According to data for the Center for Medicare & Medicaid Services, almost 1.2 million residents of Missouri were covered under Medicare in 2019.  Here’s what you need to know about Medicare coverage in the state and to help you determine if you’re eligible for benefits.

What is Medicare?

Let’s start with the basics.

Medicare is managed by the Centers for Medicare and Medicaid Services (CMS).  It is a health insurance program administered by the federal government that provides coverage from a variety of options that are available nationwide, including Missouri.

It provides coverage for seniors who are 65 years and older as well as some other people with disabilities or special circumstances.

Medicare has four parts.

Part A covers hospital stays, skilled nursing facility care, home health services, hospice and some additional follow-up costs as long as certain eligibility requirements are met.  Part A coverage combined with Part B coverage is often referred to as Original Medicare.

Part B covers a variety of services for outpatient care, including services and supplies that are medically necessary to treat illness, disease or an ongoing condition.  Some of the specific things that Part B covers are lab tests, doctor visits, surgeries in a hospital or doctor’s office, x-rays, emergency room visits, screening exams for cancer, diabetes, heart disease and others, surgical second opinions, ambulance services, flu shots, in-home skilled nursing care, and physical and speech therapy, among others.

Part C is also known as Medicare Advantage.  It is optional coverage that is administered by private health providers that, by law, must provide all the coverage in Part A and Part B, plus additional benefits.  With Part C, you are still in Medicare, but you enjoy different and enhanced coverage for an added premium.  Typically, Part C coverage will include vision, dental, hearing and prescription drug coverage and other related services.  There are a variety of providers to choose from including HMOs, PPOs, PFFSs, and Special Needs Plans.

Part D is specifically designed to enhance prescription drug coverage. Any individual who is eligible for Medicare Part A or Part B may purchase a Part D plan, regardless of income or health status.  Part D plans are also offered by private insurers.  Their benefit levels and costs vary widely depending of the carrier and the coverage you choose.  Part D is available on through an insurance company or other private company that has been approved by Medicare.   Part D plans are impacted by a number of factors.  They will vary by cost, the drugs that are covered, whether or not you need prior authorization and what quantity of drugs you can purchase at any one time.  Some plans also limit you to buying certain less expensive generic drugs than those prescribed by your doctor.

Eligibility and Costs for Medicare in Missouri

Each part of Medicare has certain eligibility requirements that must be met.

Medicare Part A

If you are 65 or older, you can qualify for Part A coverage at no cost if you meet the following criteria:

• You currently get Social Security benefits or you’re eligible to receive Social Security benefits. You must have 40 credits you have accumulated through payroll tax deductions.  As long as you meet minimum income requirements, you will earn one credit for each quarter you worked.  The means you will need to pay into the system for 10 years over the course of your working life. If you do not have enough credits, you can still qualify for Part A coverage, but you will have to pay a monthly premium.
• You currently receive railroad retirement benefits or you are eligible to receive them.
• Your spouse currently gets Social Security benefits or is eligible to receive Social Security benefits and/or railroad retirement benefits. This applies to spouses who are living, deceased or divorced from a person who is seeking Part A benefit coverage.
• You or your spouse held government jobs that paid Medicare taxes.
• You are a dependent parent with a child who is deceased but was fully insured.

If you are under 65 years old, you can qualify for Part A coverage at no cost if you meet the following criteria:

• You are entitled to receive or you have received Social Security disability benefits for at least 24 months.
• You are getting railroad retirement disability benefits and you meet certain conditions.
• You worked for the government and paid Medicare taxes for a long enough period, and you have received or are entitled to Social Security disability benefits for at least 24 months. This also extends to those who are children or are a widow(er) who is at least 50 years old of the person who is eligible for coverage.
• You suffer from amyotrophic lateral sclerosis (Lou Gehrig’s disease) and you currently receive Social Security disability benefits.
• You have end stage renal disease, receive kidney dialysis or have had a kidney transplant, as well as meeting other requirements.

If you meet eligibility requirements, the cost for Part A is covered by your years working and paying social security taxes.  It should be noted that there may be some deductible requirements for certain hospital stays.

If you don’t qualify for no-cost Part A coverage, you can pay a premium and receive coverage as long as you meet citizenship and residency requirements, you’re 65 years or older, and you are in the process of enrolling or you have already enrolled in Part B coverage.

