Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). If you or your spouse have worked full time for 10 or more years over a lifetime, you are probably eligible to receive Medicare Part A for free.
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. What Medicare covers is based upon, Federal and state laws, National coverage decisions made by Medicare about whether something is covered, local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area. weblink offers excellent info on this.
Medicare Part B is available at a monthly rate set annually by Congress ($121.80 in 2016 for incomes $85000.00 or less for an individual). Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Some seniors are eligible to receive the medical insurance portion (Part B) free as well, depending on their income and asset levels. For more information, inquire about the Qualified Medicare Beneficiary (QMB), Special Low Income Medicare Beneficiary (SLMB), and Qualifying Individual programs through your county social services office. Remember, in most cases, if you don’t sign up for Part B when you are first eligible, you will have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn’t sign up for it. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B, and coverage will start July 1 of that year. Usually, you don’t pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period.
Medicare Part C (Medicare Advantage Plans) are a type of Medicare health plan offered by a private insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), Private Fee-for-Service Plans (PFFS’s), Special Needs Plans (SNP’s), and Medicare Medical Savings Account Plans (MSA’s). If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and are not paid for under Original Medicare. Most Medicare Advantage Plans have prescription drug coverage included.
Medicare Part D (prescription drug coverage) adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare.
Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. Keep in mind, you may owe a late enrollment penalty if you go without a Medicare Prescription Drug Plan (Part D), or without a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage, or without creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over.
How Medicare Works
Original Medicare is coverage managed by the federal government. Generally, there is a cost for each service. In most cases, you can go to any doctor, other health care provider, hospital, or other facility that is enrolled in Medicare and is accepting new Medicare patients. With a few exceptions, most prescriptions are not covered in Original Medicare. However, you can add drug coverage by joining a Medicare Prescription Drug Plan (Part D). With Original Medicare you don not need to choose a primary care doctor. In most cases, with Original Medicare, you don’t need a referral to see a specialist, but the specialist must be enrolled in Medicare. You may already have employer or union coverage that may pay costs that Original Medicare does not. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy.