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Medicare | Eligibility, Parts, Benefits, Costs & How to Enroll ?

Medicare


What is Medicare ?


Medicare is a government national health insurance program in the United States, begun in 1965 under the Social Security Administration (SSA). The Centers for Medicare and Medicaid Services (CMS) presently oversees the program. In addition to some younger people with disability status as established by the SSA, such as those with end-stage renal illness and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), it primarily offers health insurance for Americans 65 and older.

Medicare enables the elderly and disabled to pay for the necessary medical treatment. Medicare is broken down into various plans that cover a range of medical circumstances, some of which are paid for by the insured person. While doing so enables the program to give consumers more cost and coverage options, it also makes the enrollment process more difficult.

The American government's health insurance program, Medicare, provides financial assistance for medical services. The program assists with the cost of healthcare, although it does not pay for the majority of long-term care costs or all medical expenses. You can choose how you want to sign up for Medicare. You can purchase a Medicare Supplement Insurance (Medigap) policy from a commercial insurance provider if you decide to have Original Medicare (Part A and Part B) coverage.

Medicare doesn't cover all medical expenditures, but it can help you pay less out of pocket for healthcare. Applying for a Medicare supplement (Medigap) policy or a Medicare Advantage plan will help you fill in some of these gaps. Medicare does not pay for long-term care or custodial care needed to handle daily living activities including eating, taking a shower, and getting out of bed.

If they have worked and paid Medicare taxes for a sufficient amount of time, the majority of adults 65 and older are eligible for free Medicare hospital insurance (Part A). You can enroll in Medicare Part B medical insurance by making a monthly premium payment. Some recipients who earn more will pay a larger Part B premium each month. Read Medicare Premiums: Rules For Higher-Income Beneficiaries for more information.

Key Facts of Medicare


  • Medicare is a federal program that pays for healthcare services for those who are 65 years of age or older, as well as younger persons who meet certain requirements and those who have certain disorders.
  • The four parts of Medicare—Medicare Part A, Part B, Medicare Part C (commonly known as Medicare Advantage), and Part D for prescription drugs—are separated into separate groups.
  • For those have paid into Medicare through payroll taxes for ten or more years, Part A premiums are free.
  • Other components of the Medicare program require patients to pay premiums.
  • If you don't enroll during your initial enrollment period, there may be long-term late enrollment fees.
  • In general, you can sign up for Parts A, B, and D together with a Medigap coverage, or Parts A and B and a Medicare Advantage plan.

How the Medicare Program Funded ?


Medicare is funded by a combination of a specific payroll tax, beneficiary premiums, and surtaxes from beneficiaries, co-pays and deductibles, and general U.S. Treasury revenue.

How Does Medicare Works ?


Medicare is a federally sponsored national healthcare program. The program was established by Congress in 1965 as part of modifications to the Social Security Act to provide coverage for seniors 65 and older who lacked health insurance.

The Centers for Medicare and Medicaid Services (CMS), which now oversees the program, has expanded its coverage to include those with specific disabilities, end-stage renal disease, and amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease.

Medicare is divided into four sections, each of which offers its insured members a variety of services.

You are enrolled in Original Medicare by Social Security (Part A and Part B).
  • Hospital inpatient care and short-term stays in skilled nursing facilities are financed in part by Medicare Part A (hospital insurance) (following a hospital stay). Hospice care and some home health care are also covered by Part A.
  • Inpatient care, outpatient care, home health care, durable medical equipment, and some preventive services are all covered by Medicare Part B (medical insurance).
Private insurance companies that adhere to Medicare rules manage other aspects of Medicare.
  • Medicare out-of-pocket costs for co payments, coinsurance, and deductibles are covered by supplemental (Medigap) insurance.
  • Prescription medicines and extra benefits including vision, hearing, and dentistry are all covered under Part A and Part B by the Medicare Advantage Plan (formerly known as Part C), which combines all of these benefits into a single plan.
  • Prescription drug costs are partially covered by Medicare Part D (Medicare prescription drug coverage).

Who is Eligible for Medicare ?


All people 65 years of age or older who have been lawful residents of the United States for at least five years are eligible for Medicare, though eligibility is contingent on a number of factors. If they are receiving Social Security Disability Insurance (SSDI) benefits, people with disabilities under 65 may also be eligible.