The cost of your premium will depend on how long you have worked and how close you are to meeting the requirement of having 40 Social Security credits.

Medicare Part B

If you are eligible for premium-free Part A then you are eligible for Part B by enrolling and paying a monthly premium. If you are not eligible for premium-free Part A, you can qualify for Part B if:

• You are 65 years or older.
• You are a U.S. citizen, or a permanent resident lawfully residing in the U.S for at least five continuous years.

You can also qualify for automatic Part B enrollment if you have a disability. If you are under 65 and receiving Social Security or Railroad Retirement Board (RRB) disability benefits, you will automatically be enrolled in Medicare Part A and Part B after 24 months of disability benefits.

You may also be eligible to enroll in Part B enrollment before age 65 if you have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS/Lou Gehrig’s disease).

Costs for Part B coverage are as follows:

The standard monthly premium for Medicare Part B enrollees is $135.50 for 2019.  About 2 million Medicare beneficiaries will pay less than the full Part B standard monthly premium amount because there is a statutory hold-harmless provision that limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits.

The annual deductible for Part B beneficiaries is $185 in 2019.  After the deductible is met, Part B covers 80% of the cost and you pay the remaining 20%.

Since 2007, the Part B monthly premium is based on a beneficiary’s income. These income-related monthly adjustment amounts impact about 5% of people with Medicare Part B.

If you don’t sign up for Part B when you first become eligible, you might have to pay a late enrollment penalty.  This enrollment penalty will stay in effect for as long as you have Part B coverage.

In most instances, the Part B premium is taken out of a Social Security or Railroad Retirement check, streamlining the payment process.

Medicare Part C

Before you can enroll in a Part C Advantage Plan, you must first be enrolled in Medicare Part A and Part B.  After you enroll in a Part C plan, you must still continue paying your Part B premium.

Costs for Part C will vary by provider.  Each Medicare Advantage plan establishes how much they will charge for premiums, deductibles, co-payments and what services they will cover.  Because of the flexibility in each plan, some people will pay more each month for a smaller deductible or for less expensive copayments for doctor visits.

An important distinction to make is that Medicare Advantage Plans also have out-of-pocket maximums for each year while Original Medicare does not.  Once you reach the maximum amount, there are no charges for covered services.

Another thing worth noting is that due to an agreement with Medicare, Medicare Advantage premium costs can only change once a year beginning on January 1.

Medicare Part D

Those who have Medicare Part A and/or Part B, or a Medicare Advantage plan are eligible to enroll in Medicare Part D.  Keep in mind that some Medicare Part C plans already include prescription drug coverage.

If you are currently enrolled in a Medicare Advantage plan that includes drug coverage and enroll into a Medicare Part D plan, you will be automatically disenrolled from the Medicare Advantage plan and reverted back to Original Medicare.

You must also live in the service area of a plan that provides prescription drug coverage.

Monthly premiums can vary widely depending on the type of plan and coverage that you select.

Your best bet is to shop around and pay attention to yearly deductible amounts, what copayments might be required, what the costs for catastrophic coverage are and what the coverage gap will be.

Enrolling in Medicare in Missouri

For some people, enrollment in Medicare is automatic.  For others, it may depend on how and when they become eligible.

If you’re already collecting Social Security retirement benefits or Railroad Retirement Board benefits when you turn 65, you will automatically be enrolled in Medicare Part A and Part B if you sign up for Medicare Part B at the time you sign up for retirement benefits.

If you are under 65 and receiving certain disability benefits from Social Security or the Railroad Retirement Board, you will be automatically enrolled in Original Medicare after 24 months of disability benefits. The exception to this is if you have end-stage renal disease (ESRD). If you have ESRD and had a kidney transplant or need regular kidney dialysis, you can apply for Medicare.

If you have amyotrophic lateral sclerosis, you will automatically be enrolled in Original Medicare in the same month that your disability benefits start.

If you are automatically enrolled in Part B coverage but don’t want to keep it, you have the option of dropping it and not paying any premiums.  If you signed up for Medicare through Social Security, then contact them to drop Part B coverage.

If you currently have health coverage through an employer, then you may want to hold off on Part B coverage.  Talk to your employer about how your current coverage would work and what the consequences are if you drop Part B coverage.

