Alemay Business Insurance
Understanding Medicare: your parts, your terms, your questions
Original Medicare, Medicare Advantage, Part D and Medigap do not work the same way. A good decision starts with understanding how you actually use care and what you need to protect.
At Alemay Business, we explain Medicare in plain English and help you organize your situation and your questions. This page is general education: it does not present, market, recommend or enroll you in a specific Medicare Advantage or Part D plan. If you later request plan-specific assistance, it is handled separately by an appropriately licensed, certified and authorized professional under the applicable rules and disclosures.
English and Spanish, with a Miami office and virtual service when the process and jurisdiction allow.
At a glance
- Service
- General Medicare education and orientation for people entering Medicare or trying to understand the coverage they already have.
- Topics
- Original Medicare, Medicare Advantage, Part D and Medigap, explained as general concepts rather than as specific plans.
- What to verify
- Doctors, medications, hospital, pharmacy, network and cost structure, in official plan materials.
- Access
- If plan-specific assistance is requested later, it is handled separately by an appropriately licensed, certified and authorized professional.
- Where
- Miami and South Florida, and virtually where plans and licensing allow.
- How to start
- Schedule a consultation or reach out on WhatsApp.
Alemay Business Insurance
What Medicare is, and who it may be for
Medicare is a federal health insurance program administered under federal rules. It is primarily for people age 65 and older, and for certain people under 65 who meet the applicable requirements related to disability or certain conditions.
Medicare has different parts, and there is more than one way to receive the coverage. Eligibility, enrollment rules and available options are determined under the applicable federal rules, and depending on the action involved, Social Security and Medicare/CMS processes may come into play.
Alemay Business can explain how the pieces fit together and assist within its scope, but it does not determine eligibility and cannot approve Medicare enrollment.
This may be for you if
- You are approaching Medicare eligibility and want to understand your options first.
- You may qualify for Medicare before age 65 under the applicable federal rules.
- You are helping a parent or relative understand Medicare.
- You are already enrolled and want to review where you stand.
- You want to check whether your doctors and hospital participate in a plan you are considering.
- Your prescriptions changed and you want to review drug coverage.
- You want to understand what you could pay, not only the monthly premium.
- You are trying to understand the difference between Original Medicare and Medicare Advantage.
- You want to understand how Medicare Supplement (Medigap) works.
- You are moving, traveling often or changing your service area.
- You received an Annual Notice of Change and are not sure what changed.
- You are transitioning from Marketplace or employer coverage into Medicare.
The parts of Medicare, without the alphabet soup
These categories are not interchangeable. They have different purposes, different rules and different enrollment requirements.
Part A — Hospital Insurance
Original Medicare
- Inpatient hospital care
- Certain skilled nursing facility care
- Hospice care
- Certain home health services
Part A helps cover certain services subject to Medicare rules. It does not cover every hospital-related cost.
Part B — Medical Insurance
Original Medicare
- Physician and other provider services
- Outpatient care
- Durable medical equipment
- Certain home health services
- Many preventive services
There is generally a Part B premium. Applicable amounts change over time and should be verified against current official information.
Part C — Medicare Advantage
A private plan approved by Medicare
- An alternative way to receive your Medicare coverage
- Offered through a private plan approved by Medicare
- Enrollment generally requires having Part A and Part B
- May use a provider network, a service area and plan-specific rules
Medicare Advantage does not replace Medicare. It is another way to receive Medicare benefits, and calling it simply “Medicare” creates confusion.
Part D — Prescription Drug Coverage
Standalone or built into a plan
- Helps with certain prescription drugs depending on the plan
- Can be a standalone Part D plan alongside Original Medicare
- Is built into many, but not all, Medicare Advantage plans
- Drug lists and rules vary by plan
Not every Medicare Advantage plan includes drug coverage. That has to be verified plan by plan.
Original Medicare and Medicare Advantage: two different structures
Neither structure is categorically better than the other. They work differently, and what matters in each one depends on your own situation.
