1. 5402 Glenside Drive, Suite D, Richmond, VA 23228
Medicare
Joley L. steffens
Joley L. Steffens, PLLC
5402 Glenside Drive, Suite D, Richmond, VA 23228 ;
President of

2. Medicare Part A- Hospital Insurance Part B- Medical Insurance
Part C- Medicare Advantage Plans
Part D- Prescription Drug Insurance
Medicare Supplement/Medigap

3. Medicare Eligibility Individuals age 65 or older
Individuals under age 65 who have been receiving Social Security Disability benefits for a period of 24 months
Individuals of any age with End-Stage Renal Disease (ESRD)- permanent kidney failure requiring dialysis or a kidney transplant
Individuals of any age with ALS (Lou Gehrig’s Disease)

4. Enrollment in Medicare
*Most individuals are not automatically enrolled in Medicare.
Automatic Enrollment in Part A & Part B if already receiving:
Social Security Retirement Benefits
Social Security Disability Benefits
Railroad Retirement Benefits
If not receiving benefits, can apply via Social Security Administration during Initial Enrollment Period which is:
3 months before turning 65
The month beneficiary turns 65
Three months after turning 65

5. General Enrollment in Medicare
Delayed Enrollment
May delay enrolling if:
Individual (or spouse) is actively employed, AND
Is covered under group health insurance policy based on active employment (does not include COBRA insurance policy)
If Employer Group Health Insurance ends, you get a eight-month Special Enrollment Period. (Eight (8) month period begins the month after the employment ends or the coverage ends, whichever happens first. COBRA coverage does not extend this period.)

6. Medicare Enrollment at or after age 65
Special Enrollment Period
Anytime while still covered by group plan, or
During eight (8) month period that begins the month after the employment ends or the coverage ends, whichever happens first.
*COBRA does not extend enrollment period.

7. Delaying Enrollment in Medicare
If you do not enroll during the Initial or Delayed/Special Enrollment periods, then you can enroll during General Enrollment Period :
January 1st – March 31st of each year
Coverage begins July 1st
Penalty is assessed on Part B and Part D premiums

8. Medicare Enrollment Options
Basic Medicare
(Parts A and B)
as primary coverage
Medicare Part C
(Medicare Advantage Plan)
as primary coverage
Usually includes
Part D coverage
Use this chart to explain everyone who gets Medicare starts out in the top box. The can they choose from the top box how they want to get their Medicare benefits for the choices in the second row of box
Access to Part C still requires enrollment in
Basic Medicare
Supplement
(Medigap)
Part D
Drug Plan

9. Medicare Costs- Part A Hospital Insurance
Most individuals pay $0 premium (since worked 40+ quarters)
If individual worked quarters, $248 monthly premium
If worked <30 quarters, $413 monthly premium.
Deductible
$1,316 per hospital stay
Copayments/Coinsurance
$329 copay for hospital stay days 61-90; $658 copay days ; All costs after day 150 (includes 60 lifetime reserve days)
Skilled Nursing Facility $0 copay days 1-20, $ copay for days ; all costs after day 100

10. Medicare Part A- Coverage
Inpatient Care in Hospitals
Inpatient Care in a Skilled Nursing Facility (not custodial or long‑term care)
Hospice Care Services
Home Health Care Services

11. Medicare Part A Covered Services
Inpatient Hospital Stays
Semi-private room, meals, general nursing, and other hospital services and supplies. Includes care in critical access hospitals and inpatient rehabilitation facilities. Inpatient mental health care in psychiatric hospital (lifetime 190-day limit). Generally covers all drugs provided during an inpatient stay received as part of your treatment.
Skilled Nursing Facility Care
Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies.
Home Health Care Services
Can include part-time or intermittent skilled care, and physical therapy, speech-language pathology, a continuing need for occupational therapy, some home health aide services, medical social services, and medical supplies.
Hospice Care
For terminally ill and includes drugs, medical care, and support services from a Medicare-approved hospice.
Blood
If you need blood as an inpatient (up to 3 pints), you won’t have to pay for it or replace it.
Medicare Part A, hospital insurance covers medically necessary services.
Hospital inpatient care - Semi-private room, meals, general nursing, and other hospital services and supplies. Includes care in critical access hospitals and inpatient rehabilitation facilities. Inpatient mental health care in a psychiatric hospital (lifetime 190-day limit). Coverage does not include private duty nursing, television or telephone in your room if there are separate charges for these items, and private rooms unless medically necessary. Generally covers all drugs provided during an inpatient stay received as part of your treatment.
Skilled nursing facility (SNF) care (not custodial or long-term care) - Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies.
Home health care services – Covers medically-necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, a continuing need for occupational therapy, home health aide services, medical social services, and medical supplies. A doctor enrolled in Medicare, or certain health care providers who work with the doctor, must see you before the doctor can certify that you need home health services. That doctor must order your care, and a Medicare-certified home health agency must provide it. You must be homebound, which means that leaving home is a major effort. You pay nothing for covered home health services.
Hospice Care - For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling.
Blood - In most cases, if you need blood as an inpatient, you won’t have to pay for it or replace it.

