Medicare

Medicare 65

It is a federal health insurance program that primarily caters to Americans aged 65 or older.

The program also provides exceptional coverage for individuals under the prime age of 65 who may be suffering from certain disabilities or End-Stage Renal Disease (ESRD) which includes permanent kidney failure and require dialysis or a transplant.

The program is under the administration of the Centers for Medicare & Medicaid Services. This program currently caters to some 64 million Americans.

How Medicare Works

You have two options for getting coverage:

Original Medicare

• This is inclusive of Medicare Part A and Part B.
• You pay will pay for services as you get them. (A deductible at the beginning of each year, and you usually pay 20% in coinsurance).
• A separate drug plan (Part D) is required if you wish to have drug coverage.

Original Medicare caters to some medical costs but not all. It’s prudent to co-opt a Medicare Supplement Insurance (Medigap) policy to help offset copayments, coinsurance, and deductibles.

Some Medigap policies will have an addition that will cover emergency medical care when traveling outside the U.S.

Medicare Advantage

This is a Medicare-approved plan offered by a private company as an alternative to Original Medicare coverage.

These are “bundled” plans with elements of Part A, Part B, and sometimes Part D.

This plan offers extra benefits not found in the Original Medicare— vision, hearing, and dental services.

Medicare Advantage Plans sign annual contracts with Medicare and are bound by Medicare’s coverage rules. The plan is obliged to issue advance notices in respect of any changes that will affect you before the beginning of the next enrollment year.

Each Medicare Advantage Plan is allowed to have its own charges for out-of-pocket costs. They are also allowed to tailor their rules regarding how you access their services.

Medicare prescription drug coverage (Part D)

Drug coverage helps in the payment of prescription drugs.

To get this coverage, you have to join a Medicare-approved plan that comes with drug coverage like:

• Drug plans and
• Advantage Plans with drug coverage.

These two plans vary in cost and the drugs covered but at least do offer the standard level of coverage as set by Medicare for both generic and brand-name drugs.

Plans are allowed to vary the list of prescription drugs covered (formulary) and the placement of drugs into these “tiers” on their formularies.

Plans have different monthly premiums (other costs not included). How much you are required to pay for each drug depends on the plan chosen.

What Medicare Covers

Medicare 4 Parts

These are the 4 parts of the plan(Part A, Part B, Part C, and Part D);

1. Part A

Part A helps to cater for inpatient costs when admitted formally on a doctor’s order, and when in need of limited skilled nursing facilities (for 3 days-not of custodial or long-term care). You will get coverage benefits for:

• Walkers
• wheelchairs
• hospice care
• some home healthcare services
• blood transfusions

Cost:

Most Americans are not required to pay monthly premiums for Part A. Most employees (or their spouses) already paid Medicare taxes while in employment. This is why it’s sometimes referred to as “premium-free Part A.”

If Medicare taxes were paid for between 30–39 quarters, the standard Part A premium will be $274.

However, If you (or your spouse) never paid Medicare taxes(or less than 30 Quarters) while on employment and aged above 65, you may be allowed to purchase Part A(up to $499 per month in 2022).

You will pay a further $1,556 for each benefit period as for Part A deductible.

After meeting the deductibles for the year, coinsurance will be as below:

2. Part B

Part B covers two types of benefits;

• Doctor’s services(diagnosis or treatments) and
• Preventive services (yearly doctor checks and tests).

There is usually no cost for preventive services from a healthcare provider who accepts the assignment.

It’s prudent to have both A and B together to get the most coverage. For example, if admitted, inpatient costs will be covered by Part A and the doctor’s fees will be covered under Part B.

Part B covers an array of tests and services, which includes:

• Cancer screening, treatment for depression(inpatient, outpatient, and partial hospitalization), and diabetes
• Clinical research
• Ambulance and evacuation services
• Vaccination (influenza and hepatitis)
• Durable Medical Equipment (DME)
• diabetes supplies
• Limited outpatient prescription medication

Cost:

Part B premiums are payable every month. They are automatically deducted from payments. This is done through:

• The Social Security
• Railroad Retirement Board
• Office of Personnel Management

If you don’t qualify for any of the above benefit payments, expect a bill.

Most people will pay the standard premium amount ($170.10 in 2022).

However, if your modified adjusted gross income (MAGI) falls above a certain amount (based on the previous 2 years’ return), you may be required to pay an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an added charge to your current premium.

You will also be expected to fork in a further $233 for the Part B deductible.

After meeting the deductibles for the year, you typically incur 20% of the coinsurance for below:

• Most doctor services (includes inpatient doctor services while hospitalized)
• Outpatient therapy
• Durable Medical Equipment (DME)

Part C

Also called Medicare Advantage is a privately sold insurance option that has been approved by Medicare(like HMO or PPO) with the same coverage as parts A and B but with additional extra benefits like prescription drug plans, wellness programs, hearing, vision, dental and others that are not embedded in Medicare.

Medicare pays a fixed monthly amount for your care to this private insurance. However, these private insurance options come with different out-of-pocket costs and have their own rules on access to these services (like referrals to specialists). These rules do change every year.

In order to qualify for the Medicare Advantage plan, you must be enrolled in the original Medicare.

Cost:

The Part C monthly Premium will vary according to the plan enrolled. You will need to compare costs for the specific Part C plans(like HMO or PPO).

Part D

This plan does cover prescription drugs (including many recommended shots or vaccines) that are not covered by Part B, typically the kind of drugs or medications that need to be administered by a doctor (infusion or injection).

Medicare part D is optional, but the majority of people co-opt it so that their medications are fully covered.

Cost: The Part D monthly Premium will vary according to the plan enrolled ((higher-income consumers always pay more).). You will need to compare costs for the specific Part D plans.