Original Medicare
- Includes Part A and Part B
- A standalone Part D plan can be added for prescription drugs
- Can be supplemented, when applicable, by a Medigap policy
- Generally allows you to use doctors and hospitals that accept Medicare
- Generally does not operate through a private plan network
- Usually does not require prior authorization for most covered services the way a private plan may
- Deductibles, coinsurance and other applicable costs exist
- On its own, it does not have the same annual out-of-pocket limit that Medicare Advantage plans have
Medicare Advantage (Part C)
- A private plan approved by Medicare that offers an alternative way to receive Part A and Part B
- May use provider networks
- May apply service area rules
- Certain plans may require referrals
- May require prior authorization for certain services
- In many cases includes prescription drug coverage (Part D)
- You must continue to meet Part A and Part B requirements and normally remain responsible for your Part B premium
What can differ from one plan to another
- Doctors
- Specialists
- Hospitals
- Prescriptions
- Pharmacy
- Network
- Referrals
- Prior authorization
- Costs
- Travel
- Where you live
- Coverage you already have
- General medical needs
- How often you receive care
- Extra benefits when a plan includes them
- Access outside your service area
- How comfortable you are with different cost structures
Medicare Supplement (Medigap)
Medigap is private insurance designed to help with certain cost sharing you pay under Original Medicare. It is a different category from Medicare Advantage, and the two are not designed to be used together.
Availability, pricing and enrollment or underwriting rules can vary by state, by timing and by individual circumstances. Guaranteed issue applies only in the situations where applicable law and rules provide it.
What to keep in mind
- Private insurance designed to help with certain costs you pay under Original Medicare
- Not the same thing as Medicare Advantage, and not a substitute for it
- Generally requires having Part A and Part B
- Availability, pricing and enrollment or underwriting rules can vary by state, timing and individual circumstances
- Guaranteed issue exists only in the situations where applicable law and rules provide it
Enrollment periods, explained at a high level
Each period has its own rules about who can use it and what changes it allows. Specific dates change from year to year and should be verified against current official information rather than assumed.
Initial Enrollment Period
The initial period tied to when a person first becomes eligible for Medicare. It has its own rules about when it can be used and what it allows.
General Enrollment Period
A period that applies to certain people who did not enroll in Part A or Part B when they were supposed to, under the rules in effect.
Special Enrollment Period
May exist because of certain circumstances or coverage changes. Each Special Enrollment Period has its own rules, and not every life event creates one.
Medicare Open Enrollment (AEP)
The annual period when certain Medicare Advantage and Part D changes can be made, under the rules in effect for that year.
Medicare Advantage Open Enrollment
A specific period for people already enrolled in a Medicare Advantage plan, allowing certain changes under the applicable rules.
Not every life event creates a Special Enrollment Period. Whether one applies depends on the circumstance and the rules in effect.
What factors can differ among plans available in a service area
Medicare Advantage and Part D plan availability varies by county and service area and by plan year. The same plan is not offered everywhere, and what was available last year is not necessarily available this year. This page does not present or list any plan.
Eligibility, current coverage, where you live, whether you are still working, employer or retiree coverage, COBRA and other individual circumstances also shape which Medicare pathways are relevant to understand in a given case.
Because of that, no one should assume that every consumer is eligible for every Medicare option. What applies to your neighbor may not apply to you.
Doctors, hospitals and networks
With Original Medicare you can generally use providers who accept Medicare, subject to the applicable rules. With Medicare Advantage, provider networks are plan-specific and can change.
If a particular doctor, specialist or hospital matters to you, verify participation against the plan's current materials and directly with the provider before you decide.
Worth checking
- Primary care physician
- Specialists
- Hospital
- Clinics
- Providers you use frequently
- Location and travel
Prescription drugs and formularies
Formularies and drug tiers are plan-specific and can change. Coverage of a specific medication cannot be guaranteed in advance, which is why the list of drugs you actually take should be reviewed against the plan materials.
What to verify for yourself
- Your current medications
- The plan formulary
- The tier assigned to each drug
- Pharmacy
- Preferred pharmacy when it applies
- Prior authorization
- Step therapy
- Quantity limits
- Costs
- Covered alternatives when they exist
What makes one Part D option different from another
- The plan drug list
- Tiers
- Pharmacy and pharmacy network
- Deductible when one applies
- Copays and coinsurance
- Utilization rules
- Estimated total annual cost
Cost considerations, without promises
Premiums, copays, coinsurance, deductibles, benefits and prior authorization rules depend on the specific plan and can change from one plan year to the next. Amounts set under federal rules, such as the Part B premium, also change over time.
