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Medicare
O'Brien Senior Benefits helps individuals confidently navigate the often-complicated world of Medicare by offering personalized guidance and ongoing support. Medicare includes many choices and details that can feel overwhelming, which is why I focus on clear education and practical information.
I explain Medicare benefits, rights, and coverage options in plain language, tailored to each person’s specific situation. Partnering with me provides reassurance that Medicare decisions are well understood and aligned with each individual’s healthcare needs.
Medicare 101
Medicare Part A and Part B is known as ORIGINAL MEDICARE.
Medicare Part A
Hospital Insurance
Medicare Part A, also known as hospital insurance, provides coverage for inpatient care in hospitals, skilled nursing facilities (SNFs) for a limited time after a hospital stay, hospice care, and some home health care services.
Here are some additional details about what Part A covers:
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Hospital care: This includes inpatient care in hospitals, critical access hospitals, and mental health care facilities.
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Skilled nursing facility care: Part A covers up to 100 days of care in a skilled nursing facility following a hospital stay. This includes skilled nursing care, rehabilitation services, and other medically necessary services.
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Hospice care: Part A covers hospice care for individuals with a terminal illness. This includes medical, nursing, and social services, as well as counseling and support for the individual and their family.
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Home health care: Part A covers medically necessary skilled nursing care, physical therapy, speech therapy, and occupational therapy, as well as medical social services and some medical supplies.
It's important to note that Part A does not cover most outpatient care, prescription drugs, or long-term care. That's where Medicare Part B and other supplemental insurance plans come in to help fill in those coverage gaps.
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Medicare Part B
Medical Insurance
Medicare Part B, also known as medical insurance, provides coverage for a wide range of healthcare services and items, including:
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Doctor and other healthcare provider services: This includes services provided by physicians, nurse practitioners, physician assistants, and other healthcare professionals.
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Outpatient care: This includes services such as diagnostic tests, surgeries, and other procedures that don't require an overnight hospital stay.
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Home health care: Part B covers medically necessary skilled nursing care, physical therapy, speech therapy, and occupational therapy provided in the home.
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Durable medical equipment (DME): This includes items such as wheelchairs, walkers, and hospital beds that are medically necessary for your care.
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Preventive services: Part B covers a range of preventive services, including screenings for cancer, cardiovascular disease, diabetes, as well as your annual wellness visits and a few more.
Once you meet your yearly deductible, which is $283 for 2026, you will typically pay 20% of the Medicare-approved amount for most Part B services.
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Medicare Part C
Medical Advantage Plan
Medicare Part C, also known as Medicare Advantage, is a health insurance plan offered by Medicare-approved private companies.
These plans provide a "bundle" of benefits that includes all services covered by Medicare Part A (hospital insurance) and Part B (medical insurance). In addition, many Medicare Advantage plans also include prescription drug coverage (Part D).
Medicare Part C, also known as Medicare Advantage, is a type of health insurance plan that is offered by Medicare-approved private companies. These plans are designed to provide a "bundle" of benefits that includes all the services covered by Medicare Part A (hospital insurance) and Part B (medical insurance). In addition, many Medicare Advantage plans also include prescription drug coverage (Part D).
Medicare Advantage plans must cover all the same services as Original Medicare, but they may also offer additional benefits or services that are not covered by Parts A and B, such as dental, vision and hearing coverage. Some plans may also offer coverage for other services, such as wellness programs, gym memberships, and transportation to medical appointments. Some Medicare Advantage plans also offer programs to help manage chronic conditions, such as diabetes or heart disease.
It's important to note that while Medicare Advantage plans may offer additional benefits, they may also have different rules, costs, and restrictions than Original Medicare. It's important to carefully review the details of any Medicare Advantage plan before enrolling to ensure it meets your needs.
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Medicare Part D
Standalone Prescription Drug Plan
Medicare Part D plans help people pay for their prescription drug costs.
Coverage can vary by plan, but generally, Medicare Part D plans cover a wide range of prescription drugs, including both generic and brand-name drugs. Some drugs may require prior authorization, step therapy, or other restrictions, and there may be limits on the amount of medication that can be obtained at one time.
