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Medicare Basics:
Fitting together all the pieces to the puzzle we call Medicare

With decades of experience as a caregiver and insurance professional I help fit the puzzle pieces together and determine how Medicare coverage might work for my clients.  If you are currently Medicare eligible, even if you have been enrolled for years, we can review how your coverages works/doesn't work.
 
The Medicare Part D program has major changes starting in 2025, with large premium price increases, larger co-payments and co-insurance and drug Formularies (lists of medications) are changing. 

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What If...

Black Puzzle Pieces

Q. What if I get to the pharmacy and they tell me my prescription is $250, not the small co-pay I was expecting? 
 
**A.** Co-pays or cost-sharing amounts can vary depending on the benefit structure of each Part D prescription plan. Medications are listed in a **Formulary**, a fancy name for the complete list of medications covered in that plan year. It may be possible that the drug your doctor prescribed is not on the Formulary. Check these annually.

Understand how to access your plan’s current Formulary and be ready to discuss alternative medications with your doctor if the prescribed drug isn’t covered or exceeds your budget. If the drug is not covered, you may need to pay the full cost out of pocket. Keep in mind that newer medications, especially those seen advertised on television, are quite costly.

As a patient, it's important to be informed about potential costs, while your doctor’s role is to prescribe the best medications. 

Q. What vaccines does Medicare cover?

**A.** Vaccines covered by Part D include the following:
RSV vaccine, Shingles vaccine
Tdap vaccine (tetanus, diphtheria and pertussis/whooping cough)
Other vaccines covered are those that are "reasonable and necessary" to prevent illness and are not covered by Part B

Medicare Part B covers four important vaccines as part of its preventive care benefits. The Flu vaccine, COVID-19 vaccine, Pneumonia vaccine, Hepatitis B vaccine.

Part B also covers vaccines you may need if you’re exposed to a harmful virus or bacteria by accident. You might need a tetanus shot, for example, if you step on a rusty nail. Or you may need rabies shots if you’re bitten by a stray dog.

Q. What is Medicaid in Texas? Does it work with Medicare?
 
**A.** The Medicare Savings Program uses Medicaid funds to help eligible persons pay some out-of-pocket Medicare expenses, such as Part B premiums, deductibles, or coinsurance. For example:

1.  (QMB)  the Qualified Medicare Beneficiary  Program pays Medicare premiums, deductibles, and coinsurance for a person who meets the requirements.

2. (SLMB) the Specified Low-Income Medicare Beneficiary Program  pays only Medicare Part B premiums for a person who meets the requirements.

3. (QI) the Qualified Individual  Program  pays only Medicare Part B premiums to a person who meets the requirements.

4. (QDWI) the Qualified Disabled and Working Individual  Program pays only Medicare Part A premiums for a person who meets the requirements.
Click this link for income levels:
 
Texas Health and Human Services

Q. I'm still confused?
**A.** Call or email me now. I can help you understand your situation and discuss your next steps.

Click the "Talk To Me" button on this page.
 

Q. I just want to research various questions on Medicare?

**A.** Check out the government website. Their search tool is very good.  www.medicare.gov

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