What You Need to Know About Medicare

Medicare options-835089-edited

Medicare is complex.


From late enrollment penalties to coverage ambiguities, deciding the when, what and how about your Medicare coverage can be painstakingly confusing. Fortunately, our employees at Sylvia Group have the expertise to help you understand your options and choose the plan that's right for you.

Who is eligible for Medicare?

Medicare is the health insurance program that provides coverage for most Americans after age 65. Medicare provides medical coverage for people under age 65 who are disabled and entitled to Social Security benefits, people who have End Stage Renal Disease (ESRD), or who are diagnosed with Lou Gehrig’s Disease (ALS). For more information on disability-based Medicare eligibility visit ssa.gov.

What does Medicare cover?

Original Medicare refers to Medicare Part A and Part B Insurance. Original Medicare covers many of your health care costs, including hospitalization, skilled nursing care, outpatient medical care and testing, etc. While Medicare covers a portion of your medical costs, it does not cover everything. Certain services are not covered by Original Medicare, although you may purchase private insurance policies to cover some of these services.

The program offers four parts:

Medicare Part A is a baseline health plan that covers hospital inpatient services, care in skilled nursing facilities, home health visits and hospice care.

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Medicare Part B is a supplemental health plan to cover physician services. Coverage includes physician care, durable medical equipment, physician-ordered supplies, ambulatory surgical services, outpatient hospital care, outpatient mental health services and laboratory services.

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Medicare Part C is also referred to as Medicare Advantage. It is required to cover all services in Parts A and B.

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Medicare Part D provides affordable prescription drug plans.

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What doesn't Medicare cover?

Helps provide for the cost of long-term care beyond a predetermined period that is not covered by health insurance, Medicare or Medicaid. Can include nursing home, assisted living facility, adult day care, or in-home assistance, depending on the policy.

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Medicare does not offer coverage for dental care, including preventative and diagnostic care.
Medicare does not offer coverage for ongoing vision care expenses such as routine eye exams, prescription glasses and contact lenses.
Medical expenses incurred while abroad are not covered under Medicare.
Medicare does not cover cosmetic surgery, but it does cover plastic surgery in some scenarios.

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Medicare Part A and Part B does not cover acupuncture. However, some Medicare Advantage plans may provide additional benefits, including acupuncture.
Medicare covers diagnostic hearing exams ordered by your doctor or other health care provider, but it does not cover costs associated with hearing aids.
While Medicare Part B covers medically necessary treatment of foot injuries or diseases, it doesn't cover routine foot care like pedicures.

Medicare Supplement Insurance

Since Medicare requires you to pay deductibles, coinsurance and co-payments for most services, many people purchase private Medicare Supplement insurance to cover their out-of-pocket expenses. In most states, you can only purchase a Medicare Supplement plan within eight months of your Medicare enrollment date. After that, you may be subject to health underwriting to purchase Medicare Supplement insurance. Medicare Supplement plans are standardized across most states. In Massachusetts, however, there are only two Medicare Supplement plans – Core Coverage and Supplemental 1 Coverage. Massachusetts residents do not need to furnish evidence of good health to purchase Medicare Supplemental insurance after their initial enrollment period, and may change their plan at the annual open enrollment period: October 15 to December 7 each year.

Outpatient Prescription Drugs

Outpatient prescription drugs are not covered by Original Medicare. Under the Medicare Modernization Act of 2006, Medicare beneficiaries must purchase prescription drug coverage referred to as Part D insurance. If you postpone the purchase Part D prescription insurance until after your initial enrollment ends, a late enrollment penalty will apply to your insurance premium. 


Q: Is it necessary to shop for a new prescription plan every year? 

A: Given that premiums for most prescription plans are staying about the same or dropping slightly for 2018, you may not need to change plans this year.  However, if your health has changed in the past year – that is, if you are taking more medications, you’ve recently been prescribed medications which are not covered by your plan, or you were notified that your medications are not included in the plan formulary for 2018, for example – then you should review your options during open enrollment.  

Q: What specifically do I need to do if I'm turning 65?

A: Depending on whether you're still working, the answer is, “It depends.” There's no doubt it can be a complicated and confusing process to transition to Medicare — which is why Sylvia Group hosts our annual Medicare webinar every October. You can listen to the webinar and view the accompanying PowerPoint presentation in this video. For an overview of 2018 information regarding deductibles and premiums, including the Income-Related Monthly Adjustment Amounts (IRMAA) for Medicare Part B and Part D premiums, click here.

If you have more questions, contact our Vice President of Employee Benefits and health insurance expert Julie Jennings.

Customized coverage to meet your family's needs

We've been serving needs of families on the SouthCoast and beyond with health insurance for more than 65 years. Because we're an independent agency, we can work with multiple companies to find the policy that best suits your circumstances.


Contact us about Medicare


DISCLAIMER: This information is provided as an overview of Medicare for adults age 65 and older.  Medicare is also the health insurance program for younger disabled adults and those with specific medical conditions. Eligibility requirements, other rules regarding Medicare and details regarding coverage are available through the Medicare website, www.medicare.gov.  


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