Medicare Insurance

Navigating Medicare coverage can be intricate and overwhelming, but you don’t have to do it alone. At LJ Adams Insurance Services, we specialize in providing personalized Medicare insurance solutions for the residents of Arlington, Texas. With years of experience in the insurance industry, our company is an established pillar of the Arlington community, here to guide you through the maze of Medicare options.

Senior Man and Doctor

How to Get Started with Medicare

If you are new to Medicare and are not sure where to start, you are not alone.  Most people just starting out often find Medicare to be a bit confusing.  Every year, thousands of Medicare beneficiaries feel frustrated after trying to read the Medicare handbook and researching all the different Medicare plans available. It can be overwhelming to find the one that meets your needs and budget.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, combines coverage for hospital costs, doctor visits, and other medical services. Often Medicare Part C covers prescription drug costs as well and can include additional benefits, such as routine vision, hearing, dental, and wellness services. Medicare Part C coverage is much more extensive than Parts A and B and can provide a well-rounded coverage solution. Enrollment begins three months before the month of your 65th birthday and ends three months afterward.

While the majority of people with Medicare get their health coverage from Original Medicare, some choose to get their benefits from a Medicare Advantage Plan, also known as a Medicare private health plan or Part C. MA Plans contract with the federal government and are paid a fixed amount per person to provide Medicare benefits.

Having advise with a gynecologist
Senior Man and Doctor

The Most Common Medicare

Advantage Plans

1. Health Maintenance Organizations (HMOs)

2. Preferred Provider Organizations (PPOs)

3. Private Fee-For-Service (PFFS)

You may also see:

  • Special Needs Plans (SNPs)

  • Provider Sponsored Organizations (PSOs)

  • Medical Savings Accounts (MSAs)

Remember, you still have Medicare if you enroll in an MA Plan. This means that you likely pay a monthly premium for Part B (and a Part A premium, if you have one). If you are enrolled in an MA Plan, you should receive the same benefits offered by Original Medicare. Keep in mind that your MA Plan may apply different rules, costs, and restrictions, which can affect how and when you receive care. They may also offer certain benefits that Medicare does not cover, such as dental and vision care.

All Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and B services. For example, the maximum out-of-pocket cost for HMO plans in 2023 is $6,700. These limits tend to be high. In addition, while plans cannot charge higher copayments or coinsurances than Original Medicare for certain services, like chemotherapy and dialysis, they can charge higher cost-sharing for other services.

How are MA Plans different?

  • Networks of providers

  • Coverage rules

  • Premiums (in addition to the Part B premium)

  • Cost-sharing for covered services

Even plans of the same type offered by different companies may have different rules, so you should always check with a plan directly to find out how its coverage works.

Many Medicare Advantage Plans also offer prescription drug coverage (Part D). If you join an MSA plan or a PFFS plan without drug coverage, you can enroll in a stand-alone Part D plan. Remember that people with Original Medicare who want Part D coverage also enroll in a stand-alone Part D plan.

If you have health coverage from your union or employer (current or former) when you become eligible for Medicare, you may automatically be enrolled in an MA Plan that they sponsor. You have the choice to stay with this plan, switch to Original Medicare, or enroll in a different MA Plan. Be aware that if you switch to Original Medicare or enroll in a different MA Plan, your employer or union could terminate or reduce your health benefits, the health benefits of your dependents, and any other benefits you get from your company. Talk to your employer/union and your plan before making changes to find out how your health benefits and other benefits may be affected.

Having advise with a gynecologist

Medicare Supplement Basics

When you reach age 65, you are eligible to enroll in Medicare, our federal health insurance program. Sounds like your health insurance coverage gets simpler by this age, right? Well, not really. This governmental health insurance may not be comprehensive in covering all your health care costs, so you might want to consider buying Medicare supplement insurance as well.

Medicare supplement insurance — also referred to as a Medigap policy because it is used to fill in the gaps in your Medicare — is private health insurance designed to supplement Medicare. It helps pay your health care costs that Medicare does not pay, including copayments, coinsurance and deductibles.

There are many standardized Medicare supplement insurance plans and must follow federal and state laws designed to protect you. These various policies help you lower your out-of-pocket expenses and get more health insurance coverage. Medicare supplement insurance plans are neither connected with nor endorsed by the United States government or the federal Medicare program.

All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs.

With one of our Medicare Supplement plans, you can choose the providers you want to see – no network restrictions, no referrals. You can see any provider anywhere in the United States and U.S. territories as long as the provider, doctor or hospital accepts Original Medicare. There are no network requirements.

Use your Medicare Part A and Part B covered benefits – then the policy covers your cost sharing amounts. You may have little to no out-of-pocket cost.

As a Medicare Supplement member, you do not need any of the following:

– No primary care provider (PCP)

– No referrals to see a specialist

– No prior authorization for services. If the service is covered by Original Medicare (Part A & B), then it is covered under your Medicare Supplement plan – your provider will always bill Original Medicare first and then bill your Medicare Supplement policy carrier.

Prescription Drug Plan

Medicare Part D prescription drug coverage, often referred to as Part D, is provided and coordinated by Medicare-approved private insurance companies. Any beneficiary who is eligible for Original Medicare, Part A and/or Part B, and permanently resides in the service area of a Medicare Prescription Drug Plan, can sign-up for Medicare Part D. Medicare Part D coverage is optional, but if you decide not to get Medicare drug coverage when you’re first eligible, you’ll likely pay a late enrollment penalty if you join later, unless one of these applies:

  • You have other prescription coverage 

  • You get extra help

Part D is provided only through private insurance companies that have contracts with the federal government—it is never provided directly by the government (unlike Original Medicare). If you have Medicare Part C, you can get prescription drug benefits by enrolling in a Medicare Advantage plan that includes this coverage. Also known as Medicare Advantage Prescription Drug plans, these plans give you the option to get your Medicare health and prescription drug benefits covered under a single plan.

Every Medicare Prescription Drug Plan has a formulary— that is, a list of covered drugs. The formularies vary among plans. The formulary may change at any time. You will receive notice from your plan when necessary.

Keep in mind that if you fill a prescription that is not in your plan’s formulary, then you may be responsible for the full retail cost of the drug.

The design for a Part D plan includes:

  • An annual deductible

  • The Initial Coverage Limit

  • The Coverage Gap – known as the “Donut Hole”

  • Catastrophic Coverage

Part D drugs fall into tiers that depend on the cost of a drug. A co-pay amount or percentage is assigned to each tier. A plan may have 4 or more tiers such as:

  • Tier 1 – Generic drugs

  • Tier 2 – Preferred Name Brand drugs

  • Tier 3 – Non-Preferred Name Brand drugs

  • Tier 4 – Specialty drugs

Schedule Your Complimentary Evaluation

Experience the LJ Adams Insurance Services difference with our Complimentary Evaluation, exclusively tailored for your Life Insurance, Medicare, and Retirement Plans. Let us be your trusted partner in safeguarding your future. Connect with us today and discover insurance solutions that exceed expectations!

Why Opt for a Complimentary Evaluation?

Personalized Guidance: Our experts will assess your individual needs and provide personalized recommendations, ensuring you get the coverage that matters most to you.

Optimal Protection: Discover the insurance plans that offer the optimal protection for your home, auto, business, Medicare, and senior life needs.

Transparent Insights: Get a clear understanding of your insurance options, terms, and benefits, empowering you to make informed decisions about your coverage.