What Is Medicare and What Does It Cover?

Do you qualify for Medicare? If so, you may be able to obtain healthcare coverage for many of your needs.

What Is Medicare?

Medicare is a type of national health care program in the United States. It is available to certain people who reach the age of 65 as well as those who qualify due to a disability. It also provides coverage to people who have amyotrophic lateral sclerosis and end stage renal disease. It provides health insurance to those who qualify.

Medicare isn’t a new program. It’s been present in the U.S. since 1966, but it has changed and continues to change. That’s why it’s so important to know what your rights are when considering this investment. The Centers for Medicare and Medicaid Services oversees the program.

If you qualify for it, it may provide you with the medical insurance you need. Medicare coverage isn’t a simple policy, though. Here is what you need to know.

When Can You Sign Up for Medicare?

Typically, a person can sign up for Medicare when they reach retirement age, which is turning 65. However, if you are still working at that point and have health insurance from your employer, it may be better to maintain that policy longer and enroll in Medicare later.

When you begin to approach retirement age, you’ll learn more about open enrollment. That is the period of time that starts three months before you turn 65. It will end 7 months after your birthday. That means you need to be able to act within that timeframe.

If you become disabled or qualify for Medicare due to other health conditions, you can apply for Medicare directly at any time. You’ll need to meet the government’s requirements for qualifying based on your health condition.

Understanding Medicare’s Plans

The federal health insurance program gets confusing when you start looking at the various “plans” available. Let’s break down the details.

Original Medicare                

The term “original Medicare” refers to the basic form. Under this policy, you will receive coverage for parts A and B.

Part A Medicare coverage is hospital insurance. That means this part of the policy covers some of the costs you pay when you are admitted to the hospital for medical care. Part A may cover the following:

• Inpatient care at the hospital
• Hospice care at the end of life
• Skilled nursing facility care
• Home health care, with limitations

Part B Medicare coverage is designed to provide you with medical insurance. It helps you cover costs related to going to the doctor and receiving the preventative screenings you need. Part B includes:

• Outpatient care at your doctor’s office
• Home health care, in some cases
• Doctor care at a facility when you do not stay overnight
• Durable medical equipment, such as lifting equipment, wheelchairs, and hospital beds, you may need at home
• Preventative health care and screenings

When you sign up for this type of policy, it is very important to see the limitations. Parts A and B do not provide coverage for prescription drugs. They also do not cover dental and vision care. It does not cover any coinsurance, deductibles, or copayments that you have to pay for service either.

Remember, Part A covers the costs of your stay in the hospital, while Part B medical insurance covers preventative care, like when you see your doctor for a checkup. That’s where additional policy options are available that are not included in Original Medicare.

Many people who have Original Medicare will purchase a Medigap plan or go with Medicare Advantage Plan options. These are different types of services that could help to extend our coverage beyond what Original Medicare does.

Part D Prescription Drug Coverage

Prescription drugs are a big part of the out of pocket costs most people have over time. To get coverage for your medications, you will need to purchase Prescription Drug Coverage, also known as Part D. Private insurance companies provide Part D coverage. It does not come from the federal government.

Part D prescription drug coverage is regulated by the federal government. That means many plans are similar to each other. However, it’s still wise to compare policies to find the best one for your needs.

What Is Medigap Coverage?

When choosing health coverage, it is very important to choose a policy that gives you ample protection against the cost of medical care. Medicare coverage does not do that. It does not provide for all of the costs you are likely to need.

This is where choosing additional coverage that goes above and beyond what the federal government offers is very important. While you can purchase private insurance, most private insurance policies are very expensive, and that makes them difficult to access as you get older. However, Medigap can offer some protection.

Medigap coverage is also known as Medicare Supplement Insurance. This is one option that you can select to help fill in some of the gaps left by Original Medicare. It can help to cover things like copayments, coinsurance, and deductibles. Here’s how it works.

