Medicare Matters: A Video Timeline about Medicare
(Kaiser Family Foundation, www.KFF.org)
Overview
Medicare is modeled after private health insurance. Thus, it covers some of the cost of some health care. Generally, coverage is available for the cost of health care (except for hospice care and specific preventive services) only when the services are medically reasonable and necessary for diagnosis, treatment or rehabilitation of illness or injury. Skilled care to maintain or slow decline of a condition can also be covered.
Eligibility & Enrollment
Individuals who are 65 years old and eligible for Social Security or Railroad Retirement benefits are automatically eligible for Medicare Part A and may choose to enroll in Part B. Disabled individuals who have received Social Security Disability benefits for 24 months are also eligible for Medicare. People with ERSD and ALS may be eligible without waiting 24 months. Individuals can enroll and get information at their local Social Security office and on-line.
Traditional Medicare
Medicare has been in existence since 1965. Coverage is divided between two parts of Medicare, Part A and Part B. Beneficiaries are responsible for some premiums, deductibles, and co-payments. Beneficiaries in traditional Medicare can get their health care from any provider who is certified by Medicare. The traditional program generally does not cover prescription drugs. However, Medicare Part D covers prescription drugs through private plans.
Help with Medicare Co-pays & Other Expenses
Beneficiaries with limited incomes may be eligible for help from federal and/or state programs to cover some or all of Medicare’s required co-payments and to help with prescription drug costs.
In addition, Medigap health insurance can be purchased to cover some of Medicare’s co-insurances and deductibles.
Medicare Advantage
Medicare beneficiaries have the option to receive their Medicare benefits through private health insurance plans. These private insurance options are authorized by Medicare Part C, which is also called Medicare Advantage (MA).
MA plans generally require patients to obtain services only from certain providers; in return the plans may offer reduced premiums, deductibles and coinsurance payments, and/or additional benefits not offered in traditional Medicare. Many MA plans also include Part D prescription drug coverage.
MA plans contract with the Medicare agency annually. An MA plan may elect not to renew its contract with Medicare at the end of the year for any reason, and, in some instances, during the year. MA plans can also change providers, benefits, premiums, and copays each year. Most plans require prior authorization for health care. Use caution before choosing a Medicare Advantage plan. Be sure your doctors and other health care providers are in the plan.
Prescription Drug Coverage
Medicare provides help paying for prescription drugs through the Medicare Part D program. Part D helps pay for certain drugs through a variety of private plans. People with traditional Medicare are eligible to enroll in a Part D plan but usually have to take steps to do so. People in an MA plan may have Part D included in their MA plan or choose a separate one.
Medicare Appeals
Medicare is a complicated program. Coverage is often denied when it should be granted. If the individual’s physician orders medically necessary care that is coverable, but is denied by Medicare, it is wise to seek help with an appeal. Medicare denials can be appealed whether the beneficiary is in traditional Medicare or a Medicare Advantage plan. Appeals can be successful, but it takes time.
Medicare Coverage
PART A
- Inpatient Hospital Care
- Skilled Nursing Facility Care
- Home Health Care
- Hospice Care
PART B
- Physician Services
- Outpatient hospital care. Services and therapy
- Durable Medical Equipment
- Prosthetic Devices
- Ambulance Services
- Home Health Care
- Certain Preventive Services:
- One physical exam when 1st enrolled in Part B
- Flu, Pneumococcal, Hepatitis B vaccines
- Annual Mammograms
- Some pap smears and pelvic exams
- Colorectal Screening
- Diabetes Self-Management Training /Tests
- Bone Mass Measurements
- Prostate Cancer Screening
- Some Glaucoma Screening
- Some Medical Nutrition Therapy Services
- Some cardiovascular tests
- Annual “Wellness Visit”
PART C
- A system of various private plans that deliver Medicare benefits. Also known as Medicare Advantage.
PART D
- Help paying for certain prescription drugs, provided by private plans.
Revised 1/2024