Medicare

Medicare is the federal health insurance program that covers most people age 65 and older.

Some younger people who are disabled or who have End-Stage Renal Disease (permanent kidney failure) are also eligible for coverage (visit Who is Eligible for Medicare for more information).

People covered by Medicare are called beneficiaries. Medicare pays for much of their health care, but not all of it. That is, most acute medical conditions – conditions from which a patient usually recovers – are covered. But, despite what many people think, most care given at home, in assisted living facilities or in nursing homes, for people with chronic disabilities and lengthy illnesses are NOT covered. And for many people, there are large gaps in Medicare’s prescription drug plans.

Benefits are provided in 4 parts – A, B, C and D. Part A helps pay for inpatient hospital care, some skilled nursing facilities, hospice care, and some home health care. Part A is premium-free for most people. Most beneficiaries do pay a monthly premium to be covered under Part B – the part that helps pay for doctors, outpatient hospital care, and some other care that Part A doesn’t cover, such as physical and occupational therapy.

Part C allows various HMOs, PPOs and similar health care organizations to offer health insurance plans to Medicare beneficiaries. At a minimum, they must provide the same benefits that the Original Medicare Plan provides under Parts A and B. Part C organizations are also permitted to offer additional benefits such as dental and vision care. But, to control costs, Part C plans are allowed to limit a patient’s choice of doctors, hospitals, etc., to just those who are members of their networks. This can be a major disadvantage if a patient’s favorite doctor or hospital is not a member of their networks.

Part D provides prescription drug benefits through various private insurance companies. For more information, including how to enroll, click on Medicare Prescription Drugs benefit. Like Part B, most people have to pay extra premiums each month to be covered for prescription drugs under Part D. Premiums for Part D vary from state-to-state, and from company-to-company. For more information, visit Medicare’s website.

Most seniors are covered under the Original Medicare Plan. That plan requires them to pay for some of their health care in addition to their monthly Part B and Part D premiums. Those additional amounts are called deductibles and coinsurance. All premiums, deductibles and coinsurance amounts change every year on January 1st. To see the current Part B premiums, deductibles and coinsurance amounts, click on 2012 Medicare Coverage Gaps.

Seniors can purchase other insurance policies to cover part or all of Medicare’s deductibles and coinsurance amounts, or to cover many types of care that it doesn’t cover. These include:

• Supplemental Medicare insurance (Medigap) from a private insurance company. To avoid confusion, 12 standardized plans have been defined by federal law, but not all states allow all 12, and not all companies offer all 12. For more information, click on Supplemental Medicare Insurance for Seniors.
• Employer or union coverage
• Long-Term Care insurance
• Other kinds of insurance

Seniors don’t need to buy Supplemental Medicare insurance if they are covered under Medicaid, or if they are enrolled in a Part C plan such as a …

• Medicare Advantage Plan
• Private Fee-for-Service Plan
• Medical Savings Account
• Religious Fraternal Benefit Plan

Medicare has more than 100 booklets to help you find answers to your questions.

— Medicare FAQs, Tips and Nasty Surprises —

Medicare often runs smoothly without a hitch. At other times, it can be very annoying – even downright frustrating. For some people, it is full of potholes that cost them thousands of dollars out of their own pockets. Bottom line – what you don’t know can hurt you. For some helpful tips, visit our page FAQs, Tips and Nasty Surprises.