Understanding Medicare

| August 9, 2010 | 0 Comments | 320 views

Medicare 101

Understanding Medicare

This document was created to empower people with a better understanding of the Medicare system.  A better understanding will help you make an informed decision, instead of being sold by a smooth talking salesman…..  Yes I am an insurance professional, but I am a Christian first and abhor salesman that push products.  I believe in educating consumers about all of their options.  Once properly informed they will make the correct decision for themselves.

Medicare is a GREAT health insurance program!!  The problem is most people feel intimidated by it.  They are overwhelmed by the choices and get frustrated and ultimately turned off by the whole system.  That is unfortunate, but hopefully this article will clear up some of these issues. 

Medicare is a health insurance program designed for seniors (people 65 & older) and people with certain disabilities.  It covers Hospitalization costs (Medicare Part A) and doctors or outpatient services (Medicare Part B).  It was signed into law in 1965 by Lyndon B. Johnson.  It has gone through many changes over the years and now there is also Medicare Part C (also called Medicare Advantage) and Medicare Part D (prescription Drug coverage).

Who is eligible for Medicare?

People age 65 & older
People under age 65 with certain disabilities
People of all ages with end-stage renal disease 


How to start Medicare

Medicare will start automatically for people turning 65.  Medicare will send out information to you a few months prior to your 65th birthday.  You will get a Medicare welcome package, which includes a Medicare & You book (filled with everything you could possibly want to know about Medicare), and your Medicare ID card.  This will have your Medicare Claim # as well as your Part A & Part B effective dates of coverage.  The Part A & Part B effective dates of coverage should be the 1st day of your birthday month.  So if you were born on July 17th, your Part A & Part B effective dates of coverage would be July 1.

How much does Medicare cost?

For most Americans Medicare Part A is free.  Medicare Part B costs for most people $96.40 / month.  This is for people with individual income levels up to $82,000 or jointly $164,000 a year.  The monthly premium will be higher for people with higher income levels.

What does it cover?

Medicare Part A

Helps cover your inpatient care in hospitals. Part A also helps cover skilled nursing facility, hospice, and home health care if you meet certain conditions.


All costs for the first 3 pints of blood you get as an inpatient, then Medicare approved amount for additional pints of blood (unless you or someone else donate to replace what’s used).

Home Health Care

$0 for Home Health Care services.   20% of the Medicare approved amount for durable equipment.

Hospice Care

Copayment of up to $5 per prescription for outpatient prescription drugs and 5% of the Medicare approved amount for inpatient respite care (short term care given by another caregiver, so the usual caregiver can rest).  You may have to pay room and board if you get hospice care in a facility other than short term general in-patient care or respite care.

Hospital Stay

$1,024 Deductible and no co-insurance for days 1-60 each benefit period
$256 per day for days 61-90 each benefit period
$512 per “lifetime reserve day” after day 90 each benefit period (up to 60 days over your lifetime)

Skilled Nursing Facility Stay

$0 for the first 20 days each benefit period
$128 per day for days 21-100 each benefit period
All costs for each day after day 100 in the benefit period

Medicare Part B

Helps cover medically-necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse.

Clinical Laboratory Services

$0 for Medicare covered services

Home Health Care

$0 for Home Health Care services.   20% of the Medicare approved amount for durable equipment.

Medical & other services

20% of the Medicare approved amount for most doctor services, outpatient therapy, most preventive services, and durable medical equipment

Mental Health Services

50% for most outpatient Mental Health Care

Other Covered Services

Copayment or Coinsurance amounts

Outpatient Hospital Services

Coinsurance or copayment amount that varies by service

Part B Deductible

The first $135 yearly for Part B covered services or items

Medicare Part C

Another way to get your Medicare benefits. It combines Part A, Part B, and, sometimes, Part D (prescription drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare. These plans must cover medically-necessary services. However, plans can charge different copayments, coinsurance, or deductibles for these services.

Medicare Part D

Helps cover prescription drugs. This coverage may help lower your prescription drug costs and help protect against higher costs in the future.

What is not covered by Medicare Part A or Part B

Items and services that Medicare doesn’t cover include, but aren’t limited to, the following:

Chiropractic services
Cosmetic surgery
Custodial care (like help with bathing or using the bathroom), except when you also get skilled nursing care in a skilled nursing facility, at home, or in a hospice 
Deductibles, coinsurance, or copayments when you get certain health care services. People with limited income and resources may get help paying these costs.
Dental care and dentures (with only a few exceptions) 
Eye care (routine exam), eye refractions (exam that measures your ability to see at specific distances), and most eyeglasses
Foot care (routine), like cutting corns or calluses (with few exceptions) 
Hearing aids and exams for the purpose of fitting a hearing aid 
Hearing tests that haven’t been ordered by your doctor 
Most Laboratory tests for screening purposes
Long-term care, for example, if you only need custodial care in a nursing home 
Orthopedic shoes (with few exceptions) 
Physical exams (routine or yearly). Medicare will cover a one-time physical exam within the first 6 months of enrolling in Part B (coinsurance and Part B deductible applies)
Prescription drugs. Most prescription drugs aren’t covered by Part A or Part B
Shots to prevent illness
Syringes or insulin, unless the insulin is used with an insulin pump, but it may be covered by Medicare prescription drug coverage (Part D) 
Travel (Most health care while you’re traveling outside the United States)

Medicare Coverage Options

Medicare Supplement Insurance

Health insurance policies sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage that assist in paying for some of the health care costs that the Original Medicare Plan doesn’t cover, plus benefits not covered by Original Medicare, like emergency health care outside the United States (subject to plan purchased).

You pay a monthly premium to the private health insurance company that sells you the policy. Medicare and the Medicare Supplement policy both pay their shares of covered health care costs.

Medicare Advantage Plans

Health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare. Some of the plans require referrals to see specialists.

In many cases, the premium can be lower than they are in the Original Medicare Plan or the Original Medicare Plan with a Medicare Supplement policy. Medicare Health Plans charge different premiums and have different costs of services, so it is important to check with the plan before you join.

They generally offer extra benefits, and many include prescription drug coverage.

In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans.

Some of the plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you.

You don’t need to buy a Medicare Supplement policy, if you purchase a Medicare Advantage Plan


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