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Navigating Your Path to Confident Healthcare Decisions

Presented by Sarah Christly
The Insurance Source - Benefits Expert
Sarah Christly - Licensed Benefits Expert
Your trusted partner in healthcare coverage
  • Office: 865-346-1234
  • Licensed in: South Carolina • Florida • Georgia • North Carolina • Tennessee • Texas • Utah • Virginia
  • Offering: Medicare • Marketplace • Life Insurance • Dental Insurance • Group Health • Home & Auto • Indemnity Products
What We'll Cover
Part 1: The Basics
  • What is Medicare?
  • Who qualifies?
  • Medicare Parts A & B
Part 2: Your Options
  • Medicare Advantage (Part C)
  • Prescription Coverage (Part D)
  • Medigap Supplements
Part 3: Enrollment
  • When to enroll
  • How to enroll
  • Avoiding penalties
Part 4: Costs & Savings
  • Understanding costs
  • Financial assistance
  • Making smart choices
What is Medicare?
A federal health insurance program for eligible U.S. citizens and legal residents
Medicare IS
✓ Individual health insurance
✓ Funded by taxes you paid while working
✓ Available at age 65 or with qualifying conditions
Medicare is NOT:
✗ Free
✗ A family health plan
✗ Social Security
✗ Medicaid
Who Can Get Medicare?
U.S. citizens and legal residents (must live in U.S. for 5 consecutive years)
Age 65+
Turning 65 or older
Disability
Under 65 with qualifying disability
ESRD or ALS
Any age with end-stage renal disease or ALS
Do I Need Medicare If I'm Still Working?

It depends on your employer size and coverage!
You CAN Delay ✓
If your employer:
  • Offers "creditable" coverage
  • Typically employers with 20 employees or more.
No penalty for delaying enrollment
You MUST Enroll ✗
If your employer:
  • Coverage is not "creditable"
  • Typically fewer than 20 employees
Enroll at 65 to avoid penalties
🔦Important: If you enroll in any part of Medicare, you can no longer contribute to an HSA
Original Medicare - Parts A & B
Part A - Hospital Insurance
Covers inpatient care:
  • Hospital stays
  • Skilled nursing care
  • Hospice care
  • Some home health care
Usually premium-free (if you or spouse worked 10+ years)
Part B - Medical Insurance
Covers outpatient care:
  • Doctor visits
  • Preventive services
  • Lab tests & X-rays
  • Durable medical equipment
  • Ambulance services
Requires monthly premium (adjusted based on income)
What Original Medicare DOESN'T Cover

Important: Original Medicare has gaps in coverage!
Not Covered:
✗ Prescription drugs
✗ Routine dental care
✗ Routine vision care
✗ Hearing aids
✗ Long-term care
✗ Care outside the U.S.
Limited Coverage:
$ You pay deductibles
$ You pay coinsurance
$ No out-of-pocket maximum
$ 20% of costs for most services

→ These GAPS are why additional coverage is IMPORTANT
Two Paths to Fill In the Gaps
(You can only choose ONE)
Option 1: Build Your Own
(Original Medicare + Add-ons)
  • Part A + Part B (Hospital & Medical)
  • PLUS Part D (Prescription drugs)
  • PLUS Medigap (optional - Covers out-of-pocket costs)
Option 2: All-in-One
Includes Everything:
  • ✓ Part A (Hospital)
  • ✓ Part B (Medical)
  • ✓ Usually Part D (Prescriptions)
  • ✓ Often dental, vision, hearing
  • ✓ Fitness programs
  • ✓ Out-of-pocket maximum

Trade-offs to consider:
  • May require restrictive network limitations
  • Prior authorizations may be required
  • Some plans require referrals
Part D - Prescription Drug Coverage
Crucial for covering your medication costs.
Two Ways to Get Part D Coverage:
  • Stand-alone Part D Plan: Add this to your Original Medicare (Parts A & B).
  • Medicare Advantage Plan (Part C): Most plans include prescription drug coverage as part of their benefits package.
How Drug Coverage Works:
1
Deductible
You pay the full cost of your prescription drugs until you meet your plan's deductible amount.
2
Initial Coverage
After meeting the deductible, you pay a copayment or coinsurance for your drugs, and your plan pays the rest.
3
Catastrophic Coverage
Once your out-of-pocket spending reaches a certain limit (currently $2,000 for covered drugs), your plan pays nearly all remaining costs for the rest of the year.

