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If you are a Medicare beneficiary now or planning for the future, you may be wondering how Medicare coverage works. We invite you to read on and learn the basics about Medicare coverage and the options that may be available to you in Vermont: the first step in your finding a Medicare coverage option that may meet your lifestyle.
To start, it’s important to understand that underlying these Medicare coverage options is Original Medicare. Original Medicare is a federal program offered to United States citizens and permanent legal residents who have lived in the U.S. at least five continuous years who are age 65 or older. Medicare is also offered to people under 65 who qualify by disability, if they have a health condition called end-stage renal disease (permanent kidney failure requiring a kidney transplant or continuous dialysis treatments) or amyotrophic lateral sclerosis also known as Lou Gehrig’s disease.
Under the Original Medicare program, Medicare Part A covers inpatient hospital care, post-hospitalization care in a skilled nursing facility, some home health visits, and hospice care. Medicare Part B covers doctors’ care in the diagnosis and treatment of illnesses or injuries; some disease prevention screenings and check-ups; outpatient services such as physical therapy, lab services, and x-rays; certain medical supplies such as durable medical equipment; and limited home health care services.
Take note, however, that Original Medicare does not cover most prescription drugs (except for medications during a hospital stay, or certain prescription drugs administered to you as an outpatient). Nor does it cover medical care or supplies received outside the United States. Original Medicare does not cover routine dental and vision care, nor dentures. It does not generally cover long-term skilled nursing care.
For many beneficiaries, the upfront cost you pay for Original Medicare is relatively modest. If you or your spouse have worked at least 10 years and paid Medicare taxes, there is typically no additional monthly premium for Medicare Part A. There is a monthly Medicare Part B premium you will have to pay. Other costs depend on how many doctor visits, hospitalizations, and other Medicare-related services you receive.
You may have cost-sharing expenses relative to Original Medicare. You must pay a yearly deductible for both Medicare Part A and Part B, and make hefty copayments for extended hospital stays. Under Part B, you typically must pay the 20% of doctors’ bills Medicare does not pay.
If you decide to stay with Original Medicare, you might want to learn about Medigap (Medicare Supplement) insurance plans available in Vermont. Medigap insurance plans are offered by private insurance companies and can help you pay your out-of-pocket costs for services covered under Original Medicare.
As an alternative way to get Original Medicare benefits, you may want to explore Medicare Advantage(sometimes referred to as Medicare Part C coverage). Medicare Advantage plans are offered by private insurance companies contracted with Medicare. Medicare requires these plans to provide at least the same level of coverage as Original Medicare (except for hospice care, which Medicare Part A still covers). They are also required to limit your out-of-pocket spending for services covered under Medicare Part A and Part B during the benefit year. If your out-of-pocket expenses reach this limit (including the deductible), your Medicare Advantage plan pays all covered health-care costs for the remainder of the year. In contrast, Original Medicare doesn’t have a maximum spending limit.
To be eligible to enroll in a Medicare Advantage plan, you must already have Medicare Part A and Part B, and live in the service area of the Medicare Advantage plan. If you have end stage renal disease (ESRD), you may not be able to enroll in most Medicare Advantage plans, but you might be able to sign up for a Medicare Special Needs Plan.
You can identify Medicare Advantage plans available where you live using the eHealth plan finder located on this page and typing in your zip code.
In addition to providing the benefits of Medicare Part A and Part B, many Medicare Advantage plans include additional benefits such as routine dental and vision care, hearing, wellness programs, and Medicare prescription drug coverage (Medicare Part D). Medicare Advantage plans that include prescription drug coverage are known as Medicare Advantage Prescription Drug (MA-PD) plans, and give you the convenience of having all of your Medicare medical and prescription drug benefits through one plan.
If you decide to enroll in a Medicare Advantage plan, you will have to pay your Medicare Part B premium and the Medicare Advantage plan’s monthly premium, if any. Premiums, deductibles, copayments, and coinsurance amounts vary among plans so it could be wise to compare Medicare Advantage plans available where you live.
Medicare beneficiaries in Vermont (as in other states) can get Medicare prescription drug coverage from a stand-alone Medicare Part D Prescription Drug Plan. These plans, offered by Medicare-approved private insurance companies, can work alongside Original Medicare.
To enroll in a Medicare Prescription Drug Plan available where you live, you must have Medicare Part A and/or Part B, and live in the plan’s service area.
If you decide the sign up for a Medicare Prescription Drug Plan, the plan will typically charge a monthly premium. Depending upon your income, you may qualify for “Extra Help” to offset some or all of your premium cost. Different Prescription Drug Plans may cover different pharmacy networks and specific prescription drugs, as well as different premiums, deductibles, copayments, and coinsurance. The list of prescription drugs a plan covers is called a formulary; these may vary among plans. The formulary may change at any time. You will receive notice from your plan when necessary.
Department of Disability and Aging Services – This office, which operates under the Vermont Department of Disabilities, Aging and Independent Living, provides a variety of resources to help you live independently. The office contracts with various local providers to ensure Medicare beneficiaries in Vermont get the information and assistance they require. The office provides a number of programs for seniors, as well as for adults and children with disabilities. Long-term care, food and nutrition services, and transportation are just a few of the services available through this department.
Vermont SHIP – The State Health Insurance Assistance Program (SHIP) can help Medicare beneficiaries in Vermont find counseling services to navigate their Medicare benefits. The program is free to Medicare beneficiaries. Trained volunteers counsel Medicare beneficiaries one-on-one to ensure they fully understand their health-care coverage and benefits. SHIP offices are located at various sites around the state. The program also provides information on other federal and state agencies offering information and assistance to Medicare beneficiaries in Vermont.
The Community of Vermont Elders (COVE) was established to provide education and advocacy services for the senior residents of the state. The organization is the home to Vermont’s Senior Medicare Patrol (SMP), which works to prevent Medicare fraud. The SMP is funded by the federal office of the Centers for Medicare and Medicaid Services and the U.S. Administration on Aging. The program hosts events and seminars for Medicare beneficiaries on how to prevent Medicare fraud. The organization works with other state agencies, including Vermont SHIP and Vermont National Retired Senior Service Corps.
For your convenience, listed below are some 2018 facts of interest about Medicare coverage in Vermont as reported by CMS:
Statistical data from the Centers for Medicare & Medicaid Services, “Medicare Enrollment Dashboard”; and “2018 MA Part D Landscape State-by-State Fact Sheet”
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.
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.
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eHealth's Medicare website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency doing business as eHealth. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealth and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We offer plans from a number of insurance companies.