We do not quote savings and we do not promise a premium. What we can do is help you look at the full picture: what you pay to keep coverage and what you could pay when you use it.
Certain programs exist under federal rules
Programs such as Extra Help, Medicaid and dual-eligibility options exist for people who meet the applicable requirements, and income-related adjustment amounts (IRMAA) may apply to certain higher-income beneficiaries. Eligibility for any of these belongs to the relevant program or agency under the rules in effect. We can explain what these are at a general level and coordinate the appropriate guidance, but we do not determine eligibility or promise an amount.
How Alemay helps, step by step
- 01
We understand where you are
Your age or eligibility situation, the coverage you have today and the transition you may be facing.
- 02
We organize your questions
Doctors, prescriptions, hospital, pharmacy, costs, travel and anything else you want to understand before making decisions.
- 03
We explain the pathways
Original Medicare, Medicare Advantage, Part D and Medigap explained as general concepts, so the vocabulary stops getting in the way.
- 04
We identify what should be verified
Which official enrollment period may apply to your situation, and which official documents and sources you should review.
- 05
We coordinate a professional if you ask for plan-specific help
If you later want plan-specific assistance, it is handled separately by an appropriately licensed, certified and authorized professional under the applicable rules, processes and disclosures.
Information that may be needed
Not every item applies to every case. This is what typically makes a Medicare review useful and accurate.
- Name
- Date of birth
- State
- ZIP code
- Your current Medicare situation
- Part A and Part B effective dates when they exist
- Coverage you have today
- Medications
- Doctors
- Specialists
- Preferred hospital
- Pharmacy
- Employer coverage
- Retiree coverage
- COBRA when it applies
- Medicaid when it applies
- Extra Help when it applies
- Your coverage priorities
Please do not send your Medicare Beneficiary Identifier, Social Security number, full policy numbers, banking information or sensitive documents over WhatsApp or other unsecured channels. We will point you to the appropriate secure channel when it is needed.
What the service can include
- General Medicare orientation
- Plain-English explanation of Part A, Part B, Part C and Part D
- Conceptual education on Original Medicare and Medicare Advantage
- General Medigap education
- General education on prescription drug coverage (Part D)
- Explanation of what a provider network is and where to verify participation
- Explanation of formularies, tiers and utilization rules at a general level
- Explanation of general cost concepts such as premiums, deductibles and cost sharing
- General education on enrollment-period concepts
- Help identifying which official enrollment period may need to be verified
- General education on how employer, retiree, COBRA or Marketplace coverage can interact with Medicare
- General information about Extra Help when it applies
- General information about Medicaid or dual eligibility when it applies
- General information about IRMAA concepts
- Help organizing your questions and documents
- Guidance on which official documents to read, such as the Evidence of Coverage or the drug formulary
- Coordination of an appropriately licensed, certified and authorized professional if plan-specific assistance is requested
What Alemay can and cannot control
What we do
- Explain Medicare in plain English and in Spanish
- Help you organize your situation and your questions
- Explain the general differences among Original Medicare, Medicare Advantage, Part D and Medigap
- Explain general enrollment-period concepts
- Help you identify which official information and documents to review
- Explain what to verify about doctors, medications and cost structure in official plan materials
- Explain general concepts such as Extra Help, Medicaid and IRMAA without determining eligibility
- Coordinate an appropriately licensed, certified and authorized professional if you request plan-specific assistance
- Coordinate with our tax area when it is relevant
- Stay available for your questions
What we never promise
- Eligibility
- A specific plan
- A specific insurance carrier
- A specific Medicare Advantage plan
- A specific Medigap policy
- A specific Part D plan
- A particular premium
- A $0 premium
- A Part B giveback
- Extra benefits
- Specific dental, vision or hearing benefits
- Grocery cards or flex cards
- A specific network without verification
- That a specific doctor is in network
- That a specific medication is covered
- Extra Help
- Medicaid
- A D-SNP
- A reduced IRMAA
- The removal of penalties
- An enrollment period
- Enrollment acceptance
- A universal effective date
- Savings
- That we represent every plan available
Alemay Business is a private company and is not Medicare, CMS, Social Security or a government agency. Eligibility and enrollment determinations are made under the applicable federal rules, and plan availability, benefits, networks, formularies and effective dates belong to the plan and the organization offering it.
