Medicare
Medicare is federal health insurance for people aged 65 and over, people under 65 with certain disabilities, and people with end-stage renal disease.
Medicare is divided into four parts:
- Part A is hospital insurance
- Part B is medical insurance
- Part C, known as Medicare Advantage, provides the option to choose from different health care plans
- Part D provides the option to choose from different prescription drug plans
Medicare does not cover everything, nor does it always cover the full amount.
There are 2 main ways to get your Medicare coverage – Original Medicare or a Medicare Advantage Plan.
- If you decide to go with Original Medicare, you decide if you need prescription drug coverage (Part D) and/or a Medicare Supplemental Insurance (Medigap) policy.
- If you decide to use a Medicare Advantage Plan (Part C), that plan combines Part A and Part B, and most cover Part D, or give you the option to add prescription drug coverage.
“Medicare & You” is a booklet with information on Medicare benefits, rights and protections, lists of available health and drug plans, and answers to the most frequently asked questions. This handbook as well as other available publications are revised yearly and available in both English and Spanish. You may obtain a copy by calling the Medicare office or read them online at Medicare.gov.
With questions or for information, contact:
The Official U.S. Government Site for Medicare
Medicare.gov
800-633-4227
877-486-2048 TTY
Social Security Administration
SSA.gov
Office of Public Inquiries and Communications Support
1100 West High Rise
6401 Security Blvd.
Baltimore, MD 21235
800-772-1213
800-325-0778 TTY
State Health Insurance Assistance Program (SHIP)
DOI.Nebraska.gov/consumer/senior-health
The Nebraska Department of Insurance
PO Box 95087
Lincoln, NE 68509-5087
402-471-2201
402-471-4610 Fax
Consumer Affairs Hotline:
877-564-7323 In-State Only
DOI.SHIP@Nebraska.gov
Senior Health Insurance Information Program
(SHIIP-SMP)
SHIIP.Iowa.gov
Iowa Insurance Division
1963 Bell Avenue, Suite 100
Des Moines, IA 50315
800-351-4664
800-735-2942 TTY
515-654-6500 Fax
shiip@iid.iowa.gov
Volunteers Assisting Seniors
VAS-Nebraska.org
1941 South 42nd Street, Suite 312
Omaha, NE 68105
402-444-6617
director@vas-nebraska.org
Medicare Part A
Part A (Hospital Insurance) helps pay for care in hospitals and nursing facilities, hospice care and some home health. Medicare Part A, along with Part B, is often referred to as Original Medicare.
Part A is premium-free for most people because of Medicare taxes paid while working. If you are not eligible for premium-free Part A, the 2023 premium is up to $506/month depending on your income. In most cases, if you choose to buy Part A, you must also buy Part B. Co-payments, coinsurance, or deductibles may apply for each of the Medicare Part A covered services. If you are in a Medicare Advantage Plan or have other insurance, your costs may be different.
If you are already receiving benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically be enrolled in Medicare Parts A & B the first day of the month you turn 65. Otherwise, you may enroll from 3 months prior to your birth month until 3 months after your birth month by calling Social Security or by applying online at SocialSecurity.gov/retirement. If you do not sign up when first eligible, you can sign up between January 1st-March 31st each year for coverage starting July 1st. You may receive a late enrollment penalty. If you did not sign up for Medicare because you were covered under another group health plan, you may sign up during a Special Enrollment Period.
Some covered services are listed in the chart on the following page. Services are listed by benefit period. It is important to remember staying overnight in the hospital does not necessarily mean it is an inpatient stay.
For more information on approved Medicare Part A services and to find current carriers for Nebraska, contact the Medicare office at 800-633-4227 or go online at Medicare.gov.
