Medicare

Medicare is a form of a Federally managed health care plan. Eligibility is based on the following:

  • If you have been a citizen of the United States for five years or more or are a permanent resident living continuously in the US for over five years
  • You or your spouse have been employed by a company who has paid into Medicare for at least ten years are retired and 65 years of age or older
  • Disabled and receiving Social Security Disability Insurance (SSI) for 24 months or more and meet the work requirements (having paid into the system through taxes)
  • End-stage renal disease (ESRD) on dialysis. Children may be eligible for Medicare if their parent has a diagnosis of ESRD

There are three parts to Medicare. Part A covers hospitalizations including skilled nursing facilities (for 100 days per calendar years based on medical necessity), home health and hospice. If you have own your own company, you have paid for Part A each time you have paid Social Security taxes. If you are employed, your premiums were paid each time your employer withheld Social Security taxes from your pay check. Part B covers professional visits (such as doctor's appointments), out-patient services and other services (for example, durable medical equipment/DME including diabetic supplies).

Medicare Part D covers prescription medications and is managed by private insurance providers. It is up to you to decide which provider plan best meet your needs. The cost is dependent on which plan you select, and is withheld from your monthly Social Security of SSI. The enrollment period for Part D is November 15 to March 31.

This can be very overwhelming!!!! There are hundreds of companies competing for your business. The best way to determine which plan meets your needs is to contact Medicare directly and ask for assistance in reviewing the various options.

If you have access to a computer, you can go their website , and select "Prescription Drug Plans" (the exact title may change from year to year). There, you will find valuable information to help you compare the various plans available to you.

To speak with a representative directly you can call 1-800-633-4227. I strongly suggest you have a list of your medications, the dose, and how often you are taking each medication with you at the time of your call. The representative can better assist you if this information is available while you are talking to them.

Part B and Part D are optional. If you choose to "purchase" Part B and/or Part D, the premium is deducted from your Social Security if you receive monthly checks, or you will have to make a monthly payment if you do not receive a check.

You may choose not to have Part B and/or Part D. Please be aware (!!!!), if you later decide you do want/need to have Part B and/or Part D, you will have to pay a surcharge (late enrollment fee).

Here's an example:

You are 65 years of age and retired. Your spouse is 63 years of age and working for an employer who providers him/her with wonderful insurance coverage. Under his/her insurance, your prescription benefits and physician visits are covered. You really don’t see a need to have Medicare Part B or Part D at this time.

Two years later, your spouse retires. Now that you are no longer covered by your spouse's health plan, you decide to sign up for Part B and Part D.

When you receive your next Social Security check you see a large chunk has been deducted. You contact your Medicare representative and are informed that the amount withheld is the amount you would have paid over the past two years.

Each year from November 15 to March 31, you have the opportunity to enroll into one of the following programs for Medicare Part A :

  • Original Medicare: this is a Fee-for-Service plan which allows you to select your own providers.
  • Medicare Health Plans: Private insurance carriers are responsible for the management of these plans. They have both HMO and PPO plans. Like other HMO plans, you are assigned to a primary care physician who will provide referrals to specialist as needed.

    The waiting period for appointments could be a strong disadvantage to the HMO plans, while the ability to offer benefits which are not part of the standard Part A plan could be appealing. Benefits vary greatly from plan to plan. It is important that you take time to read and compare each plan carefully!

Medigap (Medicare supplemental policies) policies provide supplemental coverage for PPO and FFS plans. Probably the most well known of the supplement plans is the plan offered by the American Association of Retired Persons (AARP). Medigap policies provide coverage for things not covered by Medicare.

Medicare does not provide dental coverage. Vision coverage may also be limited depending on the type of plan you select. The PPO or FFS plan covers vision expenses only if they are related to a medical condition such as diabetes or cataracts. They do not cover standard eye exams or prescription costs for new glasses.

To determine if you are eligible or to see plan options that are available you may contact them via their website or call them at 1-800-MEDICARE (1-800-633-4227).

Return to Understanding Types of Insurance Plans

HOME

Continue to Medicaid