Annual review and changes
Plans can change from one coverage year to the next. Reviewing those changes each year is a good habit, and reviewing does not mean switching plans is always the right answer.
What can change
- Premium
- Copays
- Deductibles
- Provider network
- Participating doctors
- Participating hospitals
- Covered drugs
- Drug formulary
- Pharmacies
- Benefits
- Prior authorization rules
- Service area
- Plan availability
Documents worth reading
- Annual Notice of Change when one is issued
- Evidence of Coverage
- Summary of Benefits
- Drug formulary
- Provider directory
These official documents, together with current Medicare information, are the sources to review when something matters to you. This page does not review or present any specific plan.
Why Alemay Business
Plain language, two languages
Medicare comes with a lot of technical vocabulary. We explain it clearly, in English or Spanish, without pushing a decision.
We start with you, not a product
We begin with your situation, your current coverage and your questions, without steering you toward any product.
Doctors, drugs and costs, explained
We explain why your doctors, your medications and the cost structure matter, and where to verify each of them in official materials.
Appropriately licensed professionals
Plan-specific sales, recommendations, marketing and enrollment are regulated activities handled only by the appropriately licensed, certified and authorized professional under the applicable rules and disclosures.
Available for your questions
Medicare keeps generating questions over time, and we stay available to explain what changed and what it means.
Part of the insurance family
Medicare sits alongside life, health, auto and home, commercial insurance and annuities within Alemay Business.
Connected to your taxes
When Medicare and taxes intersect, we can organize the information and coordinate the right areas.
Miami and bilingual service
In-person service in Miami and virtual service when the jurisdiction and the process allow it.
Ale app
Our digital platform for scheduling, resources and staying in touch throughout the process.
A coordinated team around your coverage
Alemay Business assists within the scope of applicable licenses and works with the appropriately licensed and certified professional for the product, the organization, the service area and the jurisdiction involved.
Stay connected with Alemay through Ale app
Ale app is the digital platform of Alemay Business. From your phone, you can explore our services, access helpful resources, schedule appointments and stay connected throughout the process.
Frequently Asked Questions about Medicare
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Individual and family health coverage, relevant when reviewing a transition into Medicare.
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Protection for the people and responsibilities that depend on you, reviewed before choosing a policy.
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A separate service for your personal return, useful when tax information and Medicare intersect.
View serviceTalk with us about understanding your Medicare situation
Schedule a Medicare education consultation with Alemay Business to understand where you stand, what the different parts of Medicare are and which official enrollment period may need to be verified in your case.
Alemay Business is a private company and is not Medicare, CMS, Social Security or a government agency, and nothing here implies government endorsement. Medicare is a federal health insurance program administered under federal rules. This page provides general Medicare education and does not present, market, recommend or enroll you in a specific Medicare Advantage or Part D plan. If plan-specific assistance is requested, it is handled separately by an appropriately licensed, certified and authorized professional, under the applicable licensing, certification, authorization and disclosure requirements in effect. Eligibility and enrollment determinations are made under the applicable federal rules, and Social Security and Medicare/CMS processes may be involved depending on the action. Plan availability, benefits, premiums, cost sharing, provider networks, formularies, prior authorization rules and effective dates depend on the specific plan, organization, service area and plan year, and can change. Nothing here guarantees eligibility, enrollment acceptance, plan availability, a premium, extra benefits, provider participation, prescription coverage, Extra Help, Medicaid, a Special Needs Plan, a reduced income-related adjustment amount, the removal of a penalty, an effective date or savings. Plan documents and official Medicare information control.
Alemay Business · 9380 SW 72 ST, Suite 230B, Miami, FL 33173 · 305-300-2346 · business@alemaybusiness.com · Fax 305-402-0706