Tuesday, July 16, 2024

Medicare Basics


elderly manWhat is Medicare?

Medicare is a US government health insurance program for people aged 65 and over who have paid into Social Security for 10 years. A person is automatically signed up if receiving SS payments unless specific steps are taken to opt out. It can also be used by those under 65 with certain medical conditions or those who receive certain social security disability benefits. Most people will pay small premiums and co-pays for some of their medical costs just like a regular insurance program.

Difference between Medicare and Medicaid

Since Medicare is administered through the Federal Government, people will have the same type of coverage no matter where they live in the USA. Medicaid is a state program and varies from state to state.

Medicaid is also not an insurance program, but rather, an assistance program. Participants can be any age – but must be low-income to be eligible - to receive these benefits and recipients do not pay co-pays or premiums.

Both programs are administered by the Centers for Medicare and Medicaid Services.

Original Medicare Vs Medicare Advantage

Medicare beneficiaries have the option of getting health care coverage, including their prescription drug coverage, in one of two ways: through Original Medicare or by enrolling in a Medicare Advantage Plan. Outlined below are some of the differences.

Original Medicare: Part A and B Highlights

Original Medicare is the federal health insurance program. There are two components: Part A (hospital insurance) and Part B (doctors visits and other outpatient care). You qualify for Medicare if you’re 65 and entitled to Social Security benefits, or younger than 65, disabled, and entitled to Social Security benefits.

  • Traditional fee-for-service program offered directly through the federal government.
  • Although Part A is usually free for those who have at least a 10 year work history in the United States there is usually a monthly premium for Part B.
  • Access to any doctor or hospital that accepts Medicare (and most do) without a referral.
  • No referrals needed to see specialists; no prior authorization for services
  • Can buy Medigap policy as supplemental coverage
  • Can Add Medicare Prescription Drug Plan (Part D)
  • No cap on what you spend on health care

Medicare Advantage Highlights:

If you qualify for Original Medicare, you can opt instead to enroll in a Medicare Advantage Plan from a qualified private health insurance company. A Medicare Advantage Plan contracts with Medicare and must provide you with all your Part A and B benefits. These plans are also referred to as Part C that combines your Medicare Hospitalization (Medicare Part A) and Medical insurance or Doctor's Visit Coverage (Medicare Part B) into one Health Plan.

No longer enrolled in Original Medicare – this is a private plan similar to private insurance with different premiums, co-pays and limits; but, it must cover the same Part A and B benefits as Original Medicare.

  • May cover additional benefits such as vision and dental care.
  • Patient pays a deductible and/ or co-pay for services.
  • May only be able to see certain doctors or go to certain hospitals and may need a referral from your primary care physician.
  • Cannot buy a Medi-gap policy to help pay out of pocket expenses.
  • Usually includes the equivalent of Part D drug coverage.
  • Has an annual out-of pocket limit.
  • Careful review of a participants circumstance must be made when deciding to go with Original Medicare vs. Medicare Advantage as Medicare Advantage is similar to private insurance in that based on your selections you may have additional costs.

Breaking Down the Parts of Medicare - Part A, Part B, Part C, Part D

There are four parts to Medicare:

  1. Hospital Insurance- Part A
  2. Medical Insurance- Part B
  3. Medicare Advantage- Part C
  4. Prescription Drug- Part D

Standard or “Original Medicare” comes in two Parts: Part A and Part B – A covers a portion of hospitalization expenses while B will cover doctor bills and some other medical expenses such as lab tests and preventive screenings. Some seniors may prefer Part C or Medicare Advantage as described above (you must have both Parts A and B to enroll in Part C).

Part A - Medicare hospital insurance for inpatient care
If you are 65 or older and are a United States citizen or permanent
resident you are eligible for free Medicare (Part A). Covers hospital expenses.

Part B – Medicare medical insurance for outpatient care
Anyone eligible for Medicare’s free hospital insurance (Part A) may
choose Medicare medical insurance (Part B) through monthly premiums for doctor visits and other non-hospital costs.

Part C - Medicare Advantage plans
If you are Medicare Parts A and B participant, you can opt for a
Medicare Advantage plan. Medicare Advantage plans are
offered by private companies approved by Medicare. You may pay different
monthly premium for your Medicare Advantage due to the benefits you select. These plans cover hospital and medical doctor costs.

Medicare drug coverage (Part D)
Know as a Medicare Prescription Drug Plan – it adds prescription
drug coverage to Original Medicare (Part A and/or B) or to Medicare
Advantage (Part C) participants. These plans are administered through private
insurance companies that are contracted with Medicare. Since different
types of plans exist, premiums vary.

For a description of the differences between Medicare Parts A, B, C, and D visit the Social Security official website.

Medicare Enrollment and Eligibility Facts

Eligibility Criteria

  • U.S. citizens and legal permanent residents (5 continuous years)
  • Age 65 or older – You are eligible to enroll in Medicare Parts A and B up to 3 months before your 65tth birthday through the 3 months after the month of your birthday. This is known as the Initial Enrollment Period.
  • Under the age of 65 if they meet certain disability requirements or have Lou Gerhig’s Disease or Permanent Kidney Failure.

Automatic Enrollment

  • Enrollment is automatic if you are under 65 and already getting Social Security benefits.
  • You will be contacted 3 months prior to becoming eligible if you are already receiving benefits from Social Security retirement or Disability or Railroad Retirement.
  • Part A (hospital insurance) is presently required, and free if you or a spouse has worked and paid Medicare taxes for 10 years.
  • Part B (medical insurance) is optional, and paid by a monthly premium deducted from your Social Security check. You must notify Medicare to opt out of Medicare Part B.

Medicare Enrollment Periods

Be very sure to pay close attention to Medicare enrollment deadlines. There are timeframes in which you can add or drop coverage after your official enrollment period. Visit these two sites for more on eligibility and enrollment.

For eligibility information and enrollment periods

For a Medicare Eligibility and Enrollment Date Calculator

Help for Medicare Problems

Check out the online Centers for Medicare and Medicaid Services

Contact Medicaid directly by phone at 1-800-MEDICARE (1-800-633-4227) for 24 hours a day, 7 days a week help line. TTY/TDD 1-877-486-2048 for the hearing impaired.

Create an account (for yourself or a loved one) to access and track personal information online at and to access forms, help and resources.

If you need more personalized assistance, Find a State Health Insurance Assistance Program (SHIP) Office in your state.

For extra help with prescription drug plan costs

Other Helpful Tools and Information:

Questions and Answers About Medicare for Caregivers

Medicare Eligibility and Enrollment

The Official U.S. Government site for Medicare

Social Security booklet that provides basic information about Medicare, it’s coverage and options.

Terms Of Use | Privacy Statement  | Contact Us | Feedback | Important Information ©2003-2022 Sage Life Technologies, LLC