What Medicare Covers
Learning about Medicare can feel overwhelming. It's a new language of terms, acronyms, and options. Fortunately, AARDY is here to help you learn about what's important.
Medicare offers you a plethora of choices, but we will help you receive all the benefits you're entitled to use.
What is Medicare?
Medicare is a federal health insurance program that covers an array of medical care and services. It started in 1965 to help seniors regardless of health status, medical history, or income. Congress expanded Medicare in 1972 to include people under 65 with a disability.
It includes Medicare Part A for hospitalization, skilled nursing services, home health, and hospice. Also, it provides for physician services, durable medical equipment, ambulance services, preventative care, and more under Medicare Part B. Finally, Medicare Part D includes prescription drugs.
The Centers for Medicare and Medicaid Services (CMS) administers Medicare and is a part of the US Department of Health and Human Services (HHS). CMS approves supplement, drug, and Medicare Advantage plans that insurance companies provide. Medicare and Social Security are federal entitlement programs for which most US citizens 65 and older qualify.
If you are eligible to receive Social Security payments, then you are not required to pay a premium for Medicare Part A (hospitalization). However, if you didn't work enough to qualify for Medicare benefits, you can probably still enroll, but might have to pay more.
People under 65 years of age can also receive Medicare in some cases. Typically, if you collect Social Security Disability Insurance (SSDI), you will be eligible for Medicare after a two-year waiting period. However, if you were diagnosed with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), you will be eligible without a waiting period.
Medicare is made up of four distinct parts.
Two parts (A and B) are administered by the federal government. They collect premiums and process claims. Insurance companies offer the other two parts (C and D).
When you initially enroll in Medicare, you will probably sign up for both Part A and Part B at the same time, unless you are still working. If you plan to keep Original Medicare or buy a Medicare supplement plan, we recommend you also enroll in Medicare Part D. If you delay enrollment in Part A, B, or D, Medicare may charge you a late enrollment penalty.
Check with your doctor's office and pharmacy to find out if they accept Medicare before making an appointment.
Keep in mind, Medicare only pays 80% of healthcare costs, which creates significant gaps in coverage.
Shortly, you will discover your options to fill those coverage gaps and reduce your out-of-pocket liabilities.
Medicare Advantage: Part C
Medicare Part C (Medicare Advantage) refers to private insurance plans that encompass booth Medicare Part A and Part B into a single policy.
Congress introduced Medicare Advantage in 2003 as an alternative to government-provided Medicare. It also gave Medicare Advantage plans permission to offer equal or better coverage than Original Medicare.
To enroll in Medicare Advantage, you must be enrolled in Medicare Part A and Part B and pay those premiums to the government. In turn, the government pays the insurer to cover you and process claims.
Medicare Advantage plans are top-rated because they often include extra benefits like dental, vision, hearing, SilverSneakers, and drug plans in one place. Coverage varies between insurers and states. Fortunately, some policies provide this coverage for a $0 monthly premium.
Medicare Part D
There are two ways to gain prescription drug coverage through Medicare.
First, you can buy a standalone drug plan from a private insurer. It will cover most of your prescription medications. You will pay copays and meet a deductible. You can use a Part D plan with Original Medicare, a Medicare Supplement, and in some cases, a Medicare Advantage plan.
Or, you can buy a Medicare Advantage plan that already includes prescription drug coverage. However, if your Advantage plan covers medications, you cannot buy a standalone program. If you do, Medicare will disenroll you from Medicare Advantage and put you back on Original Medicare.
Medicare Supplement Insurance
Private insurance companies offer Medicare Supplement insurance. Sometimes, it's referred to as Medigap plans.
These plans help fill the coverage gaps in Medicare Part A and Part B. Recall that Medicare only covers 80% of health costs. They expect you to pay the other 20%. Typically, Medicare supplements cover those most expensive deductibles and coinsurance, so you don't have to pay them.
Currently, most states offer eight Medicare supplement plans through privates insurers. These programs are Medicare-approved and provide standardized coverage in all states. Supplement plans are designated with letters A through N.
Worth noting, Supplement Plan A is not the same as Medicare Part A. You can buy a Supplement Plan A if you already have Medicare Part A. It will help cover your medical bills.
Not every state or insurer offers every plan. Also, prices are not standardized. Private insurers set their own rates. Consequently, it's essential to shop around to find the best plan for your situation and budget.
Medicare offers several opportunities during the year to enroll, but the best time is during your Initial Enrollment Period. It begins three months before your 65th birthday and ends three months after.
If you miss that opening, you can enroll during the Annual Enrollment Period from October 15 through December 7. Alternatively, another opportunity arises from January 1 through March 31 called the General Enrollment Period.
If you receive Social Security Disability Insurance (SSDI), your eligibility for Medicare begins in your 25th month of benefits. Social Security automatically enrolls you.
If You Are Still Employed
Even if you still work at age 65, you should apply for Medicare. Medical providers consider Medicare as your primary insurance, even if you continue paying for a group plan.
Consequently, your other insurance might not pay until the health care provider bills Medicare and Medicare denies it.
If You and Your Spouse are Both Eligible
Since Medicare benefits are individually rather than family plans, each member of your family must apply for Medicare separately.
If You're a High Earner
Most people would pay a $144/mo premium for Medicare Part B if they worked enough before turning 65.
However, people with higher incomes would pay more. You could pay $202.40-$491.60 if your adjusted gross income is more than
- $87,000 if you file single
- $174,000 if married filing jointly
Also, high-income Medicare recipients will pay more for Part D (prescription drugs). The surcharge ranges from $12.20-$76.40 over the standard premium.
If You Are Focused on Health and Wellness
Medicare Part B covers a range of preventative services including disease screenings, vaccinations, and annual checkups.
Some plans, like Medicare Advantage, take wellness to the next step. You could receive a one-time complimentary home "wellness" visit where a specialist develops a personalized prevention plan for you. Also, some Medicare Advantage programs include free gym memberships like SilverSneakers.
If You Need Long Term Care
Medicare does not provide benefits for custodial Long Term Care like for chronic illnesses. Custodial care refers to needing permanent help with the activities of daily living (eating, bathing, dressing, toileting, taking medication, transferring from bed to chair).
However, Medicare Part A provides limited coverage for stays in a skilled nursing facility. Your visit must be immediately following a hospitalization, and your physician expects your condition to resolve or improve within 60 days.
Medicaid can cover long term care if you qualify. Essentially, you would have to spend down and no longer own any assets to meet the financial requirements.
If You're Concerned About Claim Rejections
Occasionally, Medicare may not cover something you think it should. You have a right to file an appeal.
Medicare has five levels of appeals. Often, they settle the claim at a low level, but others take longer.
Provide as much documentation as you can when you make your first appeal to speed up the process. Enlist the help of your physician and her or his office.
In critical cases, Medicare provides a fast-track decision process with a 72-hour turnaround.
AARDY Can Help
AARDY is the nation's fastest Medicare insurance marketplace. You can compare Medicare supplements and Medicare Advantage plans to find the one that best fits your needs.