Medicare is available for those age 65 and older who are US citizens or legal permanent residents. In addition, either you or your spouse must have worked for 10 years (40 quarters). Some individuals under age 65 can also qualify for Medicare coverage if they have certain disabilities and meet the guidelines.
The government provides Medicare Parts A & B.
Most people do not pay a premium for Part A that covers inpatient care in hospitals, skilled nursing facility care, home health care and hospice care stays, because when you worked, you paid into the system. There is a deductible of about $1,316.00 and co-insurance after 60 days.
This is medical insurance that covers doctors and other health care provider visits, outpatient care, home health care, durable medical equipment, and some preventive services rather than hospital care. The premium is about $134.00 and the deductible is $183.00. Part B is designed for the government to pay about 80% of medical expenses.
This is called Medicare Advantage which combines Part A and B and adds additional benefits which might be prescription drug coverage (Part D) and dental or vision coverages. They can be zero premium (you still must pay the Medicare premiums) or have an additional premium based on the benefits.
Private insurance companies cover the Medicare Prescription Drug Plan and costs range from about $15.00 to $100.00 per month. They each have a list of approved drugs.
Medicare Options and Supplements
Because Medicare does not cover all healthcare costs, these policies, known as Medigap, cover some or all the costs not included in Parts A & B. However, these plans do not cover medications and have additional premiums to the Medicare Part A & B.
Many people select a combination of these to obtain the most comprehensive coverage they can. For example:
- Medicare Supplement Plan containing Medicare Part A & B and Part D (to cover prescription drugs)
- Medicare Advantage Plan (Part C) containing Medicare Part A & B, and most Part C plans include Part D (to cover prescription drugs)
Other Medicare Facts
- You cannot have both: a Medicare Supplement and a Medicare Advantage plan.
- You can change your Part C or Part D plan every year during the annual enrollment period which for 2018 ran from October 15 to December 7, 2017.
The Part B Premiums for 2018 are:
- $1340.00/month: less than $85,001 (single)/less than $170,001 (married)
- $187.50/month: $85,001-$107,000 (single)/$170,001-$214,000 (married)
- $267.90/month: $107,001-$133,500 (single)/$214,001-$267,000 (married)
- $348.30/month: $133,501-$160,000 (single)/$267,001-$320,000 (married)
- $428.60/month: more than $160,000 (single)/more than $320,000 (married)
Some individuals who qualify for Medicaid (another government program) may only qualify for QMB (Qualified Medicare Beneficiary) status. This means they receive assistance with Medicare premiums and cost-sharing items such as deductibles, co-insurance or co-pays. With this status, however, there is no coverage for other health costs. Medicare approved providers must NOT bill QMB status persons but state Medicaid may pay for these costs.
Also be aware that if Medicare denies a charge as not a covered service, the supplemental insurance will also deny. An example is a person who has an ambulance transport to a physician’s office. Medicare denies as not covered and the secondary insurance also denies. The balance is patient responsibility or the patient can appeal with medical records providing medical necessity for the transport.
While you might be receiving better coverage than before, the Medicare maze is still something you must pay attention to. Carefully review your bills and Medicare Summary Notices and take action to have a claim decision reconsidered before your appeals deadline expires.