a type of Medicare Advantage plan where the plan determines reimbursement levels for healthcare providers and the patient cost-sharing amounts for received medical services. This plan model differs significantly from Original Medicare, and enrollees must carefully adhere to the specific rules of their Private Fee-For-Service plan. Within this plan structure, an individual's out-of-pocket expenses for Medicare-covered benefits may be more or less than under Original Medicare. Close attention to plan benefit designs and network status is important for Private Fee-For-Service enrollees.
Medicare Savings Program
State-administered programs that provide financial assistance to individuals with limited means, enabling them to offset some or all Medicare premiums, deductibles, and coinsurance.
Medicare Select
A type of Medigap policy that may require the policyholder to utilize in-network hospitals and, if applicable, in-network physicians in order to qualify for full insurance benefits.
Medicare Special Needs Plan (SNP)
A Medicare Advantage plan that provides targeted and specialized healthcare to specific patient populations, such as individuals who are dually eligible for both Medicare and Medicaid benefits, reside in nursing homes, or live with particular chronic medical conditions.
Pilot Programs
Special projects that aim to test enhancements to Medicare coverage, reimbursement, and quality of care. These are sometimes called demonstrations or research studies.
Program of All-inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) is a special health plan that provides comprehensive medical and social services covered by both Medicare and Medicaid. In addition to these standard benefits, PACE also offers further medically necessary care and services as determined by an interdisciplinary healthcare team based on the individual's specific needs. By combining medical, prescription drug, social support, and long-term care services, PACE aims to serve enrollees who remain in the community.
State Health Insurance Assistance Program (SHIP)
A state program that receives federal funding to provide free local health insurance counseling services to Medicare beneficiaries.
State Pharmaceutical Assistance Program (SPAP)
A state program that provides financial assistance for prescription drug coverage eligibility based on financial need, age, or medical condition.
