Healthcare is one of the top issues facing the American society today. Businesses, different social groups and non-governmental organizations (NGOs), and government agencies on both the federal and state levels all play important roles in the running of our medical system. But for you as an individual, your top concern should be make sure that you and your family have comprehensive health insurance coverage.
With an aging population -- about one in five Americans will be age 65 or above by 2040 -- it is important that there is affordable healthcare available for senior and individuals who are in need. Luckily, our government has long recognized this problem. Since 1965, the Medicare program has been providing health coverage for older Americans who are not served by the individual and employer-linked insurance markets.
But despite the program's many benefits, the working of Medicare can be complicated and confusing, making it difficult for users to navigate. And this is especially so for the elderlies. To make it easier for both beneficiaries and their families to sort through, the program has been split into four main parts (A,B, C, and D), with each focusing on providing coverage in one or several specific areas, ranging from emergency care to preventive services to hospital care to prescription drugs.
This blog post is the first in a series of articles that aim to help you understand what each parts of Medicare is about. While we will be focusing on Part A this time, before we go into the details, let us give you a brief and general introduction about the Medicare program itself.
What is Medicare and Who is Eligible for Medicare Enrollment?
Medicare is the federal health insurance program for people who are 65 or older, younger people with certain disabilities, and people with permanent kidney failure who requires dialysis or a transplant(a condition also known as end stage renal disease). The areas of coverage under the four parts of Medicare include the following:
- Medicare Part A: Hospital Insurance -- covers all inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care
- Medicare Part B: Medical Insurance -- covers some doctors' services, outpatient and preventive care, and medical supplies
- Medicare Part C: Medicare Advantage Plan -- the private health insurance alternative to the original Medicare
- Medicare Part D: Prescription drug coverage -- covers the cost of prescription drugs, recommended shots and vaccines.
The cost for Medicare coverage may vary depending on the kind of coverage and services you get, and also the medical service providers you visit.
Medicare Part A Based on Age for People Who Must Pay a Premium
While not everything about Medicare is free, the good news is that most people don't usually have to pay a monthly premium to get coverage for Part A. This is also called the premium free Medicare part A.
You won't have to pay a premium for Part A if you belong to one of the following groups:
- Have qualified for or are already getting retirement or disability benefits from social security
- Get Medicare earlier than age 65
- 65 years old or older and have paid Medicare taxes while working working for a certain amount of time (usually 10 years). This applies as long as either you or your spouse (former or current) have been paying the taxes.
If you are unsure whether you have paid Medicare taxes long enough to qualify for Part A, you can either contact your employer, check your W2s forms when you file taxes, or login to the My Social Security account.
If you are a U.S. citizen or permanent resident (also known as green card holder) but haven't worked long enough to qualify for Medicare, you may able to buy into the program and enjoy the coverage by paying a Part A premium.
As of 2023, the premium for individuals who fall under this category is either $278 or $506, depending on how long they or their spouses worked and paid Medicare taxes.
How and When Do I Enroll in Medicare?
Enrollments are handled by the Social Security Administration. You can sign up at your local social security office or online at SSA.gov. Bear in mind that there may be penalty if you fail to enroll in Medicare on time.
The first sign up window is when you turn 65. The initial enrollment period lasts for seven months -- it starts three months before your birthday month and ends three months after that. So if your birthday is on March 10, you initial enrollment period is from December 1st until June 30th.
If you miss this window, you will get another chance that's known as the general enrollment period. And this lasts from January 1st to March 31st of each year. So while Part A is still premium-free, since you have missed the first enrollment period, you will likely have to pay higher monthly premium for Medicare Part B (doctor visits and other outpatient services).
What if I Start Receiving Social Security Benefits Early
If you started receiving social security benefits before 65, you will automatically be enrolled in Part A and Part B when you turn 65. Your monthly premium will be deducted from your monthly social security payment.
You can still qualify for Medicare if you are under 65 and are receiving certain disability benefits or are suffering from specific condition, such as end stage renal disease or amyotrophic lateral sclerosis (also known as Lou Gehrig's disease).
Are There Any Exceptions?
Even if you are turning 65, there are some circumstances under which you may be able to delay enrollment in Medicare without any late penalties. For example, if you are still working and have comprehensive health coverage through your company, or that your spouse is working and the insurance also covers you.
