Medicare is a government-sponsored healthcare program in the United States that provides medical coverage for individuals aged 65 and older, as well as certain younger individuals with disabilities. Established in 1965 under President Lyndon B. Johnson, Medicare was designed to alleviate the financial burden of healthcare expenses for older Americans. In recent times, it has played a crucial role in ensuring access to essential healthcare services for millions of seniors and disabled individuals, providing them with much-needed financial support and peace of mind.

How Does Medicare Work?

It works through a combination of different parts, each covering specific aspects of healthcare.

1. Original Medicare

These are the two main parts of Medicare.

Part A, also known as Hospital Insurance, covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care service.  Most people do not have to pay a premium for Part A if they or their spouse have paid Medicare taxes while working. Generally Medicare part A covers home healthcare, skilled nursing facilities and psychotherapy.

Part B covers outpatient care, doctor visits, preventive services, medical supplies, and certain diagnostic tests. Part B requires a monthly premium, which is based on income. Individuals can opt out of Part B if they have other health coverage.

2. Medicare Advantage (Part C)

This is an alternative offered by private insurance companies approved by Medicare. Medicare Advantage plans typically provide the same coverage as Original Medicare but also offer additional benefits such as dental, vision, hearing, and prescription drug coverage. However, these plans typically have network restrictions, requiring beneficiaries to use healthcare providers within the plan’s network to receive full benefits.

3. Medicare Prescription Drug Coverage (Part D)

Part D is a component of Medicare that helps individuals afford necessary prescription drugs, thus ensuring better access to medication and promoting overall healthcare management. Offered through private insurance companies approved by Medicare, Part D plans are available to all Medicare beneficiaries. These plans also have a formulary, which is a list of covered medications, and different plans may have different formularies and cost-sharing structures. Beneficiaries typically pay a monthly premium, an annual deductible, and a portion of the prescription costs.

Who Is Eligible for Original Medicare?

Individuals aged 65 or older are generally eligible for Medicare. For Part A, most individuals who have worked and paid Medicare taxes for at least ten years are automatically enrolled without a premium. Those who don’t meet the criteria may still be eligible but have to pay a premium. Part B eligibility applies to individuals aged 65 or older, as well as those with certain disabilities who have been receiving Social Security Disability benefits for 24 months. Part B requires a monthly premium, and beneficiaries can decline coverage if they have other qualified health insurance.

Receiving Social Security Disability

What Are the Enrollment Requirements?

For most individuals turning 65, enrollment is automatic if they already receive Social Security or Railroad Retirement Board benefits. Those not receiving benefits need to actively enroll during the initial enrollment period, which starts three months before their 65th birthday and lasts for seven months. For individuals who miss this initial period, there are general enrollment periods where they can enroll but may face late enrollment penalties. Additionally, individuals can enroll or make changes during the annual enrollment period, which occurs from October 15th to December 7th each year.

What Are the Limits of Original Medicare?

There is no set financial limit or cap on the services covered. However, beneficiaries are responsible for certain costs, including deductibles, coinsurance, and copayments. Part A has a deductible for each benefit period, and there may be coinsurance or copayments for extended stays in hospitals or skilled nursing facilities. Part B also has an annual deductible, and beneficiaries typically pay a percentage (usually 20%) of the Medicare-approved amount for covered services. It’s crucial for beneficiaries to understand their cost-sharing responsibilities and consider additional coverage options to help manage expenses.

Can One Be Deregistered From Original Medicare?

Beneficiaries can be removed from the program if they are found to be involved in fraudulent activities or other violations. Medicare fraud involves deliberately submitting false information or deceitful practices to obtain healthcare payments or benefits. If beneficiaries are found guilty of fraudulent actions, their Medicare coverage can be terminated, and they may face legal consequences. This ensures the program’s integrity and protects the healthcare resources for those who genuinely need them.

Our health is the most vital aspect of our life. It affects our overall well-being, productivity, and happiness. By recognizing the significance of maintaining good health, original Medicare plays a crucial role in ensuring that beneficiaries are covered. This vital program enables beneficiaries to receive the help they need to address their medical needs and enhance their quality of life. By prioritizing healthcare through original Medicare, one can proactively safeguard their health and well-being, ultimately leading to a more fulfilling and satisfying life.