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Medicare
I. Introduction To Medicare
Medicare is the country’s health insurance for people 65 and older.
The function of medicare is the same as private insurance, but it is specially designed and financed for a unique age group.
In July 1965.
Medicare had provided hospital and medical insurance for over $43 million people 65 and older and 9 million disabled people under the age of 65.
Center of Medicare & Medicaid Services.
It is a separate state-run program that provides hospital and medical coverage for people with low income.
The application process is through Social Security Administration.
II. Eligibility For Medicare Benefits
Medicare Part A, B, C and D.
Medicare Part A helps pay for room, board, and inpatient care in a hospital or skilled nursing facility if it follows a hospital stay.
Note: Part A also pays for some home health care or hospice care.
Medicare Part B helps pay for medical services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.
Medicare Part C consists of Medicare Advantage Plans which are private insurance plans that replace the benefits and services covered under Part A and Part B. Advantage can be Health Maintenance Organizations (HMOs), Preferred Provider Organization (PPO), or other arrangements.
Note: Some Part C plans also include Medicare prescription drug coverage (Medicare Part D) and other extra benefits and services.
Medicare Part D helps cover the cost of prescription medicines.
Medicare Part A and B are referred to as Original Medicare and are the core parts of the Medicare program.
Medicare Part A and B.
He or she is a citizen or permanent resident of the US.
He or she meets one of the four requirements as follows:
- Age – The person is eligible when he or she turns 65.
- Disability before age 65 – If the person is disabled and entitled to either Social Security it Railroad disability benefits for at least two years, a person is then eligible for Medicare.
- Lou Gehrig’s Disease (amyotrophic lateral sclerosis).
- End-Stage Renal (Kidney) Disease (ESRD) – If someone has permanent kidney failure and receives maintenance dialysis or kidney transplant, they are eligible for Medicare if they are, 1). Eligible for or receive Social Security or railroad retirement system benefits; or 2). They have worked long enough un a Medicare-covered government job; or 3). They are the child or spouse of a worker (living or deceased) who worked long enough in Social Security or Medicare-covered government job.
He or she must either meet a certain work requirement or pay a premium to gain Medicare eligibility Part A and B.
Eligibility for Social Security retirement, disability, family or survivor payments, or
Eligibility for a pension from the Railroad Retirement Board, or
Payment of Medicare taxes in non-covered government work, sufficient for eligibility in private section work.
If a retiree has less than 40 quarters of work credit, they can purchase Medicare Part A premium. The retiree must be enrolled in Medicare B and be a citizen or legal resident for at least five years to buy Part A.
There is no work requirement for Medicare Part B.
$134 per month.
For a retiree with modified adjusted gross income above certain levels, an additional amount will be applied to the standard Medicare Part B premium.
The premium can increase up to Social Security COLA.
The increase of the standard premium is determined based on a retiree’s MAGI from two years prior.
Anyone who is enrolling in Part B for the first time.
Anyone who is not receiving social security and being billed for the premium or is paying an additional premium due to higher income.
Anyone who is receiving both Medicare and Medicaid.
$134 standard premium.
Note: The standard premium also applies to a married couple with MAGI of $170,000 or less.
$134 standard premium + $53.50.
Note: This amount of Medicare Part B premium also applies to a married couple with MAGI above $170,000 up to $214,000.
$134 standard premium + $133.90.
Note: This amount of Medicare Part B premium also applies to a married couple with MAGI above $214,000 up to $320,000.
$134 standard premium + $214.30.
Note: This amount of Medicare Part B premium also applies to a married couple with MAGI above $320,000 up to $428,000.
$134 standard premium + $294.60.
Note: This amount of Medicare Part B premium also applies to a married couple with MAGI above $428,000.
III. Medicare Benefits
Semi-private rooms, meals nursing care, medications, and other inpatient supplies and services.
Note: Doctor’s services received in the hospital are not covered by Medicare Part A and the services are covered under Part B.
Medicare Part A covers the first 60 days after the deductible is paid.
