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Medicare in South Carolina


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Overview of Medicare in South Carolina

As a Medicare beneficiary, you may be able to choose from a variety of Medicare coverage options in South Carolina. The government program and most common Medicare plan options are described below.

First, there’s Original Medicare. Medicare is a federal program whose rules are the same all over the country. Original Medicare is available to American citizens and permanent legal residents (of at least five continuous years) aged 65 or older, those who qualify by disability, and some people with permanent kidney failure.

Most people are automatically enrolled in Original Medicare as soon as they qualify.

Original Medicare is made up of two parts: Part A and Part B.

  • Medicare Part A provides basic coverage for inpatient hospital stays and limited post-hospital nursing facility and home health care.
  • Medicare Part B may pay most basic doctor and laboratory costs, and some outpatient medical services, including medical equipment and supplies, home health care, and physical therapy.

Typically, you get Medicare Part A without a premium if you’ve worked at least 10 years (40 quarters) and paid Medicare taxes; otherwise, you may owe a premium for your Part A coverage. You must pay a yearly deductible for both Medicare Part A and Part B, and may make sizable copayments for extended hospital stays. Under Part B, Medicare typically pays 80% of your doctor’s bill after you have met your deductible and you must pay 20%. Part B also charges a monthly premium you must pay.

It is also important to note that Original Medicare does not pay for all the services that seniors or disabled beneficiaries may need. If you have Original Medicare, some of the services or items you may be responsible for paying include:

  • Custodial long-term services (nursing home care)
  • Routine vision care, eyeglasses and contacts
  • Routine dental care and dentures
  • Health services received outside of the country
  • Most prescription drugs, except for those you get in an inpatient hospital or skilled nursing facility setting and certain medications you receive in an outpatient setting

As mentioned, Original Medicare coverage of prescription drugs is very limited. However, Medicare Prescription Drug Coverage (Medicare Part D) is available to cover your prescription drug costs. One option you have is to enroll in a stand-alone Medicare Part D Prescription Drug Plan (PDP) to help pay for prescription drug costs. These are separate Medicare plans that work alongside your Original Medicare coverage, and are available through private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS).

If you choose to enroll in a Medicare Prescription Drug Plan, you typically pay a monthly premium. Other costs may include any annual deductible and coinsurance or copayments your Medicare Prescription Drug plan has. You may be able to reduce these costs if you qualify for a low-income subsidy, also called “Extra Help”. To learn if you qualify for Extra Help, visit the South Carolina Office on Aging website (listed below under Resources) for more information.

As an alternative to Original Medicare coverage, you may be eligible to enroll in a Medicare Advantage plan in South Carolina. These plans provide a different channel for obtaining Medicare Part A and Part B coverage, and often even Part D benefits. Medicare Advantage plans are offered by private insurance companies that contract with CMS. Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, with the exception of the hospice benefit, which continues to be paid by the government Medicare Part A program.

One reason why Medicare Advantage plans are popular with some beneficiaries is that many plans include additional benefits, such as routine dental and vision care, hearing aids, wellness programs, nutrition and dietary counseling, and prescription drug coverage. Medicare Advantage plans that include prescription drug coverage are known as Medicare Advantage Prescription Drug (MA-PD) plans. These plans give you the convenience of having your Medicare medical and prescription drug benefits through one plan, instead of having to enroll in a separate plan for your Medicare Part D coverage.

Another feature of Medicare Advantage plans is that they are required to limit beneficiaries’ out-of-pocket expenses for services covered under Medicare Parts A and B. All Medicare Advantage plans must include a yearly out-of-pocket spending limit; once your out-of-pocket costs reach this limit (including the deductible), your Medicare Advantage plan pays 100% of covered health-care costs for the remainder of the year. In contrast, Original Medicare doesn’t have a maximum spending ceiling, so there’s no limit to how high your out-of-pocket costs could rise.

If you’re interested in enrolling in a Medicare Advantage plan, you must:

  • Have Medicare Part A and Medicare Part B
  • Live in the Medicare Advantage plan’s service area
  • Not have end-stage renal disease, or ESRD (unless you meet certain exceptions). However, if you have ESRD, you might be eligible to enroll in a Medicare Special Needs Plan.

To find out which Medicare Advantage plans are available where you live, use the eHealth plan finder located on this page. Simply type in your zip code in the tool, and you will see a listing of Medicare Advantage plans. You can also provide your current list of prescription drugs to find Medicare Advantage plan options that cover those medications.

