Medicare is a health insurance program administrated by the government, providing health insurance coverage to people who are aged 65 and over, or to meet other special criteria. The Centers for Medicare and Medicaid Services, a component of the Department of Health and Human Services, administers Medicare. Medicare is the largest health insurance service in the country. In order to be eligible for Medicare you must be a citizen of the United States and meet certain requirements.
If you can answer any one of these questions, then you could be eligible for Medicare:
- I am 65 years of age or older.
- I have certain disabilities, but I don’t meet the age requirement.
- I have End-Stage Renal Disease, which requires a transplant or dialysis.
Medicare is broken down into two main categories: the Original Medicare Plan and the Medicare Advantage Plan. Each of these categories consists of four sub categories:
- Hospital Insurance Part A
- Medical Insurance Part B
- Medicare Advantage Part C
- Prescription Drug Coverage Part D
The Original Medicare plan consists of Part A. A person won’t have the option of adding Part B and Part D. You will automatically be enrolled in the Original Medicare Plan unless the person specifically chooses to join a Medicare Advantage Plan, Part C. The Original Medicare Plan is managed by the federal government. This plan operates on a fee for service charge. Most people pay a deductible and then a copayment or coinsurance.
The Medicare Advantage Plan or Plan C is a combination of your Part A and B coverage, which is offered by private insurance companies. There is the option to include Part D if drug coverage isn’t already included. Medicare Advantage Plans consists of four plans, Health Maintenance Organization, HMO, Preferred Provide Organization, PPO, private fee for service plans,PFFS, and Medicare special needs plans.
The Four Sub Categories:
Hospital Insurance (Part A)
Medicare has several parts to consider when making your health care insurance choices. One part of the Medicare program is called Part A. Most people do not have to pay a premium for Part A because the individual or their spouse paid Medicare taxes while working. Others would be able to buy Part A if they meet certain requirements.
Part A is a type of hospital insurance provided by Medicare. Hospital Insurance coverage includes inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals. Part A does not include long term or custodial care. If you meet specific requirements, then you may also be eligible for hospice or home health care. Medicare does not cover everything, nor does it cover the total cost for many of the covered services or medical supplies. Coverage amounts are based on which Medicare plan you have. Part A helps cover on the medically necessary services below:
- Blood Transfusions: This is blood work that you receive during a covered stay in a hospital, critical access hospital, or a skilled nursing facility
- Hospital Stays: Part A covers hospital stays, which includes a semi-private room, meals, general nursing, and miscellaneous hospital services and supplies. Inpatient care in critical access hospitals and mental health care are covered as well. Hospital stays must be at least 3 days. The time begins on the first midnight after admission and does not include any hours on the discharge date.
- Nursing Home or Skilled Nursing Facility stays must be related to diagnosis during a hospital stay. A nursing home or skilled facility stay included a semi-private room, meals, and rehabilitative and skilled nursing services and care. The coverage is limited to a maximum of 100days. The first 20days are paid in full, and the remaining 80days will require a copayment.
- Home Health Services include limited reasonable and only medically necessary part time care and services such as skilled nursing care, physical or occupational therapy, home health aide service, speech language pathology, and medical social services. It also includes certain home use medical equipment and other medical supplies.
- Hospice Care is for the terminally ill who have six months or less to live. This coverage includes pain relief and symptom control drugs, medical and support services, grief counseling, and other services. Medicare does not cover many of the services that are provided to patients who receive Hospice assistance.
Medical Insurance (Part B)
Most people have to pay a premium for Part B. You can check to see if you qualify to receive help from your state to pay for premiums and deductibles. If you don’t qualify for this, then the premiums are usually deducted from a Social Security, Railroad Retirement or Civil Service Retirement check. There are many payments options for premiums such as quarterly bills, check draft, or easy pay.
Part B is a medical insurance offered by the federal government to eligible beneficiaries. Part B coverage offers medically necessary doctor’s services, outpatient care, and most other services that Part A does not cover such as some physical or occupational therapies and some home health care services. Preventive services are also covered by Part B. Though many services and products are covered, keep in mind that Part B is still not a complete insurance coverage plan. Part B helps cover only the medically necessary services listed below:
- Tests, labs, and screenings
- Preventive services
- Glaucoma tests
- Bone mass measurement
- Lab Services
- Colorectal cancer screenings
- Diabetic screenings
- Diabetic supplies
- Diabetic self management
- Cardiovascular
Preventive Shots
Flu shots are covered one time per year during flu season.
Three hepatitis B shots are covered if you are at medium or high risk.
Medicare Advantage (Part C)
Medicare Part C is a combination of your Part A and Part B options and must cover all medically needed services. One difference is that private insurance companies that are approved by Medicare provide this type of coverage. Part C is a lower cost alternative to the Original Medicare Plan and provided usually offer extra benefits and include prescription drug coverage (Part D). Part C plans often have networks, and you must use the doctors or hospitals that belong to the plan.
Medicare Advantage had several plans available. The Part C plans include the following:
- Medicare Health Maintenance Organizations (HMO): You would only be able to visit doctors in the HMO network. In most cases, you will be required to have a referral to visit a specialist.
- Medicare Preferred Provider Organization (PPO): You are able to see any doctor or specialist you prefer. If the doctor or specialist isn’t in the PPO network, your cost will increase. You usually don’t need a referral to see a specialist.
- Medicare Private Fee for Service (PFFS): You are able to se any doctor or specialist, but they must accept the PFFS’s fees, terms, and conditions. You usually don’t need a referral to see a specialist.
- Medicare Special Needs: These plans are designed for people with certain chronic diseases or other special health needs. These plans must include Part A, Part B, Part C, and Part D coverage.
- Medicare Medical Savings Account (MSA): This plan consists of two parts:
- A high deductible plan with which the effective date won’t be in effective until annual deductible is met.
- A savings account plan where Medicare deposits money for you to use for health care costs.
Medicare Prescription Drug Coverage (Part D)
Part D is a prescription drug coverage insurance that is offered by private companies, which are approved by Medicare. You would need to enroll when you first become eligible in order to not pay a penalty cost later on. Part D was designed to aide people with Medicare lower their prescription drug costs and to protect against future costs. This prescriptions drug plan will allow you to have access to medically necessary drugs.
There are two ways you can join Medicare prescription drug coverage plan. One way is by adding this plan to your Original Medicare Plan or another Medicare cost plan. The second way is by joining an HMO or PPO plan that includes Part D coverage. You would usually have to pay a monthly premium which will vary according to the plan you choose.
After you join, you will receive a membership package via mail and will have to pay a co-payment, coinsurance, or deductible when you use your membership card. Keep in mind; some Part D plans have a coverage gap. A coverage gap is when you have a certain amount of money to spend. Once you go over that amount, you will be responsible for paying the entire cost of prescriptions while you are in the gap until you reach the out of pocket limit. Once you have met the out of pocket obligation, you will only be responsible to pay small co-payment or coinsurance for the rest of the calendar year.