Important: The Formulary (drug list) dictates which medications are covered and their cost tiers. Always check it!
Medigap (Medicare Supplement Insurance)
Helps pay the out-of-pocket costs that Original Medicare doesn't cover.
What Medigap Covers:
  • Part A & B coinsurance
  • Deductibles
  • Blood transfusions (first 3 pints)
  • Foreign travel emergency care
  • Excess charges from doctors
What Medigap Doesn't Cover:
  • Prescription drugs
  • Routine dental, vision, hearing
  • Long-term care
  • Cannot be used with Medicare Advantage
Medigap policies are standardized, meaning plans with the same letter (e.g., Plan G) offer the same basic benefits regardless of the insurance company. There are 10 standardized plans labeled A, B, D, G, K, L, M, N. Plans C and F are only available if you were eligible for Medicare before January 1, 2020.

Best Time to Buy: The ideal time is during your 6-month Medigap Open Enrollment Period, which begins the month you turn 65 and are enrolled in Part B. During this period, insurers cannot deny you coverage or charge you more due to pre-existing health conditions.
Medicare Advantage Plans (Part C)

An alternative to Original Medicare offered by private insurance companies
What's Included:
  • ✓ All Part A benefits
  • ✓ All Part B benefits
  • ✓ Usually prescription coverage
  • ✓ Often dental, vision, hearing
  • ✓ Fitness programs
  • ✓ Annual out-of-pocket maximum
Plan Types:
  • HMO: Network-based care
  • PPO: More flexibility
  • SNP: Special needs plans
  • Coverage and costs vary by plan

Note: Must continue paying Part B premium to Medicare
Initial Enrollment Period
A critical 7-month window around your 65th birthday to sign up for Medicare.
1
3 Months Before
Your 65th birthday month
2
65th Birthday Month
The month you turn 65
3
3 Months After
Your 65th birthday month
Two Enrollment Types:
Automatic Enrollment
If you're already receiving Social Security or Railroad Retirement Board benefits, you'll generally be automatically enrolled in Medicare Parts A & B when you become eligible.
Manual Enrollment
If you're not receiving benefits, you'll need to sign up. You can easily enroll online at ssa.gov/benefits/medicare/.

⚠️ Enroll early to avoid gaps in coverage and potential late enrollment penalties!
Other Enrollment Periods
Beyond your initial enrollment, several periods allow you to review and adjust your Medicare coverage.
Annual Enrollment Period (AEP)
October 15 - December 7
  • Switch Medicare Advantage or Part D plans.
  • Move between Original Medicare and Medicare Advantage.
MA Open Enrollment Period
January 1 - March 31
  • For Medicare Advantage members only.
  • Switch MA plans or return to Original Medicare.
  • One change allowed during this period.
Special Enrollment Period (SEP)
Triggered by qualifying life events:
  • Moving to a new service area.
  • Losing other creditable coverage.
  • Changes in Medicaid eligibility.
You usually have 2 months to make changes after the event.

Don't miss these windows! Making timely changes helps you avoid penalties and ensures your coverage meets your needs.
Understanding Medicare Costs
Navigating the financial aspects of Medicare can be complex. Here are the key terms you need to know.
Premium
The monthly amount you pay for your Medicare coverage plan.
Deductible
The amount you must pay out-of-pocket before your plan begins to cover costs.
Copay
A fixed amount you pay for a covered service (e.g., $20 for a doctor's visit).
Coinsurance
Your share of the cost for a covered service, calculated as a percentage of the approved amount (e.g., 20%).

Important: Medicare Advantage plans include an annual out-of-pocket maximum, while Original Medicare does not.
Avoiding Late Enrollment Penalties
Missing your enrollment window can be costly!
Part A Penalty
10% of your monthly Part A premium, applied only if you don't qualify for premium-free Part A.
Part B Penalty
An extra 10% for each full 12-month period you delayed enrollment. This penalty is permanent.
Part D Penalty
1% of the national average Part D premium for each month you go 63+ days without creditable coverage.
Good News: You may avoid penalties if you qualify for a Special Enrollment Period (SEP)!