If you decide to sign up for a Medicare Advantage plan, you must continue to pay your Medicare Part B premium and you may also have to pay an additional premium directly to your Medicare Advantage plan. Medicare Advantage plans have different benefit designs although most include premiums and copayments. Some Medicare Advantage plans include an annual deductible, which you would pay before you received coverage for many services other than an annual wellness exam and certain health screenings for disease prevention and early detection

Another option you may have if you’re enrolled in Original Medicare is Medigap (Medicare Supplement) insurance, which is also offered by private insurance companies. These insurance plans can help you pay your out-of-pocket costs for services covered under Original Medicare.

Medicare resources in South Carolina

Office on Aging – Managed by the office of the Lieutenant Governor, this office provides a wealth of information to seniors living in the state to help them achieve the highest quality of independent living possible. The office also offers information about South Carolina Medicare plans to help seniors make informed choices about their health-care coverage. In addition to the many facts found on the office’s website, the following programs are included under the oversight of the Office on Aging:

  • State Health Insurance Program (SHIP) – This program is also referred to as the Insurance Counseling Assistance and Referrals for Elders program (I-CARE). SHIP counselors are located throughout the state to offer one-on-one counseling and free seminars to Medicare beneficiaries in South Carolina.
  • Senior Medicare Patrol (SMP) – This program is designed to prevent Medicare fraud d by alerting seniors to what fraud looks like and how they can protect themselves. The SMP also boasts a staff of trained volunteers that will counsel Medicare beneficiaries on fraud and how to report errors on their claims forms.

South Carolina Upstate Aging and Disability Resource Center – This state office provides many similar programs to the statewide Office on Aging for residents living in the Greenville area. Sponsored by the Appalachian Council of Governments, the office offers information on various types of Medicare plans in South Carolina, including ones that offer prescription drug coverage. The website also has a listing of links to other agencies, phone numbers for SHIP counselors in the area, and contact information for the Medicare assistance program in the state. Training for SHIP counselors is also located at this office.

South Carolina Health and Human Services – For Medicare beneficiaries in South Carolina who are having trouble affording their premiums or deductibles, help may be available through the South Carolina Health and Human Services department. This state office oversees the Medicaid program for South Carolina. The website for the department offers information about the Qualified Medicare Beneficiaries (QMB) program, which offers assistance paying Part B premiums. Eligibility requirements and downloadable application forms are available through the website.

Medicare statistical trends in South Carolina according to the Medicare Enrollment Dashboard and 2018 MA Part D State by State report.

In 2018 more than  1 million South Carolinians were enrolled in Medicare, according to CMS. For your information, listed below are some facts about Medicare coverage in South Carolina in 2018.

About Medicare Advantage plans

  • If you reside in South Carolina and are eligible to participate, you have access to a Medicare Advantage plan. Statewide, 55 Medicare Advantage plans are providing coverage to beneficiaries in 2018. 28 percent of Medicare beneficiaries in South Carolina had Medicare Advantage plans and other Health plans in 2018.
  • You may have access to a variety of Medicare Advantage plans. Examples of the types of Medicare Advantage plans operating in South Carolina may include:
    • Health Maintenance Organizations (HMO) plans, in which your primary care physician providers or arranges most of your health-care services. In an HMO, your health care must be delivered by providers who participate in the plan’s network in most cases. Some plans include prescription drug coverage.
    • Preferred Provider Organizations (PPO) plans, in which you pay a lower cost-share when you receive covered services from providers who participate in the plan’s network and a higher cost-share when you receive covered services from a non-network provider. Some plans include prescription drug coverage.
    • Special Needs Plans (SNP), which are designed to assist people who are eligible for Medicare and Medicaid, and those with certain health conditions. Special Needs Plans include prescription drug coverage.

Monthly premiums may vary among plans. Some may have premiums as low as $0. You must continue to pay your Part B premium.

About Medicare prescription drug coverage

  • 22 Medicare Prescription Drug Plans are available in South Carolina.
  • 81% of people who had Medicare Part D coverage in 2018 have access to a plan with a lower premium than what they paid in 2017.
  • The lowest monthly premium for a stand-alone Medicare Prescription Drug Plan is $12.60.
  • 29% of people enrolled in Medicare Part D pay less than the lowest monthly premium because they qualify for and receive Extra Help (also called the low-income subsidy, or LIS).

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

The product and service descriptions, if any, provided on these eHealth Insurance Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.
Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

The provider network may change at any time. You will receive notice when necessary.

Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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