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Does Medicare Offer Family Plans?

Many Americans are currently enrolled in family health care plans either through the exchange or through their employer-provided health insurance. It is not uncommon for entire families to be covered under one policy. Medicare, however, only provides individual coverage to single beneficiaries. Two spouses can be both enrolled in Medicare, but must each have their own individual plans. This means that beneficiary’s families will need separate coverage, because they cannot be added to the Medicare policy.

Therefore, the short answer is no, Medicare does not offer family plans. But it’s more complicated than that. Although over half of all Medicare eligible Americans aged 65 and older are married, Medicare is not dependent on marital status.

The beneficiary and their spouse must enroll in their own separate Medicare plans, at whatever time they become eligible as individuals. Married partners may even need to enroll at different times, depending on factors such as age, health, and disability. However, marital status can influence some Medicare costs.

The reason that marital status can influence some of the Medicare costs is this: for Medicare Part B, the combined household income is what is considered for determining the premium. In most cases, each beneficiary will still pay the standard monthly part B premium, which is $164.90 per month for this year (2023).   This premium is adjusted annually by the Centers for Medicare & Medicaid Services (CMS). If the beneficiary’s tax returns show a combined household income of $194,000, then each beneficiary will pay more for their monthly premiums. The higher the family’s combined annual income, the higher their individual Medicare Part B premiums will be.    The additional premium amount is known as the Part B IRMAA (Medicare income-related monthly adjustment amount).   Like the Part B premium, IRMAA amounts are also adjusted annually.

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What is a Medicare Advantage Plan

Original Medicare includes benefits for Part A (hospitalization) and Part B (doctor visits).  However, not all of a beneficiary’s needs may be satisfied.   (Click here to learn 5 things that are not covered.)  A Medicare Advantage Plan, also known as Medicare Part C or MAPD, can be an effective and financially smart way to ensure that senior citizens have the medical coverage they need going into their golden years.

While not part of the original federal health plan, Medicare Part C became law in 1982. The way it works is that the federal government pays private insurance companies a specific amount of money per person to bundle the original Medicare benefits. Many companies also add prescription drug coverage, or Medicare Part D, in their advantage plans. Some of these plans cover additional services than original Medicare, making them a smart choice for many senior citizens.

Because many Medicare Advantage plans work like private insurance plans, the options for them include:

• Health maintenance organization plans (HMOs)

• Preferred provider organization plans (PPOs)

• Private fee-for-service (PFFS)

Because of their connection to the federal plan, Medicare usually sets the fee for both the provider and the individual enrollee. But, for a PFFS plan, the private insurance company sets those fees. Medicare Advantage plans must follow Medicare rules and guidance from the federal government, though each private company can have different out-of-pocket costs or access to services. In addition, insurance companies can, and do, change the rules of their Medicare Part C (Advantage) plans each year.

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Who Needs Medicare Supplemental Insurance

One of the most common questions you will have to answer from your clients will be, “why do I need supplemental insurance?” This is a good question, and will allow you to explain exactly why supplemental insurance and/or Medicare Advantage plans make financial sense for many seniors.   Seniors have the option of adding Medicare Supplement or Medicare Advantage plans to fill the coverage gaps.

Medicare Part A and B cover many of the typical medical expenses of senior citizens. Some of these include visits to primary care doctors or specialists, laboratory tests, or hospitalization. These original parts of Medicare also cover stays in skilled nursing facilities, surgical procedures, and outpatient procedures.

However, Parts A and B do not cover all of a typical senior citizen’s expenses. For example, despite the near ubiquitous use of hearing aids in old age, Medicare does not cover hearing care, hearing exams, or hearing aids. Also not covered are dental care, dentures, vision care, routine foot care, or long-term care. Additionally, prescription drugs, for the most part, are not covered under the original Medicare but by Part D, which has to be purchased separately as supplemental insurance.

Therefore, if a senior citizen knows or anticipates that they will need any of the typical healthcare used by their demographic, such as hearing aids, glasses, dentures, or prescription medication, they would benefit from purchasing a supplemental insurance plan.

This video will help you determine whether a Medicare Supplement or Advantage plan best suits the needs of your client.   Click here to view. 

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Interested in marketing Medicare Supplements and Advantage plans?   Click here to learn how to get started.

What is the difference between Part A and Part B of Medicare?

In order to help your clients choose the best healthcare coverage for their needs, you need to understand the coverage they already have: Medicare. There are four parts to Medicare.  Medicare Part A and Medicare Part B are provided by Medicare.  Those two parts make up the original federal health program.  Part A and B are referred to as Original Medicare.  Remember, Medicare is a US government entity.   Part C and Part D are purchased from private insurance carriers.