It's important to note that Medicare Part D plans typically charge a monthly premium, in addition to deductibles, copayments, and coinsurance, which can vary by plan. It's also important to review the details of each plan and compare them to your specific medication needs and budget before choosing a Medicare Part D plan.
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Medigap
Medicare Supplemental Insurance Program
Medicare Supplemental Insurance, also known as MediGap, is a type of insurance policy that you can purchase from a private insurance company to help pay for the out-of-pocket costs associated with Original Medicare (Part A and Part B). These costs can include things like deductibles, co-payments, and coinsurance.
MediGap policies are designed to work alongside Original Medicare, so they cover only costs not covered by Medicare. In other words, a Medigap policy will not cover any services or expenses that are not covered by Medicare.
MediGap policies are standardized by the federal government, meaning each policy must provide the same basic benefits, regardless of the insurance company that sells it. MediGap policies are standardized and identified by letters (A, B, C, D, F, G, K, L, M, and N) in most states. This means that a specific lettered policy will have the same benefits regardless of which insurance company offers it, but the premiums and additional benefits can vary by insurer.
Medicare 201
Below you'll learn about the following:
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Eligibility and Enrollment Periods
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Medicare Supplement vs. Medicare Advantage
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Medicaid and Medicare Savings Program
Medicare Eligibility
Medicare is a federal health insurance program primarily for people aged 65 and over, as well as some younger individuals with certain disabilities or medical conditions.
To be eligible for Medicare, you must generally meet one of the following criteria:
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You are at least 65 years old and either a U.S. citizen or a legal permanent resident for at least five consecutive years.
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You have worked 40 quarters (10 years) or are a spouse of someone who has worked 40 quarters (10 years).
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You have been receiving Social Security disability benefits for at least 24 months.
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You have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS)
Medicare Enrollment Periods
There are different enrollment periods for Medicare that you should be aware of to ensure you don't miss important deadlines. Here are the different Medicare enrollment periods:
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Initial Enrollment Period (IEP): This is the first opportunity to enroll in Medicare. It's a seven-month period that begins three months before the month of your 65th birthday, includes the month of your 65th birthday, and ends three months after the month of your 65th birthday.
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General Enrollment Period (GEP): If you missed your IEP, you can enroll during the GEP, which runs from January 1 to March 31 each year. However, you may have to pay a late enrollment penalty.
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Special Enrollment Period (SEP): If you have a qualifying event, such as losing employer-sponsored health coverage, you may be eligible for a SEP. The timing and length of the SEP varies depending on the situation.
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Annual Enrollment Period (AEP): This period is from October 15 to December 7 each year. During this time, you can make changes to your Medicare coverage, including switching from Original Medicare to a Medicare Advantage plan, changing your Medicare Advantage plan, joining a Medicare Supplement or Advantage plan, or changing your Part D prescription drug coverage.
It's important to note that missing certain enrollment periods can result in late enrollment penalties and coverage gaps. It's recommended to stay informed about the enrollment periods and deadlines to ensure you have the coverage you need.
Different Types of Medicare Supplements (Medigap)
Medigap plans, also known as Medicare Supplement plans, are private insurance plans that help cover out-of-pocket costs not covered by Original Medicare (Parts A and B). There are 10 standardized Medigap plans labeled A, B, C, D, F, G, K, L, M, and N.
Here's an overview of the different types of Medigap plans:
Different Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) Plan
A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage plan that provides healthcare coverage through a network of healthcare providers. With an HMO plan, you typically need to choose a primary care physician from the plan's network, and you'll usually need referrals to see specialists. HMO plans have a list of in-network providers, and if you receive care from an out-of-network provider, you may be responsible for covering all the out-of-pocket costs. HMO plans often have lower out-of-pocket costs than traditional Medicare plans, but less flexibility in choosing healthcare providers.
