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Understanding Medicare

Medicare is a federal health insurance program for the elderly and disabled. The main segments of the program are Medicare Part A (inpatient health coverage) and Part B (outpatient health coverage). Medicare Part C, also known as Medicare Advantage, is a relatively new program instituted in 2003. Those who enroll can either select Part C or combine Parts A, B and D (prescription coverage) for total, affordable health insurance.

Like Social Security, Medicare is an entitlement program, and it is funded through three sources. The Medicare program draws funding from the taxes that United States Citizens pay, the funding allotted by the national government and the premiums paid by Medicare recipients. These combined sources are the reason that many people who enroll in Medicare Part A pay low premiums or do not have to pay any premiums at all. It is also the reason the premium costs of the other four Medicare parts can be kept affordable.

What is Medicare?

Medicare is a program created by the federal government that offers health coverage for the disabled and the elderly. This health coverage is available in two forms. Original Medicare includes health insurance offered by the federal government, and Medicare Advantage is private insurance offered by companies that have a contract with Medicare. Medicare Advantage includes all of the same benefits that a person could get through Original Medicare. For more information about the differences between the two, review the following sections.

About Original Medicare

The main programs under Original Medicare are Medicare Part A (Inpatient/Hospital Coverage) and Medicare Part B (Outpatient/Medical Coverage). However, some Americans also choose to enroll in Part D (Drug Coverage). While Part A and Part B are established parts of Original Medicare, and some eligible parties will be automatically enrolled in both programs, beneficiaries must actively choose the Medicare Part D plan in order to get prescription drug coverage.

Medicare Part A coverage includes inpatient care in a hospital, skilled nursing facility care, hospice care, and home health care. All candidates get Medicare Part A benefits even when they have the option to delay their enrollment into Part B. The only beneficiaries who pay a monthly premium for the insurance covered by Part A are those who did not work long enough to satisfy the program’s tax contribution requirements, approximately 10 years.

Medicare B covers medically necessary and preventive services. For example, mental health screening, ambulance services, limited prescription drugs and clinical services are all covered under Medicare Part B plans. There are premium fees for Part B, but candidates who have dual eligibility for Medicare and Medicaid can typically use their Medicaid benefits to pay the Medicare premiums. Those who do not have Medicaid eligibility will pay deductibles on their Medicare plan.

About Medicare Advantage

Also known as Medicare Plan C, Medicare Advantage launched in 2003. Part C of Medicare is the catch-all bundle that includes every benefit of Parts A, B and D. The most common plans under Medicare Advantage are:

  • Health Maintenance Organization (HMO) plans.
  • Private Fee-for-Service (PFFS) plans.
  • Preferred Provider Organization (PPO) plans.

Unlike other Medicare plans, Part C is the option that beneficiaries can use to buy insurance from a private provider rather than claim coverage from the government. Unlike other Medicare options, those who use Medicare Advantage will not use the red, white and blue Medicare card. They will get a card from their own service provider that can be used at in-network offices and hospitals.

A Medicare HMO will give limited coverage to doctors within certain locations and do not give for out-of-network services. To use this plan, a beneficiary would have to live in the limited region covered by the HMO in order to find health services. Prescription drug coverage is included with most HMOs. However, if drug coverage is not included in the plan, the beneficiary can purchase a Medicare prescription plan.

Private Fees-for-Service plans are private insurance plans. The plan determines how much it pays for medical services and the co-pays for health coverage. You do not need to select a primary care doctor for a PFFS plan or get a referral to see specialists. Medicare PFFS plans usually cover services outside of the network providers, but costs will be lower for service within the network.

A Medicare PPO plan is like the PFFS plan in that a primary care physician and referrals to see specialists are not required. Costs of a PPO tend to be slightly lower than the costs of a PFFS. Services are given out-of-network but will come with higher costs than those got in-network.

Who qualifies for Medicare?

Medicare eligibility is restricted to the elderly and disabled. There are three key classifications of people who are eligible for Medicare, which includes people older than 65 years of age, people, with disabilities and people of any age with End-Stage Renal Disease (ESRD).