Medicare Part A is hospital insurance.  As hospital insurance,  Part A generally covers the following.

• Inpatient hospital stays

• Prescription drugs administered in the hospital

• Skilled nursing facility stays

• Mental health inpatient stays

• Hospice care

• Limited or temporary home health care

Medicare Part B is medical insurance.  As medical insurance, Part B generally covers the following.

• Annual wellness exams

• Doctor and specialist visits

• Preventative services (flu shots, etc.)

• Bone mass measurements

• Tests and screenings for certain diseases

• CPAP machines for sleep apnea

• Certain diabetes equipment and supplies

• Limited home health visits

• Durable medical equipment (walkers, wheelchairs, etc.)

This is not a complete list of the medical services covered by Medicare Part B.  However, it is a starting point to help your clients understand where their gaps in coverage are and how to choose supplemental insurance to address those gaps.

Click here to learn how to compare Medicare Advantage plans.

Click here to learn how to compare Medicare Supplement plans.

Medicare Advantage and Supplemental Sales Video

Five Things Medicare Does Not Cover

The reason that supplemental and advantage plans are so crucial is that Medicare Part A and Medicare Part B do not cover everything. Without sufficient insurance, this can mean out-of-pocket expenses and surprise bills later in life, when many people are on a fixed income.

Here are five things Medicare does not cover:

1. Long-term or custodial care. Custodial care includes the everyday tasks that a person may need help with as they age, which can include anything from getting dressed to putting in eye drops or using the bathroom.

2. Most dental care.  Even though dental health is an extension of physical health,  Medicare does not offer any benefits.  Click here to view standalone Metlife Dental plans.

3. Eye exams.  Vision care is not covered.   Many independent carriers offer standalone vision plans.

4. Dentures.

5. Hearing aids and the exams for fitting them.

There are tools that the government provides so that seniors can find out if a service or supply is covered under their Medicare Part A or B plan.  Click here to access the Medicare.gov coverage tool. 

Some other common services that are not covered by government-issued Medicare include the following.

• concierge care,
• retainer-based medicine,
• boutique medicine,
• covered items and services you get from an opt-out doctor or institution (except in the case of a qualified urgent or emergency need).

Note: If an individual is not present in the US, Medicare will not pay for Part A or Part B claims.   Additionally, that individual can not enroll in a Medicare Advantage plan or a Medicare Drug plan.

What Does Will Medicare Pay for?

Click here to learn with Medicare does pay for.

Medicare Donut Hole 2023

The Medicare Donut Hole 2023 is also known as the Part D coverage gap. The coverage gap occurs after the initial coverage period, when the beneficiary’s total drug cost reaches a specified limit. For 2023, the limit is $4,660.00. This cost includes a combination of what the beneficiary AND the insurance carrier has paid, which is why so many seniors can fall into the donut hole. Once people are in the donut hole, or coverage gap, they are responsible for a percentage of the cost of their prescribed medication(s).

What happens when the donut hole is reached?

Although beneficiaries are responsible for a percentage of the cost of their medication while in the coverage gap, they typically pay no more than 25% of the cost of approved, brand-name prescription drugs. Some plans offer even lower costs while in the coverage gap. The discount applies to the beneficiary’s plan negotiated pricing that specific drug. Although members pay no more than 25% of the price for the brand-name drug, almost the full price of the drug will count as out-of-pocket costs. This helps get them out of the donut hole faster, because member costs count toward out-of-pocket maximum payments.

How do I get out of the donut hole?

Catastrophic coverage kicks in to cover the costs of medication once a beneficiary has spent $7,400 in out-of-pocket costs. This number includes what the beneficiary pays in covered medication(s) and some costs that are covered by family members, charities, or other persons on their behalf. During this period, beneficiaries will pay significantly lower copays or coinsurance for their approved drugs for the remainder of the year. These out-of-pocket costs that help them reach catastrophic coverage include:

• Their deductible

• What they paid during the initial coverage period

• Almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap

• Amounts paid by others, including family members, most charities, and other persons on their behalf

• Amounts paid by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and the Indian Health Service

The Medicare Part D plan should keep track of how much money beneficiaries have spent out of pocket for covered drugs and their progression through coverage periods. This information should appear in monthly statements.

Note: Beneficiaries with Extra Help do not have a coverage gap. They pay different drug costs during the year. Drug costs may also be different for those enrolled in a SPAP.

Click here to learn more about Medicare Drug Pricing.