Additionally, certain medical problems may make persons eligible for Medicare enrollment. A person is automatically qualified if they suffer from a specific disability, such as amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease), or chronic renal failure.

There is no income limit for Medicare. However, there is a point at which your Medicare premiums may increase.

The following situations qualify a person for Medicare coverage and completely waive their Medicare Part A premiums:
  • They have paid Medicare taxes for at least 10 years and are 65 years of age or older US nationals or permanent legal residents who have lived in the country for five consecutive years.
  • They are under 65, disabled, and have been receiving either Social Security SSDI benefits or Railroad Retirement Board disability benefits. Prior to being qualified for Medicare, a person must have been receiving one of these benefits for at least 24 months following the date of entitlement (eligibility for the first disability payment).
  • For end-stage renal disease, they get ongoing dialysis or require a kidney transplant.
If they or their spouse have not paid the required Medicare payroll taxes, those 65 and older who opt to participate in Part A Medicare must pay a monthly premium to maintain their enrollment.

Anyone who gets Social Security benefits is automatically enrolled in Parts A and B. Enrollment in Part D coverage is up to the individual, and it is optional.

People with impairments who receive SSDI remain eligible for Medicare as long as they continue to receive SSDI payments; but, if they cease receiving SSDI, they lose their disability-based eligibility for Medicare. SSDI recipients must typically wait 24 months after receiving their initial check before becoming eligible for Medicare, while the program exempts those with ALS and/or chronic renal failure from this rule.

Some recipients qualify for two benefits. They are therefore eligible for both Medicaid and Medicare. Medicaid will cover some of the beneficiaries' out-of-pocket medical and hospital expenses in some states for those earning below a specified income level, as well as their Part B premium (most beneficiaries have worked long enough to have no Part A premium).

NOTE :
Regardless of age, Medicare is immediately available to everyone with ALS.

Types of Medicare


Parts A, B, C, D, and Medigap plans make up the various components of Medicare. Each component has its own restrictions regarding premiums, deductibles, enrollment, and late enrollment fees. It also covers a particular spectrum of services.

What is Medicare Part A ?


Medicare Part A pays for the expenses that hospitals and other inpatient or inpatient-like settings, including skilled nursing facilities, hospice care, and some home healthcare, charge. Long-term or custodial care are not, however, covered by this plan. Anyone who receives Social Security income is automatically covered. On the SSA website, enrollment is possible for persons who do not receive benefits.

Deductible :
The Part A hospital inpatient deductible will increase to $1,556 in 2022 from $1,484 in 2021.

The Part A deductibles and coinsurance are as follows:

Part A Deductible and Co-insurance Amounts for Calendar Years 2021 and 2022

 

2021

2022

Inpatient hospital deductible

$1,484

$1,556

Daily co-insurance for 61st–90th Day

$371

$389

Daily co-insurance for lifetime reserve days

$742

$778

Skilled nursing facility co-insurance

$185.50

$194.50


Premium
As long as you or your spouse paid the required amount of payments toward Medicare taxes while working, Part A usually does not require you to pay a premium. Work must be done for forty quarters.

Enrollment periods:

Initial enrollment: 
This seven-month period runs from three months prior to your 65th birthday until three months following that milestone.

Special enrollment: 
You can enroll at any point while you're still covered by the group health plan, or during the first eight months after your employment or coverage expires, whichever comes first, if you didn't enroll during your first enrollment period because you're covered by a health plan from your employer.

General enrollment: 
The general enrollment period, which runs from January 1 to March 31, is when you can enroll each year. However, there may be a late registration fee.

Outside a designated enrollment period: 
If you are eligible for premium-free Part A and weren't automatically enrolled, you can enroll at any time after becoming eligible for Medicare. Six months before the application deadline, Part A coverage will start. Retroactively, but no earlier than the month you first met the eligibility requirements, it will take effect.

Late enrollment penalty: 
If you're obliged to pay a premium and don't enroll when you're first eligible, you'll be assessed a late enrollment fee that can raise your monthly premium by up to 10% for twice as many years as you didn't enroll.

What is Medicare Part B ?