Within the initial identity categories, there are further requirements. Every applicant must be a United States citizen and have paid taxes into the Medicare program. The requirements are as follows:

  • Medicare qualifications for those older than 65 years of age: If you are 65 years of age or older, a United States citizen and have paid Medicare taxes for at least 10 years, you are eligible for the Medicare program. Candidates in this program are eligible for Part A premium-free if they are currently getting or eligible for Social Security or Railroad Retirement Board benefits. Additionally, petitioners are eligible if they or their spouse previously had Medicare-covered government employment.
  • Medicare qualifications for Americans with disabilities: If you are younger than 65 years of age and have got Social Security Disability Insurance, you are eligible for Medicare. To qualify for Medicare under this category, there is a 24-month waiting period. All people who can claim SSDI are eligible for Medicare but may not enroll for benefits until two years after the distribution of the first SSDI check.
  • Medicare eligibility for those with ESRD: Kidney dialysis or kidney transplant patients meet the requirements to qualify for Medicare Part A premium-free. To fully qualify, a candidate must need regular dialysis or have already had a transplant. Additionally, the candidate must be eligible for Social Security or Railroad Retirement Board benefits or have paid Medicare taxes for at least 10 years.

Note: If you need Medicare and are the child or spouse of someone who meets the Medicare eligibility requirements, you are also eligible for Medicare.

When to Apply for Medicare

Most candidates must enroll for Medicare during the initial eligibility period when they or their spouse reach 65 years of age. However, some candidates get eligibility automatically and do not have to apply.

A beneficiary will get Medicare automatic enrollment in Part A or Part B if he or she is already getting benefits from another program. For example, you are automatically enrolled in Medicare if:

  • You got Social Security or Railroad Retirement Board benefits for at least 4 months before you reached 65 years of age. You will be automatically enrolled in Medicare Part A and B in the first month after you turn 65. Your Medicare card will arrive in the mail three months before your birthday.
  • You have gotten Social Security Disability Insurance for at least 24 months. You are automatically enrolled in Part A and Part B on your 25th month of benefits. Your Medicare card will arrive in the mail three months before your 25th month of benefits.
  • You have gotten disability benefits from the Railroad Retirement Board for at least 24 months. You are automatically enrolled in Part A and Part B and will get your Medicare card three months before your 25th month of disability benefits.
  • You have Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease. You are automatically enrolled in Part A and Part B, and you will get your Medicare card in the mail the month your disability benefits begin.

All other eligible parties should review how to apply for Medicare during the initial eligibility period. The seven-month initial eligibility period begins three months before the applicant reaches 65 years of age, includes the birthday month and ends three months after the candidate’s birthday. If the applicant does not enroll during this period, he or she may be charged a Part B late penalty or suffer a delay in health coverage. Applicants may enroll even if they are still getting health insurance from an employer.

You can sign up for Medicare online through the Social Security Administration web portal. The application takes approximately 10 minutes, and there is no required documentation. Further, there are no forms that must be signed. Social Security will review the initial Medicare application and make an enrollment decision, or let the applicant know that he or she must share more information. If the candidate is deemed eligible, his or her coverage card will arrive in the mail.

Note: You do not have to enroll for Medicare each year, though each year gives the opportunity to renew coverage or change your Medicare plan.

Differences Between Medicare and Medicaid

Like Medicare, Medicaid is a federal health insurance program. Medicaid, however, is a program designed to benefit the very low income, and its benefits and eligibility requirements are wildly different from those of Medicare. If you do not meet the Medicare requirements, Medicaid may be the program for you. Alternatively, if you are eligible for both programs, you may combine them to claim benefits from both.

Medicare and Medicaid are both health coverage programs, but they are run by different agencies. The biggest differences between Medicare and Medicaid are:

  • Medicaid is a state and federal program. While Medicare is federally-funded and federally-administered, Medicaid is administered by the states. This means each U.S. state and territory has a different set of eligibility guidelines, and there is not one simple Medicaid application, but many state-specific enrollment processes.
  • Medicaid is an income-based program that does not have an age requirement. Medicaid is available to low-income families, qualified pregnant women, Americans with disabilities and newborns, among many other qualification groups.
  • Medicaid coverage varies by state. The federal government sets the standards for what services are required, which includes nursing home and home health coverage, physician and laboratory services and inpatient and outpatient services, among a long list. However, because Medicaid is a state program, the non-mandatory benefits offered are determined by state governments.