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Health & Medical

Ultimate Overview of Medicare

Health insurance is a vital thing that everyone should have, no matter what age they are. You can never know when you're going to have a health scare. Being without any type of coverage means you'd have to pay everything out of pocket, which can eventually lead to debt. Medicare is just one of the many types of insurance coverage for individuals that meet certain criteria.

What is Medicare?

Medicare is a health care program covered by the federal government to qualifying individuals. Some people are automatically enrolled when they turn 65, others do have to enroll to begin receiving the benefits.

Medicare doesn't cover all medical expenses, and there are different plans that cover different health care expenses. You might not have to pay a premium to receive Medicare Part A benefits, but you may have to pay one to receive anything else.

Who is Eligible to Receive Medicare Benefits?

To become eligible to receive Medicare benefits, individuals do need to meet certain criteria. You can receive these full benefits if:

  • You are 65 and older
  • You're a United States Citizen or you have lived in the U.S. for at least five years as a permanent resident
  • You're a government employee (this can include your spouse) and have paid Medicare payroll taxes but have not paid into Social Security during their time working

There are ways you can be eligible for Medicare if you're under the age of 65. These ways include:

  • Lou Gehrig's disease will make you automatically qualified
  • Permanent kidney failure and you receive regular dialysis and you or your spouse has already paid Social Security taxes
  • You're getting Social Security disability benefits for 24 months
  • You're receiving a disability pension from the Railroad Retirement Board

If an individual does not qualify with their own career history, they might be able to qualify under their spouse's.

Are There Different Medicare Plans?

As with most health insurance plans, there are different Medicare plans available.

  • Medicare Part A is the hospital insurance which covers a stay in a skilled nursing facility, hospice care, and hospitals.
  • Medicare Part B is the medical insurance plan. This plan covers medical supplies, preventative services, outpatient care, ambulance services, mental health services, limited prescription medications, and clinical research.
  • Medicare Part D is the prescription coverage plan. Instead of being required to pay full price for medications, Medicare Part D will pay for most of the cost and patients only have to pay a copay. Patients do have to stay within the network of pharmacies provided by the insurance provider.

There are also programs known as Advantage plans which are bundled services approved by Medicare but offered by private companies. The advantage plans are often referred to as Medicare Part C or MA plans. Medicare pays the companies that offer these programs to pay for your benefits. These advantage plans include:

  • HMO or Health Maintenance Organization plans: This includes Medicare parts A and B, and you can include Part D too for prescription coverage. This plan is restricted in some ways, including that patients can only see in-network providers and patients need to receive referrals to see a specialist.
  • PPO or Preferred Provider Organization plans: Under these plans, you can usually use any service provider you wish, however going outside the insurer’s network typically incurs an additional cost.

You're able to enroll in Medicare Part B without being enrolled in Part A, however, if you enroll in Part A, you must enroll in Part B. You're able to get Part D, the prescription plan, if you’re enrolled in either part A or Part B. You’re unable to enroll in any Medicare Advantage plan unless you’re already enrolled in Part A and B.

Not everyone has to pay a premium for Medicare Part A, but if you want Part B, you would have to pay for it except if you have a $0-premium advantage plan. You would pay for it by having it taken out of your Social Security benefits or your Railroad Retirement Board for two years.

How To Switch Medicare Plans

It's easy to switch Medicare plans. You do have to wait each year for the open enrollment period to switch your plan that would go in effect the following year. During the open enrollment period, you're able to:

  • Switch from the Original Medicare plan to Medicare Advantage or go from the Advantage plan to original Medicare
  • Join or drop the prescription drug plan
  • Switch amongst the different Medicare Advantage plans
  • Switch the prescription drug plans

The open enrollment periods run from October 15th to December 7th and January 1st to March 31st for Medicare Advantage and Medicare prescription drug coverage.

What is Medigap?

Since Medicare does not cover all health care related expenses, you might need to purchase additional insurance from a private company. This secondary insurance is referred to as Medigap. Medigap and Medicare Advantage have similarities, except Medigap has a higher monthly premium but usually results in individuals paying less out of pocket expenses.

There are some things you do need to keep in mind when looking for a Medigap plan including:

  • You have to be enrolled in Parts A and B of the original Medicare plan to qualify
  • Medigap plans only cover one person, so your spouse would need their own
  • If you drop your Medigap plan, there’s a chance you won’t be able to get it back
  • Your Medigap monthly insurance premium is a separate cost from your Medicare premiums
  • You can’t be enrolled in Medicare Advantage unless you’re in the process of switching to the Original Medicare

Since there are different Medigap plans available, you can compare them to find the one that best fits your needs and budget.

Medicare and Hospice Care

When a loved one is terminally ill and has six months or less to live, they may need hospice care. Hospice care can get expensive for families because the patient would require constant care. Medicare does help in these situations within certain parameters.

