Medicare Information, Part I

Medicare Information, Part I

This is intended for the person getting ready to apply for Medicare coverage for the first time, the child of a parent who is enrolled in the program and needs more information, or someone who might be eligible for Medicare because of disability.  Future posts will provide additional information about the program, including anticipated changes being enacted through the Affordable Care Act.

History of Medicare

Medicare was enacted in 1965 as part of the Social Security Act. It is a federally funded program that is the primary source of health insurance for older people and many people with permanent disabilities.

Medicare pays a portion of the cost of services considered to be “reasonable and necessary for the treatment, diagnosis, or rehabilitation of an illness, injury, or malformed body member.” (Medicare Act)  Those enrolled in Medicare can expect to pay premiums, deductibles and co-pays.  Enrollees also often have a supplemental insurance policy to provide payment for services not covered in full or in part by Medicare.

Medicare does not pay for private duty home care or non-skilled services.  There are specific guidelines and timelines for nursing home and rehabilitation facility Medicare coverage eligibility.

Medicare Components

Medicare is divided into four parts:

Part A covers inpatient hospital care, skilled nursing facilities (nursing homes), skilled home health services, and hospice care. The skilled care being provided to the patient has been ordered by a physician.

Part B is an optional component.  It covers medical care provided by doctors and other health care providers(office visits), durable medical equipment (wheelchairs, walkers, hospital beds, etc.) outpatient hospital services (lab tests and x-rays), physical, speech, and occupational therapy. Once again, these services or equipment has been ordered by a physician for the patient.

Part C, Medicare Advantage, includes managed care plans and private insurance Medicare programs. (Often retirees continue their Medicare coverage through their corporate benefit program.)

Part D, is the prescription drug program, which became effective in January, 2006.

Who Is Eligible For Medicare:

1.  Social Security retirement recipients who are over 65 years of age

2.  Individuals who have received Social Security disability benefits for 24 months

3.  Individuals who receive Railroad Retirement Benefits

4.  Individuals who have End Stage Renal Disease (ESRD)

4.  Individuals who have Amyotrophic lateral Sclerosis (ALS or Lou Gehrig’s Disease)

The Enrollment Process

There is an initial enrollment period, beginning in the third month before an individual reaches 65, (or reaches 65 and becomes a citizen of the United States, or a permanent resident who has lived continually in the US for the five years immediately preceding application for Medicare).  This initial enrollment period for Medicare A lasts for seven months.

If you turn 65 and delay receiving your Social Security benefits, you must complete an application to enroll in Medicare.

If you do not also enroll in Medicare B at the same time you apply for Medicare Part A, there is a general enrollment period every January 1 through March 31, with Part B benefits becoming effective July 1 of that same calendar year.

Medicare enrollees have the opportunity to switch their Part D coverage at the end of every year, to be effective January 1 of the next year.  I highly recommend that you take the time to review the prescription benefits which you currently have and see what other options might be available to you.  The prescriptions which you are currently taking might be different from those in the previous year.  It is worthwhile to see which Part D plans provide you with the best coverage options and are the most cost-effective for you.  Maintenance medications will often be covered through a mail order program.  Check with your pharmacist if you have specific questions about the coverage of your current prescriptions and their cost to you through the Medicare D program.

Additional Resource

Use this link to the Social Security website.  You can set up your own personal account to answer lots of your questions about retirement and your social security benefits.   http://www.ssa.gov

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