The Basics Of MEDICARE

Medicare is the Federal health insurance program for individuals who are aged (65 and over) and younger individuals who have certain serious health conditions or are disabled.

• Medicare eligibility does not take into consideration an individual’s income. However,

         o individuals may pay higher premiums based on income, and
         o low-income individuals may be eligible for additional assistance. 

• Individuals can receive their Medicare medical coverage:

         ○ directly from the Federal Government, which pays for services on a fee-for-service basis (this                            program is known as “Original Medicare” or “Fee-for-Service Medicare”); or
         ○ through a private health plan.
Original Medicare:
    o Original Medicare covers only Part A and Part B benefits.
    o Under Original Medicare, beneficiaries can receive covered services from any physician or facility that accepts Medicare anywhere in the United States.
    o No referrals are required under Original Medicare.
    o Original Medicare has substantial deductibles and other cost sharing. 

Individuals must receive their Medicare Part D outpatient drug benefits through a private health plan (even if they get their medical coverage through Original Medicare). CMS (Centers Of Medicare Services) requires Medicare Beneficiaries to have a Medicare qualified Part D plan even though they do NOT provide one.

 

 

Medicare coverage is often known by the part of Medicare law under which it is authorized or regulated. Parts A and B define the basic Medicare benefits. These benefits are covered regardless of how an individual chooses to receive their Medicare benefits.

• Medicare Benefits and Coverage Part A is referred to as “Hospital Insurance Benefits” but also covers other inpatient benefits and home health services. Part A provides coverage for:

          o Inpatient hospital care (including care provided by acute care hospitals, critical access hospitals,                      inpatient rehabilitation facilities, and long-term care hospitals)
          o Skilled nursing and rehabilitation care up to 100 days, but only after a three-day hospital stay (most                Medicare Advantage plans may waive the 3-day stay requirement)
          o Blood
          o Hospice care
          o Up to 100 days of home health care after an individual is in a hospital or skilled nursing facility (SNF)                 (Note that Part B covers home health care without the prior hospital or SNF stay if Part B                                   conditions are met)
          o Inpatient psychiatric care (up to 190 lifetime days)

• Medicare Benefits and Coverage Part B covers a broad range of outpatient services. Part B generally covers:
  • Physician and other health care professional services
  • Outpatient hospital services and emergency department services
  • Clinical lab and diagnostic tests, such as X-rays, MRIs, CT scans
  • Durable medical equipment
  • Home health care that is not covered under Part A (because the individual was not in a hospital or SNF or has exceeded 100 days)
  • Physical, occupational, and speech therapy
  • Ambulatory surgical center services (usually on an outpatient basis)
  • Chemotherapy provided on an outpatient basis
  • Ambulance services
  • Chiropractic services and acupuncture – for very limited situations
  • Certain preventive health services, such as flu shots, mammograms, and bone mass measurement (there is no cost-sharing for many services)
  • Diabetic supplies
  • Kidney dialysis
  • Outpatient mental health and substance abuse care (limits apply)
  • E-visits

• Medicare Benefits and Coverage - Part D
  Part D covers prescription drug benefits (for self-administered drugs, such as those picked up at a pharmacy and taken at home) and regulates Medicare prescription drug plans.
    • Part D benefits are only offered through private health plans, including certain Medicare Advantage         Plans, some Medicare Cost Plans, PACE plans, and stand-alone Medicare Prescription Drug Plans.

• Medicare Benefits and Coverage- Part C
  Although not a underlying benefit as A, B and D, Part C regulates and authorizes Medicare Advantage plans. Medicare Advantage plans are private health plans that contract with the government to provide and administer Medicare benefits. Medicare Advantage plans must cover Part A (except for hospice) and Part B benefits. Medicare Advantage plans may also cover items and services not covered by Original Medicare, such as hearing aids or dental care.                                                                                            • Individuals enrolled in a Part C plan still get hospice benefits, but Original Medicare pays for them.

• Medicare Benefits and Coverage – Part E
  There is also a lesser-known Part E of Medicare law that regulates other miscellaneous programs including:
  • Medicare cost plans (which also cover Part A and Part B benefits) Medicare cost plans are only offered in a limited number of states and are most frequently found in rural areas.
    • Medicare supplemental insurance (Medigap Plans)
    • The program for all-inclusive care for the elderly (PACE)