There is an initial enrollment period of seven months that extends from three months before the month of your 65^th birthday to three months after your 65^th birthday.  It is very important to enroll during this window, or you may face late enrollment penalties or have a gap in your Medicare coverage.

If you don’t sign up during the initial period, there is a general enrollment period each year between January 1 and March 31.  When you sign up during this period, your Medicare coverage begins on July 1.

Where to go to Enroll for Parts A and B

You have several options to enroll in Part A and/or Medicare Part B:

• Online at SocialSecurity.gov
• By calling Social Security at 1-800-772-1213 (TTY users 1-800-325-0778), Monday through Friday, from 7AM to 7PM
• In-person at your local Social Security office.

Enrolling in Medicare Part C or Part D

You can apply directly through an insurance company for Part C and Part D coverage.  In most cases, you should be able to enroll by submitting a paper application, calling the plan, or enrolling online. You may also enroll through a licensed insurance agent.

When you enroll in Part C or Part D, you will have to provide your Medicare number and the date your Medicare Part A and/or Medicare Part B coverage started. You can find this information on your Medicare card.

You can enroll in Medicare Part D coverage during your Initial Enrollment Period which is the same as for Medicare Parts A and B and begins three months before you turn 65 years of age, includes the month you turn 65, and ends three months after.

If you are not eligible to enroll in Medicare Part D because you do not live in a Part D-covered service area, your Initial Enrollment Period would not begin until three months before you permanently reside in the service area of a Medicare Part C or a Part D plan.

If you do not enroll during your Initial Enrollment Period you can enroll or make changes during the Annual Election Period (AEP), which occurs from October 15 to December 7 of every year.

Medicare Advantage plans and Medicare Prescription Drug Plans are rated on a scale of 1 to 5 for overall quality and performance.  If you are a member of a plan that does not hold a 5-star rating, you can use the 5-star Special Election Period to enroll in a Medicare Advantage with prescription drug coverage or a Medicare Prescription Drug Plan that has been awarded a 5-star rating outside of AEP. This period runs from December 8 to November 30 of every year.

If you have prescription drug coverage through a Medicare Advantage plan, you can leave this plan and go back to Original Medicare during the Medicare Advantage Disenrollment Period. You will have until February 14 to enroll in a stand-alone Medicare Prescription Drug Plan, since Original Medicare doesn’t include prescription coverage.

Special Election Periods (SEP) allow you to make changes under some special situations that include:

• If you move out of your plan’s service area
• If your plan ends its contract with Medicare
• If you lose your creditable prescription drug coverage, or your plan changes and is no longer considered creditable
• If you live or move into an institution, such as a nursing home
• If you qualify for the Medicare Extra Help Program, which helps low income and limited resource people pay for Part D expenses.

Enrolling before you turn 65

There are also some situations that allow you to apply for Medicare before age 65:

• You’re a disabled widow(er) between 50 and 65.
• You work for the government and became disabled before turning 65
• You or an immediate family have permanent kidney failure
• You had Medicare Part B coverage in the past but dropped coverage
• You turned down Medicare Part B coverage when you first got Medicare Part A coverage.
• You or your spouse worked for the railroad industry.

What to Know About Medicare Supplements (Medigap)

Medicare Supplements are insurance products offered by insurance companies to cover the “gaps” in Original Medicare.  Medicare Part B covers 80% of costs after the Part B deductible is met, leaving the Medicare beneficiary responsible for 20%.  Those with appropriate Medicare Supplement plans could have the cost sharing covered completely producing a significant benefit in many situations.

Medigap can pay for services not covered by Part A and Part B, and for deductibles, coinsurance, and copayments.

Medigap coverage requires a monthly premium and it is only available if you are currently enrolled in Part A and Part B coverage.

What Does Medicare Cover in Missouri?

In some cases, coverage for some tests, services and medical care items depends on where you live. But many things are also covered throughout the United States, no matter where you live.

