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Article: Guide To Financial Benefits
Medicare
Table of Contents
- Social Security Benefits
- Medicare
- Medicaid
- Family Medical Leave Act (FMLA)
- Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
- Omnibus Budget Reconciliation Act of 1989 (OBRA)
- Health Insurance Portability and Accountability Act (HIPAA)
- Private Health Insurance
- Long Term Disability (LTD) Insurance
- Long Term Care Coverage and Financing
Overview
Medicare Part A and Part B
Medicare Plans and Options
Medicare Eligibility
Overview
Medicare was first established in 1965 to help protect individuals 65 and older against high healthcare costs. In 1972, the program was extended to include individuals with disabilities and those with permanent kidney failure. Today this program provides health coverage for all these individuals and is overseen by the Social Security Administration (SSA).
Medicare is one of two government assistance programs that provide health care benefits. The other program, Medicaid, has some distinct differences from Medicare. Refer to the table below to learn the differences.
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Medicare |
Medicaid |
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Who is Eligible? |
Medicare covers:
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People ages 65 or older.
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Some people under 65 with disabilities
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People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.
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Medicaid covers people with low income and resources. Some people on Medicare are also eligible for Medicaid. |
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Who Administers the Program |
Medicare is a federal program. The rules and regulations for Medicare will be the same in every state. |
Both federal and state governments jointly fund Medicaid. Therefore, the rules that govern the Medicaid program are different in all 50 states. |
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Coverage Provided |
Part A of Medicare provides basic coverage for hospital visits, post-hospital nursing facilities, and home health care.
Part B of Medicare pays for most basic doctor and laboratory costs, some outpatient medical services, medical equipment and supplies, home health care, and physical therapy. |
In many states, Medicaid covers services and costs that Medicare does not cover, including prescription drugs, diagnostic and preventive care, and eyeglasses. |
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Costs to Consumer |
Consumers pay a yearly deductible for both Medicare Part A and Part B. Reasonably large co-payments are also required for extended hospital stays. |
Medicaid can be used to pay for Medicare deductibles and the 20 percent portion of charges not paid by Medicare. You can also use Medicaid to pay the Medicare premium.
In some states, Medicaid charges consumers small amounts for certain services. |
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Medicare Part A and Part B
Medicare has two parts. They are:
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Medicare Part A(hospital insurance), which helps pay for hospital care, skilled nursing facility care, home health care, and hospice care
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Medicare Part B (medical insurance), which helps pay for doctors, outpatient hospital care, and other medical services.
Most people do not have to pay for Medicare Part A. However, most people pay for Medicare Part B.
Medicare Plans and Options
Different options are available under the Medicare plan to help individuals cover co-payment costs and prescription drugs. To determine which option is best for you, you will want to think about present health needs and anticipate future health needs. Your Medicare plan choices are:
Original Medicare
Original Medicare or Traditional Medicare is a fee-for-service plan where the federal government pays for part of the services rendered. Without supplemental coverage, hospital deductibles can be expensive and annual doctor deductibles can add up. In addition, an extra 20 percent of most outpatient medical care can be charged to Medicare patients.
Original Medicare allows you to go to any doctor you want and allows you to get medical care whenever you feel you need it.
Original Medicare with supplemental coverage (Medigap)
You can purchase supplemental coverage called Medigap that pays for things that Original Medicare doesn't cover (i.e. deductibles, doctor and hospital co-insurance, and emergency care outside the country). Medigap plans are offered through private insurance companies and can include numerous benefits.
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Private Medicare plans
Health Maintenance Organization (HMO)
A Medicare HMO is run by a private insurance company but is funded by the government. To be covered under a Medicare HMO you must be enrolled in both Parts A & B of the Medicare program. Unlike Original Medicare, under the HMO plan, you are only allowed to see certain doctors and hospitals in your area (unless there is an emergency).
A Medicare HMO can save you money on deductibles and premiums. Usually, all you have to pay is a small co-payment each time you visit the doctor.
Preferred Provider Organization (PPO)
A Medicare PPO is much like an HMO in that you need to be enrolled in Medicare Parts A & B to be eligible. They too save you money on deductibles and premiums while you only have to pay a small co-payment. However, you still get limited coverage if you decide to visit a doctor outside the network.
Private Fee-For-Service (PFFS)
Private insurance companies contract with other companies in providing PFFS plans. Like HMO and PPO plans, you must be enrolled in both Parts A & B of the Medicare program. PFFS plans pay doctors and hospitals on a fee-for-service basis. Individuals enrolled in this program have the option to go to any doctor or hospital they want as long as the provider agrees to the terms of the PFFS plan.
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Medicare Eligibility
Individuals are generally eligible for Medicare if:
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They or a spouse worked for at least ten years in Medicare-covered employment.
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They are 65 years old.
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They are a citizen or permanent resident of the United States.
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Younger individuals with a disability or with permanent kidney failure (requiring dialysis or transplant) may also qualify for coverage.
Medicare
Medicare.gov is the official site of the U.S. Government for people with Medicare and has multiple sections serving the needs of individuals using or requiring Medicare services. Get detailed explanations of services, determine eligibility for services, understand enrollment periods, and investigate long term care planning tools.
How Originial Medicare Works
In this section of the Medicare.gov website you can get background information on Original Medicare Part A and Part B.
Medicare & You
Medicare publications, available in two online formats, have a summary of Medicare benefits, rights and obligations, and answers to the most frequently asked questions about Medicare.
Medicare Eligibility Tool
This section of the Medicare.gov website defines eligibility requirements and has basic answers about enrolling in Medicare.
Centers for Medicare & Medicaid Services (CMS)
CMS coordinates Medicare and Medicaid services. Their website contains information about Medicare and Medicaid as well as links to state and other programs. Its content complements but does not replace the content found in the official Medicare website.
Disability Benefits 101
Disability Benefits 101, supported by the World Institute on Disability, has updated and accurate information on employment, health coverage, and benefits.
Medicare, Electronic Booklet
The Social Security Administration (SSA) has a comprehensive electronic booklet on Medicare. This booklet has basic information on Medicare, including who is covered and some of the options you have for choosing Medicare coverage.
Medicare Rx Benefits
On this site, you can learn about discount cards for Medicare services and prescriptions for each state. There is also updated information on new benefits that are available.
Medicare Drug Benefit Calculator
This Medicare benefit calculator computes the beneficiary out-of-pocket costs under the new benefit from an individual's annual drug costs.
Last Updated on 12/27/2017