Medicare – How and When

Medicare is government sponsored healthcare for seniors aged 65 and older, people who are disabled and people with permanent kidney failure requiring dialysis or a kidney transplant. 

Medicare works like private insurance only that it is the government that is the one reimbursing doctors and hospitals, and not private insurance companies. You become eligible when you become 65 or if you are medically disabled before age 65, or have kidney failure requiring a transplant or dialysis. 

Medicare Coverage

Medicare benefits come under four heads - A, B, C and D.

• Part A is hospital insurance. It helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care. There are certain conditions laid down regarding such care.

• Part B is medical insurance that helps cover medically necessary services. It includes outpatient care and doctors' services, and also covers some preventive services to maintain your health and to keep certain illnesses from getting worse.

• Part C, the Medicare Advantage plan, is another way to get healthcare benefits. It is managed by private insurance companies approved by Medicare. These plans must cover medically necessary services. They are cost-effective and offer better benefits than Parts A and B together. They can even supplement Parts A and B. Medicare Advantage plans can charge co-pays, deductibles and coinsurance.

• Part D is Prescription Drug Coverage and may help lower drug costs. 

When is Medicare Health Insurance Used

If a Medicare beneficiary has an accident and needs to spend time in hospital, Medicare Part A can offset the costs of the catastrophe. If a person eligible for Medicare comes down with a fever or a cold, he would need Medicare Part B to cover his doctor’s visit. Medicare Part D will pay for the medicines he needs to get better. 

Medicare Eligibility/Enrolment

• Parts A and B

Most people are automatically eligible for Parts A and B of Medicare. You automatically get Parts A and B: 

-If you get benefits from Social Security or the Railroad Retirement Board (RRB); 

-After you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months, if you are under age 65 and disabled; 

-The month your disability benefits begin, if you have ALS (Amyotrophic Lateral Sclerosis).

If you have End-Stage Renal Disease, rules are different. For information on this, contact your local Social Security Office or call Social Security 

Some people need to sign up for Part A. If you do not get Social Security or RRB benefits (for instance, because you are still working), you will need to sign up for Part A (even though you get it free). You have to get in touch with Social Security 3 months before you turn age 65. If you worked for a railroad, you should contact the RRB to sign up. 

If you delay signing up for Part B, you can only get it during the general enrollment period (between January 1 and March 31 each year) and you may have to pay a late enrollment penalty.

• Part C or Medicare Advantage Plans include Health Maintenance Organization (HMO) Plans, Preferred Provider Organization (PPO) Plans, Private Fee-for-Service (PFFS) Plans, and Special Needs Plans (SNP). You can join by completing a paper application, or enrolling on the private insurer’s website.

• Part D is not available through the federal government, but only through private insurance companies approved by Medicare. Part D is available through Medicare Prescription Drug plans and Medicare Advantage Plans. If you do not enroll in a Medicare drug plan when you first become eligible, you may have to pay a late premium penalty.

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