MEDICARE

Medicare and Medicaid are both government-sponsored health insurance programs in the U.S., but they serve different populations and have distinct eligibility requirements.

🏥 Medicare

Medicare is a federal program primarily for people aged 65 and older, but also covers certain younger individuals with disabilities or end-stage renal disease (ESRD).

Eligibility •Age 65 and older (any U.S. citizen or legal resident) •Under 65 with specific disabilities (must have received Social Security Disability Insurance (SSDI) for at least 24 months) •Any age with end-stage renal disease

COVERAGE

Medicare has different parts, which help cover specific healthcare services:

Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facilities, hospice care, and some home health care.

Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some medical supplies.

Part C (Medicare Advantage): Offers an alternative to Original Medicare (Parts A and B) through private insurance plans, often including additional benefits like vision and dental.

Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications.

Costs

Part A is usually free if you've worked and paid Medicare taxes for at least 10 years.

Part B, C, and D often require monthly premiums, deductibles, and co-pays.

🏥 Medicaid

Medicaid is a joint federal and state program that helps with medical costs for low-income individuals and families. Unlike Medicare, Medicaid eligibility is based on income, and it may vary by state.

Eligibility •Low-income individuals/families (income thresholds vary by state) •Pregnant women, children, elderly individuals, and people with disabilities often qualify, depending on the state. •Eligibility is expanded in many states under the Affordable Care Act (ACA) for adults under 65 with low income.

COVERAGE

Doctor visits, hospital stays, and preventive care

Prescription drugs, mental health services, long-term care (nursing homes, home care), and specialized services like dental, vision, and hearing (varies by state)

Costs

Medicaid generally has low or no premiums, and no deductibles for most beneficiaries.

Some states may have small co-pays or cost-sharing for services.

💡 Key Differences Between Medicare and Medicaid Aspect Medicare Medicaid Eligibility 65+, or under 65 with disabilities or ESRD Low-income individuals/families, eligibility varies by state Administration Federal program Joint federal and state program Cost to Beneficiaries Premiums, deductibles, co-pays Low or no premiums, small co-pays in some states Coverage Part A (Hospital), Part B (Medical), Part C (Advantage), Part D (Prescription) Comprehensive coverage including medical, dental, vision, and long-term care (varies by state) How Are They Related?

Medicare and Medicaid can work together: Some individuals may be eligible for both programs. This is called "dual eligibility". For instance, low-income seniors may qualify for both programs, with Medicare covering primary healthcare and Medicaid filling in gaps, such as long-term care or additional prescription coverage.

Let me know if you need more details on how these programs interact or if you want to dive deeper into either Medicare or Medicaid!

Medicare and Medicaid are both U.S. government health insurance programs, but they serve different groups:

Medicare: A federal program that provides health insurance mainly for people aged 65 and older and some younger people with disabilities. 👉 Funded by payroll taxes and run by the federal government.

Medicaid: A state and federal program that provides free or low-cost health coverage for low-income individuals and families. 👉 Funded jointly by federal and state governments, and rules can vary by state.

In short:

Medicare = elderly and disabled

Medicaid = low-income individuals and families

MEDICARE & YOU 2026 -A federal program that provides health insurance mainly for people aged 65 and older and some younger people with disabilities. 👉 Funded by payroll taxes and run by the federal government.

Part A- Hospital Insurance (original medicare) Part B- Medical Insurance (original medicare) Part C- Medicare Advantage Part D- Prescription Drug Coverage

PART A- Hospital Coverage //pays for room, meal and other general cost.

Part B- Doctor and Outpatient// pays for Lab results, xray, wheelchair, medical equipments

Part C- Combination of Part A, B and D

Part D- covers the cost of prescription medicine, this part is rewarded to private insurance companies. HELPS REDUCE THE COST OF PRICES.