| Medicare (Part A): Hospital Insurance Covered Services Per Benefit Period(1) | |||
| Service | Benefit | Medicare Pays(2) | You Pay(2) |
| Hospital Stays Semi-private room, meals, general nursing, drugs & other hospital services and necessary supplies; includes mental health or acute care.(3) |
Days 1-60 | All but $1,600 | $1,600 |
| Days 61-90 | Amt over $400/day | $400/day | |
| Days 91-150(4) | Amt over $800/day | $800/day | |
| Days 150+ | Nothing | All Cost | |
| Post-Hospital Skilled Nursing Facility Care Semi-private room, meals, skilled nursing & rehab services. Medicare-approved facility, must be within 30 days after discharge of at least a 3-day hospital stay.(3)(5) |
Days 1-20 | All Cost | Nothing |
| Days 21-100 | Amt over $194.50/day | $194.50/day | |
| Days 100+ | Nothing | All Cost | |
| Home Health Services Skilled care, therapies & DME ordered by a doctor and provided by a Medicare-certified agency. Individual must be homebound. |
Unlimited as long as doctor ordered and Medicare-approved. | 100% or approved amount. 80% of approved durable medical equipment. | Nothing for services if approved amoiunt. 20% or approved durable medial equipment |
| Hospice Care Drugs for pain relief & symptom management; medical, nursing, social & grief services.(5) |
Unlimited; Doctor must certify you are expected to live 6 months or less. | All hospice care. All but $0-$5 copay for outpatient drugs. 95% of inpatient respite care. | 0% for hospice care. $0-$5 copay for oupatient drugs. 5% of inpatient respite care. |
| Blood If not from a blood bank or donated.(6) |
Unlimited | After first 3 pints | First 3 pints |
| (1) A benefit period begins on the first day you are admitted as an inpatient in a hospital or skilled nursing facility and ends after you have been out the hospital or skilled nursing facility for 60 days in a row. There is no limit to the number of benefit periods. (2) These figures are for 2023 and are subject to change each year. (3) If religious beliefs prohibit conventional medical care and you qualify for hospital or skilled nursing facility care, Medicare may cover non-religious, non-medical items and services in a non-medical health care institution. (4) Lifetime Reserve Days give you a total of an extra 60 days that can be used when hospitalized for over 90 days. They are non-renewable. Inptaient mental health care in a psychiatric hospital is limited to 190 days in a lifetime. (5) Medicare and private insurance will not pay for most nursing home care. Medicare does not cover housing when you hospice care in your home or another facility. Medicare may cover some inpatient respite care for hospice patients. (6) If from a blood bank or donated, there is no charge in Part A. Once the blood deductible is met, it is met for both Part A and Part B. |
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Medicare Part B
Part B (Medical Insurance) helps pay for medically necessary doctor’s services, outpatient care, home health, durable medical equipment and some preventive services. Medicare Part B, along with Part A, is often referred to as Original Medicare.
The standard 2023 premium is $164.90/month. The premium can be up to $560.50/month for those with higher incomes. It is deductible from Social Security, Railroad or Civil Service Retirement. If the Part B deductible ($226 in 2023) applies, you must pay all costs until you meet the yearly deductible. At this point, Medicare begins to pay its share. After your deductible is met, you typically pay 20% of the Medicare-approved amount for medically necessary services and nothing for preventive services if the provider accepts the Medicare rate. There is no yearly limit to what you pay out-of-pocket. If you are in a Medicare Advantage Plan or have other insurance, your costs may be different.
If you are already receiving benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically be enrolled in Medicare Parts A & B the first day of the month you turn 65. Otherwise, you may enroll from 3 months prior to your birth month until 3 months after your birth month by calling Social Security or by applying online at SocialSecurity.gov/retirement. If you are automatically enrolled in Part B and do not want to enroll yet, follow the instructions that come with the card and send it back. If you do not sign up when first eligible, you can sign up between January 1st – March 31st each year for coverage starting July 1st. You may receive a late enrollment penalty. If you did not sign up for Medicare because you were covered under another group health plan, you may sign up during a Special Enrollment Period.
Some covered services are listed in the chart on the following page. For further information about Medicare Part B covered services, you can view “Your Medicare Benefits” at Medicare.gov or order a copy by calling 800-633-4227.
To find current carriers for Nebraska, contact the Medicare office at 800-633-4227 or go online at Medicare.gov.
