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Knowing What Medicare Covers & How to Utilize It

It might be stressful to start learning about Medicare because there are so many terms to learn and options to weigh. Therefore, it’s totally acceptable if the handbooks and pamphlets have left you feeling disoriented and a bit puzzled. The good news is that we can assist you in sorting through Medicare’s red tape.

We can quickly compare every Medicare option that is available to you.

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Medicare: What is it?

Medicare is a government health insurance program covering a range of medical costs and services, including hospital stays, doctor visits, prescription medications, preventative care, skilled nursing facility and home health care, as well as hospice care. Medicare was established in 1965 for those 65 years of age and older, irrespective of their financial situation, medical history, or state of health. The program was enlarged in 1972 to include those with long-term disabilities under the age of 65.

The Centers for Medicare & Medicaid Services (CMS), an arm of the U.S. Department of Health & Human Services (HHS), is responsible for managing Medicare. Medicare is an entitlement program, much like Social Security, with the majority of Americans 65 and over being eligible to receive Medicare Part A. When a person or their spouse is qualified for Social Security benefits, they are also exempt from paying a premium for Part A if they have paid payroll taxes for at least ten years. You may still be able to enroll in Medicare even if you didn’t work long enough to qualify for benefits, at a high premium.

Individuals under 65 who receive Social Security Disability Insurance (SSDI) benefits typically have to wait two years before becoming eligible for Medicare; with the exception of those with end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS).  

Medicare Insurance - Components

Original Medicare often refers to Medicare Part A and Medicare Part B. The Medicare program is divided into four components. While Medicare Part C is private health insurance and Medicare Part D provides coverage for prescription medicines.

Medicare Parts A and B

Hospitalisation coverage in Part A and medical coverage in Part B make up Original Medicare. When you schedule an appointment with your doctor, you should ensure that they accept Original Medicare because not all of them do. It's crucial to realize that Original Medicare only covers roughly 80% of healthcare expenses, thus it's crucial to think about alternatives to fill the remaining 20%. For individuals who enroll in Medicare Parts A and B, ancillary coverage plans are also available to complement their original Medicare coverage.

Medicare Part C

Also commonly known as Medicare Advantage, Medicare Part C is an alternative offered by the government through private insurers. This plan, is required by law to provide at least the same benefits as Original Medicare. Depending on the private insurer you choose to buy from, the costs, regulations, and even the coverage criteria of the policy can change. Plans under Medicare Part C frequently offer extra advantages with insurance companies being legally required to provide atleast the same benefits as Original Medicare.

Medicare Part D: Prescription Drug Plan

Most of your outpatient prescription drugs will be covered by Medicare Part D - an independent drug plan provided by private insurers. It's important to realize that if you select a Medicare Advantage plan over Original Medicare, the Part D benefits are frequently included in your plan.

Medicare Supplement Insurance

Since Original Medicare doesn’t cover all costs, for additional protection, many people choose to buy a Medicare Supplement Insurance plan (also known as a Medigap plan).

Eight Medicare Supplement Insurance policies are now offered by private insurers in the majority of states. The programs being uniformly offered by all states, have been segregated in an alphabetical manner from A to N. Remember that not all private insurers offer supplement plans, and that private insurers determine their own premium costs, so it’s crucial to compare shop.

How to Enroll in Medicare?

Medicare enrollment is possible during the Initial Enrollment Period (IEP), which commences from three months before your 65th birthday and spans through three months after your 65th birthday. In the 25th month of receiving Social Security Disability Insurance (SSDI) benefits, respective beneficiaries are entitled to Medicare and are thus automatically enrolled in the program by Social Security. Some persons can qualify for unique enrollment periods, depending on their employment history or access to alternative health insurance.

Key Considerations for Enrollment

Medicare is regarded as your primary insurer once you turn 65, rendering all other insurance companies as secondary insurers. Even if you haven't yet applied for Medicare, the same principle applies. Whether you have COBRA, individual health insurance, or retiree health insurance; Medicare stills remains to be your primary insurer. This is crucial information to know and comprehend because once you turn 65, you might not be able to rely on secondary insurance companies to cover your hospital or doctor expenditures.

You can still enroll in Medicare if you missed the Initial Enrollment Period (IEP) during the General Enrollment Period, which runs from January 1 to March 31. Those who enroll during the general enrollment period will be able to receive coverage starting in July, the following year. People who miss their initial enrollment period frequently face late enrollment fines. These fines can range from 1% to 10% for each month you delay enrollment, depending on the Medicare Part you apply for.

Medicare Parts A and/or B should be enrolled in your name automatically when you turn 65 if you're receiving Social Security, which you can start receiving at age 62. You should, though, double-check this by getting in touch with Medicare or Social Security to make sure it's accurate, as failing to do so could result in a late enrollment fee.

Each member of your family must submit a separate application because Medicare is an individual benefit. Family Medicare plans do not exist.

If your income is over a particular level, you will pay more for Parts B and D. There may be an additional fee for both halves of the premium if your combined gross income (after deducting tax-exempt interest) is greater than:

  • $97,000 for unmarried individuals 
  • $194,000 for married couples filing jointly 

High earners will pay between $230.80 and $560.50 per month for Part B in 2023, depending on their income level. In addition, they will pay an extra $12.20 to $76.40 per month for Part D coverage.

Medicare alternatives available today, particularly Medicare Advantage plans, frequently provide a number of complimentary preventative services. You can, for instance, receive one free in-home "wellness" visit to create or revise a customized preventative plan. Additionally, you might be qualified for complimentary tests for cardiovascular diseases, prostate, and colorectal cancers as well as free annual flu shots and cervical screenings.

Many people are astonished to hear that Medicare often does not cover long-term care, including those who are new to the program (and even others who have been enrolled for some time). There are some situations where coverage is possible. When coverage is accessible, for instance, is following a hospitalization for the management of an acute-care occurrence. In this situation, Medicare will cover home health care or skilled nursing facility care that is required for medical reasons. However, "custodial care" services like assistance with daily living chores like clothing and bathing are not covered. If you fulfill the income and asset requirements, you may be able to fill in these gaps using your own savings, long-term insurance, or Medicaid.

There may be times when you disagree with a decision made by the Medicare health plan regarding your coverage or payment. You have the right to appeal in this situation. The appeals procedure has five levels, some of which are resolved quickly and others of which take longer. When making your initial appeal, be sure to provide as much pertinent information as you can; your doctor can assist. Additionally, it's crucial to compile any pertinent healthcare data or records from suppliers or additional providers. You can ask for a fast-track decision in circumstances where a choice must be made right away, and it must be made within 72 hours. This needs to be approved by your doctor and/or Medicare plan.

How can I learn more about my Medicare options?

Our area of expertise is educating people on Medicare and simplifying the process. We can make sure you receive all of the Medicare benefits that are available and that you are entitled to. We can quickly compare all of your Medicare options. Don’t wait to make sure you’re receiving all the benefits for which you qualify. There is no commitment to enroll, so get started now.

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