Part C MEDICARE ADVANTAGE

• Alternative of Part A& B
• instead of getting coverage directly from government, client chooses PRIVATE insurance.
• Private insurance approved my Medicare

DOCTOR & HOSPITAL CHOICE

ORIGINAL MEDICARE

• You can use and Dr. or hospital that takes medicine, anywhere in the US

MEDICARE ADVANTAGE (PART C)

• You may need to use Dr. and other providers who are in the plan's network and services area.

Insurance Terminologies

1. Copay (Co- payment) - a fixed amount that a beneficiary must pay out of pocket for a covered healthcare service after paying the deductible.

2. Decuctible- The amount a medicare must pay out of pocket for healthcare services before medicare starts paying its share.

3. Premium- The monthly fee paid for Medicare coverage (either Part A,B,C,/ D). This is usually deducted from the beneficiary's social security payments.

4. Coinsurance- is the percentage of healthcare costs you pay after you’ve met your deductible.

5. The Out-of-Pocket Maximum is the most you’ll have to pay for covered healthcare services in a year.

Once you reach this limit, your insurance pays 100% of the remaining covered costs for the rest of the year.

1. Medicare Part A (Hospital Insurance) helps cover the cost of inpatient care in hospitals and some other facilities.

🏥 What it covers:

Inpatient hospital stays (room, meals, nursing care)

Skilled nursing facility care (after a hospital stay)

Hospice care (for terminally ill patients)

Some home health care services

💵 Costs:

Most people don’t pay a monthly premium (if they or a spouse paid Medicare taxes while working).

There is a deductible you pay each time you’re admitted to the hospital.

After certain days in the hospital, you may also pay coinsurance.

1. Medicare Part B (Medical Insurance) helps cover the cost of outpatient and medical services that Part A doesn’t cover.

💉 What it covers:

Doctor’s visits and outpatient care

Preventive services (like vaccines, screenings, and checkups)

Lab tests and X-rays

Durable medical equipment (wheelchairs, walkers, etc.)

Some home health services

💵 Costs:

You pay a monthly premium (amount depends on your income).

You also pay an annual deductible (a set amount before coverage begins).

After the deductible, you usually pay 20% coinsurance, and Medicare pays 80%.

1. Extra Help (Low-Income Subsidy) is a Medicare program that helps people with limited income and resources pay for prescription drug costs under Medicare Part D.

💊 What it helps pay for:

Monthly premiums for drug coverage

Annual deductibles

Copayments or coinsurance for prescriptions

🧾 Eligibility:

You may qualify if you have:

Limited income and savings

Medicare Part D (prescription drug plan)

Some people get Extra Help automatically — for example, if they have Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program.

1. Medigap (Supplemental Insurance) is private health insurance that helps pay for the “gaps” in Original Medicare (Parts A and B) coverage.

💵 What it covers:

Copayments

Coinsurance

Deductibles

Some plans even cover emergency care while traveling abroad

🧩 Key points:

You must have Medicare Parts A and B to buy a Medigap policy.

It is sold by private insurance companies (not the government).

It doesn’t cover prescription drugs (you need a Part D plan for that).

You can’t have Medigap and Medicare Advantage (Part C) at the same time.

1. Dual Eligibility means a person is qualified for both Medicare and Medicaid at the same time.

🩺 Who qualifies:

People who:

Are 65 or older or have a disability (→ Medicare)

Have low income and limited resources (→ Medicaid)

💵 What it provides:

Medicare pays first for covered services.

Medicaid may cover what Medicare doesn’t — like premiums, deductibles, coinsurance, and sometimes long-term care.

🧩 Types of dual eligibility:

Full Duals: Get full Medicaid benefits and help with Medicare costs.

Partial Duals: Medicaid helps pay some Medicare costs (like premiums only).

1. The Open Enrollment Period is the time each year when people can join, switch, or drop a Medicare plan.

📅 Dates:

October 15 – December 7 every year.

🔄 What you can do during this time:

Join or switch a Medicare Advantage (Part C) plan.

Join, drop, or change a Medicare Part D (drug plan).

Return to Original Medicare (Parts A & B) from a Medicare Advantage plan.

