Benefits Covered By Medicare

Different types of Medicare cover different situations. Medicare Part A is hospital insurance and covers inpatient stays at hospitals, hospice, and skilled nursing facilities. Medicare Part B is more generalized insurance, including doctor visits, outpatient care, medical equipment, and some preventative services. Prescription drugs are covered by a separate Medicare plan (Part D). Part A and Part B are often referred to as “Original Medicare.”

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What Do Medicare Plan Coverages Include?

Generally speaking, if you have Medicare Part A, only hospital visits, hospice, and skilled nursing facility stays are covered. If you have Medicare Part B, much more may be covered, including:

  • Doctor visits (routine, necessary and preventative care)
  • All preventative services (such as a flu shot and routine screenings)
  • Ambulance services
  • Mental health (inpatient, outpatient, partial hospitalization)
  • Second opinions prior to surgery

A Medicare Advantage Plan, sometimes referred to as Medicare Part C, is a type of Medicare health plan offered by a private company that contracts with Medicare to provide your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans (PFFS), Special Needs Plans (SNP). If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan instead of under Original Medicare. Most Medicare Advantage plans also offer extra benefits such as prescription drug coverage.

What are some key differences between Original Medicare and Medicare Advantage plans?

Each individualized Medicare plan can offer additional benefits, as is the case with private health insurance and Medicaid. For specific questions, it’s best to consult with your plan provider. For example, Medicare Advantage plans can have networks, like HMOs and PPOs, offer special needs plans, and often include prescription drug coverage. They may also include things that Original Medicare does not cover such as additional dental, vision, or hearing coverage. Consult with an Aevo Services representative to find out which plan could meet your medical and financial needs.

Do the benefits ever run out?

Medicare benefits rarely end or expire for senior citizens and retirees. For disabled persons receiving Social Security Disability Insurance (SSDI), however, Medicare benefits can end if the person is no longer considered disabled by the Social Security Administration (SSA). The person could also elect to go to back to work if they are no longer disabled, and then Medicare benefits could end. It is important to note that there is a maximum allotment of hospitalization days Medicare Part A will cover. After that maximum is reached, Medicare recipients will need to cover their own hospital costs, which is why it’s important to review the additional Medicare options available in your area which can help you with your Medicare costs.

Who is eligible for Medicare?

Senior citizens over age 65 and disabled persons who receive SSDI are eligible for Medicare. Medicare is different than Medicaid, which is a federal and state-based assistance program for low-income persons of any age. Those who need medical assistance and cannot afford it should apply for Medicaid through their state of residence.

How does the process of Medicare work? What are the steps that everyone goes through, including those on SSDI?

A person must receive Social Security disability benefits for 24 months (2 years) to begin receiving Medicare benefits, and this happens via auto-enrollment. SSDI recipients are automatically enrolled in Part A and Part B, with an option to decline Part B.

If you are ready to retire at age 65 and are deemed eligible, you will need to contact your local Social Security Office to enroll in Medicare Part A and Part B. Even though you are entitled to Medicare benefits, enrollment does not happen automatically, you must still sign up. If you are not ready to retire, you are still able to apply for Medicare on Social Security’s website. It’s best for those turning 65 to be proactive and sign up for Medicare on the website starting three months before their birthday, when your election period begins, to avoid a lapse in insurance coverage.

What are the out of pocket costs with Medicare?

Everyone will still be responsible for cost-sharing with Original Medicare, just as you would be with most health insurances. Most people will not pay a monthly premium for Part A Hospital coverage, but if you’re admitted inpatient to a hospital you will have a deductible of $1,316 (2017) which will cover you for days 1 – 60 that you’re in the hospital. If you’re in the hospital longer than that, your cost-sharing changes to a co-payment amount of $329 per day for days 61 – 90. Most people will have a monthly premium for Part B, the current rate is $134 per month unless you fall into a higher income bracket. Part B does have a small annual deductible of $183 (2017), after that you’ll pay a 20% coinsurance for all Medicare-approved services, Medicare will cover the remaining 80%.

In-Network vs. Out-of-Network Services

For the most part, Original Medicare doesn’t operate like private health insurance, where there are hefty fees for going to an out-of-network provider. With Original Medicare, you must see doctors who accept Medicare, or the cost will be completely out of pocket. However, you will find that many physicians accept Medicare. Medicare Supplement (Medigap) policies can help you cover the costs that Original Medicare does not cover, or Medicare Advantage (Part C) plans can change the out-of-pocket costs you’d be responsible for paying under their coverage. The Medicare Advantage plans are designed with networks, such as HMOs or PPOs. This is something to discuss with your Aevo representative to ensure that you are selecting a plan where your doctors are in-network, medications are covered, and your needs are met.

How and when do I sign up for Medicare?

You can apply for Original Medicare, Parts A and B, by going to the official Social Security website at However, if you have been deemed disabled, you will be auto-enrolled in Medicare and no signing up is necessary. Your auto-enrollment documents will provide you the Medicare application information you need on how to keep or drop Medicare Part B.

What plan has the best coverage for me?

There are many different types of individual Medicare Advantage plans, and questions on this are best answered by a licensed Aevo professional. Plans include: Preferred Provider Organization (PPO) Plans, Health Maintenance Organizations (HMO) Plans, Private Fee for Service Plans (PFFS), and Special Needs Plans (SNP), to only name a few. To find coverage that meets your needs, please contact Aevo.

Are prescription costs covered?

To have prescription insurance through Medicare you’ll need a Part D Prescription Drug Plan. Many medications are covered under Medicare Part D, but not all, so we recommend you speak with an Aevo professional to review your Part D plan options and see if your particular medications are covered by a plan. You can opt to get prescription coverage by signing up for a Medicare Part D stand-alone plan, or by signing up for a Medicare Advantage (Part C) plan that also includes prescription coverage.

When do I have to enroll?

New Medicare recipients, whether you’re eligible due to disability or turning age 65, have an Initial Election Period which starts three months before your Medicare entitlement begins, and lasts for three months after that. During this seven month window you can enroll in a Medicare Advantage or Part D prescription drug plan. Outside of this time frame, you’ll generally need to wait for the Annual Election Period, October 15th – December 7th, to add new policies which will start the following year. However, there are also a number of Special Election Periods that you may qualify for under certain circumstances when you can also pick a new plan.

Aevo Insurance Services, LLC

Whether you have recently been awarded Social Security Disability benefits, are currently uninsured, or have coverage through an employer or government plan, the licensed Medicare specialists at Aevo Insurance Services, a subsidiary of The Advocator Group, are here to support you in making the proper financial decisions as you transition onto the Medicare program.


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