Medicare is a program of health insurance for the elderly that is administered by the federal government. Most persons automatically become eligible for Medicare at age 65, but the program also includes persons under age 65 who are disabled. Personal income is not a factor in determining eligibility.
Medicare consists of three parts:
- Part A (Hospital Insurance) provides hospital benefits, limited post hospital skilled nursing facility care, part-time home health services, and hospice care. It is financed through Social Security payroll tax deductions. Medicare beneficiaries participate in the financing of Part A services through deductibles, coinsurance and premium payments.
- Part B (Supplemental Medical Insurance or SMI) is a voluntary program of health insurance which covers physician's services, certain outpatient services, home health care, diagnostic tests, medical appliances, and prescription drugs. It is financed partly from the monthly premiums paid by enrollees and partly by federal contributions.
- Part C (Medicare Advantage) is a delivery system that covers the same services and items that are covered under Parts A and B. A beneficiary can elect to participate in either original Medicare, or may choose from among several Part C - Medicare Advantage plans.
Part D is a Medicare Prescription Drug Benefit. People who are entitled to benefits under Part A or enrolled in Part B are ''Part D eligible individuals.'' Each individual is entitled to obtain ''qualified'' prescription drug coverage by enrolling in a Prescription Drug Plan (PDP) or a Medicare Advantage Plan with prescription drug coverage (MA-PD).
Medigap insurance is supplemental health insurance which individuals can purchase from private insurers. Medigap insurance is supposed to cover required copayments and health services not provided by Part B.
Part A Eligibility
The following groups of persons are eligible for hospital insurance benefits under Part A:
- Persons age 65 and older who are insured workers
- Disability beneficiaries
- Persons under age 65 with ''end-stage renal disease''
- Federal employees
- Voluntary purchasers of coverage
People qualify for hospital insurance benefits under Part A of Medicare when they become age 65 and are entitled to Social Security retirement benefits or are certified as a qualified railroad retirement beneficiary. They should apply for the retirement benefits and for Medicare.
Part B Eligibility
An individual age 65 or over is eligible for enrollment in SMI if the individual is either:
- Entitled to hospital insurance under Part A or
- A resident of the United States and is either an American citizen or a permanent resident alien who has resided in the United States for the five years immediately before the month of application for enrollment
Eligibility for Part B does not depend on Part A eligibility.
Part B Enrollment
Enrollment occurs either by written application or automatically by establishing entitlement to Social Security benefits or Part A hospital insurance.
Part B Payment
Once an individual is properly enrolled in SMI, a monthly premium must be paid for coverage until termination or death. The amount of the premium is established annually by the Department of Health and Human Services.
In addition to the monthly premium, a Medicare Part B beneficiary must pay an annual deductible and a coinsurance charge for each covered item or service.
Part C Eligibility
An individual eligible for Medicare Advantage can elect to receive Part C Medicare from a Medicare Advantage organization. Eligible individuals are people who:
- Are entitled to benefits under Medicare Part A and are enrolled under Medicare Part B
- Meet the residency requirements
- Complete and sign the election form
- Agree to abide by the Medicare Advantage organization's rules
Questions for Your Attorney
- Does Medicare Part A cover physician's services?
- Can I enroll in Part D for prescription drug benefits if I am eligible for benefits under Part A?
- Who is eligible for hospital insurance benefits under Part A?