Act now: Understanding and respecting Medicare's enrollment deadlines is essential to avoid these lasting financial penalties.
Original Medicare vs Medicare Advantage
Choosing between Original Medicare with a supplement and a Medicare Advantage Plan is a key decision for your coverage.

Consult an expert: Your personal health needs, budget, and lifestyle should guide your decision. A licensed agent can help!
How to Save Money on Medicare
Maximize your healthcare savings with smart choices and by understanding available assistance.
Smart Healthcare Practices:
  • Utilize preventive services (often free).
  • Stay within your plan's network for lower costs.
  • Ask for generic drugs when available.
  • Use preferred pharmacies to save on prescriptions.
  • Consider mail-order for maintenance medications.
  • Understand the difference between inpatient vs. observation status.
Financial Assistance Programs:
  • Extra Help: Assists with Part D prescription drug costs.
  • Medicaid: State programs for low-income individuals.
  • Medicare Savings Programs: Help pay premiums and other costs.
  • PACE: Comprehensive care for frail elderly individuals.

Shop During AEP! Plans change annually, so review and compare options during the Annual Enrollment Period to ensure you have the best coverage for your needs and budget.
Medicare and Medicaid Together
You can have both Medicare AND Medicaid!
What is Medicaid?
  • State government program
  • Helps pay healthcare costs
  • For people with limited income and resources
  • Programs vary by state
  • Eligibility varies by state
Dual Eligibility Benefits:
  • Medicare and Medicaid work together
  • May cover some or all healthcare costs
  • Special Dual Special Needs Plans (D-SNP) available
  • Additional benefits and lower costs

Check eligibility: Contact your state Medicaid office or call 1-800-MEDICARE to understand if you qualify for these combined benefits.
Choosing the Right Coverage
Making the best Medicare choice means aligning your health needs and lifestyle with the right plan. Ask yourself these critical questions:
Your Doctors
Confirm your preferred physicians and specialists are in-network or accept your plan.
Prescription Drugs
Verify your medications are on the plan's formulary and understand their cost tiers.
Frequent Travel
Consider Original Medicare or PPO plans for broader coverage when traveling.
Your Budget
Evaluate premiums, deductibles, copays, and potential out-of-pocket costs.
Extra Benefits
Many Medicare Advantage plans offer dental, vision, and hearing coverage.

Personalized Guidance: These questions form the foundation for a Medicare plan tailored to your unique situation. Don't hesitate to seek expert advice!
Where to Get Help
Navigating Medicare can be complex, but you don't have to do it alone. Here are key resources for assistance:
Medicare.gov
Your official online hub to compare plans, find providers, and manage your Medicare account.
1-800-MEDICARE
Direct line for Medicare support: 1-800-633-4227 (TTY: 1-877-486-2048). Available 24/7.
SHIP
State Health Insurance Assistance Program offers free, unbiased counseling. Find local help at shiphelp.org.
Social Security
Contact Social Security for Medicare enrollment questions. Visit ssa.gov/benefits/medicare/ or your local office.

Don't hesitate to reach out! These resources provide valuable information and support to help you make informed Medicare decisions.
Key Takeaways
Enroll on Time
Your Initial Enrollment Period (IEP) is crucial. Enroll within this window (3 months before to 3 months after your 65th birthday) to avoid lifelong penalties.
Mind the Gaps
Original Medicare (Parts A & B) doesn't cover everything. Consider a Part D plan and either Medigap or a Medicare Advantage plan for more comprehensive protection.
Review Annually
Plans change every year. Use the Annual Enrollment Period (Oct 15 – Dec 7) to reassess and ensure your coverage still meets your evolving needs and budget.
Help is Available
Don't navigate Medicare alone. Utilize official resources like Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP).
Compare Carefully
Your health needs, preferred doctors, medications, travel habits, and budget should guide your plan choice. Evaluate all options before deciding.

Your personalized plan: Making informed decisions now ensures optimal health coverage and financial peace of mind for your future.
Thank You! Questions?
It was a pleasure guiding you through Medicare essentials. I'm here to help with any further questions.
Contact Sarah Christly
Office: 865-346-1234
For More Information
  • Call 1-800-MEDICARE (1-800-633-4227)
  • TTY: 1-877-486-2048

Disclaimer: This presentation provides educational information only. Always verify details with official Medicare resources.