Medicare is a government program that provides health insurance coverage for people aged 65 or older, people suffering from specific disabilities, and people with end-stage renal disease.
Medicare is a vital part of the social safety net for Americans, and it covers more than 50% of all elderly Americans.
The program was created on July 30, 1965, by the Social Security Act. Medicare's primary goal is to provide health insurance coverage to those who qualify for it while also providing access to healthcare services as well as prescription drugs.
Who is Eligible to Apply for Medicare?
To be eligible for Medicare, you'd have to meet certain requirements. The following people are eligible to apply for Medicare:
Citizens of U.S. at least 65 years old or older
People under 65 with disabilities that could qualify for Social Security Disability Insurance (SSDI) benefits
What are the Different Parts of Medicare Coverage?
Medicare Part A and B are the Original Parts of Medicare. In 1992 Medicare supplement insurance ( Medigap ) was made available to plug the holes or “gaps” in Original Medicare. Both Medicare Part C and Part D were added in the Late 90’s and early 2,000’s to offer both a privatized version of Original Medicare and a coverage for prescription drugs.
Medicare Part A and Part B
Original Medicare or Medicare Part A and B provide coverage for hospital stays, doctor visits, some prescription drugs, durable medical equipment, emergency services, and outpatient services.
Medicare Part A, which is hospital insurance coverage, helps to pay for inpatient care in a Hospital setting. Part A also helps cover inpatient skilled nursing, home health care, and hospice care provided by a Medicare-certified provider.
Medicare Part B, which is medical insurance coverage, helps to pay for doctor visits and outpatient care. Part B covers medical services such as lab tests, X-rays, some cancer screening tests, preventative care services, and other outpatient treatments.
If you're either enrolled in Medicare Part A or Part B but need prescription drug coverage, you can purchase a separate plan called Part D, as Original Medicare does not provide prescription coverage ( except in the case of certain prescriptions that are administered in an inpatient hospital setting or by your doctor in a clinical setting )
Medicare Part C
Medicare Advantage is an alternative to traditional Medicare and the easiest way to describe it is that it represents a way to receive the Original Medicare coverage through private insurance companies instead of through the federal government.
Part C plan sponsors must follow the rules set by the government and must cover the same services as Original Medicare A and B but can restrict access to care through Prior Authorizations and referral requirements depending on the plan, however this will vary from plan to plan.
With Medicare Advantage, you can choose a managed care plan or a private fee-for-service plan (if one is available) to get medical and health care services. You can enroll in a Medicare Advantage part C if you're enrolled in Medicare Part A and Part B and live in county where a plan is available
In addition to the coverage offered by traditional Medicare, a Part C plan may also provide prescription drug coverage, vision, and dental benefits,, along with other extra services. It is important to note that plan availability and benefits will vary based on the county that a beneficiary resides in.
Medicare Part D
Medicare Part D is the optional federal program that provides prescription drug coverage and can substantially reduce out-of-pocket medication expenditures for individuals who have previously paid for prescription drugs entirely.
Who can apply for Medicare Part D? Anyone with Medicare Part A or Part B benefits is eligible for Medicare Part D. This includes enrollees in the traditional Medicare program and those who have a Medicare Advantage plan. People can enroll in Part D or Part C within their initial enrollment period (IEP) 3 months before and after the month of their Part B effective date.
There is also a period called AEP (Annual Election Period) that lasts from Oct 15th through Dec 7th every year where people who are eligible can enroll, disenroll, or change Part D or Part C plans. Once a beneficiary has made an election, coverage for the following year does not begin until January 1.
Medigap is a supplemental insurance policy that can be purchased to help pay out-of-pocket costs or fill gaps in the Original Medicare A and B coverage like some copays, deductibles, and coinsurance. Buying a Medigap policy can help you avoid certain expenses, such as copayments for Medicare-covered services and the annual Part B deductible.
Medicare Advantage Plans Vs. Medigap
The difference as mentioned above is that Medicare Advantage plans (Part C) is not a supplement but just a way to receive the Original Medicare coverage through a private insurance company that will have its own set of copays and deductibles, and max out of pocket limits for covered Medical services.
Medicare Advantage plans include HMOs, PPOs, and private fee-for-service (PFFS) plans. If you have a Medicare Advantage plan, then a Medigap policy is not needed.
HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations) are types of Medicare Advantage plans. With an HMO plan, you must use doctors, hospitals, and other health care providers who are part of the HMO's network. If you go to a doctor or hospital that is not in the network, you will have to pay the full cost yourself.
With a PPO plan, you can use “Out-of-Network '' doctors or hospitals, but you will typically have to pay more if you use a doctor or hospital that is not in the PPO's network.
Private fee-for-service plans (PFFS) are also types of Medicare Advantage plans. With a PFFS plan, you can use any doctor or hospital, but you might have to pay more if you use a doctor or hospital that is not in the plan's network.
Do you need a Medicare supplemental policy?
While there are plenty of supplemental insurance plans available, not everyone needs one. If you live on a fixed income and need to make your money stretch, you may want to think about whether or not it's worth the cost of a supplement.
Someone who turns 65 and is eligible for Medicare can get a Medigap policy without health questions or underwriting for six months before and six months after their Part B effective date.
After that period of time, if someone waits to enroll, they will have to go through underwriting and may have to pay more for Medigap coverage or may not qualify at all.
Medicare Advantage is a popular option for people because many plans are now available with premiums as low as $0 per month. Long-term, if someone stays healthy and doesn't visit the doctor much, financially it may be much less expensive to go with an MAPD or Part C plan. But, if someone gets sick and sees a lot of providers, they may pay more on an MA-PD (Part C) plan than they would on a Medigap plan.
People who are in good health and don't have many doctor appointments may not have a need for supplemental insurance. However, if you are constantly going to the doctor or need prescription drugs on a regular basis, consider adding a Medigap plan.
How and When to Enroll for Medicare?
Some people Must manually enroll while others will be enrolled automatically.
If someone is already drawing Social Security before age 65 then they will be automatically enrolled in Medicare A and B and usually receive their card about 3 months prior to their 65th birth month. Apart from that, there are three enrollment periods for Medicare:
The Initial Enrollment Period (IEP) is the month you turn 65, plus the three months before and after.
The General Open Enrollment Period is from January 1 to March 31 of each year.
The Special Enrollment Period (SEP) is a time outside of the IEP and the General Enrollment Period. This enrollment period is for people who delayed enrolling beyond the age of 65 due to being covered by employer group coverage.
Medicare Eligibility Requirements
Eligibility is determined by several different factors, including citizenship, residency, the age at which one becomes eligible for Medicare benefits, and whether or not they are disabled.
The four main requirements necessary to be eligible for Medicare are citizenship/residency, age, valid Social Security number (SSN), and proof of legal status.
Medicare Eligibility at 65 and Older
If you are a U.S. citizen or a legal immigrant who has been in the United States for five continuous years, you will be eligible for healthcare benefits once you turn 65 years old.
Medicare Eligibility If You Are Under 65
Medicare eligibility if you are under 65 is determined by a few factors:
If you are under the age of 65 and have received SSDI benefits for at least 24 months, you are eligible for Medicare.
People that are under 65 and have End-Stage Renal Disease (ESRD) are also eligible.
Individuals diagnosed with amyotrophic lateral sclerosis (ALS) are immediately eligible for Medicare without a waiting period.
Who Is Eligible for Medicare Advantage Plans
In some cases, Medicare Advantage plans offer additional benefits that Original Medicare does not. Individuals that are enrolled in Medicare (Part A and Part B) might be able to enroll in a Medicare Advantage plan (Part C) instead. This includes people under 65 who have qualified for Medicare because of a disability.
In order to be eligible for a Part C plan, you must meet the following requirements:
You must be a U.S. resident.
And you must have Medicare Part A and Part B
Must live in the plans service area
Some part C plans require the beneficiary to be over the age of 21
In order to enroll in a Medicare Advantage plan, you must have a valid enrollment period. You can enroll in a Medicare Advantage plan during your Initial Enrollment Period (IEP) or during the fall Annual Election Period (AEP) which lasts from Oct. 15th to Dec. 7th each calendar year.
To find out more, feel free to give us a call today at 877-438-9564. Our services come at NO Cost to you. Our team at Your Local Medicare Help can assist you to navigate through the Medicare system and answer any questions you may have. We look forward to assisting you in any way we can.