Joseph R. Anticaglia MD
Medical Advisory Board
In 1965, Medicare was signed into law by President Lyndon Baines Johnson. It is a federal health care insurance program to help Americans 65 and older pay their medical expenses. At the same time, Medicaid was created for low income families.
Medicare has been expanded and revised over the years to provide coverage for younger people with end-stage kidney disease and those with disabilities. President George W. Bush signed into law in 2003, Medicare Part D designed to help seniors pay their prescription drug costs.
Eligibility
In most situations, you’re eligible to receive full benefits if you’re 65 years of age and if you or your spouse has paid Medicare and Social Security payroll taxes for at least 10 years.
Four Parts of Medicare
Medicare is a complex web consisting of many “parts or plans”. Recipients need to make an annual review of the costs, coverage and which doctors and pharmacies are in their network. What follows are the A, B, C, D s of Medicare.
Medicare Part A (Hospital Coverage)
It’s often called “Original Medicare” and is managed by Medicare. It provides insurance and benefits for:
- Inpatient hospital stays
- Care in skilled nursing facilities
- Hospice care
- Some home health care services
Medicare Part B (Medical Coverage)
This part is also often called “Original Medicare” and is managed by Medicare. It provides insurance and benefits for:
- Doctor visits
- Clinical lab services
- Outpatient care
- Medical supplies
- Preventive care
- Physical and Occupational therapy
- Surgical fees
- Screenings
You need Parts A & B to get Parts C and D.
Medicare Part C (Medicare Advantage Plans)
A private company manages this type of Medicare health plan. The company contracts with Medicare to provide you with Part A and Part B benefits in one plan. They can also be combined with Part D prescription drug coverage. These plans are offered by insurance companies as:
- HMO’s Health — Health Maintenance Organizations
- PPO’s — Preferred Provider Organizations
- MA-PD Medical Advantage Prescription Drug Plan
- PFFS — Private Fee For Service Plan
- SNP — Special Needs Plan
Medicare Part D (Prescription Drug Plan — PDP)
This part adds prescription drug coverage to the Original Medicare (Parts A & B). It’s an optional plan that can stand-alone — not be combined with — or be combined with a Medicare Advantage Prescription Drug Plan.
Doughnut Hole
The “doughnut hole” is the coverage gap in your Part D prescription plan. You’re required to pay out of pocket money, as if you have no insurance, when the combined prescription costs of you and your insurer exceed a certain dollar amount in a given year.
Medigap — Supplemental Insurance
Medigap insurance is a backup plan sold by private insurance companies to help pay the costs that Medicare does not cover. Seniors must have Original Medicare Parts A&B to obtain this coverage. It covers:
- Part A deductibles and coinsurance — the 20% Medicare doesn’t cover for hospital admissions.
- The part Medicare doesn’t pay for Part B doctor bills
- Hospice care coinsurance
- Overseas health coverage
- First three pints of Blood
Enrolling in Medicare
There are time frames to enroll in Medicare called the Initial Enrollment Period (IEP). It’s advantageous to note these windows of opportunity. Not to act during the enrollment period can result in penalties and a reduction in benefits. It’s advisable to enroll during the deadlines noted below:
- Three months before your 65th birthday
- The month of your 65th birthday
- Three months after your 65th birthday.
Not all doctors accept Medicare. The plans and costs can change from year to year. It’s advisable each year to review your plans’ premiums, deductibles, drug costs and to foster good relationship with your pharmacists.
An important question is whether you decide to go with the government’s Original Medical plan (Parts A&B) or choose one run by a private insurer, a Medical Advantage plan? There are many twists and turns to the Medicare labyrinth.
The above highlights the A, B, C and Ds of Medicare. Additional resources are:
- Medicare.gov
- Call 1 800 Medicare
- SHIP State Health Insurance Assistance Program
- AARP
- Senior Centers
This article is intended solely as a learning experience. Please consult your physician for diagnostic and treatment options.