Currently, those universally available tests and services include:

 

Abdominal aortic aneurysm screening Acupuncture Air-fluidized beds & other support surfaces Alcohol misuse screening & counseling Ambulance services Ambulatory surgical centers Anesthesia Artificial eyes & limbs Bariatric surgery Blood Blood processing & handling Blood sugar (glucose) monitors Blood sugar (glucose) test strips Bone mass measurement (bone density) Braces (arm, leg, back, and neck) Breast prostheses Canes Cardiac rehabilitation programs Cardiovascular disease (behavioral therapy) Cardiovascular disease screenings Cataract surgery Cervical & vaginal cancer screenings Chemotherapy Chiropractic services Clinical research studies Colorectal cancer screenings Commode chairs Concierge care Continuous passive motion (CPM) machine Cosmetic surgery Crutches Custodial care Defibrillator (implantable automatic) Dental services Depression screenings Diabetes screenings Diabetes self-management training Diabetes supplies & services Diagnostic tests Dialysis (children) Dialysis (kidney) services & supplies Doctor & other health care provider services Drugs Durable medical equipment (DME) coverage EKG (electrocardiogram) screening Emergency department services

Enteral nutrition supplies & equipment (feeding pump) Eye exams Eyeglasses/contact lenses Federally qualified health center services Flu shots Foot care Foot exam Glaucoma tests Glucose control solutions Gym membership & fitness programs Health education & wellness programs Hearing & balance exams & hearing aids Hepatitis B shots Hepatitis C screening test HIV screening Home health services Hospice & respite care Hospital beds Humidifiers Hyperbaric oxygen (HBO) therapy Incontinence supplies & adult diapers Infusion pumps & supplies Inpatient hospital care Insulin Kidney disease education Kidney transplants (adults) Kidney transplants (children) Laboratory services (clinical) Lancet devices & lancets Long-term care Long-term care hospitals Lung cancer screening Macular degeneration Mammograms Manual wheelchairs & power mobility devices Massage therapy Mental health care (inpatient) Mental health care (outpatient) Mental health care (partial hospitalization) Nebulizers & nebulizer medications Nursing home care Nutrition therapy services (medical) Obesity screening & counseling Orthotics, artificial limbs, & eyes Ostomy supplies

Outpatient hospital services Oxygen equipment & accessories Pancreas transplants (adults) Patient lifts Physical therapy/occupational therapy/speech-language pathology services Pneumococcal shots Prescription drugs (outpatient) Preventive & screening services Preventive visit & yearly wellness exams Prostate cancer screenings Prosthetic devices Pulmonary rehabilitation program Radiation therapy Religious non-medical health care institution (RNHCI) items & services Rural health clinic services Second surgical opinions Sexually transmitted infections (STI) screening & counseling Shingles shot Shots (vaccinations) Skilled nursing facility (SNF) care Sleep apnea & Continuous Positive Airway Pressure (CPAP) devices & accessories Sleep study Smoking & tobacco use cessation (counseling to stop smoking or using tobacco products) Substance-related disorders Suction pumps Supplies (you use at home) Surgery (estimating costs) Surgical dressing services Tdap shot (tetanus, diphtheria, & pertussis shot) Telehealth Therapeutic shoes or inserts Traction equipment Transplants (adults) Transportation Travel (when you need health care outside the U.S.) Urgently needed care Walkers X-rays Yearly eye exam

 Source:  .  Because changes in what is covered does take place from time to time, if you require a certain test, service, exam or medical device not listed here, contact your healthcare provider to explore possible coverage options. 

 Medicare Resources in Missouri

You may have several questions related to Medicare coverage in Missouri.  There are several resources you can pursue to get answers.

The official U.S. government website for Medicare has an online enrollment calculator you can use to verify current or future enrollment in Medicare. You can also find out if you’re eligible and calculate your premium for Medicare services by going here.

If you prefer, you can also talk to a customer service representative 24 hours a day, 7 days a week by calling 1-800-MEDICARE.

Medicare maintains a comprehensive list of providers where users can find out about what services are offered, make side-by-side comparisons on what care they provide and information to help make informed decisions.

Providers are broken out by categories.  Click on these links for more details:

• Hospitals
• Nursing homes
• Home health services
• Dialysis facilities
• Long-term care hospitals
• Inpatient rehabilitation facilities
• Doctors and other health professionals
• Health and drug plans
• Where to get covered medical items

NOTE:  In 2018, CMS estimated that Missouri citizens would be served by 24 Medicare Prescription Drug Plans and 68 Medicare Advantage plans available statewide.

The state of Missouri also has several resources you can access as well.

The Missouri Department of Health and Senior Services oversees the office for Senior and Disability Services which offers information, programs and services to seniors living in the state.  To find a local DSS office, go here.