12. Medicare Part A- Cost Most individuals pay a $0 premium for Part A.
Individuals who are not eligible for premium-free Part A coverage can pay $413/month if:
Aged 65 and older, have or are enrolling in Part B, and qualify under the citizenship and residency requirement; OR
Under age 65, disabled, and premium-free Part A coverage ended because they returned to work.
(Coverage continues for up to 8.5 yrs after return to work.)
Late Enrollment Penalty
For those ineligible for premium-free Part A who don’t buy in when first eligible, monthly premium increases by 10%. Higher premium enforced for 2x the number of years the individual could have had Part A, but didn’t enroll.

13. Medicare Costs- Part B Medical Insurance
Most individuals pay $134 premium; existing enrollees pay less (~$109)
Higher earning individuals have surcharge
Deductible- $183
Copayments/Coinsurance- normally 20%

14. Medicare Part B- Coverage
Outpatient care
Medically Necessary Services from doctors and other health care providers
Home health care
Durable medical equipment
Some preventive services

15. Medicare Part B Covered Services
Doctors’ Services
Services that are medically necessary (includes outpatient and some doctor services you get when you’re a hospital inpatient) or covered preventive services.
Outpatient Medical and Surgical Services and Supplies
Medically necessary services and supplies, such as clinical laboratory services, diabetes supplies, kidney dialysis services and supplies, mental health care, certain outpatient prescription drugs, diagnostic X-rays, MRIs, CT scans, and EKGs are covered.
Durable Medical Equipment
Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds for use in the home. Some items must be rented.
Medicare Part A, hospital insurance covers medically necessary services.
Hospital inpatient care - Semi-private room, meals, general nursing, and other hospital services and supplies. Includes care in critical access hospitals and inpatient rehabilitation facilities. Inpatient mental health care in a psychiatric hospital (lifetime 190-day limit). Coverage does not include private duty nursing, television or telephone in your room if there are separate charges for these items, and private rooms unless medically necessary. Generally covers all drugs provided during an inpatient stay received as part of your treatment.
Skilled nursing facility (SNF) care (not custodial or long-term care) - Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies.
Home health care services – Covers medically-necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, a continuing need for occupational therapy, home health aide services, medical social services, and medical supplies. A doctor enrolled in Medicare, or certain health care providers who work with the doctor, must see you before the doctor can certify that you need home health services. That doctor must order your care, and a Medicare-certified home health agency must provide it. You must be homebound, which means that leaving home is a major effort. You pay nothing for covered home health services.
Hospice Care - For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling.
Blood - In most cases, if you need blood as an inpatient, you won’t have to pay for it or replace it.

16. Medicare Part B Covered Preventive Services
“Welcome to Medicare” exam
Yearly “Wellness” exam
Abdominal aortic aneurysm screening*
Bone mass measurement
Cardiovascular disease screenings
Colorectal cancer screenings
Diabetes screenings
Flu shots
Glaucoma tests
Hepatitis B shots
HIV Screening
Mammograms (screening)
Pap test/pelvic exam/clinical breast exam
Prostate cancer screening
Pneumococcal pneumonia shots
Smoking cessation
Medicare Part A, hospital insurance covers medically necessary services.
Hospital inpatient care - Semi-private room, meals, general nursing, and other hospital services and supplies. Includes care in critical access hospitals and inpatient rehabilitation facilities. Inpatient mental health care in a psychiatric hospital (lifetime 190-day limit). Coverage does not include private duty nursing, television or telephone in your room if there are separate charges for these items, and private rooms unless medically necessary. Generally covers all drugs provided during an inpatient stay received as part of your treatment.
Skilled nursing facility (SNF) care (not custodial or long-term care) - Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies.
Home health care services – Covers medically-necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, a continuing need for occupational therapy, home health aide services, medical social services, and medical supplies. A doctor enrolled in Medicare, or certain health care providers who work with the doctor, must see you before the doctor can certify that you need home health services. That doctor must order your care, and a Medicare-certified home health agency must provide it. You must be homebound, which means that leaving home is a major effort. You pay nothing for covered home health services.
Hospice Care - For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling.
Blood - In most cases, if you need blood as an inpatient, you won’t have to pay for it or replace it.

