Medicare is government-managed health insurance that you can get when you turn age 65. Medicare in Delaware is also available to people under age 65 who meet certain criteria.
Medicare includes four main parts:
- Part A: hospital care
- Part B: outpatient care
- Part C: Medicare Advantage
- Part D: prescription drugs
What it covers
Each part of Medicare covers different things:
- Part A covers care you receive as an inpatient at a hospital and also includes hospice care, limited coverage for short-term skilled nursing facility (SNF) care, and some part-time home health care services.
- Part B covers outpatient care, such as doctor’s visits, preventive care, and some durable medical equipment.
- Part C bundles your coverage for Part A and Part B into a single plan that may include other benefits, such as dental or vision coverage. These plans often include prescription drug coverage as well.
- Part D covers some or all of your prescription drug costs outside of a hospital (medication you get during a hospital stay is covered under Part A).
In addition to the four main parts, there are also Medicare supplement insurance plans. Often called Medigap, these plans covers out-of-pocket costs like copays and coinsurance that original Medicare plans don’t and are available through private insurance carriers.
You may not purchase both Part C and Medigap. You must choose type one or the other.
Medicare plans in Delaware have certain costs that you pay for coverage and care.
Part A is available without a monthly premium as long as you or a spouse worked for 10 or more years in a job and paid Medicare taxes. You can also purchase coverage if you don’t meet eligibility requirements. Other costs include:
- a deductible each time you are admitted to the hospital
- additional costs if your hospital or SNF stay lasts longer than a set period of days
Part B has several fees and costs, including:
- a monthly premium
- an annual deductible
- copays and 20 percent coinsurance after your deductible is paid
Part C plans may have a premium for extra benefits that are available through the plan. You also still pay the Part B premium.
Part D plan costs vary based on coverage.
Medigap plan costs vary based on the plan you choose.
Medicare Advantage plans are approved by the Centers for Medicare and Medicaid Services (CMS) and are available through private insurance companies. Benefits include:
- all your benefits from each part of Medicare are covered under a single plan
- other benefits that original Medicare does not include, such as dental, vision, hearing, transportation to medical appointments, or home meal delivery
- out-of-pocket maximums of $7,550 (or less)
There are five types of Medicare Advantage plans in Delaware. Let’s take a look at each type next.
Health Maintenance Organization (HMO)
- You choose a primary care provider (PCP) who coordinates your care.
- You must use providers and facilities within the HMO’s network.
- Usually you need a referral from your primary care provider (PCP) to see a specialist.
- Care outside the network is usually not covered except in emergencies.
Preferred Provider Organization (PPO)
- Care from doctors or facilities within the plan’s PPO network is covered.
- Care outside the network may cost more, or may not be covered.
- You do not need a referral to see a specialist.
Medical savings account (MSA)
- These plans combine a high deductible health plan and savings account.
- Medicare contributes a certain amount of money each year to cover expenses (you can add more).
- MSAs can only be used for qualified medical expenses.
- MSA savings are tax-free (for qualified medical expenses) and earn tax-free interest.
Private Fee-for-Service (PFFS)
- PFFS are plans with no network of doctors or hospitals; you can choose to go anywhere that accepts your plan.
- They negotiate directly with providers and determine how much you owe for services.
- Not all doctors or facilities accept these plans.
Special Needs Plan (SNP)
- SNPs were created for people who need more coordinated care and meet certain qualifications.
- You must be dual-eligible for Medicare and Medicaid, have one or more chronic health conditions, and/or live in a nursing home.
Available plans in Delaware
These companies offer plans in many counties in Delaware:
- Aetna Medicare
- Lasso Healthcare
Medicare Advantage plan offerings vary by county, so enter your specific ZIP code when searching for plans where you live.
To be eligible for Medicare, you must be:
- 65 years or older
- a U.S. citizen or a legal resident for 5 years or more
If you are younger than age 65, you can get Medicare plans in Delaware if you:
- have a kidney transplant or end stage renal disease (ESRD)
- have amyotrophic lateral sclerosis (ALS)
- have been receiving Social Security or Railroad Retirement Board benefits for 24 months
You can use Medicare’s tool to see if you’re eligible.
To receive Medicare or Medicare Advantage you must enroll at the correct time.
- Initial enrollment period (IEP) is a 7-month window around your 65th birthday, starting 3 months before and continuing for 3 months after your birthday. If you sign up before you turn 65 years old, your coverage begins in your birthday month. Signing up after this period will mean a delay in coverage.
- Special enrollment periods (SEPs) are designated times when you can sign up outside of open enrollment if you lose coverage for various reasons, including losing an employer-sponsored plan or moving outside of your plan’s coverage area.
- General enrollment (January 1 to March 31): If you did not sign up for Medicare during your IEP, you can enroll in Part A, Part B, Part C, and Part D plans. You may pay a penalty for signing up late.
- Medicare Advantage open enrollment (January 1 to March 31): You may switch to a new plan if you are already on Medicare Advantage or you can continue with original Medicare.
- Open enrollment (October 15 to December 7): You may switch between original Medicare and Medicare Advantage, or sign up for Part D if you didn’t sign up during your IEP.
Choosing the right plan for depends on the following factors:
- your healthcare needs
- projected expenses
- which doctors (or hospitals) you want to see for care
You can find answers to your Medicare Delaware questions from these organizations:
Delaware Medicare Assistance Bureau(800-336-9500)
- the State Health Insurance Assistance Program (SHIP), formerly known as ELDERinfo
- free counseling for people with Medicare
- local counseling sites throughout Delaware (call 302-674-7364 to find yours)
- financial assistance to help pay for Medicare
- serves as the official Medicare site
- has trained staff on calls to help answer your Medicare questions
- has a plan finder tool to help you find available Medicare Advantage, Part D, and Medigap plans in your area
Here are your next steps to find the best Medicare coverage to meet your needs:
- Determine whether you want original Medicare or Medicare Advantage.
- Choose a Medicare Advantage or Medigap policy, if applicable.
- Identify your enrollment period and deadlines.
- Collect documentation such as a list of the prescription medications you take and any medical conditions you have.
- Ask your doctor if they accept Medicare, and which Medicare Advantage network they belong to.
This article was updated on November 20, 2020, to reflect 2021 Medicare information.
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