• You sign up for Original Medicare and Medigap coverage. Medigap is a separate supplement insurance that is sold by private insurance companies.
• When you file a claim, Original Medical care will pay for some of those costs – usually 80% of most covered needs.
• Medigap then fills in the rest, paying the rest of your cases.

Medigap has limitations. For example, it does not provide you with prescription drug coverage. You still have to purchase prescription drug coverage separately. This is a big drawback for many people since medications can be a large part of the out of pocket costs you pay for your medical needs.

What Is a Medicare Advantage Plan?

An alternative for purchasing Medicare supplement insurance is to invest in a Medicare Advantage plan. Medicare Advantage Plans are sometimes called Part C Medicare or MA Plans. These policies come from private insurance companies that must follow specific rules and regulations set up by the federal government to protect policyholders.

Medicare Advantage plans often include drug coverage, Part D. That means that, instead of purchasing Original Medicare, Medicare Medigap Plans, and Part D, you can purchase Medicare Advantage plans that include all components of your coverage.

In these plans, you will receive health coverage for many of your needs. You will likely have to choose a medical provider that is within the plan’s network. There is then a limit to the amount of money you have to pay in out of pocket costs for your care.

What healthcare services do Medicare Advantage plans include?

In addition to providing Medicare Part A and B benefits, Medicare Advantage can go further than this. These plans often include the following:

• Emergency medical care
• Urgent medical care
• Preventative services like wellness checkups
• Home health services
• All medically necessary services that are provided under Original Medicare
• Hospice care
• Some plans include vision, dental, and cash cards to help you with additional costs
• Some plans cover things like fitness programs, like a gym membership or discounts.
• Some may cover transportation to doctor’s visits.
• Some plans cover over-the-counter medications that Part D insurance does not cover that help to support health and wellness

When choosing these plans, you will need to compare their details carefully. There are several options, and not all are the same. This lets you choose coverage that is a good fit for your specific needs, though, and that can be well worth it.

There are some exclusions to all of these health coverage options. For example, your doctor visits are covered if they are in network, and some providers will cover some out-of-network doctor visits. However, this type of policy typically does not cover cosmetic surgery or non-health-based care. It is important that you know what the policy offers to ensure you receive ongoing coverage that meets your needs.

Common Questions About Original Medicare and Medicare Advantage

There’s a lot to think about and plan for when it comes to getting the medical health insurance you need. It’s best to take some time to really explore what your options are. To help you, consider these common questions.

What Does Original Medicare Mean?

If you have Original Medicare, that means you have Parts A and B, which are a part of your Social Security benefits. Part A hospital insurance will help pay for the costs of your medical care when you are admitted into the hospital for a qualified need. The services covered in the hospital include most testing, your care, procedures you have to have, and other needs for inpatient hospital care.

Part B medical insurance helps provide for your routine medical appointments. It may also help cover the costs you have for specific concerns like end stage renal disease when you have permanent kidney failure, Lou Gehrig’s disease, skilled nursing facility care, and outpatient medical care.

How Do I Get Drug Coverage?

If you meet the requirements of the general enrollment period right now, you can sign up for Original Medicare along with Part D drug coverage. This is a separate fee from a private insurance provider. Medicare Part D prescription coverage is an additional cost for your care but can cover most of the cost of your medications as a component of your Medicare benefits.

An alternative to this is to use Medical Advantage Plans. This will cover your Medicare Part B medical, Medicare Part A hospitalization, and Medicare Part D coverage. This means you will have hospital care, medical care for your health care costs, and drug coverage.

Do You Need Supplement Coverage if You Have an Advantage Plan?

No, If you decide to choose a Medicare Advantage Plan, you cannot have supplemental coverage through Medigap.

What Is the Cost of Medicare?

One of the difficult components of getting the medical care you need is understanding the costs Medicare charges.

The cost of Medicare will change each year. During the general enrollment period, you will be able to see the costs so you can choose what works best for you.