Medicare Part B often pays for the costs of outpatient care, including trips to the doctor. Preventive services, ambulance services, specific medical supplies, and mental health coverage are also covered by Part B. Some prescription medications are also covered by this plan.

Premium
The regular Part B premium will rise from $148.50 in 2021 to $170.10 in 2022. Your income will determine whether you pay extra.

Deductible: 
The Part B deductible will rise from $203 in 2021 to $233 in 2022.

Enrollment periods:

The enrollment windows for Part B are substantially similar to the windows for Part A.

Initial enrollment: 
This seven-month period runs from three months prior to your 65th birthday to three months following it.

Special enrollment: 
You can join at any time while you're still protected by the group health plan or during the first eight months after your job or coverage ends, whichever comes first, if you choose not to do so because you have an employer-sponsored health plan.

General enrollment: 
The general enrollment period, which runs from January 1 to March 31, is when you can enroll each year. However, there may be a late registration fee.

Late enrollment penalty: 
If you don't enroll in Part B when you become eligible, you might have to pay a permanent late enrollment fee. For each year you didn't sign up, you'll incur a penalty equal to a 10% premium rise.

What is Medicare Part C ?


Part C, often known as Medicare Advantage, is available to those who qualify for Medicare Parts A and B. Instead of through the government, consumers purchase Medicare Advantage plans from private insurers. Medicare Advantage plans must provide protection at least on par with Original Medicare (Parts A and B).

A lot of these plans have yearly caps on out-of-pocket expenses. Many also offer extra advantages, such as co-pays, co-insurance, deductibles, and even charges associated with insurance while travelling outside the United States, that Original Medicare patients would otherwise have to obtain through supplemental insurance like a Medigap plan. Additionally, dental, eye, and hearing care may be included by some policies.

Though some Medicare Advantage plans do offer hearing services as supplementary benefits, standard Medicare does not cover hearing aids.

Premium: 
In addition to your Part A premium (if applicable) and Part B premium, certain MA plans require additional premium payments from you. Others don't charge a premium and might contribute to paying all or some of your Part B premiums.

Deductible: 
The deductibles for each plan differ.

Enrollment period:

Initial enrollment: 
This seven-month period runs from three months prior to your 65th birthday to three months following it.

Special enrollment: 
If a circumstance arises that leaves you without coverage, such as losing another type of coverage, you might be eligible to enroll in a Medicare Advantage plan.

Open enrollment: 
If you already have Original Medicare (Parts A and B) and want to enroll in a Medicare Advantage plan, you can do so between October 15 and December 7 of each year.

General enrollment:
If you already have Part A and acquire Part B for the first time during this time, you may join during regular enrollment, which runs from January 1 to March 31.

Late enrollment penalty: 
You must have Parts A and B in order to enroll in this plan, but there is no penalty for enrolling late. If you fail to enroll in Part A (if you must pay for it) or Part B during your initial enrollment period or a special enrollment period, you may still be subject to a penalty.

What is Medicare Part D ?


Private insurance providers under Medicare Part D offer drug coverage, which aids in defraying the cost of prescription medications. Medicare Part A or Part B beneficiaries may sign up for Part D in order to get financial assistance for prescription medication expenditures that Original Medicare plans do not cover.

Premium: 
The majority of Part D plans have monthly premiums. However, depending on the plan you select, your premium, deductible, co-payment, and coinsurance will all be different.

Deductible: 
Deductibles vary between plans.

Enrollment period:

Initial enrollment: 
This seven-month period runs from three months prior to your 65th birthday to three months following it.

Special enrollment: 
If something happens that results in you losing coverage, such moving or quitting your work, you could be eligible to sign up for a Medicare Part D medication plan.

Open enrollment: 
As long as you already have Part A or Part B, you are eligible to enrol in a drug plan during Open Enrollment, which runs from October 15 through December 7 each year.

After general enrollment: 
If you don't have Part A and enroll in Part B from January 1 to March 31, you can sign up for a Medicare drug plan from April 1 to June 30. (the general enrollment period).

Medicare Advantage open enrollment: 
If you cancel your MA plan and switch back to Original Medicare from January 1 to March 31 each year, you can enroll in Part D.