| Medicare (Part B): Medical Insurance Covered Services Per Benefit Period | |||
| You pay a $226(1) yearly deductible for Part B covered services or items.(2) | |||
| Service(3) | Benefit | Medicare Pays(1) | You Pay(1)(2)(4) |
| Medical Services Doctors & surgical services and supplies, therapies and preventative care. |
Unlimited if medically necessary | 80% of approved amount. 100% of preventative care.(3) | 20% of approved amount. Nothing for most preventative care.(3) |
| Mental Health Diagnosis and outpatient treatment.(5) |
Unlimited if approved | 80% of approved amount | 20% of approved amount |
| Clinical Laboratory Services Blood tests, urinalysis, etc. |
Unlimited if medically necessary | 100% | Nothing |
| Durable Medical Equipment (DME) O2 supplies, wheelchairs, hospital beds, etc. from a Medicare-approved supplier. |
Unlimited if medically necessary | 80% of approved amount | 20% of approved amount |
| Home Health Services Intermittent skilled care, therapy & aides from a Medicare-certified agency. Must be homebound. |
Unlimited if medically necessary and doctor ordered | 100% of approved amount | Nothing for services |
| Outpatient Hospital Services Diagnosis & treatment services. |
Unlimited if medically necessary | 80% of approved amount (after copayment) | 20% of approved amount & hospital copayment which varies by service |
| Blood As an outpatient or part of a Part B covered service; if not from a blood bank or donated.(6) |
Unlimited | None of first 3 pints; all but copayment for any additional | First 3 pints & copayment for any additional |
| (1) These figures are for 2023 and are subject to change each year. (2) Once you have paid the $226 deductible for covered services, the Part B deductible does not apply to any further services you receive the rest of the year. (3) The above gives a generaly idea of covered services. Contact Medicare for a full listing. Some preventative services are covered at no cost to you. (4) You pay for charges higher than the amount approved by Medicare unless the doctor or supplier agrees to accept Medicare’s approved amount as the total charge for services. (5) Inpatient mental health services are covered under Part A hospital stays. (6) If from a blood bank or donated, there is a processing copayment in Medicare Part B. Once the blood deductible is met, it is met for both Part A and Part B. |
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Medicare Part C
Instead of getting your coverage through Original Medicare, you can choose Medicare Part C, commonly known as Medicare Advantage. These are Medicare-approved plans obtained through private health insurance companies. They cover all services offered by Part A and Part B and often offer other benefits such as vision, hearing, dental and wellness depending on the plan. Most offer prescription drug (Part D) coverage. You may join a Medicare Prescription Drug Plan if it does not. Hospice is still covered under Part B. You pay the Medicare Part B premium and usually an additional premium for added benefits.
There are different types of Medicare Advantage Plans including (but not limited to) HMO plans and MSA Plans. MSA Plans combine high deductible Medicare Advantage Plans with a Medical Savings Account (MSA). Medicare pays a fixed amount each month to companies offering Medicare Advantage Plans. Each plan can charge different out-of-pocket costs and have different rules for obtaining services.
Comparisons of Medicare Advantage Plans available in Nebraska and Iowa can be found using the Medicare Plan Finder at Medicare.gov/find-a-plan. Call the specific plans you are interested in to find out more about the type of plan as well as specific rules, costs and benefits to make sure they meet your needs. You may also call SHIP at 402-471-2201 in Nebraska or SHIIP at 800-351-4664 in Iowa for more information about individual plans.
If you are turning 65, you may enroll in a Medicare Advantage plan from 3 months prior to your birth month until 3 months after your birth month. If you already have a Medicare Advantage Plan and wish to change it, you may do so between October 15th and December 7th each year for coverage beginning January 1st of the following year. You may enroll in the plan on the Medicare Plan Finder site or on the individual plan’s site, by completing a paper enrollment form, by calling the plan directly or by calling 800-633-4227. Once you join a plan, you will be automatically disenrolled from any old plans. If you join a Medicare Advantage Plan, your Medigap policy will not work.
Medicare Part D
Medicare Part D is a voluntary prescription drug insurance program. They are stand-alone drug plans offered by private insurance companies. Persons enrolled in Original Medicare are eligible for a Medicare Part D Prescription Drug Plan (PDP) that offers only prescription drug coverage. Those who opt for a Medicare Advantage Plan (Part C) are eligible for a Medicare Advantage Prescription Drug Plan (MA-PD) that offers both prescription drug and other health coverage.
There are different PDP and MA-PD options to choose from in Nebraska and Iowa. Things to consider when deciding on a prescription drug plan that best benefits you include:
- Drugs covered by that plan
- Pharmacies available with that plan
- Annual deductibles
- Monthly premiums & co-payments
- Possible future needs
Comparisons of prescription drug plans available in Nebraska and Iowa can be found using the Medicare Plan Finder at Medicare.gov/find-a-plan. Costs may vary by the specific drug plan you choose, your geographic location and your income. If you have limited income or resources, you may qualify for extra help paying your drug costs.
If you are turning 65, you may enroll in a Medicare drug plan from 3 months prior to your birth month until 3 months after your birth month. If you already have a Medicare drug plan and wish to change it, you may do so between October 15th – December 7th each year for coverage beginning January 1st of the following year. If you do not join a Medicare prescription drug plan when you are first eligible and do not have other creditable prescription drug coverage, you may owe a late penalty when joining. You may enroll in the drug plan on the Medicare Plan Finder site or on the individual plan’s site, by completing a paper enrollment form, by calling the plan directly or by calling 800-633-4227. Once you join a plan, you will be automatically disenrolled from any old plans. If your Medicare Advantage Plan already includes prescription drug coverage and you join a separate Medicare Prescription Drug Plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.