Preferred Provider Organization (PPO) Plan
A Preferred Provider Organization (PPO) plan is a type of Medicare Advantage plan that offers more flexibility in choosing healthcare providers compared to an HMO plan. While each PPO plan has a list of in-network providers, you usually have the option to receive healthcare services from out-of-network providers, but at a higher cost. PPO plans don't require you to choose a primary care physician or get referrals to see specialists. PPO plans offer more freedom and flexibility compared to HMO plans.
Private Fee-For-Service (PFFS) Plan
A Private Fee-For-Service (PFFS) plan is a type of Medicare Advantage plan that allows you to choose any healthcare provider that accepts the terms of the plan. PFFS plans do not require you to choose a primary care physician or get referrals to see specialists. However, the plan decides how much it will pay for your healthcare services and how much you will pay. PFFS plans offer flexibility in choosing healthcare providers but can be more expensive than other types of Medicare Advantage plans.
Special Needs Plans (SNP)
A Medicare Advantage Special Needs Plan (SNP) is a type of Medicare Advantage plan that is designed to provide targeted healthcare coverage for individuals with specific chronic health conditions and other special healthcare needs. These plans cover everything that Original Medicare covers and are required to provide prescription drug coverage. There are three types of SNP plans available:
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Chronic Condition Special Needs Plans (C-SNPs): These plans are for individuals with specific chronic conditions, such as diabetes, heart failure, or end-stage renal disease.
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Institutional Special Needs Plans (I-SNPs): These plans are for individuals who live in institutions such as nursing homes or have chronic conditions that require institutional care.
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Dual Eligible Special Needs Plans (D-SNPs): These plans are for individuals who are eligible for both Medicare and Medicaid benefits. They provide additional benefits to cover gaps in coverage and may include benefits such as dental, vision, and hearing coverage.
SNP plans may have specific provider networks and may require referrals to see specialists. However, they also offer additional benefits, such as transportation services or personal care assistance, that may not be available with other Medicare Advantage plans.
Medicaid & Medicare Savings Program
Medicaid and Medicare are both federal healthcare programs, but they serve different populations and cover different services. Here's a brief overview of the differences:
Medicaid:
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Medicaid is a joint federal and state program that provides health coverage to people with low income and limited resources.
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Eligibility for Medicaid is based on income and other factors, such as age, disability, and family size.
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Medicaid covers a range of healthcare services, including doctor visits, hospital stays, prescription drugs, and long-term care.
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Medicaid is administered by the states, so the benefits and eligibility requirements can vary from state to state.
Medicare:
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Medicare is a federal health insurance program primarily designed for people who are 65 years or older, as well as for certain individuals with disabilities and those with end-stage renal disease (ESRD).
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Eligibility for Medicare is based on age or disability, regardless of income or assets.
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Medicare covers a range of healthcare services, including hospital stays, doctor visits, and prescription drugs.
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Medicare is administered by the federal government, so the benefits and eligibility requirements are the same across the country.
The Medicare Savings Program (MSP) helps certain individuals with limited income and resources pay their Medicare premiums and/or out-of-pocket healthcare costs. The MSP is administered by the states, and eligibility requirements and benefits can vary from state to state.
There are three different types of MSPs in TN:
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Qualified Medicare Beneficiary (QMB) Program: This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. QMB beneficiaries also receive full Medicaid coverage.
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Specified Low-Income Medicare Beneficiary (SLMB) Program: This program helps pay only Medicare Part B premiums.
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Additional Low-Income Medicare Beneficiary (ALMB) Program: This program helps pay Medicare Part B premiums only; funding is limited, and benefits are awarded on a first-come, first-served basis.
To be eligible for an MSP, an individual must be enrolled in Medicare Part A and/or Part B and meet certain income and asset requirements. Income and asset limits can vary by state, but typically, an individual's income must be below a certain percentage of the federal poverty level, and their assets must be below a certain limit.
The MSP can provide significant cost savings for eligible individuals and help make healthcare more affordable. It's recommended to contact your state's Medicaid agency to determine if you qualify for an MSP and how to apply.
Terri O'Brien
Your Local Independent Medicare Advisor
