We’re here to help you understand Medicare.
Medicare Part A and Part B, otherwise referred to as Original Medicare, is a health insurance program that is provided by the federal government. To be entitled to Original Medicare, you must be a U.S. citizen or a permanent legal resident for at least 5 years and meet one of the following criteria:
- People 65 years of age or older
- People under age 65 with certain disabilities
- People of all ages with End-Stage Renal Disease (kidney failure) or ALS (Lou Gehrig’s disease)
65 years old
U.S. citizen and resident
(at least 5 consecutive years)
(i.e. people of any age with end-stage renal disease or ALS)
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Medicare, or “Original Medicare” is a federal program that is administered by the Centers for Medicare & Medicaid Services (CMS), which is a division within the U.S. Department of Health and Human Services. At the local level, district offices of the Social Security Administration accept Medicare enrollment applications, process claims, and provide general information about the Medicare program. However, the Social Security Administration does not make Medicare policy; it handles the paperwork.
The Medicare program provides basic medical benefits for millions of Americans and controls the costs for these medical services through a system of regulations and procedures. The Medicare program is funded by Social Security, Medicare taxes, Medicare premiums, and the federal budget.
Original Medicare differs from Medicare Advantage and Medicare Supplement, which are insurance plans offered by a private insurance company (instead of the federal government). Original Medicare does not require a network of doctors and hospitals, so you have the freedom to go to any doctor or provider within the United States that accepts Medicare. Enrolling in Original Medicare is easy because you cannot be turned down due to your medical history or a pre-existing condition.
These are common points of confusion for people:
- Even if you are already collecting Social Security, you must wait until you are 65 to enroll in Medicare.
- You must be 65 to enroll in Medicare – your spouse’s age does not count
(Medicare plans are individual plans – not family plans).
When you turn 65, and if you are already drawing your Social Security, then you will automatically receive a letter in the mail from Social Security with your Medicare card.
If however, you are not drawing your Social Security at age 65 – you can still join Medicare, but you will need to sign up directly through the Social Security office. In other words, it will not happen automatically.
Your Medicare card shows that you have Medicare health insurance and whether you have Part A, Part B, or both.
Contrary to popular belief, Original Medicare (Part A and Part B) does not cover all medical expenses. There are exclusions or services not covered, including:
- Prescription drugs
- Comfort or convenience items
- Private duty nursing
- Long-term care
- Cosmetic surgery
- Most chiropractic services
- Routine foot care
- Routine eye care
- Routine hearing tests
- Most dental care
- Most care while traveling outside the United States
- Custodial care (help with bathing, dressing, eating, etc.)
- There is no yearly limit for what you pay out-of-pocket
- You do not generally need to file Medicare claims (providers and suppliers file your claims for the covered services and supplies you get)
- Your out-of-pocket costs are affected by whether your doctor accepts assignment
- If you choose to get services or supplies not covered by Medicare, you pay all the costs unless you have other insurance that covers it
- The amount you have to pay can be different if you have Medicaid or get state help paying your Medicare costs
Original Medicare helps to pay for many health care items and services, but you will pay a share of the cost too. Your Medicare costs include:
A premium is a fixed amount that you pay each month to have the insurance policy in place (and can change from year to year).
A deductible is a set amount that you pay before your plan begins to pay.
A co-payment (or co-pay) is a preset, fixed amount you pay at the time you receive a covered service. For example, you might pay $25 each time you go to the doctor.
Co-insurance is when you and Medicare split the cost of a covered service. For example, you might pay 20% of the allowed amount and your plan would pay 80%.
Many people continue working after they reach age 65. Their employer may have group health insurance. How does Medicare affect these people?
If You Are Still Working At 65:
- You can still enroll in Medicare Parts A and B but you may choose to delay enrollment in Part B since there is a monthly premium cost
- Consider speaking with your benefit administrator to find out the options and how your employer coverage works with Medicare
- Keep records of your health insurance coverage
Once Retiring After 65:
- When you retire or otherwise lose your employer insurance coverage, you are eligible to then enroll in Medicare
- Allows for enrollment in a Medicare plan after employer coverage ends without penalty
- Best to sign up before you retire to avoid a lapse in coverage
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