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Medicare Insurance

Medicare InsuranceMedicare insurance was first implemented in 1966 under Title XVIII of the Social Security Act. It’s one of the Social Security Amendments of 1965 that’s entitled “Health Insurance for the Aged and Disabled”, and is part of a package for seniors that completes survivors, disability and retirement benefits.

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There were 19.1 million people enrolled when Medicare began on July 1, 1966; by 2003 that number had increased to more than 41 million.

People should know that if they don’t sign up when they first become eligible for Medicare, which is three months before to three months after age 65, they will only be able to sign up between November 15 and December 31 of each year thereafter.

What Does Medicare Consist of?

Generally, Medicare insurance consists of four sections commonly referred to as parts. These part included hospital coverage, supplemental coverage, a private health care option known as Medicare Advantage, and the prescription drug program.

Medicare Insurance Coverage

When Medicare coverage first began, most people aged 65 and over who were eligible to receive social security benefits were qualified to enroll in Medicare. In 1973, eligibility expanded to include people who had contracted certain specific diseases and other elderly people who were otherwise not eligible for coverage and/or disabled who chose to pay a monthly premium to receive Medicare benefits. The four parts and their benefits are described below.

Part A Coverage: Hospital Insurance (HI)

  • Medicare Insurance Hospital CoverageInpatient Hospital Care: This coverage includes all medically necessary services and supplies that are provided in a hospital for inpatient care. However, a deductible payment is required upon admission into the hospital and co-payments will have to be paid if the beneficiary remains in the hospital pass 60 days.
  • Skilled Nursing Facility Care (SNF): Beneficiaries are eligible to receive this service only if it follows within 30 days of a hospital stay of three or more days and is certified as medically necessary. In addition to covering similar services as inpatient hospital care, SNF coverage also includes rehabilitation and appliances. SNF coverage is limited to 100 days per benefit period and a co-payment is required after the 21st day.
  • Home Health Agency (HHA) Care: HHA or home health care furnishes services in the residence that are not associated with a hospital or skilled nursing facility stay and this service is covered by HI and SMI. The care is provided on a part-time basis and a treatment plan must be implemented followed by periodic reviews by a physician. This service requires no deductible or co-payments.
  • Hospice Care: Patients who suffer from a terminal illness with a life expectancy of less than six months can opt to have hospice care instead of the standard medical treatments. This service includes symptom management, pain relief, physical therapy, nursing services, and other supportive medical and social services.

While the patients are responsible for paying coinsurance amounts for inpatient respite care and drugs, they don’t have to pay deductibles.

Part B Coverage: Supplementary Medical Insurance (SMI)

All citizens and certain legal aliens who are 65 and older and disabled who are entitled to receive HI are eligible to enroll in SMI for payment of a monthly premium. Some of the services provided under SMI are as follows:

  • Medicare Insurance Supplemental CoveragePhysicians and Surgeons Services: This includes various types of physicians such as podiatrists, dentists and optometrists. It also includes practitioners who aren’t necessarily physicians but are approved by Medicare such as clinical psychologists and social workers, physician assistants and nurse practitioners.
  • Services in Outpatient Clinics or Emergency Rooms: This includes ambulance services and same-day surgery.
  • Home Health Care: This part will cover the remaining home care services that aren’t covered under HI.
  • Diagnostic Radiology Services, X-Rays and Laboratory Tests: Also includes certain screening tests for preventive care.
  • Most Occupational and Physical Therapy Services: Also includes speech pathology services.
  • Radiation Therapy, Dialysis and Organ Transplant Surgery: Transplants currently include most of the major organs.
  • Drugs and Biologicals that can’t be Self-Administered: However, certain anticancer drugs that are self-administered are covered.
  • Durable Medical Equipment Approved for Home Use: Besides appliances such as oxygen equipment and wheel chairs, this also includes casts, surgical dressings, prosthetic devices and splints.

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Part C Coverage: Medicare Advantage

This coverage was formerly known as Medicare + Choice. It was added to Medicare in 1997 and offers more options for beneficiaries to participate in health care plans in the private sector.

Medicare Insurance For SeniorsPrivate sector companies under contract with a Medical Advantage program must operate under certain Medicare guidelines and meet specific financial and organizational requirements. For a fee, many people can then choose to enroll in a Medicare Advantage program instead of an HI or SMI to seek medical assistance from practitioners who are contracted under the Medicare Advantage program.

Organizations that operate under Medicare Advantage include three management options: preferred provider organizations (PPOs), health maintenance organizations (HMOs), and provider-sponsored organizations (PSOs). Find out how Consumer Reports compares your options here.

Part D- Prescription Drug Coverage

Part D is the latest addition to Medicare and it was authorized for use in 2003. This part provides prescription drug benefits for seniors and people living with disabilities.

This service helps to cover the cost of generic and brand named prescription drugs sold at participating pharmacies.

Everyone on Medicare is eligible for prescription drug coverage.

Medicare Insurance For Senior CitizensThere are several drug coverage plans under Part D and formularies or preferred drug lists name the prescription drugs that are covered under each plan.

When choosing a plan, patients should look for the one that covers most or all of the drugs they take. Also, patients must use a pharmacy that’s approved by the plan so they also have to keep this in mind when choosing a plan. Patients will pay a monthly premium and for part of the cost of their prescriptions. However, in cases of limited resources and income, these patients may qualify for extra assistance that could result in their not having to pay deductibles or premiums.

The Differences Between Medicare and Medicaid

At first glance, some may find it confusing when first encountering the programs under Medicaid and Medicare insurance. After all, both are government-sponsored programs with names that sound very similar so for many, explanations are warranted.

A major difference between the two is that Medicare assists with the long-term care of the elderly and disabled regardless of income levels, and Medicaid assists with health care costs for low-income individuals and families regardless of their age.

Medicare insurance coverage is financed by a combination of premiums paid into the programs and taxes paid by the working class, while Medicaid is jointly funded by the state and federal government. The interesting fact is that, in spite of the major differences, a person could be eligible to receive both Medicaid and Medicare insurance under Dual Eligibility.

My Medicare Insurance

Those individuals and families with income limits that are only slightly above the limits to qualify them for Medicaid can receive assistance from Medicare Saving Programs. Under these programs, low-income recipients who aren’t eligible for Medicaid can receive financial assistance to help pay their Medicare premiums and co-payments.

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