The office also offers advocacy services for those who are not treated fairly and provides important information for people seeking long-term care for themselves or a family member.

Senior and Disability Services also operates a number of programs such as the

Area Agencies on Aging and Services, a network of statewide offices that provides local help to Medicare beneficiaries in Missouri, including legal assistance.

The agency also administers Missouri CLAIM, a state program that gives free local health insurance counseling to people with Medicare.  This office has also been the official location for the State Health Insurance Assistance Program (SHIP) since 1993.

Another resource is KEPRO.  It is the official Quality Improvement Organization for the state of Missouri.  KEPRO provides information to Medicare providers, beneficiaries, and their families and assists with beneficiary complaints, discharge appeals, and other Medicare-related issues.

State Health Insurance Assistance Program (SHIP): Toll-free number 1-800-390-3330. Local 1-573-817-8320. Representatives are available Monday through Friday, 9 am to 4 pm

National Institute on Aging Information Center: Toll-free number 1-800-222-2225. Representatives are available Monday through Friday, 8:30 am to 5 pm.

You can also find overview information on who Medicare plans work in Missouri including:

• Medicare Advantage plans in Missouri
• Medicare Supplement (Medigap) plans in Missouri
• Medicare Part D plans in Missouri

Can I Have Medicare and Medicaid in Missouri?

Medicare does not provide full coverage for healthcare in all instances, leaving some gaps in coverage. But there are several ways to pay for medical services through supplemental coverage.

These can include Medicare Advantage Plans, retiree insurance, currently employed coverage, or Veterans’ Administration benefits.

Another way to bridge the gap is through Medicaid.  Medicaid helps low-income families pay for costs of long-term medical and custodial care. You must meet income qualifications to receive benefits.  It is a joint program of the federal government and state governments. The federal government largely funds the program, but Medicaid is administered by state governments, and coverage may vary from state to state.

What is the Best Medicare Supplement Plan in Missouri?

In 2018, CMS projected that there are 24 Medicare Prescription Drug Plans and 68 Medicare Advantage plans available statewide.

That is a lot of choices, but the short answer is the best Medicare Supplement Plan in Missouri is the one that is the most suited to your individual needs.

It’s a personal decision and you should consider several things as you shop for a plan.

There are 10 standardized Medicare Supplement plans available in 47 states, including Missouri.  Each of these are identified by one of 10 letters (A, B, C, D, F, G, K, L, M, and N).  Plans with the same letter offer the same benefits. Massachusetts, Minnesota, and Wisconsin offer versions of standardized Medigap plans.

Does the plan you’ve considered match up well with what you think you’ll need for the coming year?  In addition to the types of benefits, deductibles, copays and so forth, you should understand how a plan will interact with your other kinds of Medicare coverage.

Cost should be a consideration as well.  The lowest plan is not always the best plan.  Determine what deductible levels you can tolerate and how important it is to spread your healthcare costs out over a year.

Also think about what kind of access you will have to doctors and services.  Each provider has a different network and system of services.  What are the locations and the hours of operation?  What about the location of pharmacies?  Can you get prescriptions filled by mail?  Make the plan you choose fit to your lifestyle if possible.

Look at ratings and reviews.  If you are currently enrolled, try to determine how satisfied you are with your current provider network.

The Medicare Plan Finder makes it easy to compare plans based on several key factors, so you can choose a plan that meets your needs.

After you’ve narrowed your options, call the plans you’re interested in to get more details about their benefits and services, or check out their websites.

What is the Medicare Cost Savings Program in Missouri?

The Qualified Medicare Beneficiary (QMB) and Specified Low Income Medicare Beneficiary (SLMB) programs are commonly referred to as Medicare Cost Savings Programs.

These programs help people by making Medicare payments to medical providers for coinsurance and deductibles for Medicare services or by paying Medicare Part B premiums.

To qualify for the QMB/SLMB program, applicants must meet eligibility requirements:

• Be enrolled in Part A Medicare
• Have resources not exceeding the QMB/SLMB resource maximums for an individual or couple. Refer to the Aged, Blind and Disabled Income and Asset Limitchart for current resource amounts.
• Have income not exceeding the QMB/SLMB standard of the Federal Poverty Level for the assistance group size

For more details on Medicare Savings Programs, go here.