🧾 When changes take effect:

All changes made during open enrollment start on January 1 of the next year.

1. Medicare Savings Programs (MSPs) are state-run programs that help people with limited income and resources pay for Medicare costs.

💵 What they help pay for:

Medicare Part A and/or Part B premiums

Deductibles, coinsurance, and copayments

🧩 Four main types of MSPs:

QMB (Qualified Medicare Beneficiary Program) – Pays for Part A & B premiums, deductibles, coinsurance, and copayments.

SLMB (Specified Low-Income Medicare Beneficiary Program) – Pays for Part B premium only.

QI (Qualified Individual Program) – Also pays for Part B premium, but you must apply every year.

QDWI (Qualified Disabled and Working Individuals Program) – Helps certain working disabled people pay for Part A premium.

1. Preventive services are healthcare services that help prevent illnesses or detect them early, before they become serious.

🩺 Examples include:

Vaccinations (like flu or COVID-19 shots)

Screenings (for cancer, diabetes, cholesterol, etc.)

Annual wellness visits

Blood pressure checks

Counseling for quitting smoking, diet, or mental health

💵 In Medicare:

Most preventive services are free if you get them from a doctor who accepts Medicare — meaning you pay no deductible or coinsurance.

1. Prior Authorization is a requirement from your insurance company (including some Medicare plans) that your doctor must get approval before providing a specific service, treatment, or prescription.

🩺 Purpose:

To make sure the service or medication is medically necessary and covered by your plan.

💡 Example:

Your doctor wants you to get an MRI or a certain expensive medication — the insurance company must approve it first before it’s done or prescribed.

🧾 In Medicare:

Original Medicare (Parts A & B): Rarely requires prior authorization.

Medicare Advantage (Part C): Often does require it for some procedures, hospital stays, or drugs.

1. In-network vs. Out-of-network refers to whether a doctor, hospital, or healthcare provider has a contract with your insurance plan.

🏥 In-Network:

The provider has an agreement with your insurance company.

You pay lower costs (your insurance covers more).

Example: You visit a clinic listed in your plan’s network.

🚫 Out-of-Network:

The provider does not have a contract with your insurance.

You may have to pay more, or your plan might not cover the costs at all.

Example: Seeing a doctor who isn’t listed in your plan’s network.

💡 In Medicare:

Original Medicare: You can see any provider that accepts Medicare (no networks).

Medicare Advantage (Part C): Usually has network rules — you may pay more if you go out of network.

1. Catastrophic Coverage is the final stage of Medicare Part D (prescription drug coverage) that helps protect you from very high drug costs.

💊 How it works:

When your out-of-pocket spending on prescription drugs reaches a certain amount in a year, you enter catastrophic coverage. After that, you pay only a small coinsurance or copayment for your medications for the rest of the year.

📅 For 2025:

Once your total out-of-pocket costs reach $2,000, you’ll enter catastrophic coverage — and your Medicare drug plan pays 100% of your drug costs after that.

AFTER LUNCH

<< PART A >>

• vital component ages 65yrs older
• IRS form, form serves as the proof that you had health coverage during the past year.
• it depends how long are you employed to get the medicare.
• 10 years of working to be eligible for premium Free
• Payment for Premium is 285$ to 518 per month
• Late premium fee will increase 10% mandated fee for (every 12months)
• if additional years that they cant pay its additional 10%
• email reminder is sent to the member to avoid late enrolment (SEP) -even if they enroll during SEP they are still responsible to pay the late enrollment fee (Unless they are not beyond ICEP period)

Health Coverage Form (IRS Form 1095-B): You may receive this form, but it's not required for tax filing.

Premium-Free Part A: You won’t pay a premium if you or your spouse worked and paid Medicare taxes.

Buying Part A: If you don’t qualify for premium-free Part A, you may need to buy it, with premiums ranging from $285 to $518.

Late Enrollment Penalty: Delaying enrollment could lead to higher premiums for up to 4 years.