How Medicare Works With Other Insurance

If you have coverage with Medicare and another coverage from another health insurance (group health plan, retiree coverage, or Medicaid), each type of coverage is referred to as a “payer.”

Always, when there is more than one payer, “coordination of benefits” rules will be used to settle on who should pay first.

The “primary payer” will pay up to its limit of the coverage, and then transfers the rest of the bill to the “secondary payer”.

The same applies if there is a third payer.

If the primary payer fails to settle the Claim in time (within 120 days), Medicare is usually billed. Medicare will make conditional payments, and later recover any payments from the primary payer.

Medicare 8 Minute Rule

The 8-Minute Rule provides guidelines on how practitioners are to go about the determination of billable units to Medicare for the provision of outpatient services on a particular date of service.

Basically, practitioners need to provide direct, one-on-one time physical therapy for a minimum of eight minutes to qualify for reimbursement for a unit of a time-based treatment code.

Its importance is seen in cases where a practitioner needs to bill for both time and service-based codes in a single patient visit. A number of factors will have to be met for a service to be billed according to this rule.

Example: If a practitioner’s initial evaluation lasts for 35 minutes with a 7-minute physical therapy, only the bill for evaluation is valid. In order for the physical therapy bill to be valid, the practitioner will have to spend more time with the patient.

Medicare Long-Term Care

The plan doesn’t cover any type of long-term care, nursing homes, assisted living communities, or your own home as this fall under custodial care.

The program will cater to medical costs in this setting, however, it will not cater for the cost of staying in a long-term care center or custodial care — especially — if has anything to do with “activities of daily living.”

However, Medicare does provide coverage for:

• Long term Care that’s being provided in a hospital
• Skilled Nursing care to be provided in a skilled nursing facility
• Eligible home health services
• Hospice/Respite care

Medicare Where to Apply

The enrollment window opens three months before your 65th birthday. This includes the seven-month window before your 65th birthday (including three months to your 65^th birthday month, and three months after your birthday month)

You will be enrolled automatically(Medicare Part A and Part B) if you clock 65years and already receiving Social Security benefits.

If you are not taking Social Security, you need to enroll for both Medicare Part A and Part B in 3 ways; through the Social Security Administration website, Calling the Social Security at 800-772-1213, Or Contacting your local Social Security office.

This is the time to initiate your enrollment:

• Initial Enrollment Period:

  It should be automatic for most individuals. If not, you need to enroll at least seven months around your 65th birthday: the three months before and after your birthday month, plus your birthday month.

• General Enrollment Period:

  If you missed an application during your initial enrollment period, you can do so during Medicare’s general enrollment period, which is the period between Jan. 1 to March 31 each year. Coverage will kick on July 1, and you may owe a 10% late penalty.

• Special Enrollment Period:

This is the period when you can;

1. Join Medicare or
2. Make changes to your coverage based on a few specific life events.

Around enrollment time, Medicare will dispatch a “Welcome” packet that contains your Medicare card.

The open enrollment period is between Oct. 15th and Dec. 7^th of every year. At this time, every year beneficiaries can;

• Pick their new Medicare Part D drug plan,
• Make a selection for a Medicare Advantage plan, or
• Switch their Original Medicare into a Medicare Advantage plan or the other way around.

Keep in mind the best time for enrolling in the Medigap plan is during the first enrollment window (around your 65th birthday).

Missing the initial deadline for Medicare Part B sign-up period might expose you to penalties for life. It may also mean having to wait before your insurance kicks in.

Enrolled in Medicare Part D for prescription drug coverage is by choice — not automatic.

Enrollment exceptions

Medicare 65 Still Working

Taxpayers who are over 65 and still have qualifying health insurance through their employer, have a bigger enrollment window.

If you work with an employer that has more than 20 employees you delay Medicare Parts A and B after turning 65.

If your employer has less than 20 employees, it’s safer to enroll for Medicare Parts A and B the moment you attain eligibility. In such a scenario, Medicare will provide primary coverage and employer-based will be secondary coverage.

Individuals under the Age of 65 with Disabilities

The program is available for disabled individuals who are younger than 65.

Qualification for Social Security Disability can lead to automatic enrollment into Medicare.

However, handled on a case-by-case basis, and sometimes there is a waiting period before you access the Medicare card.

Is Medicare Free

Most Americans will get coverage for Part A for free. This will apply to the majority of individuals who (or their spouses) had already contributed to Medicare taxes while in employment (this is the “premium-free Part A.”)

If the individual only paid Medicare taxes for between 30–39 quarters, they will pay a premium of $274 for the standard Part A.

If they (or your spouse) never paid taxes (or paid for less than 30 Quarters) while on employment and they have attained the age of above 65, they have the option of purchasing Part A (for up to $499 per month in 2022).

A further $1,556 is payable for each benefit period of the Part A deductible.

Medicare to Medicaid

Is Medicare and Medicaid the Same

Do not confuse Medicare with Medicaid-medical coverage assistance for low-income households run by individual states.

If you qualify for both health services, Medicare is the primary payer for the plan-covered costs, and Medicaid pays second.

Medicare and Social Security Tax

Social security and Medicare taxes are applicable to all payments in lieu of wages in the United States, regardless of the citizenship or residency status of either the employee or the employer. On some limited occasions, these taxes may apply to wages paid for services outside the border of the United States.

With these taxes, the federal government is able to fund Original Medicare (Part A and Part B).

Private insurance companies are running the other parts under supervision.

Bottom-line

 Please take note;

• IRS does not allow Voluntary social security payments if taxes are not payable.
• The program is not available in the Health Insurance Marketplace hence fully compliant with the health care law.