Frequently Asked Questions about Medicare and ACA Insurance in Kansas

Medicare is a federal health insurance program for people aged 65 and older, some younger people with disabilities, and individuals with End-Stage Renal Disease. It includes four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).

• Part A: Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
• Part B: Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
• Part C (Medicare Advantage): Combines Part A and Part B, often includes Part D, and may offer extra benefits.
• Part D: Provides prescription drug coverage.

Enrollment can be automatic or manual:

• Automatic Enrollment: If you receive Social Security or Railroad Retirement Board benefits, you are automatically enrolled in Parts A and B.
• Manual Enrollment: If not automatically enrolled, sign up through the Social Security Administration website, by phone, or in person.

• Initial Enrollment Period (IEP): Starts three months before the month you turn 65 and ends three months after.
• General Enrollment Period (GEP): January 1 to March 31 each year for those who missed IEP.
• Open Enrollment Period (OEP): October 15 to December 7 for changing plans.
• Medicare Advantage Open Enrollment Period (MA OEP): January 1 to March 31 for those already in a Medicare Advantage Plan to switch plans or revert to Original Medicare.
• Special Enrollment Period (SEP): For qualifying life events.

Costs vary:

• Part A: Free if you or your spouse paid Medicare taxes for at least 10 years; otherwise, up to $506 per month.
• Part B: Standard premium is $174.70 per month (2024); higher premiums for higher incomes.
• Part C and Part D: Costs vary by plan and provider.

In 2024, the Part A deductible is $1,632 per benefit period. This deductible covers inpatient hospital services.

The standard monthly premium for Part B in 2024 is $174.70, with adjustments for higher-income beneficiaries.

Medicare Advantage Plans (Part C) cover all services offered by Parts A and B and often include additional benefits like vision, dental, hearing, and wellness programs. Many plans also include Part D (prescription drug) coverage.

Medicare Part D provides prescription drug coverage through private insurance companies approved by Medicare. Plans vary by cost, covered drugs, and participating pharmacies.

Medigap (Medicare Supplement Insurance) helps pay for some of the costs not covered by Original Medicare (Parts A and B), such as copayments, coinsurance, and deductibles. There are standardized Medigap plans (A-N) available in most states.

Consider your health needs, the cost of premiums, deductibles, copayments, and whether your preferred providers and medications are covered. Use Medicare’s Plan Finder tool or consult with a licensed insurance broker.

The IEP is a seven-month window starting three months before the month you turn 65, including your birthday month, and ending three months after. Enrolling during this period helps you avoid late penalties.

You can enroll during the General Enrollment Period (January 1 to March 31), but you may face late enrollment penalties. Coverage starts on July 1 of the same year.

Yes, if you qualify for both. Medicaid can help pay for costs that Medicare doesn’t cover, such as long-term care and additional medical expenses.

SEPs allow you to enroll in Medicare or make changes outside standard enrollment periods due to qualifying life events, like losing employer coverage or moving to a new area.

If you have employer coverage, you can delay Part B enrollment without penalty until you retire or lose your job-based insurance, triggering a Special Enrollment Period.

Medicare Advantage (Part C) plans replace Original Medicare and often include extra benefits and Part D coverage, typically requiring network restrictions. Medigap supplements Original Medicare by covering out-of-pocket costs and doesn’t restrict you to a network of providers.

Original Medicare (Parts A and B) does not cover routine dental, vision, or hearing care. Some Medicare Advantage plans may offer these benefits, or you can purchase separate insurance policies.

Star ratings are based on member surveys, quality of care, and performance metrics. Plans are rated on a scale from 1 to 5 stars, with 5 being the highest. Higher-rated plans may offer better quality and service.

The annual deductible for Part B in 2024 is $240. After meeting the deductible, you typically pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment.

If Medicare denies coverage or payment for a service, you can file an appeal. The process involves multiple levels, starting with a redetermination by the company that handles your claims and potentially progressing to an Administrative Law Judge hearing and further review.

