logo for integrative cardiologist Dr. Cynthia Thaik

What to Know About Medicare Health Insurance Coverage

Medical,Stethoscope,Twisted,In,Heart,Shape,Lying,On,Patient,Medical

Medicare is a health insurance program offered by the federal government and ran by the Centers for Medicare and Medicaid Services (CMS). It provides health insurance primarily for Americans over 65 and others with chronic health disabilities and conditions.

Many people often confuse it with Medicaid, but they have different offerings. Medicaid is a joint program between the state and federal governments offering health coverage to low-income people.

Medicare offers different coverage types, so it is essential to understand everything that goes into it before applying.

What Medicare Covers

Medicare comes in different parts, each offering different coverages, costs, and terms.

Part A

Also referred to as hospital insurance, it offers coverage for medical services provided when you are admitted to the hospital and other inpatient healthcare facilities.

🟣 Inpatient hospital care- The policy covers you for up to 90 days for every benefit period in a general hospital and 60 lifetime reserve days.

🟣 Inpatient rehab care- This is the care you receive after an injury, illness, or surgery after meeting specific criteria. Sometimes, you might have to stay in the hospital for three days before receiving the coverage.

🟣 Hospice care- This is care patients choose to receive if considered terminally ill. Part A Medicare covers hospice care for as long as you need care.

🟣 Limited home healthcare- The policy covers you for up to 100 days of daily home care or unlimited intermittent care.

🟣 Limited skilled nursing facility care- Part A covers board, room, and other services offered by SNFs including wound care, tube feeding, and medication administration for up to 100 days.

🟣 Inpatient psychiatric care- Part A covers inpatient therapy, standard nursing care, lab testing, and some medications. You are also covered for up to 190 lifetime days in Medicare-certified psychiatric hospitals.

Part A Medicare does not cover your outpatient hospital services like emergency room visits that don’t result in your inpatient stay. It also does not cover many hospital room amenities, custodial and private care, or long-term care.

Part B

Also referred to as medical insurance, this covers diagnostic, outpatient preventive, and treatment services. Part A and Part B are usually known as Original Medicare.

🟣 Preventive and diagnostic services- These include screenings, tests, vaccines, x-rays, and counseling.

🟣 Ambulance services- This is emergency transportation to and from the hospital. It also sometimes covers non-emergency transportation if transporting you in a non-emergency car would endanger your health.

🟣 Durable medical equipment- This equipment serves particular medical purposes, can withstand repeated use, and is safe at home, like walkers, oxygen tanks, and wheelchairs.

🟣 Chiropractic care- This is covered when you need spinal adjustments to fix a medical condition.

Part B also includes outpatient mental health services, clinical research services, and particular prescription drugs like some anti-cancer, dialysis, immunosuppressant, and anti-emetic medications.

Part C

Also called the Medicare Advantage plan, part C covers everything covered under parts A and B plus other medical services. However, some plans also cover dental, vision, hearing services, and prescription drugs according to this page.

Others include coverage for gym memberships and fitness programs. Therefore, ensure you compare the coverage options before choosing a plan.

Part D

This covers outpatient drugs and is only offered by private insurance companies with federal government contracts. You can get coverage for antidepressants, cancer drugs, anticonvulsants, HIV/AIDS drugs, anti-psychotics, and immunosuppressant drugs.

However, there are some drugs, like erectile dysfunction and over-the-counter medications, that are not covered.

Medigap coverage

This is Medicare supplement insurance offered by private insurance companies. While it does not provide extra coverage, it can help you cover some of the costs not covered by Original Medicare.

You can choose from Parts A, B, C, D, F, G, K, L, M, and N. However, you should note that it does not cover long-term care, hearing aids, private nursing, dental, and vision care.

Medicare Eligibility

Most of the people applying for Medicare are over 65 years. Many qualify to apply for original Medicare around three months before they turn 65.

People below 65 years suffering from chronic diseases also qualify for coverage. You may qualify for the coverage if you benefit from disability benefits from Social Security Disability Insurance (SSDI) or the Railroad Retirement Board (RRB).

However, you must wait at least 24 months after receiving your first check before applying for Medicare. That does not apply if you have Amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD) because you are automatically eligible.

Enrolling In Medicare

You are automatically enrolled into Original Medicare when you turn 65 and receive Social Security benefits or have ALS or ESRD.

If you want to enroll for the other Medicare parts, you can do so during the initial enrollment time. That runs from three months before your 65th birthday to three months after.

If you miss the initial enrollment, you can use the general enrollment period from 1st January to 31st March. However, if you are late, you might attract late enrollment fees. There is also a special enrollment that runs for some months, depending on your qualifying reasons.

When applying for Medicaid, you should apply six months before your 65th birthday. Part D enrollment runs from 1st April to 30th if you missed the original enrollment.

There is also an open enrollment period between 15th October and 7th December if you want to enroll, change, or drop your plan.

You should submit documents to prove your age, citizenship, and income history when applying.

Medicare Costs

Part A

You might not have to pay a Part A premium if you or your spouse have over 40 quarters of Medicare-covered employment. However, if you have below 30 Medicare-covered quarters, the premium is $506 monthly, and $278 if you have 30-39 Medicare-covered employment quarters.

You will also pay a $1,600 deductible, $400 daily copayments for the 61st to 90th day, and $800 daily copayments for lifetime reserve days.

Part B

The premiums start at $164.90 monthly, and might be higher depending on your income and family dynamic. You will also pay a $ 226 annual deductible and a 20% copayment of the Medicare-approved amount for your services.

Part C

You will pay the Original medicare costs, and some plans include plan costs like yearly deductible, monthly premium, coinsurance and copayments, and prescription drug deductible. The average monthly premium for this plan is around $18, but can go up to $ 400, depending on your plan and location.

Part D

The average monthly premium in 2023 is around $31.50, but can go up to $150 depending on your prescriptions and plan.

Medigap

You must pay a separate premium for this coverage, and the costs depend on the plan you choose. 

About the author

Dr. Cynthia Thaik, M.D., FACC is a Harvard-trained cardiologist serving the greater Los Angeles community at her holistic health center in Burbank and Valencia, CA. Dr. Thaik is the author of Your Vibrant Heart: Restoring Health, Strength, and Spirit from the Body’s Core. To learn more about Dr. Thaik or the Holistic Healing Heart Center, or to schedule an appointment, please contact info@drcynthia.com or call (818) 842-1410.

Resource Links