Medicare and its numerous plans can be quite confusing.  Friends and online guides can be helpful but having an expert to guide you in choosing the best plans for your individual needs has its advantages and this is where Capstone Insurance can help.  Medicare is confusing because there’s so much information to absorb and most of the time the important topics are not explained properly.  Capstone Insurance can explain how Medicare works and all the options available to you without all the insurance jargon.  Since we represent virtually every plan in Florida; you can see all your options in one appointment. 

Capstone Insurance will review your plan every year to see if there are any changes and if there are any better options.  Health conditions change too so a plan today may not be the best for your needs next year.  Every year, we’ll review your prescriptions and doctors to find the right fit for your needs and budget. 

Our services are paid directly by the insurance carriers so there’s no fee to you.   And commissions are regulated by Medicare so we have no financial motive to promote one company over another.  We want you to have the right coverage whether it’s a plan with a monthly premium (Medicare Supplement) or no cost plan (Medicare Advantage). 

Medicare Basics

What is Medicare and how do you get it?

  • Medicare is a federally funded program that’s administered and regulated by Centers for Medicare & Medicaid Services (CMS).
  • You are eligible for Medicare if you are:
    • A citizen or permanent resident of the United States
    • Age 65 or Older
    • Under the age 65 with certain disabilities
    • Any age with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS also known as Lou Gehrig’s disease).

4 Parts of Medicare

Medicare Parts A and B (Original Medicare)       Medicare Parts A & B offered by the Federal Government

  • Medicare Part A helps cover hospital, skilled nursing, home health and hospice care. You will have out-of-pocket costs for these services such as deductibles and co-insurance. 
  • Medicare Part B helps cover costs of doctor visits, outpatient services & preventative care. With Part B, there are additional costs, such as monthly premiums, annual deductibles & coinsurance you have to pay.

Medicare A & B cover much of your medical care but not all of it and you typically pay a deductible and coinsurance when you use it with no out-of-pocket maximum.  That’s why most people either buy a Medicare supplement or go with a Medicare Advantage plan.

  • Medicare Part D

    (Prescription Drug Plan- More Information Below) 

    Medicare Part D offered by private insurance company.

Part D is a prescription drug plan for people with Medicare.  It must offer at least the basic benefits required by Medicare. 

  • Medicare Part C (Medicare Advantage)                                                       

Medicare Part C also known as Medicare Advantage is administered by a private company and available to anyone who has Medicare Part A, Part B and a permanent resident in the plan service area.  It covers everything Original Medicare covers, most include prescription drug coverage (Part D) plus additional benefits like dental, vision and hearing at no additional cost. 

2 Common Types of Medicare Advantage Plans:

    • HMO (Health Maintenance Organization)
      • Generally speaking; primary care physician arranges your healthcare in the plans network. Costs are very low and plans offer extra benefits like money back in Social Security check.
    • PPO (Preferred Provider Organization)
      • Choose any provider without a referral however costs will be less from in network provider.

Is Medicare Advantage still Medicare or as good as Medicare?

Medicare Advantage plans are required to cover everything Original Medicare covers, including services Medicare considers medically necessary.  If you decide to enroll in a Medicare Advantage plan, you still have Medicare coverage, rights and protections; you just choose to receive your Medicare benefits through a private insurance company.

Medicare Part D: Explained 

Medicare Part D is coverage for prescription drugs.  You don’t automatically get this coverage when you become eligible for Medicare however a very important factor to consider when selecting a plan.  To receive drug coverage, you can join a Medicare Advantage Plan that includes prescription drug coverage or purchase a standalone Prescription Drug Plan (PDP). 

A formulary is a list of covered drugs by the plan and you generally pay less or nothing at all for generics. 

Every Medicare Part D Prescription Drug Coverage have four payment stages and the amount you pay to fill a certain medication will depend on which payment stage you are in.

  1. Deductible Stage
    • This is the amount you pay before the plan covers your prescriptions drug costs. Deductibles range from $0-$445.                                             
  2. Initial Coverage Stage
    • During this stage; the plan pays its share of the costs and you pay your share until the total drug costs reaches $4,130.                                                                              
  3. Coverage Gap (Donut Hole) Stage
    • When your drug costs and plan payments have reached $4,130, you enter the Coverage Gap Stage (also known as the Donut Hole). You’ll pay 25% of the cost of covered brand name and generic medications.  You will pay this amount until your yearly out-of-pocket drug costs reach $6,550.                                   
  4.  Catastrophic Coverage Stage
    • You will pay either 5% of the cost of the drug, or a copay of $3.70 for generic drugs or $9.20 for brand name drugs.