Yes, Medicare covers many preventive services at no cost to you, including screenings for cancer, cardiovascular disease, diabetes, vaccinations, and annual wellness visits.

Medicare assignment means that your doctor or supplier agrees to accept the Medicare-approved amount as full payment for covered services. Doctors who accept assignment cannot bill you for more than the Medicare deductible and coinsurance.

Use the “Physician Compare” tool on the Medicare.gov website or call Medicare directly. Always verify with the provider’s office before scheduling an appointment.

Yes, if you have been receiving Social Security Disability Insurance (SSDI) for at least 24 months, have End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS), you can qualify for Medicare before age 65.

The ACA, also known as Obamacare, is a comprehensive health care reform law enacted in March 2010. Its goals are to make affordable health insurance available to more people, expand the Medicaid program, and support innovative medical care delivery methods to lower the costs of health care. The ACA includes provisions such as the individual mandate, subsidies for low-income individuals, and protections for people with pre-existing conditions.

You can enroll in an ACA plan through the Health Insurance Marketplace during the open enrollment period. You can apply online at HealthCare.gov, by phone, by mail, or in person with the help of a navigator or broker. Open enrollment typically runs from November 1 to December 15 each year. Special Enrollment Periods (SEPs) are available for qualifying life events like losing other coverage, moving, getting married, or having a baby.

The Health Insurance Marketplace is a service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces. The Marketplace allows individuals to compare plans based on price, benefits, and other features.

ACA plans must cover ten essential health benefits:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

A premium tax credit is a subsidy that helps lower the cost of health insurance premiums for individuals and families with incomes between 100% and 400% of the federal poverty level. The amount of the credit is based on your estimated income and household size. It can be applied in advance to lower your monthly premium costs or claimed when you file your tax return.

The individual mandate was a provision of the ACA that required most Americans to have health insurance or pay a penalty. However, as of 2019, the federal penalty for not having health insurance was reduced to $0. Some states have their own individual mandates with associated penalties for non-compliance.

The ACA prohibits health insurance companies from denying coverage or charging higher premiums based on pre-existing conditions. This protection applies to all health plans offered through the Marketplace and most other health plans.

The ACA expanded Medicaid eligibility to include nearly all low-income individuals under age 65 with incomes up to 138% of the federal poverty level. However, the Supreme Court ruled that states could choose whether to expand Medicaid. As a result, Medicaid expansion varies by state.

ACA plans are categorized into four metal tiers based on their cost-sharing structure: Bronze, Silver, Gold, and Platinum. Bronze plans have the lowest premiums but the highest out-of-pocket costs, while Platinum plans have the highest premiums but the lowest out-of-pocket costs. There’s also a Catastrophic plan available for people under 30 and some low-income individuals.

CSRs are subsidies that lower the out-of-pocket costs (like deductibles, copayments, and coinsurance) for Silver plan holders with incomes between 100% and 250% of the federal poverty level. To receive CSRs, you must enroll in a Silver plan through the Health Insurance Marketplace.

SEPs allow you to enroll in a Marketplace plan outside the open enrollment period if you experience certain life events, such as losing health coverage, moving, getting married, having a baby, or adopting a child. You typically have 60 days from the event to enroll in a new plan.

The ACA provides tax credits to small businesses with fewer than 25 full-time employees to help offset the cost of providing health insurance. It also established the Small Business Health Options Program (SHOP) Marketplace where small businesses can compare and purchase health plans.

The employer mandate requires businesses with 50 or more full-time employees to provide health insurance that meets ACA standards or pay a penalty. This provision is intended to ensure that larger employers offer health coverage to their workers.

Whether you can keep your current doctor depends on the health plan’s network. Each plan has a network of providers, and you should check if your preferred doctors, hospitals, and other healthcare providers are included in the plan’s network before enrolling.

