Medicare is a form of social security for people aged 65 or older, receiving Social Security disability benefits for two years or more, or having the end-stage renal disease.
The purpose of this blog post is to list how Medicare works and the types of coverage it provides. It will cover Medicare’s eligibility requirements, the different parts that make up its coverage, and what it covers.
Medicare is the Social Security Act that created the health insurance program. Medicare is a highly complex program with many benefits, including free prescription drug coverage for most Medicare beneficiaries. The covered drugs under Medicare are called Part D coverage. They are available for those aged 65 or older with end-stage renal disease, receiving Social Security disability payments for at least 24 months, and having high blood pressure or cardiovascular conditions.
Benefits of Medicare
- Hospital insurance covers most illnesses, surgeries, and related expenses for those 65 and older.
- Supplemental medical insurance, SMA, provides a limited number of additional services or benefits to those enrolled in Original Medicare. See the sections on Part B, Hospital Insurance of the Social Security Act, below for more details.
- Medicare Advantage plans are private health insurance plans that provide a wide range of primary and preventive health care services. Private insurers contract with the federal government to offer these plans offer benefits. In some areas, these plans include a Medicare Advantage prescription drug plan.
Parts of the Medicare Program
1. Part A- Hospital Insurance or “Hospital Benefits” covers inpatient hospital care, skilled nursing facility care after 20 days of a hospital stay, home health services, and hospice care. The eligibility for this part is for those aged 65 or some end-stage renal disease cases which have been receiving Social Security disability benefits or railroad retirement benefits for at least two years. Part A is optional and must be signed up voluntarily by the beneficiary.
2. Part B- Medical Insurance or “Medical Benefits,” which covers preventive care, physician and outpatient care, hospitalization, and skilled nursing facility care that is not payable by Medicare Part A. The eligibility for this part is for those who can cover under Original Medicare.
3. Part D- Prescription Drug Coverage, Medicare Advantage gives beneficiaries prescription drug coverage. The eligibility for this part is for those who are eligible under Part B or some end-stage renal disease cases. It also must be signed up voluntarily by the beneficiary.
4. Part C- Medicare Advantage plans provide medical services to beneficiaries not covered by Parts A and B of Medicare. These plans must include prescription drug coverage, referred to as a “Part D plan.” Medicare Advantage plans are offered by private insurance companies and overseen by CMS, which sets the rules that govern these plans.
Individuals are eligible for Medicare coverage at age 65 or older, have received Social Security disability benefits for two years or more, or have end-stage renal disease.
The Social Security Act states that those aged 65 or some end-stage renal disease cases and those eligible under parts A and B of Medicare should sign up for the program through a Part C Medicare Advantage Plan. Individuals with Part C coverage can also sign up for a Part D plan, where they will receive the same benefits and restrictions that individuals with original Medicare have.
The Social Security Act also states that those eligible under Parts B or some end-stage renal disease cases should sign up for Original Medicare with Part D drug coverage when they first become eligible. Those not eligible under Parts A or B can purchase Medicare Supplemental Insurance, also called “Medigap,” on the private market.
Individuals eligible under Part C should also sign up for the same coverage when they become eligible. Those who are not eligible under Parts A or some end-stage renal disease cases, B and C, can purchase Medicare Advantage plans that include prescription or Medigap plans.
What Is Original Medicare or Parts A and B?
The original Medicare program has two parts: Part A, hospital insurance, and Part B, medical insurance. Those eligible under Parts A and B can sign up for the program through a Part C Medicare Advantage plan.
Part A is available to those eligible for Social Security disability or railroad retirement benefits for at least two years. Part A eligibility does not depend on the beneficiary’s age: instead, the beneficiary must first have been receiving disability benefits or railroad retirement payments for at least two years.
Part A does not cover certain medical and long-term care services, including:
- Long-term nursing or custodial care unless the beneficiary is age 65.
- Hospital or skilled nursing facility services are “not medically necessary,” such as cosmetic surgery, elective surgery performed solely for cosmetic purposes, and strabismus surgery.
- Any service that is unnecessary about the diagnosis, care, or treatment provided under the plan: services provided without a diagnosis, outpatient diagnostic services, including but not limited to electrocardiograms, stress tests, and other tests commonly done by physician offices, physical therapy, and speech-language pathology services, ambulance services, and laboratory services, prescription drugs other than drugs and biologicals furnished as durable medical equipment, outpatient substance abuse treatment for more than ten days in any 12 months, routine foot care or routine eye examinations or eyeglasses furnished on the same day to treat an acute condition of short duration.
The current Medicare program has several benefits and services. However, the program does not cover all the medical services that people need at all times. People who want to remain in good health and quality of life will therefore want to consider buying Medicare Supplemental Insurance.