However, sometimes your employer may still require you to enroll in Medicare Part A and B so that your employment-based insurance only acts as a secondary program to fill gaps in Medicare coverage.
Bear in mind that for you will have to sign up for Medicare once turning 65 even if you already have health coverage. For example, if you are getting your coverage through the Affor Affordable Care Act’s (ACA) health insurance marketplace, you must transition to Medicare once you turn 65.
But the bottom line is, since the vast majority of enrollees won’t have to pay premiums for Part A, enrolling will get you into the system and may make it easier for you to sign up for Part B in future. So even if you already have comprehensive health insurance and are not required to sign up for Medicare at 65, it's best for you to still enroll in Part A.
What Does Medicare Part A Covers?
You are automatically enrolled in Part A as soon as you apply for Medicare. Part A covers most inpatient services: hospital stays, hospice care, and some skilled nursing care that you may require after suffering from more severe conditions such as stroke, or if you are recovering from a major injury that require rehabilitation in a nursing facility.
Medicare pays for virtually all hospital services for the first 60 days you’re in the hospital, though there are some exceptions — it won’t pay for a private room, for example. Here are more details on the coverage provided under Part A:
Inpatient Hospital Care
Part A covers the hospital care if a patient is admitted after an official doctor's order to treat an illness or injury and that the hospital accepts Medicare. One thing to note is that the physicians at the hospital may recommend you to get services more than what Medicare covers or those that aren't covered by Medicare at all. If this is the case, you may have to bear some or all of the costs. Hospital are now required to published standard charges of all their services and items.
Some of the items that are covered include semi-private rooms, meals, general nursing, and drugs. Those that aren't covered are private-duty nursing, private rooms (unless medically necessary), and personal care items such as razors.
Skilled Nursing Facility Care
Part A covers skilled nursing facility care for a limited time if the patients have days left in their benefit period to use and a qualifying inpatient hospital stay. In addition, their doctors will have to decide that they need to be cared by skilled nursing or therapy staff and the facility has to be Medicare-certified.
The items covered include semi-private rooms, meals, skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services, medications, ambulance transportation, and dietary counselling.
Long Term Hospital Care
Long-term care hospitals treats patients with more than one serious medical condition and who are hospitalized for 25 days or more. They may improve with time and care, and eventually return home. The services offered under this include respiratory therapy, head trauma treatment, comprehensive rehabilitation, and pain management.
After you are discharged from the long-term care hospital, some people may get care in a skilled nursing facility or custodial care in a long-term care facility.
You qualify for hospice care under Part A if you meet all of these conditions: your doctors certify that you're terminally ill with a life expectancy of 6 months or less; you accept comfort care instead of care to cure your illness; and you sign a statement choosing hospice care instead of other treatment for your terminal condition.
Hospice care is usually given in your home or in the facility where you live, such as nursing homes. Once you choose this service, your benefit will usually cover everything you need. You are normally charged nothing for hospice care.
Home Health Services
You are eligible for this services if you doctor decides that you require skilled nursing care or treatment such as physical therapy or speech-language pathology, and that you must be homebound. Usually the services are coordinated by a home health care agency based on what your doctor orders for you.
But Part A Isn't Totally Free
As mentioned earlier, even for those who don't have to pay the premium, Part A isn't completely free. The Medicare program charges a substantial deductible when you are admitted to the hospital. As of 2023, the deductible for each inpatient hospital benefit period is $1,600.
A hospital benefit period starts on the day you are admitted as an inpatient, and ends when you haven't gotten any inpatient hospital care for 60 days in a row. The same calculation method applies to skilled nursing facility.
If you are admitted to a hospital or nursing facility after a benefit period has ended, a new benefit period begins. There is no limit to the number of benefit period you can have in a given year.
In addition to the deductibles, there are also copayments that comes with inpatient stays and skilled nursing facility stay, as well as home health care and hospice benefits. For a complete list of these cost, you can refer to the chart in this link.
How Medicare Works with Other Coverage
If you are concerned about the cost of deductibles and copayments, you need not worry.
Many insurance providers offer plans that either help reduce your out-of-pocket expenses under Medicare or expand coverage to services that are not covered by the program.
EASY Insurance Plans, is dedicated to finding the right Medicare plan for you. Our experts are available to provide answers and will not rest until your health care needs have been met. Best of all? Our services come at no cost to you! Let us help make sure that you get the coverage that best fits your situation - contact us today!