Medicare Is Health Insurance Provided By US Gov’t

Question: What is Medicare? I hear that all the time, but don’t understand what Medicare does.

Answer: Wow, is that a big question. So, I will cover Medicare and all its parts in a brief fashion to help clear up your confusion. Original Medicare is considered Medicare Parts A and B. Original Medicare began in 1965. Original Medicare is available to most American’s when they turn 65, sometimes younger if they are disabled or have a particular diagnosis.

Medicare is the health insurance coverage that is provided by the U.S. Government under the division of Center for Medicare and Medicaid Services (CMS).

Medicare Part A covers hospital admission, hospice, home care and rehabilitation stays. Medicare Part A has no premium as long as you have worked 40 quarters (10 years). If you worked less than 40 quarters you could have a monthly premium to get Medicare Part A. That monthly premium could be as much as $437 per month for Medicare Part A.

Medicare Part B covers outpatient procedures, things like doctor appointments, tests, X-rays, bloodwork, ambulance rides, emergency rooms, therapies and many others. Medicare Part B has a premium that is usually deducted from your Social Security monthly payment. That premium is $135.50 a month for most Americans. There is a higher premium for those individuals with a higher income.

Medicare Part D is the prescription drug coverage law. This is coverage that is not provided by the government, but is regulated by the government. If you have Medicare Part A and B, you must have prescription drug coverage (that is the law part), or if you want to sign up for it later, you will be penalized. Where and how you get that prescription drug coverage is up to you. You could get that from an employer plan, a retiree plan, the VA or one of the many Medicare approved Part D plans available in your part of the country. In Chautauqua Co, we have 44 plans available, & in Cattaraugus Co. we have 46 available plans.

Medicare Advantage Plans are plans that are offered by Independent Insurance Companies. These Insurance Companies contract with Medicare to provide you the individual Insurance Coverage that replaces your Original Medicare. You must have both Medicare Part A and B to sign up with a Medicare Advantage Plan. There are three types of Medicare Advantage plans available to most of us, Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), and Private Fee For Service (PFFS’s). There is a fourth category called Special Needs Plans (SNP’s) available to individuals who live in a Nursing Home, or have a particular diagnosis or health problems. All of these Medicare Advantage Plans take over your Medicare coverage. They become your only Health Insurance Coverage, Medicare goes inactive, and won’t pay any medical bills directly.

Medicare Supplement Plans are another type of coverage available to those with Medicare Part A and B. These are plans that work with Original Medicare and become the secondary coverage. Original Medicare would be your primary insurance, and the Medicare Supplement Plan (Medigap) becomes the secondary insurance coverage. The Medicare Supplement Plans come in a variety of types (letters) and the cost of the premium depends on the type of coverage you choose (letter) and the company you buy it from.

So, that is a very quick summary of all the common Medicare related types of coverage. Each type of coverage, Part A, Part B, Medicare Supplements, Part D, & Medicare Advantage Plans have different rules, and procedures that go along with them.

There is no one rule that applies to all of them. There is no one enrollment period timeline that applies to all of them. There is no one cost structure that applies to all of them. That is what makes Medicare so hard to understand.

When individuals ask questions about ‘Medicare’, we have to ask additional questions back to clarify what they are specifically asking about. Every type of Medicare coverage would have a different answer.

Often when individuals read my weekly column, they tell me that all the different answers I give confuse them. I am not surprised at all when I hear that! Medicare can be confusing. It is especially confusing when you are new to Medicare. Or when you are talking to someone about a Medicare product, you may think they are talking about Original Medicare, but they are in fact talking about a Medicare Advantage Plan.

To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at janells@lutheran-jamestown.org.

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