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Medicare 101: A Guide to Each Plan

One reality of life is that the older a person gets, the more money they spend on medical care. The United States government understands this monetary crunch on its elderly citizens, and also the spouses of those citizens, and established the Medicare program in July of 1965.

Hospital, consultation and doctor at patient bed for check up. Diagnosis, medicare and medical aid

Getting Started with Medicare

Medicare enrollment is open to individuals who qualify under one of the following categories:

  • Individuals that are at least 65 years of age.
  • People below the age of 65 who struggle with certain disabilities.
  • Individuals with End-Stage Renal Disease, a chronic failure of the kidneys that necessitates dialysis or organ transplants.

The Initial Window

In normal cases, a person can sign up for Part A and Part B of Medicare up to three months before they turn 65 years old. Medicare’s many parts will be covered further in this article. Generally speaking, the “Initial Enrollment Period” begins 3 months before the month a person turns age 65 and extends to three months after that month, enrolling later than this period tends to incur a penalty. Beyond the IEP, general enrollment opens up from January to March of each year.

Physician doing medicare consultation with senior patient

In cases where a Medicare recipient is suffering from ESRD, they can begin enjoying Medicare assistance starting on the fourth month of their need for dialysis or, in the case of a kidney transplant within a two-month timeframe, the window changes to the first day of admission into a Medicare-certified facility. It is also worth mentioning that dialysis patients can receive retroactive coverage for up to 12 months, even if they do not initially file for Medicare eligibility.

When Does Medicare’s Coverage Start Assisting with Costs?

There are two possible answers to this question and the difference is entirely dependent upon when you initially signed up for the program.

  • If qualifying for Premium-Free Part A, coverage begins on the month of your 65th birthday, unless it falls on the first day of that month, these special cases begin enjoying coverage a month before their birth month.
  • Individuals qualified for Part B can begin enjoying coverage either on their birth month if they enrolled during the three months before turning 65, or the month after their birth month if they signed up during the IEP after turning 65.

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Breaking Down the Parts

Despite being referred to as a single entity, Medicare is an umbrella of services that is broadly divided into four parts. Each of these parts is relevant to a specific subsection of medical care and treatment.

Medicare Part A

This section of Medicare is synonymous with hospital insurance. If you need assistance paying for staying in a hospital, receiving care at a qualified nursing facility, hospice care, or certain forms of home health care, Part A is the relevant division of Medicare for you. It should be mentioned that Part A carries no monthly premium if you enroll on time.

Medicare Part B

This section is relevant to medical insurance. A short list of the charges that this portion of Medicare can assist enrollees with includes doctor bills, outpatient medical care, the purchase of medical supplies, like catheters and insulin, and preventative services. Unlike Part A, everyone pays a monthly premium for Part B.

Medicare Part C

This specific subsection is sometimes called an MA Plan and it is a health plan that comes from a Medicare-certifies third party operating within the private sector. These “Medicare Advantage” plans, also known as “Medigap” policies, entail Part A and Part B but often cover even more than those programs on their own.

Medicare Part D

This is the simplest part of the Medicare program to understand and governs prescriptions and most commonly recommend shots/vaccines.

Original Medicare vs Medicare Advantage (Part C)

Medicare gives you plenty of options regarding your coverage, beginning with the two choices you have to make upon enrollment.

Original Medicare

This program covers Part A and Part B. Services are paid for as they are received based on an annual deductible that is usually 1/5 of the cost of the service, known as coinsurance. Part D does not come part and parcel with original Medicare and must be added separately. While Medicare can cover a lot of payments, there are some gaps in that coverage that may require looking into a Medigap policy to fill. Medigap policies can vary a great deal, like providing coverage for emergency care while traveling abroad.

Medicare Advantage

As briefly discussed in an earlier section on the parts of Medicare, Medicare Advantage is a health plan that bundles Part A, Part B, and often Part D. These plans are highly dependent on the individual company but most cover services that Original Medicare ignores, like dental, hearing, and vision care. These sorts of health plans have annual contracts with Medicare and must abide by all rules regarding Medicare coverage. Furthermore, you must be notified about any changes your plan may undergo before enrolling in the following year.

More on Part D

Medicare drug coverage assists in paying for prescriptions but only if your plan is approved by Medicare and offers drug coverage. Every plan can vary in cost and what drugs it will cover but the bare minimum is the standard coverage of Medicare. Medicare drug coverage handles both generic and branded drugs and these plans can alter the list of prescriptions they will handle, known as a “formulary. These formularies help to determine what “tier” of drugs a given prescription is considered. Medicare drug plans can have different monthly premiums and the amount you pay for each drug is entirely dependent on your plan’s tiers and formularies.

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