Medicare

Orion Financial Services LLC Disclaimer

Orion Financial Services LLC is not connected with or endorsed by the U.S. Government or the Federal Medicare program. We may not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE for comprehensive information on all options available to you.

Overview of Medicare

Medicare is a federal health insurance program primarily designed for individuals aged 65 and older, although it also serves certain younger individuals with disabilities or specific medical conditions. The program consists of different parts that cover various healthcare services:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
• Part B (Medical Insurance): Covers outpatient care, preventive services, and some home health care.
• Part C (Medicare Advantage): A plan offered by private insurance companies that combines coverage from both Part A and Part B, often including additional benefits like vision and dental coverage.
• Part D (Prescription Drug Coverage): Provides prescription drug coverage through private insurance plans.

Medicare is vital for millions of Americans, providing access to necessary healthcare services and financial protection against high medical costs.

Medicare Supplement 

Medicare Supplement Insurance (Medigap) is a type of private insurance designed to cover some of the out-of-pocket costs that Original Medicare does not cover. This includes deductibles, copayments, and coinsurance. Medigap policies are standardized, meaning that they must offer the same basic benefits, regardless of the insurance company providing them, although premiums can vary.

1. Coverage:

   • Original Medicare: Consists of Part A (Hospital Insurance) and Part B (Medical Insurance). It covers many health services but has gaps in coverage, including costs for services like hospital stays and outpatient care.
   • Medicare Supplement: Specifically designed to fill the gaps left by Original Medicare, helping to reduce the financial burden of out-of-pocket costs.

2. Cost Sharing:

   • Original Medicare: Beneficiaries are responsible for deductibles, coinsurance, and copayments for most services.
   • Medicare Supplement: Covers many of these out-of-pocket costs, depending on the plan selected.

3. Enrollment:

   • Original Medicare: Enrollment is typically automatic at age 65 or upon disability qualification.
   • Medicare Supplement: Requires enrollment in Original Medicare first, and Medigap plans must be purchased from private insurers.

4. Network Restrictions:

   • Original Medicare: Offers flexibility in choosing healthcare providers, as long as they accept Medicare.
   • Medicare Supplement: Generally does not have network restrictions but may have specific rules depending on the provider.

5. Premiums:

   • Original Medicare: Has standard premiums for Part B, with Part A being premium-free for most beneficiaries who have paid Medicare taxes.
   • Medicare Supplement: Involves an additional premium paid to the private insurer, which can vary based on the plan and the insurer.

Overall, while Original Medicare provides essential health coverage, Medigap policies are meant to enhance that coverage by reducing out-of-pocket expenses for beneficiaries.

Definition of IRMAA

Income-Related Monthly Adjustment Amount (IRMAA) is an additional charge that higher-income Medicare beneficiaries must pay for their Medicare Part B and Part D premiums. This surcharge is designed to ensure that individuals with higher incomes contribute more towards the cost of their Medicare coverage. The IRMAA is determined based on the beneficiary’s modified adjusted gross income (MAGI) from two years prior and applies to individuals and couples whose incomes exceed certain thresholds.

For instance, beneficiaries with incomes above specific limits will see increased premiums for Part B and/or Part D, which are assessed annually by the Centers for Medicare & Medicaid Services (CMS).

Income-Related Monthly Adjustment Amount (IRMAA) for 2025

If you are a higher-income beneficiary, Medicare will impose a surcharge known as IRMAA (Income Related Monthly Adjustment Amount).

2025 IRMAA Table

Definitions of Medicare Savings Programs and Low-Income Subsidy (LIS)

Qualified Medicare Beneficiary (QMB)
Definition: The QMB program helps low-income individuals pay for Medicare premiums, deductibles, coinsurance, and copayments.
Income Guidelines for 2025:

• Monthly Income Limit: Up to $1,345 for an individual; $1,800 for a couple (approximately 100% of the Federal Poverty Level).
• Cost Sharing: QMB enrollees do not pay deductibles, coinsurance, or copayments for services covered by Medicare.

Specified Low-Income Medicare Beneficiary (SLMB)
Definition: The SLMB program assists low-income individuals in paying their Medicare Part B premiums.
Income Guidelines for 2025:

• Monthly Income Limit: Between $1,345 and $1,600 for an individual; $1,800 to $2,150 for a couple (between 100% and 120% of the Federal Poverty Level).
• Cost Sharing: SLMB enrollees only receive assistance with their Part B premiums, not with deductibles or copayments.

Additional Low-Income Medicare Beneficiary (ALMB)
Definition: The ALMB program provides assistance for paying Medicare Part B premiums for individuals who exceed the SLMB income limits.
Income Guidelines for 2025:

• Monthly Income Limit: Between $1,600 and $1,850 for an individual; $2,150 to $2,600 for a couple (between 120% and 135% of the Federal Poverty Level).
• Cost Sharing: Like SLMB, ALMB only covers Part B premiums, not deductibles or copayments.

Low-Income Subsidy (LIS)
Definition: Also known as Extra Help, LIS helps eligible individuals pay for prescription drug costs under Medicare Part D.
Income Guidelines for 2025:

• Monthly Income Limit: Up to $2,000 for an individual; $2,700 for a couple (up to 150% of the Federal Poverty Level).
• Cost Sharing: Depending on income and resources, LIS can reduce premiums, deductibles, and copayments for Part D plans. For example:
  • No premiums for those with incomes below 135% of the FPL.
  • Reduced copayments for generics and brand-name drugs, ranging from $1.45 to $9.85 based on income levels.

Important Guides and Information

• CT Standardized Medicare Supplement (Medigap) Plans
• Original Medicare 2024 Cost-Sharing 
• Part B Excess Charges in CT
• Who Pays First (Coordination of Benefits)
• 2024 Medicare Costs
• 2025 Medicare and You

Conclusion

If you are turning 65, an existing Medicare beneficiary, or newly eligible for Medicare, we strongly recommend reading the Medicare & You Handbook provided by CMS annually. Our agents are available to review this handbook with you during any appointment by request.