What is Medicare? What governmental agency administers it?
Medicare is a national social insurance program; it is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease known as a permanent kidney failure requiring dialysis or transplant. Medicare helps cover different specific medical cost. As a social insurance program, Medicare spreads the financial risk associated with illness across society to protect everyone, and thus somewhat different social role from for-profit private insurers, which manage their risk portfolio by adjusting their pricing according to, perceived risk. Medicare is managed by the Health Care Financing Administration (HCFA), a division of the U.S Department of Health and Human Services which also administers Medicaid.
Who is eligible for Medicare? Who is not eligible for Medicare?
People who are at age 65 or older qualifies if he or she is A U.S citizen or a permanent legal resident He/She or their spouse has worked long enough to be eligible for Social Security or railroad retirement benefits – usually having earned 40 credits from about 10 years of work He/She or their spouse is a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes while working. Note that He/She can qualify for Medicare on their spouse’s work record if he or she is at least age 62 and he/she is at least age 65.
They may also qualify on the work record of a divorced or deceased spouse. Following the Supreme Court’s ruling on the Defense of Marriage Act in June 2013 people in same sex marriage may qualify on their spouse’s work record if they live in the state where they were wed or in another state that recognizes same-sex marriage, or if they are civilian or military employees of the federal government. People who are under age 65 qualifies if he or she is
Have been entitled to Social Security disability benefits for at least 24 months ( which need not be consecutive) Receive a disability pension from the Railroad Retirement Board and meet certain conditions Have Lou Gehrig’s disease ( amyotrophic lateral sclerosis), which qualifies them immediately Have permanent kidney failure requiring regular dialysis or a kidney transplant , and either he/ she or their spouse has paid Social Security taxes for a certain length of time depending on their age.
People do not qualify for Medicare if they do not meet the above requirements.
How do you apply for Medicare?
Check whether he/she qualifies to receive, by verifying whether or not he/she qualify to receive government assistance through its Medicare program. They must be low-income, income is measured against the Federal Poverty Level, for FPL, which changes annually but is currently set $23,550, are pregnant, are elderly (65+) and younger (under 21), are blind or disabled, have no health insurance, guardians of a minor but have restricted sources of income, are SSI eligible. Go to your state of residence’s Medicare website to get more detailed information on state eligibility requirements. Individual state links are posted at the Center for Medicare & Medicaid Services’ website. This site also provides a detailed listing of what services are and are not covered under Medicaid. State eligibility sometimes differ. Federal law requires states to cover certain mandatory eligibility groups, but allows them to provide coverage to other population groups. Some states do, other states don’t. This means that state eligibility laws will differ from state to state.
Check with your state and learn the eligibility requirements. Many states are expanding coverage, especially for children. Read over the application form in its entirety before inputting your information. Make sure answers are accurate as Medicare fraud is a serious offense that carries equally serious penalties. Schedule a time to meet with a Medicare officer or a social or human services representative if he/she has any questions or concerns about eligibility. Organize all the documents necessary to apply for Medicare. The state will need to verify information on the application by cross-referencing it with certain documents you may be in possession of. In order to do this, you should make duplicate copies of:
1) birth certificate, social security number or guardianship papers
2) Driver’s license and vehicle registration
3) Proof of residency in the state in which you are applying for
4) Any pay stubs or other proof of income
5) Names of your financial institutions and any bank accounts numbers
6) Real estate deeds
7) Unpaid doctor or health care bills
8) Medicare Benefit Card Consult with an elder lawyer or one who specializes in family law before submitting your Medicare application. This is especially important if the person who is applying for Medicare will be entering a skilled nursing facility. Inquire as to the average turnaround time for reviewing an application.
It generally takes 45 days for the state to process an application that does not involve a disability. It can take up to 90 days to process an application associated with a disability. Be sure to follow up on the status of your application if you don’t receive a response within a reasonable time after that. Know that you can combine Medicaid and Medicare coverage if you meet certain eligibility requirements. Renew your eligibility once a year
What types of coverage does Medicare provide? What does it not provide?
Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions. Part A: Hospital care, Skilled nursing facility care, Nursing home care, Hospice, Home health services Part B covers 2 types of services
Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment. Part B covers things like:
1) clinical research
2) ambulance services
3) durable medical equipment (DME)
4) mental health
7) partial hospitalization
8) Getting a second opinion before surgery
9) Limited outpatient prescription drugs
What are the “options” under Medicare (ie. can you pick your own doctor, can you pick your own drug plan? Etc.)
In most cases, people can choose their own doctors, other health care provider, hospital, or other facility that’s enrolled in Medicare and is accepting new Medicare patients. However for drug, most prescriptions aren’t covered in Original Medicare but people are given the choice to join a Medicare Prescription Drug Plan. Each Medicare Prescription Drug Plan has its own list of covered drugs, many medicare drug plans place drugs into different tiers on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost less than a drug in a higher tier.
Do you have to pay for Medicare benefits?
Yes, generally people have to pay for Medicare benefits. Part A usually cost $441 each month if a person is not eligible for premium free. For part B, a person pays a premium each month for Medicare Part B (Medical Insurance). Most people will pay the standard premium amount. However, their modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, they may an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to premium. Part B for $ 147 and Premium B for; If your yearly income in 2011 was
You pay (in 2013)
File individual tax return
File joint tax return
$85,000 or less
$170,000 or less
above $85,000 up to $107,000
above $170,000 up to $214,000
above $107,000 up to $160,000
above $214,000 up to $320,000
above $160,000 up to $214,000
above $320,000 up to $428,000
Are there co-pays associated with Medicare?
Yes. In traditional Medicare ( Part A and B) you pay 20% of the Medicare- approved amounts for most Part B services. In Part A, after meeting the deductible you pay nothing more for up to 60 days in the hospital in any one benefit period, but additional days may require daily copays.
If you grandpa had severe dementia and needed 24 hour care, but your family wanted to keep him out of the nursing home, would his care be reimbursed through Medicare?
Medicare has the choice to not reimburse the cost because it is not under the beneficiaries.
Is Medicare working or is it just a broken socialized medicine program that needs to be redone? Why?
I think that Medicare should be redone, it has too many processes to it, and it doesn’t make any sense if it’s for society who are poor and old, why do people still need to fork out so much of money per month to keep their Medicare benefits? Also, the paper work needed to apply for Medicare is tedious and not exactly friendly for somebody who is trying to apply for it.
How easy was this information to find? How would a person with less education then you navigate this system?
The Medicare website was rather easy to find, however the information was not the easiest thing to grasp especially when they have so many terms and conditions and different tiers to it. A person with less education will definitely have difficult time trying to navigate through the system and to get the right paper work done to apply.
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