Understanding Medicare

Medicare is a federal health insurance program for people age 65 and over and people of any age who are disabled. There are four parts to Medicare:

Medicare Part A

Part A is part of “Original Medicare”. It is considered hospital insurance.

Coverage and Costs

Medicare Part A generally provides cost coverage for inpatient care received in facilities such as hospitals and skilled nursing facilities, as well as home health care and hospice. There is no premium for Part A if you or your spouse worked for 10 years and paid Medicare taxes.

There are costs, however, that are your responsibility under Medicare Part A. These include inpatient hospital deductibles and skilled nursing co-pays as well as payments for long-term custodial care.

2011 Coverage Example: With Part A of Original Medicare, if you are hospitalized (and have not been hospitalized in the last 60 days), you will pay a deductible of $1,132.

UPMC for Life and Medicare Part A

UPMC for Life, a Medicare Advantage plan, replaces Part A coverage with a managed care plan such as an HMO, PPO, PFFS, or Specialty plan. Medicare Advantage plans may offer different hospital insurance coverage costs from those required with Original Medicare Part A. For example, if a UPMC for Life HMO member is hospitalized in one of our network hospitals in 2011, there is a $300 co-pay and no deductible. This co-pay is much lower than the $1,132 deductible that is charged with Part A Medicare coverage for the same hospital stay.

To see other differences between UPMC for Life and Original Medicare, please review our Summary of Benefits documents for each of our plans. These documents contain a side-by-side comparison of our plans to Original Medicare.

Enrolling

To find out more about enrolling in Medicare Part A, please visit the federal government's Medicare Eligibility Tool.

Although UPMC for Life replaces Part A, you must have Original Medicare Part A coverage before you can enroll in UPMC for Life.

Medicare Part B

Part B is part of “Original Medicare”. It is considered medical insurance.

Coverage and Costs

Medicare Part B generally provides some cost coverage for medically necessary outpatient care. (Some Part B covered services include: outpatient surgery, lab and x-ray services, ambulance services, preventive services, and durable medical equipment like prosthetics, wheelchairs, and hospital beds.)

There are some types of outpatient care that are not covered by Medicare Part B. Excluded from coverage are: routine annual physical exams (after an initial “Welcome to Medicare” visit), routine hearing and vision exams, hearing aids or glasses.

Part B Medicare requires individuals to pay a monthly premium. In 2011, depending on when you signed up for Medicare Part B, this amount is $96.40 or $110.50. This premium cost is adjusted according to your income level, however.

In addition to this monthly premium, there is a Part B yearly deductible ($162 in 2011). Individuals with Part B coverage will also be responsible for any percentage of the cost (co-insurance) that Part B does not cover. For example, Part B covers 80% of the cost of a doctor’s visit. The covered individual will be responsible for the remaining 20% of the cost.

2011 Coverage Example: With Part B of Original Medicare, if you have a $300 office appointment with a cardiologist and have already met your deductible your cost would be $60 (20% of $300).

UPMC for Life and Medicare Part B

UPMC for Life, a Medicare Advantage plan, works with your part B coverage. All members of a Medicare Advantage plan continue to pay their Part B premiums and potentially additional premiums based on their selected plan. Some Medicare Advantage plans may offer lower standard co-pays instead of co-insurance as well as some coverage for health care costs not covered by Original Medicare Part B (such as routine eye exams and routine annual physical exams)

2010 Coverage Example: If a UPMC for Life HMO member has a $300 office appointment with a cardiologist, the copay would be $30 (half of the co-insurance for the same visit with Part B coverage).

Enrolling

To find out more about enrolling in Medicare Part B, please visit the federal government’s Medicare Eligibility Tool.

You must have Original Medicare Part B coverage before you can enroll in UPMC for Life. You will continue to pay the Part B premium even after enrolling in UPMC for Life.

Medicare Part C

Part C is the name given to Medicare Advantage plans. UPMC for Life is a Medicare Advantage plan.

Coverage and Costs

If you join a Medicare Advantage plan, you will have insurance that covers all the services that Original Medicare (Part A and Part B) covers. Medicare Advantage plans may have lower costs associated with them compared with Original Medicare. Often times this is possible because a Medicare Advantage plan may have a network of physicians that accept both the insurance and the physician payments associated with the plan. PPO Medicare Advantage plans provide out-of-network coverage, but often with a higher cost-sharing or coinsurance compared to HMO Medicare Advantage plans.

Medicare Advantage plans may also offer extra coverage including routine vision, hearing, and dental care. Many people consider enrolling in a Medicare Advantage plan because of the extra coverage that it offers.

To see the differences between the UPMC for Life Medicare Advantage plans and Original Medicare, please review our Summary of Benefits documents for each of our plans. These documents contain a side-by-side comparison of our plans to Original Medicare.

Please note: Members of a Medicare Advantage plan continue to pay the Original Medicare Part B premium in addition to any other premiums associated with the Medicare Advantage plan.

Enrolling

UPMC for Life offers a variety of Medicare Advantage plans for you to consider. We’ve included tools on this website that will assist you in exploring your options. If you have questions, please call us toll-free at 1-866-400-5077 (TTY/TDD: 1-800-361-2629). When you find the UPMC for Life plan that is right for you, we offer a variety of ways to apply for enrollment.

Medicare Part D

Part D is the name given to prescription drug coverage offered as standalone coverage (PDP plan) or in conjunction with a Medicare Advantage plan (MAPD plan). UPMC for Life provides Part D coverage with most of its Medicare Advantage plans. This is indicated by an 'Rx' in the plan name (e.g., UPMC for Life HMO Rx).

Coverage and Costs

If you enroll in a plan that includes Part D prescription coverage, you will have insurance coverage for brand-name and generic medications. You will pay a part of the cost of your prescriptions through copayments or coinsurance. The drugs that a plan covers are listed in a document called a "formulary." You can search the online UPMC for Life formulary (coming soon) for prescriptions you currently take or call us at 1-866-400-5077 from 8 a.m. to 8 p.m.,* seven days a week (TTY/TDD: 1-800-361-2629) for assistance.

Some people who have high prescription costs may reach a coverage gap, known as the donut hole, during any particular plan year. This coverage gap means that when the total yearly amount spent on your drugs by both you and your plan reaches $2,930 in 2012, you will pay a maximum of 86% of the costs for generic drugs and a discounted price for the total cost of brand-name drugs. Once your total out-of-pocket cost exceeds $4,700 in 2012, you will pay the greater of $2.60 for generic and $6.50 for all other drugs, or 5% coinsurance.

Enrolling

UPMC for Life offers a variety of Medicare Advantage plans with Part D prescription drug coverage for you to consider. We've included tools and additional information about Part D coverage on this website that will assist you in exploring your options. If you have questions, please call us toll-free at 1-866-400-5077, from 8 a.m. to 8 p.m.,* seven days a week (TTY/TDD: 1-800-361-2629). When you find the UPMC for Life plan that is right for you, we also offer a variety of ways to apply for enrollment.

Click here for a list of additional plan documents and forms.