What You Should Know About Medicare
by LB Sedlacek
Medicare is the Federal health insurance program that is available to older people and to many of those with disabilities. Generally, a person is eligible for Medicare when turning age 65. In other instances, a person with a disability may be eligible, regardless of age.
There are two parts to Medicare: Part A and Part B. Inpatient hospital services, skilled nursing facility, home health care and hospice services are covered by Medicare Part A. Physician services, durable medical equipment, clinical diagnostic laboratory services, laboratory tests, X-rays, diabetes self-management, outpatient hospital services, ambulance services, outpatient mental health services, mammograms, pap smears, colon or prostate cancer screenings, flu and pneumonia shots, bone density measurement, and physical therapy are covered by Medicare Part B. Medicare generally does not cover preventive care services, private duty nursing, hospital room telephone or television, private hospital rooms, dental services, eyeglasses, chiropractic services, care outside of the U.S., acupuncture, hearing aids, long term or custodial care in nursing homes or most prescription drugs.
To qualify for Medicare, a person must meet at least one of the following:
(1)Be age 65 and eligible for Social Security or railroad retirement benefits,
(2)Have been receiving Social Security disability income for at least 24 months, or
(3)Have end stage renal (kidney) disease.
If one continues to work after age 65 or decides not to enroll for Social Security benefits at age 65, he/she may still receive Medicare benefits. Permanent legal aliens also qualify for Medicare when they have lived in the U.S. for at least five years or more continuously prior to eligibility date. They may also qualify when they are not eligible for Social Security benefits or railroad retirement benefits, but they usually will have to pay the premiums for Medicare Part A.
If one qualifies for Social Security or railroad retirement benefits, his or her Medicare enrollment is automatic. If one is not age 65, he/she may apply with the local Social Security office during the 7 month period that starts 3 months before their 65th birthday. When applying 3 months before turning 65, the Medicare coverage begins in the birthday month. When applying in the birthday month or during the 3 months following, coverage will be delayed for up to 3 more months. Enrollment may also be done between January 1 and March 31 of any year once becoming eligible, but there may be a penalty for late enrollment and an effective date of July 1.
If one has coverage with a group or business health plan, he/she may enroll any time while still working and if the employer has more than 20 employees. If one cancels group coverage while still working or retires, he/she is given a special 8 month enrollment period beginning when the group coverage ends. Be aware that when applying for a Medicare Supplement policy 6 months after Medicare Part B coverage is effective or after open enrollment ends, health questions would have to be answered on the application. Also, when one is covered with a group health plan and Medicare, as long as the employer has 20 or more employees one has the option of making the group health coverage primary and Medicare secondary.
If one is automatically eligible for Medicare Part A then there is no premium to pay. A premium is required for Medicare Part B. If one does not enroll in Medicare Part B when initially eligible, then there is a 10% premium penalty for each year of delayed enrollment.
Medicare options include original Medicare which comes direct from the Federal government, and Medicare PPO (preferred provider organization), Medicare PFFS (private fee-for-service plan), Medicare MSA (medical savings account plan), and Medicare HMO (health maintenance organization) or Medicare PSO (provider-sponsored organization) which are offered by private health plans. There are also special Medicare programs for people with low incomes of $4000 per individual or $6000 per couple not including a house or car. These programs are: QMB, SLMB, Q1-1, Q1-2, or Medicaid.
Over 80% of those eligible for Medicare select original Medicare. It is available everywhere in the U.S. and one is enrolled in it automatically when becoming eligible for Medicare. Just about any doctor or hospital may be used with original Medicare, and it pays providers and doctors directly for the services one receives. To fill in any gaps in the original Medicare coverage, a Medicare Supplement insurance plan may be purchased.
For more information, please contact Social Security at 1-800-722-1213 or log onto www.medicare.gov.