If you miss the open enrollment period, you may still qualify for a Special Enrollment Period if you have a qualifying life event. If not, you will have to wait until the next open enrollment period to apply for coverage.

ACA premiums are based on several factors, including your age, location, household size, and income. Premium subsidies (premium tax credits) can also reduce the amount you pay for coverage.

A health insurance subsidy, also known as a premium tax credit, is financial assistance provided by the federal government to help lower-income individuals and families afford health insurance coverage purchased through the Health Insurance Marketplace.

ACA-compliant plans cover a range of preventive services at no cost to you when delivered by a network provider. These include screenings, vaccinations, and counseling services aimed at preventing illness, disease, and other health problems.

No, if you have Medicare, you cannot purchase an ACA Marketplace plan. Medicare is considered minimum essential coverage under the ACA, so you do not need an additional plan through the Marketplace.

The ACA requires all Marketplace plans to cover mental health and substance use disorder services as essential health benefits. This includes behavioral health treatment, counseling, and psychotherapy. Insurers must provide these services at parity with medical and surgical benefits.

The ACA sets limits on out-of-pocket costs for Marketplace plans. For 2024, the out-of-pocket maximum is $9,450 for an individual plan and $18,900 for a family plan. Once you reach this limit, your insurance pays 100% of covered essential health benefits for the rest of the year.

Yes, you can cancel your ACA plan at any time. However, you may not be able to enroll in a new plan until the next open enrollment period unless you qualify for a Special Enrollment Period.

A catastrophic health plan is a type of ACA-compliant health insurance available to people under 30 and to some low-income people who qualify for a hardship or affordability exemption. These plans have lower premiums but very high deductibles and are designed to protect against worst-case scenarios.

The ACA allows young adults to stay on their parents’ health insurance plan until they turn 26. It also requires plans to cover pediatric services, including dental and vision care, as essential health benefits.

The ACA mandates coverage for a range of preventive services for women at no cost, including well-woman visits, contraceptive methods, and counseling, breastfeeding support and supplies, and screenings for conditions like gestational diabetes, HPV, and domestic violence.

Undocumented immigrants are not eligible to purchase health insurance through the ACA Marketplace and are also ineligible for premium tax credits and other savings on Marketplace plans. However, they may still get coverage through their employer, if offered, or purchase private insurance directly from insurers outside the Marketplace. Additionally, they can receive emergency medical care through Emergency Medicaid and access health services at community health centers.

Yes, green card holders (lawful permanent residents) are eligible to purchase health insurance through the ACA Marketplace. They can also qualify for premium tax credits and cost-sharing reductions if their income meets the required thresholds. Green card holders must meet the same eligibility requirements as U.S. citizens, including having income between 100% and 400% of the federal poverty level to receive subsidies.

Green card holders must meet certain residency requirements to qualify for ACA coverage and subsidies. They need to be lawfully present in the U.S. and reside in the service area of the health plan they are enrolling in. They must also intend to live in the U.S. permanently or for an indefinite period. Green card holders who have been in the U.S. for less than five years may still be eligible for ACA coverage but might not qualify for Medicaid in some states due to the five-year waiting period for Medicaid eligibility.

While undocumented immigrants cannot purchase ACA Marketplace plans, they have several options for receiving health care:

• Community Health Centers: These centers provide primary care services on a sliding fee scale based on income.
• Emergency Medicaid: Available in some states to cover emergency medical conditions, regardless of immigration status.
• Charity Care Programs: Some hospitals and clinics offer charity care programs that provide free or reduced-cost services.
• State and Local Programs: Certain states and localities offer health programs specifically for undocumented immigrants.

Green card holders may qualify for Medicaid, but they must meet certain conditions. Generally, they need to have been lawfully residing in the U.S. for at least five years. However, some states have opted to cover lawfully residing children and pregnant women without the five-year waiting period under the Children’s Health Insurance Program (CHIP) and Medicaid. Eligibility for Medicaid also depends on income and other state-specific criteria.