Medicare 101

(Updated for 2023)

• Available at age 65 or due to Disability benefits from Social Security for 24 months
• Must enroll if you DON’T have creditable health coverage from an employer to avoid If you are not receiving Social Security Income, you can enroll by calling Social Security at 1-800-772-1213, in person at your local Social Security office or online at www.ssa.gov (https://www.ssa.gov/benefits/medicare)
• You have a 7-month Initial Enrollment Period (IEP) to sign up for Part A and/or Part Your IEP begins 3 months before your 65^th birthday, includes the month of your 65^th birthday, and the 3 months after your 65^th birthday.

Original Medicare Part A- Hospital Benefits

• $1,600 deductible for each benefit Days 1–60: $0 coinsurance for each benefit period. Days 61–90: $400 coinsurance per day of each benefit period. Days 91 and beyond: $800 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime). Beyond lifetime reserve days: no limit on what you will pay.
• Will cover Medicare Approved Skilled care for the first 20 From days 21-100 there is a $200 co- payment per day
• NOTE: Medicare does NOT pay for long term care!

Original Medicare Part B- Medical benefits

• Monthly premium is typically $164.90 (down from $170.00 in 2022). This premium is for Medicare beneficiaries with income under
  • $97K for single filers and $194K for joint Higher income households will pay a higher premium graded on their income- see grid below.
  • An annual deductible of $226 per year
• 20% coinsurance for all Medicare approved medical services: doctor visits, lab work, diagnostic tests
• There is NO LIMIT to this 20% co-insurance

Monthly Part B Premium for Persons with Higher Income Levels, also known as IRMAA Based on Modified Adjusted Gross Income from tax year 2 years ago.

Medicare Part D- Drug coverage

• Available when one has Part A and/or Part B
• Must sign up when eligible through me as your agent or insurance carrier Penalty of 1% for each month without drug coverage X the average cost plan today $31.50. (i.e., 10 months without Part D is 10% X $31.50 = $3.15 penalty) This is for life, if you choose not to elect this type of coverage when first eligible.
  • 2023 figures: Four phases of the drug plan are deductible, initial coverage, gap, catastrophic.
    1. Annual Deductible begins with your first prescription and in 2023 the maximum deductible is $505. So, if your plan has a $0 deductible, you skip straight to the next stage. Keep in mind that some deductibles may only apply to drugs on specific tiers, which means you may not have any deductible if you do not take any medications on those tiers. Any payments for your monthly premium or for medications on tiers that do not apply to the deductible are not counted toward reaching the deductible.
    2. Initial coverage phase. During this phase your insurance company pays a portion of each prescription, and you will pay co-payments or co-insurance during this phase. The amount you pay will depend on the tier level assigned to your drug by your insurance company. This phase will last until you and your insurance company spend up to $4,660.
    3. Gap phase – you pay discounted prices for medications, 25% of most prescriptions until YOUR total annual out of pocket expense reaches $7,400 (not including premium). This Total out of pocket cost are the amounts paid by you in the first stage plus any applicable drug manufacturer discounts applied in the coverage gap stage.
    4. Catastrophic– after your total out of pocket drug cost reaches $7,400 you will pay 5% of the cost for your drugs or $4.15 for generic and $10.35 co- payment for all other medications not to exceed 5% co-insurance.
• Low Income Subsidy Apply by calling 800-633-4227 (2022 Annual single $20,385; $1,698.75 month. Annual Joint $27,465; $2,288.75 per month. Resources: Single- $15,510, Joint-$30,950)
• All Formularies vary from plan to Some prescriptions may require Prior Authorization, Step Therapy, and/or Mail order

Medicare Part D Income-Related Monthly Adjustments Amounts

Medicare Supplements (Medigap)

• These plans are sold by private insurance companies, and you can choose plans A-N. The plan designs are the same with each insurance company. However, each insurance company can choose which of the plans they offer.
• In order to enroll and maintain your Medigap plan, you must have Part A and Part Original Medicare is primary, and the Supplement is secondary
• The Medigap plan will only pay for what Medicare approves. In some plans this means your copay and/or coinsurance responsibility is limited or even eliminated
• There is no drug You must add a part D plan for prescription drugs
• No No Referrals. You may see any doctor that is accepting Medicare.

Medicare Advantage Plans (aka Medicare Part C)

• Privatization of Medicare (You apply through me as your agent or insurance company)
• Works as Primary NOTE: You WILL still pay your Medicare Part B premium
• Pays for the same services that Medicare allows/approves but may have additional coverages Examples include.e.: annual physicals, dental, vision, hearing aids, alternative medicine, health club membership,
• Co-payments/co-insurances for services
• Many plans have drug benefits bundled into them
• Often there are networks to stay within: Examples of types of plans HMO’s, PPO’s, PFFS
• Enrollment Periods
  • Annual Enrollment October 15 – December MOST IMPORTANT DATES ANNUALLY
  • New- Jan 1st- March 31st If you are on a Medicare Advantage Plan, you can make one change to a different plan or switch back to Original Medicare (and a stand-alone Prescription Drug Plan) once during this time
  • Special Enrollment- anytime of the year due to eligible life event change.

Tamara Chandler
Independent Broker
Achieve Alpha Insurance LLC          
12505 Bel-Red Rd, Ste 106
Bellevue, WA 98005
425-802-2783 (call or text office line)
tamara@achieve-alpha.com
www.achieve-alpha.com