A benefit period is defined as the time from when a patient enters the hospital, or skilled nursing home until the patient has not received any inpatient services for 60 days in a row.
$335 coinsurance per day for each benefit period.
Note: Part A deductible and daily care charges are adjusted each year for inflation.
$670 per each lifetime reserve day after day 90.
Note: Part A deductible and daily care charges are adjusted each year for inflation.
This is beyond lifetime reserve days, the patient or the retiree pays all costs.
SNFs provide a higher level of care than the custodial care provided by a nursing home.
Note: Care provided by SNFs is close to care provided in a hospital. Therefore, an SNF provides continuous therapy by licensed professionals and medical treatments that require doctors or registered nurses.
A patient must stay in a hospital for at least three days prior to an SNF stay.
Home health benefits include physical, speech, and occupational therapy, medical social services, and certain medical supplies and equipment.
Hospice care such as pain relief, symptom management, and supportive services may be terminally ill individuals by an approved hospice organization.
Inpatient mental health care in a hospital or specialty psychiatric hospital.
Doctor’s bills, outpatient hospital care, diagnostic tests, medical equipment, ambulance services, some preventive care, and limited services from chiropractors, podiatrists, dentists, and optometrists.
Note: Medicare Part B generally does not cover dental or vision care or prescriptions.
Medicare Part B will pay 80% of the approved charges and 20% will be paid by patients or retirees.
They are allowed to charge up to 115% of the Medicare allowable fees.
Medicare Advantage plans.
A retiree who has Medicare Part A and Part B can join one of these plans.
They are required to include all the benefits and services under Part A and B.
Note: Medicare Advantage Plans sometimes also include Medicare Part D prescription drug coverage and other benefits to reduce out-of-pocket expenses.
Medicare Advantage Plan can not have a Medigap policy.
Retirees that have Medicare Part A and B plan and reside in the services area of the plan being considered.
Note: All Part D must meet the minimum standard coverage, but some are enhanced and offer additional coverage.
It is a prescription drug plan (PDP).
Note: Medicare Part D can be available as separate plans or included in Medicare Part C Medicare Advantage plans.
It is vary depending on if it is a separate plan or included in a Medicare Advantage plan.
The premium is adjusted for higher-income retirees and based on the same MAGI used to determine Part B premium.
Retiree’s plan premium + $13.
Note: This premium amount is also applicable to married couples with an MGAI of $170,000 or less.
Retiree’s plan premium + $33.6.
Note: This premium amount is also applicable to married couples with an MGAI of $170,000 up to $267,000.
Retiree’s plan premium + $54.20.
Note: This premium amount is also applicable to married couples with an MGAI of $267,000 up to $320,000.
Retiree’s plan premium + $74.80.
Note: This premium amount is also applicable to married couples with an MGAI above $320,000.
Part D prescription costs.
Deductible period, the initial coverage period, the coverage gap, and the catastrophic period.
IV. Medigap Plans
A Medical supplemental insurance plan.
Because Part A deductible is based on the benefit period and the period is up to five deductibles in a year.
1). 20% coinsurance payment required on all medical bills
2). Any excess charges that a health care provider can charge above the 115% of Medicare allowable fees.
V. Applying For Medicare
A retiree already receiving social security or railroad retirement board payments.
A retiree under 65 who has been receiving social security disability or RRB disability payments for 24 months.
Anyone with ALS, Lou Gehrig’s disease when disability benefits begin.Note:
Automatic enrollment includes Part A and Part B with the option to drop Part B.
1). Those retire at or before their 65th birthday, include 65th birthday month and three months before and after that month.
2). Special enrollment period, applies to those still working and receiving healthcare coverage from their employer or a spouse’s employer. The special enrollment period is an 8-month period beginning with the first full month after either employment or health insurance has terminated.
3). Late enrollees. This is limited to January 1 through March 31 of each year and coverage begins July 1 of the year enrolled. Premiums are increased 10% permanently for each year of delay.