17. Noncovered Services Routine Eye Care and Corrective Lenses
Routine dental care
Dentures
Cosmetic surgery
Acupuncture
Podiatry care
Hearing aids and exams for fitting hearing aids
Long-term care
Medicare Part A, hospital insurance covers medically necessary services.
Hospital inpatient care - Semi-private room, meals, general nursing, and other hospital services and supplies. Includes care in critical access hospitals and inpatient rehabilitation facilities. Inpatient mental health care in a psychiatric hospital (lifetime 190-day limit). Coverage does not include private duty nursing, television or telephone in your room if there are separate charges for these items, and private rooms unless medically necessary. Generally covers all drugs provided during an inpatient stay received as part of your treatment.
Skilled nursing facility (SNF) care (not custodial or long-term care) - Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies.
Home health care services – Covers medically-necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, a continuing need for occupational therapy, home health aide services, medical social services, and medical supplies. A doctor enrolled in Medicare, or certain health care providers who work with the doctor, must see you before the doctor can certify that you need home health services. That doctor must order your care, and a Medicare-certified home health agency must provide it. You must be homebound, which means that leaving home is a major effort. You pay nothing for covered home health services.
Hospice Care - For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling.
Blood - In most cases, if you need blood as an inpatient, you won’t have to pay for it or replace it.

18. Medicare Part B- Should you Enroll?
Consider what other coverage you have first:
Individuals with Employer or Union Coverage may be able to delay Part B without penalty.
Enrollment is mandatory for most individuals with Part A and TRICARE coverage.
Enrollment in Part B triggers the one-time Medigap Open Enrollment Period for individuals aged 65 and older.

19. Medicare Part D- Prescription Drug Plans
Monthly premiums
Vary by plan, as low as $0.
Higher income individuals have higher premiums.
Late enrollment penalty
Begins accruing after 63+ consecutive days without coverage
1% for each month without creditable drug coverage
Actual drug plan costs will vary depending on:
Plan selected, prescriptions and plan’s formulary.
Use of network pharmacies.
Eligibility for Extra Help.
Gross income.

20. Medicare Part D Prescription Drug Plans
Surcharge for Higher Earners

21. Medicare Part D Prescription Drug Plans
Eligibility Criteria
Must have Part A
Live in the plan’s service area.
Enrollment Periods
Initial 7-month Enrollment period (beginning 3 months before birthday or disability)
Annual General Enrollment/Open Enrollment October 15- December 7- can join, switch, or drop a Medicare Prescription Drug Plan. New plan takes effect January 1.
Special Enrollment Periods
Move out of plan’s service area.
Have Medicaid/Qualify for Extra Help.
Lose other creditable prescription drug coverage.
Live in an institution (like a nursing home).

22. Medicare Part D- Prescription Drug Plans
Initial Enrollment
Begins 3 months before birthday, includes birthday month, end 3 months after birthday. Coverage begins birthday month or month following enrollment.
Disabled individuals can join during the 7-month period that begins 3 months before 25th month of disability and ends 3 months after 25th month.
General Enrollment/Open Enrollment
Between October 15 and December 7 anyone can join, switch, or drop a Medicare Prescription Drug Plan. Coverage will begin on January 1.

23. Medicare Part D- Prescription Drug Plans
Special Enrollment Periods
In most cases, individuals must stay enrolled for the calendar year starting the date their coverage begins. However, individuals may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period in certain situations:
Move out of plan’s service area.
Have Medicaid.
Qualify for Extra Help.
Lose other creditable prescription drug coverage.
Live in an institution (like a nursing home).
5-Star Special Enrollment Period
From December to November, individuals can switch to a Medicare Advantage Plan that has a 5 star overall plan rating.

24. Medicare Part D- Prescription Drug Plans
Formulary- list of prescription drugs covered by the plan. Plans have “tiers” that cost different amounts.