Medicare won't cover:

  • Any treatment that would cure the terminal illness
  • Medications intended to treat the illness instead of helping manage symptoms
  • Emergency care which includes emergency room visits and ambulance transportation
  • Additional care that was not set up by the hospital medical staff

Medicare will help cover:

  • Social worker services
  • Grief and loss counseling for your family members
  • Medical supplies
  • Some medical equipment such as wheelchairs
  • Nursing care
  • Doctor’s services
  • Dietary counseling
  • Hospice aide
  • Physical therapy
  • Short-term respite care

For your loved one to qualify to receive this help, a hospice doctor, and your regular doctor (if you have one), would have to certify that that are terminally ill with six months or less to live. They would also have to be eligible for Medicare Part A and they also must sign a statement that they’re choosing hospice care instead of receiving treatment for their terminal illness.

Services that Medicare Doesn't Cover

Medicare is a great health insurance to have, but it does not cover everything. Medicare Parts A and B do not cover:

  • Long-term care including adult daycare and home healthcare
  • Routine podiatrist services
  • Exams for hearing aids and hearing aids
  • Acupuncture
  • Cosmetic surgeries
  • Many types of dental care including routine visits
  • Eye exams for prescribing glasses and routine exams
  • Dentures
  • Care that is not received in the United States
  • Medical treatment that it's deemed medically unnecessary

Trying to plan ahead and saving money is one of the best ways you can ensure you have money set aside to pay for any of the services that aren't covered. For needs such as long-term care, you could purchase a long-term care insurance plan to help cover the costs associated with the care needed.

Some Medicare Advantage plans offer dental care and vision exams so there are options available. There are some advantage plans that offer to help cover some of the costs associated with getting a hearing aid, but they won't cover the full cost of it.

How to Receive Medicare Benefits

To begin receiving Medicare, you do need to enroll in Part A or Part B. You can easily enroll by:

  • Visiting the Social Security website here
  • Calling Social Security Monday through Friday from 7 AM to 7 PM at 1-800-325-0778
  • Or you can visit your local Social Security office where someone can help walk you through the steps in applying

There are some ways in which you can automatically be enrolled into receiving Medicare. If you’re collecting retirement benefits from Railroad Retirement Board or Social Security and you turn 65, you will be enrolled in Medicare Part A and Part B.

If you're not automatically enrolled in Medicare, you would have to enroll during the general enrollment period. This is from January 1st to March 31st every year. Not enrolling during that period could result in you paying a late enrollment penalty.

If you don't sign up for Part B while you’re already covered by an employer's group medical insurance, you would have eight months to apply for benefits after your employment ends.

Can I Receive Medicare Benefits While I'm Still Working?

You can receive Medicare benefits if you're working.

You’ll automatically be enrolled in Medicare Part A at the age of 65 if you've worked at least 10 years, even if you’re still currently working. In this situation, you would qualify for a premium-free Medicare Part A plan.

If your work history does not qualify you for premium-free Medicare Part A, you can choose to delay enrollment if you’re currently still working and have insurance on your own or through your work.

Since Medicare Part B always requires a premium, you can choose to delay the enrollment for this as well if you’re working and employed through work or have your own insurance.

You do have to keep in mind though, that if you don’t sign up when you’re first eligible and you do not have other insurance coverage, you might have to pay the late-enrollment penalty.

If you do choose to start receiving Medicare benefits while receiving insurance benefits through work, you should check and see if that coverage will change at all.

What is Medicare's Extra Help Program?

This program is to help pay for many out-of-pocket expenses that low-income individuals would have to pay for their prescription drug coverage. You can qualify for the Extra Help program if:

  • You have an annual income that is below the eligibility thresholds
  • You have an annual income higher than the eligibility threshold but are responsible for supporting other family members living in the same household

This program helps with the monthly premium of Part D, the annual deductible, copayments, and coinsurance. The amount of help you receive does depend on your income.

You can apply for this program the same way you would apply for Medicare benefits, online, over the phone, or at a Social Security office.

Is There a Difference Between Medicare and Medicaid?

Medicare and Medicaid are two different things, both run by the government. They’re run by two different parts of the government, but they are both insurance programs that are intended to help individuals with the cost of healthcare.

  • Medicare is available to those that are 65 and older or if they have a severe disability. It doesn’t matter what their income is. This program is run by the Centers for Medicare and Medicaid services, which is an agency in the federal government.
  • Medicaid is a federally funded insurance program for low-income families and individuals

You can qualify to have both Medicaid and Medicare at the same time. Both programs would work together to make your health coverage costs very low and affordable. This program is run by local and state governments and there are certain guidelines for eligibility which vary in each state.

You can find out if you're dually-eligible by visiting the Social Services office in your city.

Medicare might seem confusing, but it really comes down to comparing the options available and making sure you're covered for all your healthcare needs. Healthcare is all about trying to plan ahead as much as possible and setting money aside for emergencies or trying to find a secondary insurance to help cover the gaps in your Medicare coverage. If you have any questions, you can speak to a representative at your Social Security office.

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