Medicare

Medicare is a federally funded, state-administered health insurance program. It provides support and assistance to elderly Americans 65 years of age or older and persons of any age with qualifying disabilities.

Americans with End-Stage Renal Disease (ESRD), a form of irreversible kidney damage causing them to need ongoing dialysis or an organ transplant, may also be eligible for enrollment no matter their ages.

Medicare coverage is broken out into four different types. Part A covers inpatient care at hospitals, nursing facilities and hospices. In some cases, it also funds in-home care. Medicare Part B funds outpatient care, including medical supplies and primary and preventive care. Part D is strictly prescription drug coverage, while Medicare Part C Advantage Plans give patients access to vision, hearing, dental and other supplemental services. Many Americans qualify to dual enroll in both Medicare and Medicaid. Unlike with Medicaid, however, it is essential that patients enroll in Medicare promptly as soon as they are eligible to do so.

Medicare Part A

Medicare Part A covers costs associated with in-patient and in-home medical care. This includes but is not limited to:

  • Hospital Services at acute care, critical access, psychiatric or long-term care hospitals or inpatient rehabilitation facilities. Qualifying services include room and board, nursing care, drugs and medical supplies. Medicare Part A will not pay for private nurses or room, phone and television fees or personal care items.
  • Skilled nursing facility services in non-custodial and short-term situations. Covered services include room and meals, skilled nursing care, physical and occupational therapies, speech-language pathology services, medications, medical social services, equipment and dietary counseling. Transportation may be covered where it is deemed necessary. All care in this category must be directly linked to assessments and care plans completed and developed by patients’ care teams.
  • Hospice care when patients elect to stop receiving treatment for their conditions or when their physicians determine no further effective care is possible. Medicare covers both in-home and inpatient hospice care, and most associated costs including counseling for patients and their families. Patients who begin hospice care may no longer receive funding or services related to treatment for their conditions, care from physicians not approved by their hospice teams or some forms of emergency treatment.
  • Home health care for homebound patients expected to improve in relatively short periods of time. These patients may qualify for therapy, counseling and intermittent nursing services to be delivered at their homes. Meals, personal care and custodial care are not included in home health coverage.

Medicare Part B

Medicare Part B coverage pays for outpatient care, including preventive care, medical supplies and medically necessary services. Many enrollees receive preventative care free of charge if they see participating providers. In appropriate circumstances, this category of Medicare also funds:

  • Patient participation in clinical research trials.
  • Ambulance services.
  • Mental health care services.
  • Some prescription drugs.

Medicare Part C

Medicare Part C may also be referred to as Medicare Advantage Plans or “MA plans.” These plans are Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) health insurance plans offered to enrollees by independent companies authorized by Medicare. MA plans combine and manage enrollees’ Medicare Part A and B benefits. Some MA plans also include additional coverage for vision, hearing, dental and wellness services.

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Medicare Advantage Plans must be run in compliance with Medicare standards and regulations, but they may incorporate their own additional or alternative rules regarding access to care and costs.

Medicare Part D

Medicare Part D provides prescription drug savings and coverage for Medicare enrollees. This coverage can be independent or used to supplement Medicare Parts A, B and C. Part D plans are offered and managed by private insurers who partner with Medicare.

Medicare Eligibility

Americans can meet Medicare eligibility standards based on their ages, disability status or health conditions. Older Americans become eligible for Medicare coverage when they reach the age of 65. Younger Americans may qualify for enrollment earlier if they:

  • Are diagnosed with qualifying disabilities.
  • Are diagnosed with amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease.
  • Are deemed to have End-Stage Renal Disease (ESRD).

In the case of ALS or ESRD diagnosis, applicants may need to meet certain physical conditions or have reached particular phases of their diseases before Medicare benefits apply. Prospective enrollees remain eligible for Medicare even if they are already receiving benefits or carry private health insurance.

When to Enroll in Medicare

It is essential that Americans enroll promptly upon reaching Medicare age (65 years of age), regardless of whether they intend to begin collecting benefits or not. There is no charge to enroll in Medicare Part A. Medicare Part B enrollment involves paying monthly premiums. However, it is important to enroll in both, since permanent penalties and coverage gaps can apply when applicants fail to enroll in both or either par during the appropriate windows.

Non-disabled applicants may enroll for the first time during a seven-month Initial Enrollment Period. This is a window of time that begins three months prior to the month in which they turn 65 years of age, includes their birthday month and extends three months after their birthday month.

Medicare enrollees who do not apply during the Initial Enrollment Period will be forced to wait until the next open enrollment period unless they qualify for a Special Enrollment Period (SEP). SEPs may go into effect if:

  • Applicants or their spouses remain employed and they remain covered under employer-based health insurance plans.
  • Applicants lose formerly qualifying employer-based health insurance. Applicants have eight months from the loss of their former insurance to apply for Medicare.
  • Applicants are diagnosed with a qualifying condition or disability, regardless of age.

How to Enroll in Medicare

Some eligible parties are automatically enrolled as soon as they qualify. For example, Americans who have received Social Security disability benefits for 24 months are auto-enrolled by the Social Security Administration (SSA). Americans who have received certain railroad disability benefits for 24 months are also auto-enrolled in Medicare Parts A and B. Individuals diagnosed with ALS will be automatically enrolled in Medicare when their disability benefits start.

Eligible parties who are not automatically enrolled must submit their Medicare applications during their Initial Enrollment Periods, open enrollment or Special Enrollment Periods. Applicants can elect to enroll in both Medicare Part A and Medicare Part B at the same time or may choose to wait to enroll in Part B at a later date. Americans with ESRD are not auto-enrolled and must apply themselves. These parties should apply for both Medicare Parts A and B to ensure full coverage.

Applicants can enroll in Medicare coverage online, typically without submitting any additional documentation. Alternatively, the application may be completed in hard copy and submitted in person or by mail to the applicants’ local Social Security office. Applicants who wish to apply by phone may do so toll free at 1-800-772-1213 on weekdays between 7 a.m. and 7 p.m. Applicants who are deaf or hard of hearing may call 1-800-325-0778, instead.

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