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What You Should Know About Medicareby LB SedlacekMedicare is the Federal health insurance program that is available to
older people and to many of those with disabilities. Generally, a person
is eligible for Medicare when turning age 65. In other instances, a
person with a disability may be eligible, regardless of age. There are
two parts to Medicare: Part A and Part B. Inpatient hospital services,
skilled nursing facility, home health care and hospice services are
covered by Medicare Part A. Physician services, durable medical
equipment, clinical diagnostic laboratory services, laboratory tests,
X-rays, diabetes self-management, outpatient hospital services,
ambulance services, outpatient mental health services, mammograms, pap
smears, colon or prostate cancer screenings, flu and pneumonia shots,
bone density measurement, and physical therapy are covered by Medicare
Part B. Medicare generally does not cover preventive care services,
private duty nursing, hospital room telephone or television, private
hospital rooms, dental services, eyeglasses, chiropractic services, care
outside of the U.S., acupuncture, hearing aids, long term or custodial
care in nursing homes or most prescription drugs. To qualify for
Medicare, a person must meet at least one of the following: (1)Be age 65
and eligible for Social Security or railroad retirement benefits,
(2)Have been receiving Social Security disability income for at least 24
months, or (3)Have end stage renal (kidney) disease. If one continues to
work after age 65 or decides not to enroll for Social Security benefits
at age 65, he/she may still receive Medicare benefits. Permanent legal
aliens also qualify for Medicare when they have lived in the U.S. for at
least five years or more continuously prior to eligibility date. They
may also qualify when they are not eligible for Social Security benefits
or railroad retirement benefits, but they usually will have to pay the
premiums for Medicare Part A. If one qualifies for Social Security or
railroad retirement benefits, his or her Medicare enrollment is
automatic. If one is not age 65, he/she may apply with the local Social
Security office during the 7 month period that starts 3 months before
their 65th birthday. When applying 3 months before turning 65, the
Medicare coverage begins in the birthday month. When applying in the
birthday month or during the 3 months following, coverage will be
delayed for up to 3 more months. Enrollment may also be done between
January 1 and March 31 of any year once becoming eligible, but there may
be a penalty for late enrollment and an effective date of July 1. If one
has coverage with a group or business health plan, he/she may enroll any
time while still working and if the employer has more than 20 employees.
If one cancels group coverage while still working or retires, he/she is
given a special 8 month enrollment period beginning when the group
coverage ends. Be aware that when applying for a Medicare Supplement
policy 6 months after Medicare Part B coverage is effective or after
open enrollment ends, health questions would have to be answered on the
application. Also, when one is covered with a group health plan and
Medicare, as long as the employer has 20 or more employees one has the
option of making the group health coverage primary and Medicare
secondary. If one is automatically eligible for Medicare Part A then
there is no premium to pay. A premium is required for Medicare Part B.
If one does not enroll in Medicare Part B when initially eligible, then
there is a 10% premium penalty for each year of delayed enrollment.
Medicare options include original Medicare which comes direct from the
Federal government, and Medicare PPO (preferred provider organization),
Medicare PFFS (private fee-for-service plan), Medicare MSA (medical
savings account plan), and Medicare HMO (health maintenance
organization) or Medicare PSO (provider-sponsored organization) which
are offered by private health plans. There are also special Medicare
programs for people with low incomes of $4000 per individual or $6000
per couple not including a house or car. These programs are: QMB, SLMB,
Q1-1, Q1-2, or Medicaid. Over 80% of those eligible for Medicare select
original Medicare. It is available everywhere in the U.S. and one is
enrolled in it automatically when becoming eligible for Medicare. Just
about any doctor or hospital may be used with original Medicare, and it
pays providers and doctors directly for the services one receives. To
fill in any gaps in the original Medicare coverage, a Medicare
Supplement insurance plan may be purchased. For more information, please
contact Social Security at 1-800-722-1213 or log onto
www.medicare.gov.
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