Medicare began as an amendment to the Social Security Act. It was meant to add to the Social Safety Net the needed protections for health and medical treatment for older Americans.
It starts as the hospital and medical insurance sections of Part A and Part B. Part D came later as did Medicare Advantage in Part C.
The Medicare Advantage was meant to add private sector initiatives to stimulate competition and variety. The below-listed Medicare parts describe features that applicants can choose.
Hospital Insurance Medicare Part A is the basic coverage of Medicare. Part A coverage meets the requirements of the Affordable Care Act and the individual mandate.
Original Medicare hospital and medical insurance is a complete package of coverage for inpatient and outpatient medical care. The government can automatically deduct premiums for parts A and B from those with Social Security income
Medicare Advantage hospital, medical, and prescription benefits. These are private insurance plans approved by the Centers for Medicare and Medicaid. They meet the requirements of the individual mandate.
Prescription Drug benefits with Medicare Part D is the coverage that seniors need to manage medical care. Medications are an important tool in managing illness and providing outpatient care. Applicants can get the prescription benefits in standalone plans in Part D or in combination with comprehensive care in part C.
Medigap insurance is the key to small bill balances. Particularly in Part B coverage, the gap left to the consumer can add to a significant burden. Medigap coverage also provides foreign travel emergency protection.
Usually, older Americans qualify for Medicare by reaching the retirement age of 65. They can apply for Medicare benefits at the same time they apply for retirement benefits from social security.
A clock begins to run at this time, and if they did not select benefits they will pay more later in late fees. The initial enrollment period is a seven month period. Three months before the 65th birthday month and three months afterward.
Annual Open Enrollments
The primary open enrollment for Parts C and D are in the November 1 through December 7 period of each calendar year unless otherwise announced.
The initial enrollment periods vary with the birthdate and birth year of each applicant. There are several annual enrollment periods in Medicare including the below-listed items.
Medicare Advantage Disenrollment from January 1 through February 14.
General enrollment period-January 1 through March 31 each year. Those joining during this time will wait for a July 1, start up; signers will pay late enrollment fees.
Annual election period October 15 through December 7.
Special enrollment periods for those separating from employer-sponsored benefits.
Open enrollment runs from November 1, through December 7.
Types of Managed Care
The type of managed care makes a difference in the freedom users have to choose specialists and medical care providers. Some forms of managed care restrict users to the network and its resources.
They were built on costs efficiency which it can only maintain by limiting the use of resources. Those that allow wider use usually charge for the privilege.
These plans pay smaller shares of costs for outside resources. These can cause higher copays and more coinsurance for users.
This is the health maintenance organization. This type of managed care grew from a tradition of prevention and wellness.
The early HMOs offered features that helped reduce the need for medical care by early detection of illness, and steps to avoid diseases.
The key features are a primary care doctor that directs medical care. The plan requires referrals to use most network resources and specialists.
This is the preferred provider organization. It offers flexible choices for members. They can choose to use the network resources or go to outside specialists.
The PPO pays greater cost sharing for its resources than for outside resources.
The PPO does not use a primary care physician nor does it require referrals for network resources. When using outside resources, customers may have to fill out paperwork for reimbursements.
This is the exclusive provider organization. This type of management does not provide insurance coverage for outside resources. Subscribers must use plan resources to get insurance coverage.
The EPO can offer low rates and simple procedures, and usually no consumer paperwork.
This is the HMO with a point of sale option. The HMOPOS uses a primary care physician to deliver medical care and oversee the patient’s treatment.
The PCP can make referrals to network resources, and the insurer pays its share against the consumer’s copay or coinsurance.
The POS option permits the primary care physician to make referrals to outside resources. The insurer covers these uses but at a lower rate of cost sharing than when using network resources.
This is the private fixed-fee-for-services type of managed care. It can stand alone or connect to a wide network of PPO or HMO types.
Standalone PFFS s a type of organization that uses price agreements to build a network of providers. The clients can use any of the resources with no referral or primary care doctor permission.
As the largest federal health program, Medicare management is a top priority for controlling costs, improving performance, and improving patient outcomes. Medicare moves to value-based purchasing in its relationships with medical care providers and hospitals.
The shift from a focus on treating patients and delivering care to one based on the value of patient outcomes is fundamental. It is a shift of the meaning of success. The agencies that assist hospitals ad insurers develop value-based processes can get valuable incentives based upon evidence of savings.
Medicare is a Comprehensive Health System
From state of the art research to hospice care for people with little or no family, the Medicare system shows a remarkable ability to perform its vital humanitarian work.
One can measure the quality of society by the treatment of the old and most vulnerable members.
Comparison shopping will help consumers when weighing the value of private plans in Medicare Advantage, prescription drug benefits in Part D, and Medicare Supplement.