Late enrollment penalty:
If you enroll in Part D any time after your initial enrollment period expires and you don't have alternative creditable coverage, a late enrollment fee penalty can be imposed. Depending on how long you remained without coverage, a penalty may be permanently added to your rate.

What is Medigap  ?


Private insurance companies may provide optional Medigap coverage, sometimes known as Medicare supplement insurance, which can improve the advantages of Original Medicare. Co-pays, coinsurance, and deductibles can all be covered by a variety of basic plan types. To purchase a Medigap plan, you must have both Parts A and B. Prescription medication is not covered by Medigap plans. For that, you require an MA plan or Part D. Most also don't offer insurance for hearing, vision, or dental health.

Premium: 
Premiums for Medigap is vary.

Deductible: 
Depending on the plan, deductibles can change. Many plans offer no deductibles and lower copays, coinsurance, and Part A and/or B deductibles.

Enrollment period:

Medigap open enrollment: 
If you have Part B and are 65 or older, this period starts the first month you have it. It has a six-month lifespan. When determining whether to offer you a Medigap policy and how much to charge you during this time, insurers cannot take your health into account.

Outside Medigap open enrollment: 
Though an insurer is willing to sell you a plan, you could still be able to purchase one even if your Medigap open enrollment period has passed.

Late enrollment penalty: 
If you don't purchase a plan during Medigap open enrollment, there isn't technically a late enrollment penalty, but you may end up paying significantly more for a Medigap policy or being rejected entirely. Outside of the Medigap open enrollment period, insurers may price and offer you a plan based on your health and any pre-existing conditions.

What Does the Medicare Cost ?


For Medicare coverage, you typically pay a monthly premium as well as a portion of the costs each time you receive a covered service. Unless you have additional coverage, such as a Medicare Supplement Insurance (Medigap) policy, or you enroll in a Medicare Advantage Plan, there is no annual cap on the amount you can pay out-of-pocket.

The total cost of Medicare for you will depend on what parts and plans you select for your coverage.

Cost of Medicare Part A

According to the Medicare program, 99% of enrollees get Medicare Part A for free. In 2022, those who are not eligible will pay between $274 and $499 per month; the precise amount will depend on how much Medicare taxes they or their spouse have paid.
  • Cost per month : Typically free
  • 2022 annual deductible: $1,556

Cost of Medicare Part B

The cost of Medicare Part B for high earners is determined by your adjusted gross income (AGI) from your prior year's taxes. These additional fees will only be paid by around 7% of members. You can calculate your monthly Part B premium by multiplying these income amounts by two if you and your spouse file joint taxes. Annual updates to these numbers are made by the Social Security Administration (SSA).
  • Standard cost in 2022 : $170.10
  • 2022 annual deductible: $233

Cost of Medicare Part C

Part C is a wholly private health insurance plan, which means that prices and coverage do not follow industry standards. Each policy has a unique coinsurance, premium, and deductible structure. To discover the best Medicare Advantage plan, compare options on the Medicare.gov website.
  • Average cost in 2022: $33 per month
  • In 2022, the annual deductible will vary by plan.

Cost of Medicare Part D

The cost of Medicare Part D will vary depending on the plan you select and the size of your household. In addition to the cost of the plan, those with earnings exceeding $91,000 will also pay an extra premium. This Medicare adjustment fee, which is automatically withdrawn from the Social Security benefits of individuals who qualify, is paid by only around 8% of members.
  • Cost on average in 2022: $42 monthly
  • Drug deductible typical in 2022: $344

Cost of Medicare Supplement

A Medicare Supplement plan, often known as a Medigap plan, will cost on average $163 per month in 2022. The insurance you select and the pricing system in your state will determine expenses, though.

Medicare Costs Comparing Tool


A user can utilize a tool provided by Medicare to compare the annual costs of Original Medicare and Medicare Advantage plans.

When utilizing the tool, users can choose an Advantage plan with a low, medium, or high premium. The expected annual cost of Medicare Advantage is cheaper than Original Medicare regardless of the premium they select.

The cost comparison tool also enables users to decide whether to include Medigap, a supplemental insurance that pays for expenses not covered by Medicare, and Part D, which provides prescription medication coverage.

The cost of Original Medicare rises if additional plans are added, widening the gap between Medicare Advantage and Original Medicare.
 

How to Calculate Medicare Premium ?