Here is a look at some of the costs you can expect for 2023:

Cost for Part A Medicare

Typically, this is $0 if you have paid into Medicare taxes while you were working. Most of the time that means you paid it for at least 10 years. If you do not qualify for premium-free Medicare, you may be able to purchase it at a cost.

There is a $1,600 deductible for Part A that is applied every time you are admitted to the hospital during the benefit period. You must pay this amount before Original Medicare will cover your health costs.

There is a copayment cost that is dependent on the length of your stay. There is no copayment for the first 60 days. From Day 61 to day 90, this is $400 each day. From Days 91 to 150, you pay $8000 in copayments using your 60 lifetime reserve days. After 150 days, you pay all costs.

Costs for Part B Medical Insurance

With Original Medicare, you will pay a monthly premium for your Part B medical insurance. For 2023, this was $164.90 each month but could be higher if you earn more than the limit. This amount will change each year. Even if you do not use any services covered by Part B, you still have to pay this fee to remain enrolled in coverage.

Also, you may pay a penalty if you do not sign up for Part B when you are first eligible for coverage. This is a late enrollment penalty that could be as much as 10% for each year you could have signed up but did not do so. If you learn you do not have creditable drug coverage because you did not sign up for coverage when you earned Medicare eligibility, you may have to pay this fee.

Costs for Part D Drug Coverage

When you purchase health insurance, the cost of prescription drugs is nearly always a big factor. However, since Part D is separate from Original Medicare, Parts A and B, you will pay additionally for this plan on top of the costs for Part A and B. However, these costs range widely between providers. The monthly premiums will be provided to you when you begin to compare your options, but know that the costs will vary significantly from one person to the next.

Medicare Part D coverage is one of the most important parts of Medicare for many people. Be sure that you consider the value of having this as a component of your Medicare plan.

Costs for Supplemental Coverage and Medicare Advantage

As you consider the options to enroll in Medicare, carefully consider the costs associated with supplemental coverage and Medicare Advantage plans. Both of these policies are premiums you will pay monthly to gain access to the Medicare Plan. There’s a difference though:

• Medigap supplemental coverage is an additional cost on top of Part A and B and drug coverage.
• Medicare Advantage is not an additional cost but rather a single cost you pay that will cover services.

How Does Social Security Disability Insurance Apply?

Some people become injured and cannot work as a result of that. Social Security Disability insurance may help you to cover your costs. That is, if you qualify for disability through Social Security, you may be then able to receive Medicare. In this situation, you do not have to wait until you reach the age of 65, nor do you have to wait until you have an open enrollment period. You will qualify based on your disability.

However, there is a 24-month qualifying period. That means that when you begin to receive Social Security Disability Insurance benefits, you will receive Medicare after 24 months passes. This waiting period means that you will not have health insurance through Medicare during that time.

If you need health insurance prior to this, you may be able to qualify for Medicaid services. Medicaid services are based on your income and are not the same as Medicare, but they can provide you with some of the coverage you need while you wait for disability benefits to become available to you to cover your healthcare needs.

How Do I Know When My Enrollment Period Begins?

If you are getting older, you may want to start planning for coverage. Your initial enrollment period begins three months prior to your 65th birthday. You typically do not have to do anything, but Medicare will alert you to your ability to qualify. You will likely receive a great deal of information at that time about Medicare Part A and B, as well as when you need to sign up for coverage within your enrollment period.

You will also get information about all of your options, including Medicare supplemental insurance and Medicare Advantage Plans.

How Can You Get The Coverage You Need?

From skilled nursing care to help with physical and occupational therapy after an in hospital stay, there are a lot of times when you may need medical care. Medicare is a government program that may help you cover services and costs, but understanding your options and the parts of Medicare is critical. That is why it is so important for you to seek out some help as you compare private insurers and health care providers.

If you paid Medicare taxes, you may have the ability to get benefits and let Medicare pay your medical bills. Let our team help you.