1.
Module 1: Overview Medicare P
rogram Ba
sics
2.
Navigation Inst
ructions
3.
Terms and Conditions
This training program
is protect
ed und
er United Stat
es Copyrig
ht laws
, 17
U.S.C.A. §101, et
seq. and
international t
reaties. Except as p
rovided below, t
he training pro
...
1. Module 1: Overview Medicare Program Basics
2. Navigation Instructions
3. Terms and Conditions
This training program is protected under United States Copyright laws, 17 U.S.C.A. §101, et seq. and
international treaties. Except as provided below, the training program may not be reproduced (in whole
or in part) in hard paper copy, electronically, or posted on any web site or intranet without the prior
written consent of AHIP. Any AHIP member company in good standing sponsoring a Medicare
Advantage or Part D plan may reproduce the training program for the limited purpose of providing
training and education to the company’s own employees and contractors on the subject matter
contained in the training program. Employees or contractors participating in such training may not
further reproduce (in whole or in part) the training program. No changes of any kind may be made to
the training program and any reproduction must include AHIP's copyright notice. This limited license is
terminable at will by AHIP.
The training program is intended to provide guidance only in identifying factors for consideration in the
basic rules and regulations governing coverage, eligibility, marketing, and enrollment for Medicare,
Medicare supplement insurance, Medicare health plans, and Part D prescription drug plans and is not
intended as legal advice. While all reasonable efforts have been made to ensure the accuracy of the
information contained in this document, AHIP shall not be liable for reliance by any individual upon the
contents of the training program.
4. Learning Objectives
After reviewing “Module 1: Medicare Program Basics” you will be able to explain:
• The different ways to get Medicare benefits
• Eligibility for Part A and Part B
• New special enrollment periods for Medicare
• What is covered under Part A and Part B
• Original Medicare premiums
• Help for beneficiaries with limited income
• Original Medicare beneficiary protections
• Combining Original Medicare and Part D
• Medigap coverage
5. Training Roadmap: Module I
• Medicare Program Basics
• Original Medicare: Eligibility, Enrollment, Entitlement, and Premiums
• Help for Individuals with Limited Income
• Medicare Part A Benefits and Original Medicare Cost Sharing
• Medicare Part B
• Original Medicare
• Medigap Coverage
1
6. Title Page – Medicare Program Basics
7. Medicare Basics
• Medicare is the Federal health insurance program for individuals who are aged (65 and over)
and younger individuals who have certain health conditions or are disabled.
• Medicare eligibility does not take into consideration an individual’s income. However,
o individuals may pay higher premiums based on income, and
o low income individuals may be eligible for additional assistance
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6. Title Page – Medicare Program Basics
7. Medicare Basics
• Medicare is the Federal health insurance program for individuals who are aged (65 and over)
and younger individuals who have certain health conditions or are disabled.
• Medicare eligibility does not take into consideration an individual’s income. However,
o individuals may pay higher premiums based on income, and
o low-income individuals may be eligible for additional assistance.
• Individuals can receive their Medicare medical coverage:
o directly from the Federal Government, which pays for services on a fee-for-service basis
(this program is known as “Original Medicare” or “Fee-for-Service Medicare”); or
o through a private health plan.
• Individuals must receive their Medicare Part D outpatient drug benefits through a private health
plan (even if they get their medical coverage through Original Medicare).
8. Overview of Medicare Benefits and Coverage -- Parts A, B, C, and D
• Medicare coverage is often known by the part of Medicare law under which it is authorized or
regulated.
o Part A is referred to as “Hospital Insurance Benefits.” Part A also covers other inpatient
care, including skilled nursing facilities, rehabilitation facilities, and hospice.
o Part B is referred to as “Supplementary Medical Insurance Benefits.” Part B covers a
broad range of outpatient services such as physician care, and drugs that are
administered by physicians or other health care professionals (such as certain vaccines
and intravenous medications).
o Part C regulates and authorizes Medicare Advantage plans, which must cover Part A
(except for hospice) and Part B benefits.
▪ Individuals enrolled in a Part C plan still get hospice benefits, but they are paid
for by Original Medicare.
o Part D covers prescription drug benefits (for self-administered drugs, such as those
picked up at a pharmacy and taken at home) and regulates Medicare prescription drug
plans.
9. Overview of Medicare – Part E
There is also a lesser-known Part E of Medicare law that regulates other miscellaneous programs
including:
• Medicare cost plans (which also cover Part A and Part B benefits)
o Medicare cost plans are only offered in a limited number of states and are most
frequently found in rural areas.
• Medicare supplemental insurance (Medigap Plans)
• The program for all-inclusive care for the elderly (PACE)
2
10. Different Ways to Get Medicare
There are different ways that beneficiaries can choose to receive their Medicare coverage.
• Original Medicare (Part A and Part B coverage)
o Can be combined with a Medicare Supplement Plan and/or a Medicare Prescription
Drug Plan.
• Medicare Advantage Plans (Medicare Part C health plans, with or without Part D benefits)
• Medicare Prescription Drug Plans
• Medicare Cost Plans
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10. Different Ways to Get Medicare
There are different ways that beneficiaries can choose to receive their Medicare coverage.
• Original Medicare (Part A and Part B coverage)
o Can be combined with a Medicare Supplement Plan and/or a Medicare Prescription
Drug Plan.
• Medicare Advantage Plans (Medicare Part C health plans, with or without Part D benefits)
• Medicare Prescription Drug Plans
• Medicare Cost Plans
• PACE Plans
• Medicare-Medicaid Plans
11. Different Ways to Get Medicare – Brief Overview
WAYS TO GET MEDICARE COVERAGE1
COVERAGE TYPE BENEFITS
Part A and Some of Part D Other benefits
B benefits the cost Benefits
sharing for
Part A and
B Benefits
Original X
Medicare3
Part C (Medicare X X May cover X (most offer additional
Advantage)4 depending benefits)
on plan
Cost Plans 2,3 X X May cover X (most offer additional
depending benefits)
on plan
Medicare X
Prescription
Drug Plans
(PDPs)
Original X X Some Medigap Plans
Medicare with a (Original (Medigap) cover foreign travel
supplemental Medicare) emergencies
plan (Medigap)3
PACE plans2 X X X X (Adult day center, some
meals, other benefits)
Medicare- X X X X Integrates Medicaid
2
Medicaid Plans benefits with Medicare
benefits
1
Brief overview. As detailed later, some ways can be combined and not all beneficiaries are eligible for
all types of coverage.
3
2
These types of plans are generally limited to certain geographic areas and are not available
everywhere.
3
These plans can be combined with coverage under a PDP.
4
As discussed later, a few MA plan types (PFFS and MSAs) can be combined with coverage under a PDP.
12. Title Page – Original Medicare: Eligibility, Enrollment, Entitlement, and Premiums
13 Original Medicare
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