 
Find out your premium cost and when you'll be eligible for Medicare. To find out more about your unique eligibility or premium, get in touch with Social Security (or the Railroad Retirement Board if you get railroad benefits) if your case isn't included.


How Much is the Medicare ?


Monthly $170.10 (or higher depending on your income). The sum is subject to annual revision. Even if you don't use any Part B-covered services, you still have to pay the monthly fee.

Costs for Medicare Advantage plans are capped annually, so members are not responsible for any costs that are more than the ceiling.

Out-of-Pocket Maximums :

Medicare out-of-pocket costs are the amount you are responsible to pay after Medicare pays its share of your medical benefits. 

Although Original Medicare doesn't impose an annual cap on your out-of-pocket costs, certain Medigap insurance do have a cap that applies to your Original Medicare coverage.

Alternatives to Original Medicare include Medicare Advantage, which does reduce your out-of-pocket expenses. The maximum in-network out-of-pocket expenses for the majority of Medicare Advantage plans in 2022 remain at $7,550 from 2021. This is the maximum, though many designs have lower caps.
 
Medicare Advantage enrollees typical out-of-pocket maximums are $4,972 for in-network services and $9,245 for both in-network and out-of-network services (PPOs) Since 2011, Medicare Advantage plans have been obliged by federal law to provide an out-of-pocket maximum for services covered by Parts A and B.

Drug Coverage :

All Part D plans and the majority of Medicare Advantage plans cover prescription drugs. Private insurance companies handle the administration of the plans, which might vary in terms of coverage, rates, deductibles, and other aspects. The Medicare Plan Finder allows you to compare Part D prescription plans and Medicare Advantage plans.

In 2022, a Medicare Advantage plan will have an average monthly cost of $19. The typical monthly cost for a Part D plan will be $33.

How to Apply for Medicare ?


The process you'll follow to apply for and get Medicare will be determined by your eligibility.

When you apply for disability or retirement benefits from the Social Security Administration or Railroad Retirement Board, Medicare is also automatically applied for. If you had such benefits for at least four months prior to turning 65, you'll be enrolled in Parts A and B coverage automatically.

If you're over 65, you can apply for Medicare with the Social Security Administration online, via phone, or by contacting your local Social Security office. If you missed your first enrollment window and don't have any alternative health insurance, including prescription medication coverage, late enrollment fees may be charged.

If you have ESRD and are under 65, you can apply for Medicare coverage by contacting your local Social Security office (or the Railroad Retirement Board if you or your spouse worked for a railroad). Your treatment plan and the time you apply will determine when your coverage will begin.

If you have Amyotrophic Lateral Sclerosis and are under 65, you will automatically get Medicare Parts A and B the month your disability benefits begin (ALS). To apply for disability benefits, get in touch with your local Social Security office.

If you want to enroll in a Medicare Advantage plan, you can visit the Medicare website to browse plans and evaluate options to choose the one that's best for you.

You must enroll on your own if you want Medicare Part D prescription drug coverage. Through the SSA website, you can register for this if you don't currently get Social Security payments. Around the time of your 65th birthday, you should do this within a seven-month window. The three months prior to the month you turn 65, the month of your birthday, and the three months following your birthday month are all included in this time-frame. You might be penalized if you skip this window.

You must enroll on your own if you want Medicare Supplement Insurance. When you turn 65 and enroll in Medicare Part B, the enrollment period for this begins. If you join up within that time, the private insurers that offer Medigap insurance are compelled to accept you. There is no assurance that they will sell you a Medigap plan if this is not the case.

There are other yearly Medicare open enrollment opportunities if you miss your original enrollment window or decide to switch programs later.

NOTE:
If you are under 65 and have a disability, you will automatically qualify for Medicare benefits once you have received disability benefits for 24 months.

People who had trouble calling SSA on the phone and were unable to submit premium-Part A or Part B enrollment or disenrollment petitions in a timely manner are receiving equitable assistance from the Centers for Medicare & Medicaid Services. The General Enrollment Period, Initial Enrollment Period, and Special Enrollment Period are all covered by this relief.

After January 1, 2022, if you were unable to enroll in or withdraw from Medicare because you couldn't reach the SSA by phone, you will be given an extension until December 30, 2022.


