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What is Medicare?

Medicare is a public health insurance program for people 65 and older or those with certain disabilities or diseases. It is run by the Centers for Medicare & Medicaid Services, an entity within the federal government.

Understanding the “Parts” of Medicare +

There are four different parts of the Medicare program (Parts A, B, C and D), each designed to cover a different aspect of your healthcare needs. Because Original Medicare (Parts A and B) was not designed to cover everything, many people opt for a Part D prescription drug plan, or simply choose a Medicare Advantage plan (Part C) which often includes prescription drug, dental, and vision coverage. Here is a breakdown of how each of the Parts functions:

Part A(Original Medicare)

Covers hospital stays, nursing facility stays, and, in some circumstances, hospice care. If you or your spouse has been working and paying taxes to Medicare for 10 years, there is no monthly premium for Part A.

Part B(Original Medicare)

Covers medical care services like doctor visits and outpatient services and procedures. There is a premium for Part B, which is calculated based on your income tax returns from two years ago.

Part C

Also known as Medicare Advantage, is offered through a private insurance company, like Baylor Scott & White Health Plan, and covers everything covered in Parts A and B. These plans often include coverage for prescription drugs, as well as supplemental benefits like dental, vision and hearing. There can be a monthly premium for these plans; however, many insurers do offer $0 plan premium options.

Part D

Prescription drug coverage is offered through private insurance companies that contract with the government. Many Medicare Advantage plans (Part C), like ours, include prescription drug coverage. Purchasing a separate Part D plan is not necessary in these cases.  When purchased as a standalone plan, there is a separate monthly premium for Part D. It is important to note that, except for a few special circumstances, the rules for Medicare Advantage do not allow you to purchase medical coverage from one insurer and standalone drug coverage from another.

What is the difference between Medicare Advantage and Medicare Supplement (MediGap)? +

Medicare Advantage (also known as Medicare Part C) includes the same coverages offered under Medicare Parts A and B and will often have prescription drug coverage (Part D), dental, vision and other supplemental benefits. These plans are offered through private insurance companies that are contracted with the federal government; however, you are limited to doctors and facilities within your HMO or PPO network. There can be a monthly premium payment in Medicare Advantage; however, many insurers offer plans with $0 monthly premium options. Medicare Advantage plans may offer more comprehensive coverage at a lower cost than Original Medicare plus a MediGap plan.

Medicare Supplement (MediGap) is an insurance plan that protects people with Original Medicare and Prescription Drug plans (Parts A, B and D) against many additional costs potentially accrued by a patient. Medicare Supplement plans require a monthly premium in addition to the premiums already being paid for Parts A, B and D.

What is the difference between copay and coinsurance? +

A copay is a fixed payment that you pay when you receive healthcare services from a doctor or provider. These payments may vary in amount depending on what service is performed and are typically paid at the time of the visit.

Coinsurance is the concept of shared payment between you and your health insurance provider for eligible healthcare services. Coinsurance payments kick in once you’ve reached your deductible and are typically defined as a percentage of the covered amount (i.e. “You pay 20% coinsurance for covered services”).

What happens if I have a Medicare Advantage plan and get sick while traveling? +

Generally speaking, you are always covered in the event of a medical emergency anywhere in the country through your plan. These emergencies are categorized as life-threatening. Non-life-threatening healthcare services while traveling may not be covered under your Medicare Advantage plan.

What is the difference between HMO and PPO? +

HMO (Health Maintenance Organization) plans may offer coverage for in-network services only but have lower premiums and out-of-pocket costs than PPO plans, as well as smaller deductibles. With HMO plans, you select a primary care physician who coordinates your care and initiates referrals to specialists. Some HMO plans, like BSW SeniorCare Advantage and Covenant Health Advantage, do not require referrals to specialists.

PPO (Preferred Provider Organization) plans generally have higher premiums than HMO plans, as well as a deductible you must pay out-of-pocket until your health insurance plan kicks in. With PPO plans, you do not have to designate a primary care physician and you may visit any provider in your network without a referral. While PPOs do offer coverage for out-of-network services, your out-of-pocket costs for these services will usually be higher than those for in-network services. Baylor Scott & White Health Plan offers BSW SeniorCare Advantage PPO plans in North and Central Texas.

When should I go to urgent care instead of the emergency room? +

Urgent care services can help you save time and money, as urgent care facilities typically have shorter wait times and lower copayments or coinsurance than emergency room visits. Services you might receive at an urgent care facility could be the following:

  • Lab work
  • X-ray services
  • Treatment for stitches or broken bones
  • Infusions
  • CT scans
  • Flu or cold-like illnesses

Emergency room visits should be reserved for life-threatening occurrences. A trip to the emergency room may be needed if you experience the following:

  • Numbness or weakness
  • Difficulty speaking or disorientation
  • Head injuries or other major traumas
  • Loss of vision
  • Chest pain, chest pressure, or heart attack
  • Uncontrollable bleeding
  • Coughing or vomiting up blood
  • Seizures

When am I eligible to sign up for a Medicare plan? +

See our Medicare Enrollment page for more information.

Contact us any time and a Baylor Scott & White Health Plan licensed insurance agent can answer any questions you have about Medicare.