25. Medicare Part D Prescription Drug Plans
Coverage Gap (“Donut Hole”)
To enter the donut hole, participant and drug plan together must spend $3,700 To get out of donut hole, participant alone must spend $4,950 in out of pocket costs for prescription drugs. (Includes deductibles and copays, but not monthly premiums.)
During donut hole, participants pay 40% of the plan’s cost for covered brand-name drugs and 51% for covered generic drugs.
Once out of the donut hole, catastrophic coverage kicks in, and only a small copay applies for the remainder of the year.

26. Medicare Part C- Medicare Advantage Plans
Offered by private insurance companies
Must cover same services as Medicare
Provide Part A and Part B coverage, and usually Part D coverage
Often covers more than Medicare, such as vision, hearing, dental, health, fitness and wellness plan
Monthly premiums $0 and up

27. Medicare Part C- Medicare Advantage Plans
Types of Plans
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS)
Special Needs Plans (SNP)
HMO Point-of-Service (HMOPOS)
Medical Savings Account (MSA)

28. Medicare Costs- Part C Medicare Advantage Plans
Premiums- vary
Deductibles- vary
Copayments/Coinsurance- vary
Costs depend on:
Plan selected, prescriptions and plan’s formulary.
Use of network pharmacies and providers.
Eligibility for Extra Help.
Late enrollment penalty for Part D

29. Medicare Part C- Medicare Advantage Plans
Eligibility
Individuals must:
Have Part A and Part B.
Live in the plan’s service area.
Not have End-Stage Renal Disease (ESRD).

30. Medicare Part C- Medicare Advantage Plans
Initial Enrollment
Begins 3 months before birthday, includes birthday month, end 3 months after birthday. Coverage begins birthday month or month following enrollment.
Disabled individuals can join during the 7-month period that begins 3 months before 25th month of disability and ends 3 months after 25th month.
General Enrollment/Open Enrollment
Between October 15 and December 7 anyone can join, switch, or drop a Medicare Advantage Plan. Coverage will begin on January 1.

31. Medicare Part C- Medicare Advantage Plans
Special Enrollment Periods
In most cases, individuals must stay enrolled for the calendar year starting the date their coverage begins. However, individuals may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period in certain situations:
Move out of plan’s service area.
Have Medicaid.
Qualify for Extra Help.
Live in an institution (like a nursing home).
5-Star Special Enrollment Period
From December to November, individuals can switch to a Medicare Advantage Plan that has a 5 star overall plan rating.

32. Medicare Supplemental Plan Medigap Insurance
Cost Comparison
Individuals pay a monthly premium for their Medigap policy.
Different insurance companies may charge different premiums for the same exact policy. It is important to compare Medigap policies since the costs can vary and may go up as you get older.

33. Medicare Supplemental Plan Medigap Insurance
Eligibility Criteria
Must Be age 65 or older
Have Part A and Part B.
Live in the plan’s service area.
Coverage (depending on plan selected)
Medicare Part A & B Deductibles, Coinsurances, Additional Expenses
Cost Comparison
Monthly premiums vary. Different insurance companies charge different premiums for the same exact policy. It is important to compare Medigap policies since the costs can vary and may go up as you get older.
Enrollment
6-Month Guaranteed Enrollment Period- begins on the first day of the month in which you’re 65 or older and enrolled in Part B..
If you delay enrolling in Part B because you have group health coverage based on your (or your spouse’s) current employment, your Medigap Open Enrollment Period won’t start until you sign up for Part B.

34. Medicare Supplemental Plan Medigap Insurance
Offered by private insurance companies
Reduce copays for Medicare participants
Individuals have a one-time 6-month Medigap Open Enrollment Period which starts the first month they were 65 and enrolled in Part B.
This period gives individuals a guaranteed right to buy any Medigap policy sold in their state regardless of health status.
Once this period starts, it can’t be delayed or replaced.

35. Medicare Supplemental Plan Medigap Insurance
Enrollment
The best time to buy a Medigap policy is during your Medigap Open Enrollment Period. This 6-month period begins on the first day of the month in which you’re 65 or older and enrolled in Part B. After this enrollment period, your option to buy a Medigap policy may be limited and it may cost more.
If you delay enrolling in Part B because you have group health coverage based on your (or your spouse’s) current employment, your Medigap Open Enrollment Period won’t start until you sign up for Part B.

36. Medicare Supplemental Plan Medigap Insurance

37. 5402 Glenside Drive, Suite D, Richmond, VA 23228
Joley L. steffens
Joley L. Steffens, PLLC
5402 Glenside Drive, Suite D, Richmond, VA 23228 ;