Medicare & You
Of all the health insurance programs in the United States, the most well-known for retirees is Medicare, a comprehensive program run by the Centers for Medicare and Medicaid Services (CMS).
The federal health insurance program covers people 65 years old and older, people with End-Stage Renal Disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease), and younger people with disabilities.
Medicare’s options are so numerous that CMS issues an annual Medicare & You handbook so that Medicare beneficiaries can shop and compare costs for health and drug plans. Like private insurance companies, some Medicare plans have deductibles.
From how to use telehealth and other virtual services, to determining the most economical drug plan for insulin, Medicare & You will help you understand the wide range of Medicare offerings, how the program operates, and what plans you may be automatically qualified for, particularly for those who meet the eligibility requirements set by the Social Security Administration, which enrolls people into Medicare.
People who have paid Medicare taxes for at least 10 years are eligible for Medicare Part A, which covers inpatient hospital care, a skilled nursing facility, hospice care, home health care, and more.
Part A is sometimes called “premium-free” Part A because you do not have to pay a monthly premium if you are receiving (or are eligible for, but have not yet filed for) retirement benefits from Social Security or the Railroad Retirement Board. You can also get premium-free Part A if you or your spouse had Medicare-covered government employment.
If you are eligible for Part A, Medicare will automatically enroll you in Part B, which requires paying a monthly premium. Part B covers services from health care providers, outpatient care, home health care, durable medical equipment (such as wheelchairs); and preventative services, like wellness visits, shots, and screenings.
Medicare Parts A and B
Medicare Parts A and B are commonly referred to as “Original Medicare,” but Medicare & You also explains other insurance plans including:
Part C, also called “Medicare Advantage” provides Medicare benefits through private health insurers. Medicare Advantage is described as a “bundled” plan because it includes Parts A and B, and Part D drug coverage. The insurance plans also offer benefits that Part A does not cover, such as vision, hearing, and dental services.
Part D is run by Medicare-approved private insurance companies and covers prescription drugs, shots, and vaccines. Part D is included in most Medicare Advantage plans.
Some Medicare beneficiaries still have Part F, which is supplemental insurance that covers the “gaps” left open by Parts A and B. This is why the plan is called “Medigap” or “MedSup.”
Those who have this supplemental insurance may not have to pay as much—if any—out-of-pocket costs for medical services. As of January 1, 2020, Medigap plans were no longer sold to new Medicare enrollees. However, Medicare beneficiaries who already had Part F prior to January 1, 2020, were allowed to keep Part F.
Original Medicare vs Medicare Advantage
If there’s one thing that Medicare & You does, it’s helping you decide whether you want to go with Original Medicare (Parts A and B) or Medicare Advantage, which is offered by private insurance companies.
Original Medicare, for instance, covers most medically necessary services and supplies while most Medicare Advantage plans cover services that Original Medicare does not cover, such as vision, hearing, dental, and routine exams.
There are also differences between the two plans when it comes to doctors and hospitals. With Original Medicare, you can go to any doctor or hospital in the United States that takes Medicare. But people with Medicare Advantage plans must use doctors and other providers who are in the network of the insurance company that offers the plan.
As for costs, Original Medicare has beneficiaries paying 20 percent of the Medicare-approved amount after meeting their deductible. With Medicare Advantage, out-of-pocket costs vary.
Programs For Beneficiaries With Limited Income
Like private insurances, Medicare does not cover all of your health care costs, and Medicare beneficiaries with limited income and resources may have difficulty paying for their medical expenses.
Medicare, however, has four federal and state programs available to help with costs:
Medicaid is a joint federal and state program that provides health coverage for people with very low income. Each state’s Medicaid office decides on who is eligible and what services are covered.
2. Medicare Savings Programs
Medicare has four programs for people who meet certain conditions:
1. Qualified Medicare Beneficiary Program. This program helps in paying premiums for Medicare Parts A and B.
2. Specified Low-Income Medicare Beneficiary. This program pays only for Part B premiums.
3. Qualifying Individual Program. This is a state program that helps pay Part B premiums for people who have Part A, and limited income and resources. Individuals must apply each year for these benefits and applications are given on a first-come, first-serve basis.
4. Qualified Disabled and Working Individuals Program. This program helps to pay Part A premiums only. Individuals who have a disability and are working may qualify for this program.
3. Supplemental Security Income (SSI) Benefits
SSI benefits are given to people who are blind, 65 years old or older, or have a disability. Although paid by Social Security, SSI benefits are not the same as Social Security retirement benefits.
4. Extra Help
Extra Help pays for Medicare prescription drug coverage. Medicare beneficiaries who qualify for Medicaid, one of the Medicare Savings Programs, or SSI, are automatically qualified for Extra Help.
Medicare beneficiaries can still apply for a program even if their income or resources are higher than the amounts listed by Medicare.
Contact Medicare For More Information
Medicare & You provides a wealth of information, however, some programs vary by state. For instance, Medicare beneficiaries interested in applying for Medicaid should contact their state’s Medicaid (State Medical Assistance) office to see if they qualify for the program.
If you have questions about Medicare, call 1-800-MEDICARE (1-800-633-4227) or visit medicare.gov/contacts.
To get a copy of Medicare & You via mail, call 1-800-MEDICARE (1-800-633-4227) or to download a copy, visit Medicare.gov/publications.