If you have ever dealt with any impromptu health or medical expense you would know how catastrophically expensive they can be. Thus, having health insurance in the US just makes sense.
Medicare is a government national healthcare Insurance program in the United States for seniors 65 years and older, younger people with disabilities, and patients with end-stage renal disease and amyotrophic lateral sclerosis diseases.
What is Medicare and How Does It Relate to Government Programs for Senior Citizens and Disabled Individuals?
Medicare is a government national healthcare Insurance program in the United States. Started in 1965, Medicare is now administered by the Centers for Medicare and Medicaid Services (CMS). This is a health insurance plan for seniors 65 years and older, younger people with disabilities, and patients with end-stage renal disease and amyotrophic lateral sclerosis diseases.
What is the connection between Medicare and the Social Security Administration (SSA)?
Social Security Administration is a US Government agency that provides protection to individuals in the areas of healthcare, covering disability, retirement, and other social services.
Medicare is a government health insurance program that provides healthcare to the elderly and individuals with chronic diseases and disabilities.
Both the Social Security Administration and Medicare intend to provide health and medical care to the elderly and disabled people. The connection between Medicare and the Social Security Administration is that SSA administers the enrollment for Medicare Part A (hospital insurance) and Part B (medical insurance).
SSA also checks your income information received from the IRS and determines whether you are liable to pay high premiums.
How do the Centers for Medicare & Medicaid Services (CMS) manage Medicare?
Centers for Medicare & Medicaid Services is a federal agency that supervises the healthcare system in the US to eliminate fraud and abuses. It collects vast healthcare data and supervises it to create a comprehensive research report. CMS also sets the rules and standards for Medicare eligibility, enrollment, coverage, and payment
Who is Eligible for Medicare and How Does It Relate to Disability Benefits?
To get Medicare services, you need to be 65 years old or above, or younger than 65 with a qualifying disability, or an end-stage renal disease (ESRD) patient.
Also, You should be a US resident or a permanent legal resident of the US who has lived in the US for more than 5 continuous years.
You or your spouse must have worked or paid for Medicare taxes for at least 10 years.
How does receiving disability benefits impact Medicare eligibility?
If you are enrolled with Social Security Disability Insurance (SSDI) and have been receiving SSDI disability benefits for more than 24 months, you’ll automatically be enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance).
In your initial enrollment period, which is 3 months before your 25th month of disability, you will also have the option to enroll in Medicare Part D (prescription drug coverage) or Medicare Part C (Medicare Advantage).
What Are the Different Parts of Medicare and How Do They Cover Healthcare Costs?
Medicare is divided into four parts: Part A, Part B, Part C, and Part D. They cover healthcare costs in the following ways:
What Is Medicare Part A and What Healthcare Costs Does It Cover?
Medicare Part A is one of the four parts of the Medicare Plan and it covers inpatient hospital care and skilled nursing care of formally admitted patients. It also covers home health care and hospice services.
What Is Medicare Part B and What Healthcare Costs Does It Cover?
Medicare Part B is one of the four parts of the Medicare Plan and it covers outpatient care such as doctor visits, preventive services, lab tests, and mental health services. Part B Medicare also covers durable medical equipment such as wheelchairs and oxygen tanks, Home health care, ambulance services, and most professionally administered prescription drugs.
What is Medicare Part C (Medicare Advantage) and how does it offer additional benefits?
Medicare Part C or Medicare Advantage plan is an alternative healthcare insurance plan provided by private companies in collaboration with Medicare. Medicare Part C provides benefits of both Part A (Hospital insurance) and Part B (Medical insurance). Moreover, It covers some out-of-pocket expenses that the Original Medicare Plan does not cover such as prescription drug coverage (Part D), vision care, dental care, hearing care, fitness & wellness programs, and transportation services.
In order to take advantage of Medicare Part C, a beneficiary must be enrolled in Medicare Part A and Part B.
What is Medicare Part D and What Healthcare Costs Does it Cover?
Medicare Part D is also run by private companies that are in contract with Medicare. Medicare Part D is responsible for prescription drug coverage.
How Much Does Medicare Cost and What Are the Premiums, Copays, and Deductibles?
The premium costs of the four plans of Medicare are as follows:
Part A: $0 if you fall under “premium-free Part A” which is when you or your spouse has paid Medicare taxes for at least 10 years.
If you do not fall under the “Premium-free part A”, the part A premium charges can be anywhere between $278 or $506 each month, depending on your Medicare tax history.
Part B: $164.90 each month or higher depending on your income. SSA decides your premium fees based on your income.
Part C: Monthly premiums of part C keep changing according to the insurance providers.