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• Income-Related Monthly Adjustment Amount (IRMAA)
• IRMAA is an extra premium amount added to Part B and Part D for people with higher incomes.
• If you dont sign up for Part B when your first eligible, you may have to pay a late enrollment penalty for as long as you have part B.
• if you qualified for SEP you have exeptions not to pay the penalty.

HOW TO PAY PART B:

Here are the 4 ways to pay your Medicare Part B premium:

💳 1. Social Security or Railroad Retirement deduction If you receive Social Security or Railroad Retirement benefits, your Part B premium is automatically deducted from your monthly check. ✅ This is the most common and easiest way.

🏦 2. Medicare Easy Pay (Automatic Bank Draft) You can sign up for Medicare Easy Pay, which automatically deducts your premium from your bank account each month.

💻 3. Online Payment Pay directly online through your Medicare account at Medicare.gov You can use a credit card, debit card, or bank account.

💌 4. Mail a Check or Money Order You can mail your payment to the address on your Medicare bill. Make the check or money order payable to: 👉 “Medicare Premium Collection Center.”

!!!!! MEDICARE IS THE FINAL BOSS !!!!!

"5TYPES OF COVERAGE"

• goal is to help people pay healthcare savings.

TRICARE

• Benefit for military, Veteran people in the USA.
• Medicare pays first, and Tricare will cover the additional cost.
• Tricare will served as a help to pay for medical bills, Medicare will always cover first.

Medicaid

• Low income people
• senior citizen has low income
• out of pocket costs of a member Medicaid will pay if Medicare cant cover the whole cost
• explaining why certain charges are reduced or wave.

Health insurance market place

• ACA Affordable Care Act
• design for who doesnt have coverage through work government programs -under 65 yrs old
• Obama Care
• If this person under 65 years old will soon turn 65 years old they will no longer need the Health Insurance market place since they are eligible to Medicare. It fail to enrol, it will lead to over penalties.

Health Savings Account (HSA)

• personal savings account.
• someone enrolls in Medicare, just like market place they can no longer contribute new funds to their HSA. Though, they can still use the existing balance to pay for qualified expenses.
• Not allowed to put money in HSA once medicare is applied, but still can use the remaining balance/ benefits.

1. Opening Spiel "Thank you for calling Medicare Services, this is [Your Name]. May I have your name, please?"

[After receiving the name]: "Am I speaking to the account holder, or are you calling on behalf of someone else?"

1. Member Verification (HIPAA Validation Step) “Before we proceed, for security purposes “May I have your full name, your date of birth, and your ZIP code?” HIPAA Reminder: ● Never say or repeat the full Medicare ID or Social Security Number. ● Verify using member-provided information only. ● Do not share PHI unless the member is verified or an authorized representative is on file.

2. Determine the Reason for the Call “Thank you for verifying your information. How can I help you today?” “I understand you received a hospital bill and would like to check if it’s covered under Part A.” ● “You mentioned your doctor’s visit wasn’t covered — let’s review your Part B benefits for that.” HIPAA Reminder: Avoid repeating diagnoses or personal health details unless necessary to resolve the issue.

I appreciate your efforts for calling us today, and I will be morethan happy to help you regarding with your questions the coverage of your insurance,

1. Information Gathering “May I have the date of service and the provider’s name so I can check your claim details?”

2. Provide Resolution / Explanation “Based on our records, _______________________ HIPAA Reminder: ● Discuss only the member’s claim, not other family members’ or unrelated accounts. ● Keep all PHI on-screen secure and visible only to authorized personnel.

3. Recap and Confirm Understanding “Just to summarize, we confirmed that _________________________ HIPAA Reminder: Never recap or restate any PHI (like diagnoses or procedure details) unnecessarily.

4. Closing the Call Agent Spiel: “I’m glad I could assist you today, Mr./Ms. [Last Name]. Thank you for calling [Plan Name] Medicare Services. Stay safe and have a great day!”

PROBING •Was it your first time being admitted? •Was it your first time visiting a doctor? •How long were you admitted?