G-1, Medicare

Medicare is the federal health insurance program for: 

• People who are 65 or older 

• Certain younger people with disabilities 

• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) 

Learn more: https://www.medicare.gov/

 

G-2, Medicare

Dual Eligibility

People who are enrolled in both Medicare and Medicaid, also known as dually eligible individuals, fall into several eligibility categories. These individuals may either be enrolled first in Medicare and then qualify for Medicaid, or vice versa.

 

G-3, Medicare

Understanding the Parts of Medicare

Part A 

Covers hospitals, hospice, and skilled nursing care; no charge to Medicare beneficiaries for premium, but deductibles and co-insurance apply.

 

Part B 

Covers doctors’ services, outpatient care, and preventive services; income-based premiums apply, along with an annual deductible and 20% co-insurance.

 

Part C 

Also known as Medicare Advantage. Coverage is the same as Part B, and may also include dental, vision, fitness, and meals. It is provided by private insurance carriers and requires payment of Medicare Part B premium; some plans have additional premium costs. These plans are subject to restricted networks, pre-authorization requirements, and referrals for specialist care. Usually covers medications.

 

Part D 

This is for medications only; it is administered by a private company. Subject to donut hole. Costs vary according to the plan.

 

G-4, Medicare

Donut Hole 

The coverage gap in Medicare prescription drug coverage (Part D). You enter the coverage gap when you and your drug plan have spent a certain amount for covered drugs. For 2024, that amount is $5,030. Once in the coverage gap, you will pay no more than 25% of the cost for covered generic and brand-name prescription medications until you have reached the catastrophic limit ($8,000 spent by you or on your behalf in 2024). In 2025, the coverage gap for Medicare Part D ends and the maximum out-of-pocket cost for prescription medications is capped at $2,000.

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G-5, Medicare

Medigap Policy 

Health insurance sold by private insurance companies to fill the “gaps” in Traditional Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Traditional Medicare Plan does not cover.

 

Eligibility requirements are the same as for Medicare A. Medigap covers doctors’ services and hospitalization. Medigap providers are any providers that accept Medicare.