Medicare is a government-run insurance program that gives older Americans the opportunity to obtain affordable health care insurance.
Many Americans receive health insurance through their employers; when they’re not working due to retirement, it’s important that they be able to find ways to cover the cost of their health care.
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Important Enrollment Information
You are eligible to receive Medicare benefits if:
- You are 65 or older
- You are a US citizen or permanent resident who has lived in the US for five or more years
- You or your spouse have worked long enough to qualify for Social Security benefits or Railroad Retirement Board benefits
- You or your spouse is or was a government employee who has paid Medicare payroll taxes
There are also other cases where you can receive benefits through Medicare even if you’re under 65. They include:
- Having Lou Gehrig’s disease
- Having received Social Security or Railroad Retirement Board benefits for 24 months due to a disability
- Having kidney dialysis or being a kidney transplant patient
If you meet any of these eligibility requirements, you should receive Medicare Part A without having to pay a monthly premium. You will still have to pay for Part B if you choose to go with that option.
– Why do costs and coverage change?
Exact costs and coverage can depend on the conditions outlined in your particular plan. People age 65 and above have varying needs, and the current system allows individuals to set up a plan that works best for them.
Also, you can change your policy with the open enrollment system if you feel that you need more or less comprehensive services covered under your plan.
You can change your Medicare Advantage Plan or join a Medicare Advantage Plan from October 15 to December 7, and you can switch from a Medicare Advantage plan to Original Medicare from January 1 to February 14.
– What is Open Enrollment?
When you first enroll in Medicare, you’ll also be able to apply for a Medicare Advantage plan and/or a Medicare prescription drug plan (Part D).
If you don’t choose to go with these options when you begin your enrollment, you can do so at a later point in time, but only during the open enrollment period. Those dates are October 15 to December 7.
To avoid the possibility of having a gap in coverage, you can enroll in your Medicare plan within a seven-month period surrounding the month when you turn 65. You can begin signing up for Medicare three months before you turn 65, and your enrollment window ends on the last day of the third month after you turn 65.
What are the different parts of Medicare?
A primary component of Part A is hospital care. This includes inpatient hospital care, skilled nursing facility care, and long-term care hospitals. Without coverage, these costs can be high, so it’s essential for these types of services can be paid for.
It can be important to note that the type of skilled nursing care that’s covered under Part A includes only what is medically necessary.
Custodial care, which includes assistance with daily living activities, is not covered.
Part B covers most doctor’s visits and associated services that are directly related to treating or addressing a particular health condition. The preventive care includes:
- Cardiovascular disease screenings
- Many types of cancer screenings
- Bone mass measurements
- Depression screenings
- Diabetes screenings
- Glaucoma tests
- Obesity screenings and counseling
- STI screenings and counseling
- Flu and pneumococcal shots
- Tobacco use cessation counseling
- Yearly wellness visits
Medicare Advantage plans take the place of Part A and Part B coverage and are administered through private companies. You can continue reading to find out more about Medicare Advantage.
How do I get Medicare coverage?
If you’d like to obtain Medicare coverage, you can get everything set up online, beginning three months before you turn 65, which ensures everything will be in place when you meet the age requirement. At that time, you can apply for Part A and Part B, though you can opt out of Part B if you wish.
You have a seven-month initial enrollment period to take advantage of, which includes the three months before you turn 65 and the three months after the month that you turn 65.
If you do not join a Medicare plan when you first become eligible for coverage, you’ll have to wait for the General Enrollment period, which is January 1 to March 31 of each year.
People who until recently were covered under an employer-sponsored plan may be able to apply for Medicare within eight months of their coverage ending.
What are my Medicare coverage choices?
Part A covers hospital care, which is sometimes the most critical component of health care for older Americans. Additionally, it covers skilled nursing facility care and nursing home care as well as care provided in one’s own home, such as hospice and home health services.
Part B covers most preventive services and other services classified as medically necessary to address your condition. Things covered under Part B include:
- Ambulance services
- Mental health services
- The cost of being in clinical research trials
- Ambulance services
- Durable medical equipment, such as blood sugar monitors and glucose test strips, canes, crutches, wheelchairs, nebulizers, and walkers
Part D is the component of Medicare that covers prescription drug costs. These plans vary in terms of coverage, and each policy covers only certain types of drugs. Medicare Advantage is another type of plan that can cover hospital and doctor visits.
– Original Medicare
When people refer to Original Medicare, they are talking about the basic components — Part A and Part B. Remember that when you enroll in Medicare, you can receive all the benefits that Part A covers without paying a premium, as long as you meet the eligibility requirements stated above.
If you don’t meet those requirements (usually because you didn’t work for the required period and didn’t pay enough payroll taxes), you can buy Part A for a premium up to $411 a month.
You can also choose to add Part B for more comprehensive coverage. The standard monthly premium for Part B is $121.80 but may depend on your income. The yearly deductible is $166, and after you’ve met your deductible, you usually pay 20 percent of your adjusted bill.
Part D is additional coverage intended to make prescription drugs more affordable in many instances. Each plan has set its own associated premiums, deductibles, and copayments.
If you’d like to supplement your coverage under Original Medicare, you can purchase a Medigap policy, also known as a Medicare Supplemental Insurance Plan. These plans are administered by private insurance companies, to which you pay monthly premiums, and they can help you cover the cost of copayments and deductibles.
– Medicare Advantage Plan
Some people choose a Medicare Advantage Plan, also known as MA plans and sometimes referred to as Part C plans, instead of an Original Medicare plan. These plans are administered by private companies that have established contracts with Medicare, and they offer full-scale services within one policy.
Buying a Medicare Advantage Plan means that everything you would have otherwise been eligible for under Part A and Part B will still be covered.
There are several types of plans available, including those offered by:
- Health maintenance organization (HMO)
- Preferred provider organizations (PPO)
- Private fee-for-service plans (PFFS)
Under the HMO plans, you’ll receive your care from providers within the HMO network, except for in an emergency. This may be a good idea if you have access to a provider or a group of providers in the network who you feel comfortable with.
With PPO plans, you’ll pay less to see a provider within your network, but you can still receive partial benefits if you visit someone out of your network, which gives you more flexibility than the HMO plan.
For even more flexibility, you can choose to get insured with a private fee-for-service (PFFS) plan. Some of these plans have networks, whereas others don’t.
The primary advantage of a PFFS plan is that you don’t have to receive a referral before making an appointment with a specialist. In contrast, many PPO plans and most HMO plans do require a referral to visit a specialist.
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