Understanding Medicare Health Insurance Coverage

Understanding Medicare Health Insurance Coverage

Medicare is a type of health insurance from the federal government. It covers people aged 65 yrs or older. Medicare provides Part A (hospital insurance) and Part B (medical insurance) benefits. Even though Medicare is important to older Americans, it doesn’t cover everything.  It, for example, doesn’t include hearing aids and dental care. The Social Security Administration determines eligibility for Medicare.

Medicare Eligibility for Those Under 65

The easiest way to qualify for Medicare is to be at least 65 years old. However, people that are below 65 can also be eligible for Medicare. You can qualify for Medicare if you are receiving Social Security Disability Insurance (SSDI). If you have been receiving the SSDI checks for 24 months, you automatically enroll for Medicare on the 25th month. An exception is if you receive SSDI for Amyotrophic Lateral Sclerosis (ALS). In such a case, you can enroll for Medicare in the first month. You do not have to wait for 24 months. Ultimately, the decision for who is eligible for Medicare depends on Social Security and not Medicare. They also determine whether or not you qualify for SSDI checks.

Another way to be eligible for Medicare while you are below 65 years is if you are suffering from kidney failure or End-Stage Renal Disease (ESRD). If you are suffering from ERSD, you may enroll for Medicare under the following circumstances.

  • If you are getting dialysis treatment
  • If you have had a kidney transplant
  • If you apply for Medicare benefits (up to a month retroactively)
  • If you, your spouse, or your parents have been paying Medicare taxes as required by the Social Security Administration

Other factors that may affect whether or not you receive your Medicare benefits when you are below 65 include when you apply for Medicare and whether or not you are undergoing your dialysis at a facility or home.

Medicare Supplement Insurance

If you have frequent visits to the doctor, you may have noticed Medicare Part A and Part B leave out some costs that you have to pay out of your pocket. It’s possible to avoid this payment with a Medicare supplement insurance plan. The plan, also called Medigap insurance fills in gaps that your Medicare Part A and Part B leave out. There are ten standardized Medicare Supplement insurance plans in most States. They are represented by the letters A to N (no plans E, H, I and J). Even though insurance companies do not have to offer all the Medicare Supplement Insurance plans, they have to offer plan A. If, however, they choose to offer other plans in addition to plan A, they have to offer either plan C or plan F.

Each one of the plans is unique, and it offers different benefits. Each of the lettered plans must provide standard benefits. The basic needs are similar regardless of the insurance company or State. The following are some of the benefits that each of the plans could cover.

  • Medicare Part A costs up to an extra 365 days after you exhaust your Medicare benefits.
  • If you need blood for a medical procedure, a plan could cover the first three pints
  • It could cover Medicare Part A hospice care copayments
  • Coinsurance or copayments for Medicare Part B

These are the basic benefits, and some plans could provide extra. Medicare Supplement F offers the most comprehensive coverage. It includes the following additional benefits.

  • Medicare Parts A and B deductibles
  • Excessive charges for Part B
  • Emergency care for foreign travel (80% of costs that are approved by Medicare)
  • Skilled Nursing Facility (SNF) care coinsurance
  • Preventive care coinsurance for Part B

When shopping for a Medicare Supplement Insurance plan, you need to remember that a few factors can influence your premium rates. Community no-age-rated plans offer the same premium rates regardless of age. Attained-age-rated plans offer premium rates depending on your age when you buy the policy for the first time. Premium rates increase as you get older. Issue-age-rated plans also offer their premium rates depending on your age when you first buy the policy. Find an insurance company whose plans meet your budget and needs.

You cannot get Medicare Supplement insurance plans unless you have both Medicare part A and Part B. The Medigap Open Enrollment Period lasts from the first day that you attain age 65 or older and have part B and lasts for six months. You can join any Medicare Supplement insurance plan that is available in your area. Your insurance provider may not deny you any basic benefits due to conditions that you have during this period. If you apply for your Medicare Supplement insurance after this period, your coverage may be limited. It may be difficult for you to find the right policy.

The Four Parts of Medicare Benefits

Part A

It covers a part of the costs of your stay in a hospital, hospice care, home health care, and nursing facility. To enjoy these benefits, you are required to make your payments before retirement. You do not need to make any extra payments if you paid your taxes on time.

Part B

It covers part of your costs of seeing a doctor for both inpatient and outpatient treatment. It covers a variety of outpatient medication. Part B payments are organized into five payments.

Part C

Part C offers additional coverage. It is not mandatory. It allows you to receive parts A and B, and may include a prescription drug plan for part D. It is important because it helps you pay for payments that may have been left out by your standard Medicare plan. You are required to make monthly premium payments. You must enroll for part A and part B before enrolling for this coverage.

Part D

It covers a part of the costs for your prescription drugs. You are required to make monthly premium payments for this coverage. You can get it as an independent plan or combine with it with a Medicare Advantage Plan. A Medicare Advantage Plan is also called a Medicare Advantage Prescription Drug. If the cost of your prescription drugs is high, part D can help you lower the prices.

What Is Not Covered?

Medicare does not cover dental work, and routine hearing and vision care. It, however, could cover complicated or emergency dental procedures. It does not cover your regular dental checkups or dentures. If you go for regular visual checkups, Medicare may not pay for them. It may, however, pay for complicated eye care procedures such as cataracts and glaucoma.

Advantage plans may cover your dental and visual procedures with some limits. They may, for example, set limits to the number of times you can get your benefits. If you want to get more comprehensive coverage, the best option is to get a separate policy.

Your Medicare plan may only cover you within the United States. If you plan on spending your retirement days traveling the world, you should get alternative ways to pay for your health overseas. Advantage plans may offer you coverage regardless of where you are. Medigap policies may also cover you while traveling. Medicare does not cover regular foot care, acupuncture, chiropractic services, and cosmetic surgery. Medicare does not cover alternative medicine except under circumstances when you have a medical need to manipulate your spine. It may cover cosmetic surgery if you need it to repair the functioning of a body part. It does not provide custodial care including meal preparation, laundry, and housekeeping care. Medicare does not cover your hospital services that are not medical. It, for example, does not pay for your luxuries in the hospital for instance access to television or private rooms. It does not cover your transportation needs unless you need emergency transportation.

Observation vs. Admission

Always find out whether you are in a hospital for admission or observation. The benefits that you receive from Medicare may vary depending on your reason for being in the hospital. Medicare Part A pays for skilled nursing care. If, for example, you get into an accident and have to seek medical attention, you may need to be in the hospital for a few days. After you leave the hospital, you may still need to get rehabilitation for the injury to heal completely. If the hospital only keeps you for observation, Medicare part A may not offer you any benefits. It may cover you if you have been admitted for three days or more. Observation is considered an outpatient treatment.

Long-term Care

Long-term care includes services that people may require for their daily life such as help with eating. Most of the older Americans spend a lot of money on their long-term care. On average, an American aged 65 will spend $138,000 on such services. Unfortunately, Medicare does not offer coverage for long-term care. You can, however, invest in separate health insurance policies that cover it. Payments will vary depending on your age.

How Does Medicare Work With Other Insurance?

You can get Medicare alongside other health insurance policies. Every health insurance that you have is called a payer. If you have more payers than one, ‘coordination of benefits’ determines which one will pay first.

Primary/Secondary Players

The primary player is the health insurance that pays first. It offers coverage up to its limits. The secondary player pays after the primary player. If the primary player has reached its limits and there are extra payments to be made, the secondary player fills in. It, however, may not cover all the additional costs. There may be a third player if you want. If you use your employer insurance as your secondary payer, you need a Medicare part B. If your insurance company does not make payments on time, your medical provider may contact Medicare. Medicare may then make payments on certain conditions. They may agree to pay your bill and recover payments later on.

Conditional Payments

A conditional payment is a payment that Medicare makes on behalf of the primary payer. Medicare steps in on behalf of the other payer so that you do not have to pay your medical bills out of your pocket. The payment is said to be conditional because it is paid on the condition that Medicare will recover the amount once you get compensation from your health insurance. You are expected to ensure that Medicare receives their money back.

Choosing The Most Appropriate Medicare

Even though there are many Medicare options, not all of them may be appropriate for you. It is wise to consider a few factors before making your decision. The following are some of the most important steps to keep in mind.

  • Decide if you want a Medicare or Medicare Advantage plan
  • Consider your needs and decide whether or not you need prescription drug coverage
  • Decide if you want additional coverage
  • Consider your budget limits. If you have strict budget limits, choose the traditional Medicare services
  • Compare various costs and benefits. The most affordable premiums are not necessarily the best. Pay attention to coinsurance and copays. Consider a number of options and find out the plan that best suits your needs. If, for example, you need vision or dental benefits, consider getting a plan with D, H, and V.
  • Decide whether you want to use Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Most of the people that enroll in Medicare prefer HMO plans. These plans demand that you pick a doctor to coordinate your care. If you need to see other specialists, your primary doctor should provide you with a referral. You don’t get any compensation if you do not use the doctor. PPO plans offer you compensation regardless of the doctor or medical specialist that you visit. HMOs are affordable, but they offer you a limited variety of doctors.

Investing in Medicare is a smart decision. Find the right plan for your needs to reap the maximum benefits.

About the Author:

Matthew Carter
Matthew Carter, owner/licensed agent and Oldham County resident, graduated from the University of Louisville in 1998 with a B.A. in political science/communications and completed his M.B.A. in 2009.

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