How to Apply Online for Just Medicare ?


If you choose to wait to apply for your retirement or spouse's benefits, you can utilize the online retirement application to enroll only in Medicare. There are no forms to sign, and typically no documentation is needed. It takes less than ten minutes.

Visit www.ssa.gov for the most practical method to conduct business with the SSA from anywhere and on any device. You can do a lot of things online, such apply for benefits, find publications, and acquire important information. If you're deaf or hard of hearing, you can call toll-free at 1-800-772-1213 or 1-800-325-0778 (TTY). Refer, How to Apply Online for Medicare Only.

APPLY

Other Medicare Enrollment Options :

  • You won't automatically receive Medicare Part B (medical insurance) if you reside in Puerto Rico. You must enroll in it during your IEP in order to avoid paying a fine. Call 1-800-772-1213, which is our toll-free number, to enroll (TTY 1-800-325-0778). You could also call the Social Security office in your area. Using our Office Locator, you can find the Social Security office closest to you.
  • You can also get in touch with the Federal Benefits Unit that serves your country of residence if you don't reside in the United States or one of its territories.

Upcoming Change :

Rules for 2023 and later : Your coverage will begin the month you first become eligible if you accept the automatic enrollment in Medicare Part B or if you sign up during the first three months of your IEP. Your coverage will begin on the first day of the following month if you enroll after January 1, 2023, during the month you turn 65 or the final three months of your IEP.

What Happens After Apply for Medicare ?


Medicare is overseen by the Centers for Medicare & Medicaid Services (CMS). Your Medicare card and a Welcome to Medicare pamphlet will be mailed to you when you have completed the enrollment process. Additionally, you will receive the Medicare & You guide, which contains crucial details about your options for Medicare coverage.

Medicare Contacts



Frequently Asked Questions


What does Medicare not cover?
Still, Medicare doesn't cover a number of significant medical expenses. Long-term care, often known as custodial care, is the largest of them. These custodial expenses are covered by Medicaid, a federal health program for low-income people, but not by Medicare. Medicare frequently does not cover the following costs:
  • Eye examinations and eyeglasses
  • Dentures
  • Most dental care
  • Medical care overseas
  • Cosmetic surgery
  • Massage treatment

Is Medicare a insurance ?
Medicare and health insurance both provide coverage for medical expenses for those who qualify, but that's where the similarities end. The fundamental Medicare program is free, although it offers less coverage than commercial health insurance. Frequently, dependents like your spouse and children are covered under your private health insurance. Contrarily, Medicare is a form of personal insurance. Most Medicare beneficiaries must meet independent eligibility requirements based on their age or disability.

Medicare is free?
Due to their payment of payroll taxes in accordance with the Federal Insurance Contributions Act, the majority of people have access to free Medicare Part A. (FICA). Additionally, a person's spouse's employment history may qualify them for free Medicare Part A. An individual will be required to pay a premium for Medicare Part A if they are not eligible. Medicare's other variations demand a premium contribution.

What Does Medicare Pay For?
There are four various kinds of Medicare programs that are available to people, as was already discussed. Parts A and B or the Medicare Part C plan provide the majority of the basic Medicare coverage. People may also choose to sign up for the Medicare Part D program.

How much of your Social Security is deducted for Medicare?
The majority of people will have $170.10 taken out of their Social Security each month to pay for Medicare Part B. (medical insurance). For people with greater earnings, this sum will be higher. There are options to lower your monthly Medicare expenditures if you have a modest income.

At age 65, is Medicare Part A free?
Medicare Part A is free for those who have worked for more than ten years. Benefits from having paid Medicare taxes through payroll deductions or self-employment taxes include this hospital insurance.

What is the monthly cost of Medicare?
Your monthly expenses will depend on the type of Medicare. A Medicare Advantage plan may cost as much as $33 monthly on average in 2022. A Medicare Part D coverage for prescription medications typically costs $42 per month, while Medicare Part B is typically $170.10 per month.
 
How much do Medicare beneficiaries pay out of pocket?
 
Medicare was created with significant cost sharing and no out-of-pocket maximums in original Medicare, despite the fact that it is intended to pay the majority of your medical costs.
The more medical treatments you require, the higher your Medicare expenditures will be.

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