Part D: The monthly premium of Part D varies depending on the plan you choose. The average premium cost for a standalone part D is around $31.50 in 2023, according to AARP.
How do copays, and deductibles vary among the different parts of Medicare?
Part A: You have to pay a $1600 deductible for each benefit period in 2023. The co-payment cost of the skilled nursing facility stay is $0 for up to 20 days. However, copay increases to $200 per day from day 21 to day 100. The co-payment for an Inpatient stay is $0 for up to 60 days. However, copay increases to $400 each day from day 61 to day 90. It further increases to $800 from day 91 to day 150, while using your 60 lifetime reserve days.
Part B: You have to pay a deductible of $226 once each year before the Original Medicare starts to pay for you. Inpatient hospital care costs 20% of the Medicare-approved copays for most doctor services while you’re a hospital inpatient. Similarly, Outpatient hospital care costs 20% of the Medicare-approved copays for doctors and other health care providers’ services.
Part C: Varies by plan.
Part D: Varies by plan and pharmacy.
What Are the Benefits of Medicare and How Does It Help with Nursing Homes and Assisted Living?
- Medicare helps cover the cost of healthcare services and supplies for eligible beneficiaries (65+ year-olds, disabled individuals, and patients with end-stage renal disease).
- Medicare can cover expensive healthcare costs such as hospital stays, doctor visits, preventive care, prescription drugs, and more.
- Medicare has a variety of plans to suit different health and medicare needs. These plans include Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (Medicare prescription drug coverage). It also has Medical Supplement Insurance (Medigap).
- Medicare provides access to a wide range of healthcare providers across the country. Also, Medicare comes in handy in case of health and medical care emergencies while traveling outside the U.S.
- Medicare is also beneficial for certain groups of beneficiaries such as people with low income, disabilities, chronic conditions, or end-stage renal disease.
What are the benefits of Medicare for nursing homes and assisted living facilities?
Medicare Part A and Part C (Medicare Advantage) might cover a stay in a skilled nursing facility for up to 100 days. However, Medicare does not cover custodial care, which is nonmedical assistance with personal care and daily activities.
Medicare might cover a few medical or health-related services in Assisted living facilities such as outpatient care, preventive care and screenings, prescription drugs (If you have Part C or Part D), durable medical equipment, home health care, etc. However, Medicare does not cover the cost of living in an assisted living facility, nor does it cover the custodial care that these facilities provide.
How Do I Enroll in Medicare and What Is the Process for Enrollment?
When you turn 65 and you’re eligible to receive Social Security benefits, you automatically get enrolled in Medical Part A and Medical Part B. However, you need to manually enroll for other parts of Medicare.
If you’re not enrolled with SSA or the Social Security Benefits, you must first sign up through an official SSA website. You can do this in your initial enrollment period, a 7-month window starting from 3 months before the month you turn 65 and 3 months after the month you turn 65. If you miss this enrollment window, you’ll need to pay a penalty to get enrolled.
To get a Medical Supplement Insurance plan or Medigap, you need to follow a 6-month open enrollment window. This period starts from the first month you are enrolled in Medicare Part B after age 65. If you miss this period, the insurance providers may or may not provide you the Medigap facilities.
How do I choose between the different parts of Medicare during enrollment?
Consider the following factors while choosing a Medicare plan:
- Save money by estimating how much you spent on healthcare last year and then choose a reasonable plan.
- Make a list of your medical conditions and based on that choose a plan that suffices your healthcare needs.
- Choose a plan based on medical treatment that you might need in the future.
- Check if you can use your current medical insurance, if any, with the Medicare plan.
- Will you be needing dental, visual, or hearing aids? Part A and Part B do not cover these health conditions, so you might want to get some other plan for such healthcare services.
How Do I Renew My Medicare Coverage and What Is the Process for Renewal?
You don’t have to renew your medical coverage since the Original Medicare renews automatically, annually. However, It is recommended that you review your Medicare plans at the end of each year because the costs and benefits of Medicare keep changing from year to year.
What Are the Appeals Process for Medicare and How Can I Address Coverage Issues?
You file an appeal when you disagree with a Medicare coverage or plan. To file an appeal, start by reviewing your MSN or Medicare Summary Notice which shows the summary of your Medicare activity and the amount that you owe to health care providers and suppliers. You must file an appeal before the deadline as mentioned in the MSN. However, you can still file an appeal, if you can justify a valid reason for missing the deadline.
Fill out a Redetermination Request Form and send it to the address listed in the “Appeals Information” section of the MSN.
The Medicare Administrative Contractor will review your appeal within 60 days and tell you the decision. If they find your appeal valid, they will revise your next MSN accordingly.
