Medicare is available to individuals who are citizens of the United States, who are at least 65 years old and have at least worked 10 years under Medicare employment.
For those under the age of 65 can also receive Medicare. They must meet the following requirements: proof of disability, have end stage renal disease and have been receiving disability for at least 24 months.
Some individuals may even qualify for both Medicare and Medicaid. Some states will offer both to those who earn a certain amount of income. A major benefit is that Medicaid will pay for Part B premiums and any drugs that many not be covered under Part D.
Part A: Hospital Insurance: Will cover hospital stays when these certain requirements are met:
- Hospital stay must be at least 3 days and 3 nights while excluding discharge days
- Nursing home stay must be for the same reason as the hospital stay or related to the diagnosis
- If the patient needs skilled nursing supervision, without rehabilitation, the stay will be covered
- All caregivers at the nursing home must be skilled
- Medicare Part A does Not cover non-skilled care activities, such as cooking and cleaning
- The maximum stay period that Part A will cover is 100 days. The first 20 will be paid fully by Medicare while the remaining 80 will be paid by co-payments
- If the individual goes at least 60 days without skilled services, while using a portion of Part A, the 100-day period will restart
Part B: Medical Insurance
Part B Medical Insurance is completely optional while it helps pay for some products and services that are not covered by Part A. Some individuals may be deferred if they or their spouse are still working at that time.
Part B coverage includes the following if they are administered by a physician during an appointment:
- Nursing and physician services
- Laboratory and diagnostic tests
- Influenza and pneumonia vaccinations
- Renal dialysis
- Outpatient hospital procedures
- Blood transfusions
- Immunosuppressive drugs for organ transplant recipients
- Limited ambulance transportation
- Hormonal treatments such as Lupron
- Other outpatient medical treatments performed by doctors
Part B also helps those with mobility impairments with medical equipment. Medical insurance helps provide walkers, canes, wheelchairs and mobile scooters. Prosthetics, one pair of eyeglasses and oxygen will all also be covered.
Part B coverage comes with complex rules that advisors manage and use to describe criteria. If individuals want national coverage, they can be issued National Coverage Determinations (NCD). If an individual applies for a multi-state area, they will receive Local Coverage Determinations (LCD), who are contracted under the Local Medical Review Policies (LMRP).
Private insurance companies sell Medigap policies to fill the gaps in Medicare Plans. Medigap covers health care costs that Medicare does not. If an individual has both Medicare and Medigap, both policies will pay their shares of health care costs.
Medigap policies must have all benefits listed so insurance companies can sell “standardized” policies.
There are 12 Medigap polices in which one may choose, ranging from A to L. Since these plans protect citizens, they follow Federal and State laws. All policies must be identified as “Medicare Supplement Insurance.” Each plan is set to have different benefits so ask your agent about the options from which to choose.
All Medigap plans A through L are the same no matter the insurance agency. Be sure to compare all plans for different prices.
When an individual purchases Medigap, he or she must also have Parts A and B as well. One will still pay the Part B monthly premiums as well as the Medigap premium.
Medicare Advantage Plans
Medicare Advantage Plans are still part of the Medicare program known as Part C. If one signs up for Part C, they will receive covered health care through Medicare. Medicare Advantage Plans are the following:
- Medicare Special Needs Plans (SNP)
- Medicare Health Maintenance Organization (HMOs)
- Private Fee-for-Service (PFFS) Plans
- Medicare Medical Savings Accounts (MSA)
- Preferred Provider Organizations (PPO)
This plan can include Part D which are Prescription Plans. Medicare Advantage Plans can cover prescription drugs or one may choose to have a separate Part D plan.
Part D: Prescription Plans
Prescription plans came into play back on January 1st, 2006. Individuals who have Part A and B plans are able to sign up for Part B plans. These plans were passed by the Medicare Prescription Drug, Improvement and Modernization Act. One who has Medicare must sign up for a stand-alone Prescription Drug Plan (PDP) or have a Medicare Advantage Plan that covers prescription drugs. These plans are designed and approved by private health insurance companies while Medicare programs regulate them. Prescription plans cannot be standardized since there are so many different drugs. All plans are able to choose which drugs to cover, level of coverage and the option of not cover certain ones. The drugs that Medicare excludes are the following: benzodiazepines, cough suppressants and barbiturates. Any plans that state these drugs will not be covered by Medicare.
Important to remember, any individual who is dual-eligible (covered by Part A and B), Medicare will pay for any drugs that are not covered by Plan D.