Medicare Eligibility Requirements

May 31st, 2017     Medicare

Medicare is the health insurance program for people who are 65 and above. This coverage includes four parts namely Medicare Part A, Medicare Part B, Medicare Part C and Medicare Part D. Each part has different eligibility criteria. Lets have a look at each of them.

Medicare Part A Eligibility Requirement

Medicare Part A covers mainly inpatient and hospital services. Each person can avail Part A services for free of cost  who are 65 or above, if they meet any one of the following requirements-

  • Have eligibility to Social Security benefits.
  • Have eligibility to Railroad Retirement benefits.
  • Spouse (living or deceased, including divorced spouses) is eligible to receive Social Security or railroad retirement benefits.
  • If the person or his/her spouse has worked in a government job for a long time and through which he/she paid Medicare taxes.
  • If the person is dependent parent of a fully insured deceased child.

If the person does not meet the above requirements, he/she can avail Medicare Part A by paying a monthly premium.

Each Person is eligible for Medicare Part A before the age of 65, if they meet any one of the following requirements.

  • Have eligibility to Social Security disability benefits for 24 months.
  • Have received a disability pension from the railroad retirement board and met certain conditions.
  • Have received Social Security disability benefits because the person has Lou Gehrig’s disease.
  • Have worked for a government job for a long time through which the person paid Medicare taxes and entitled to Social Security disability benefits for 24 months.
  • If the person is child or widow(er) age 50 or older, including a divorced widow(er), of someone who has worked for a long time in a government job through which he/she paid Medicare taxes and met Social Security disability program requirements.
  • If the person has permanent kidney failure and undergoes maintenance dialysis or a kidney transplant and
    • is eligible to Social Security benefits or railroad retirement benefits; or
    • worked for a Medicare-covered government job for a long time; or
    • is child or spouse (including divorced spouse) of a worker under Social Security or in a Medicare-covered government job.

Medicare Part B Eligibility Requirement

Medicare Part B covers outpatient services and preventive services. People who are eligible for Part A at no cost can avail Medicare Part B services by paying a monthly premium. People who are not eligible for Part A at no cost, can buy Part B without paying for Part A, if the person is 65 or above and he/she is:

  • A U.S. citizen; or
  • A lawfully admitted non-citizen who has lived in the United States for five years or above.

The late enrollment penalty is applicable, if the person did not sign up during designated enrollment period.

Medicare Part C Eligibility Requirement

Medicare Part C is also known as Medicare Advantage Plan which is managed by private companies that are approved by the Medicare. If the person has Medicare Part A and Part B, then he/she can join a Medicare Advantage Plan. Person with Medicare Advantage Plan is not eligible for Medigap policy.

Medicare Part D Eligibility Requirement

Part D is a prescription drug coverage of Medicare. Each person has to pay an extra premium on monthly basis for the coverage. Each person can join Medicare Part D if he/she meets the following requirements.

  • If the person is enrolled for Medicare Part A and/or Part B.
  • If the person permanently resides in the service area of the plan.
  • If the person is a U.S. citizen or lawfully present in the United States.

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Part B Preventive Services

May 25th, 2017     Medicare

Medicare Part B is the medical insurance offered by federal government to individuals who are 65 or above. Medicare Part B covers medical insurance i.e. outpatient services and preventive services. Below is the list of preventive services offered by Medicare. Each person should talk to his/her healthcare provider about which of these services is right for him/her.

  • Abdominal aortic aneurysm screening
  • Lung cancer screening
  • Alcohol misuse screenings & counseling
  • Mammograms (screening)
  • Bone mass measurements (bone density)
  • Nutrition therapy services
  • Cardiovascular disease screenings
  • Obesity screenings & counseling
  • Cardiovascular disease (behavioral therapy)
  • One-time “Welcome to Medicare” preventive visit
  • Cervical & vaginal cancer screening
  • Prostate cancer screenings
  • Colorectal cancer screenings
  • Sexually transmitted infections screening & counseling
  • Depression screenings
  • Shots:
    • Flu shots
    • Hepatitis B shots
    • Pneumococcal shots
  • Diabetes screenings
  • Tobacco use cessation counseling
  • Diabetes self-management training
  • Yearly “Wellness” visit
  • Glaucoma tests
  • Hepatitis C screening test
  • HIV screening

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Medicare Part B (Medical Insurance)

May 25th, 2017     Medicare

Medicare is a health insurance program offered by the federal government for people who are 65 and above. Within Medicare, Part-B includes two types of services. One is outpatient medical services and and the other one is preventative services. Lets have a look at each of the services in detail.

  • Doctors’ Services: Medicare covers medically necessary doctor services. It also covers services given by other health care providers, like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists. The patient has to pay 20% of the Medicare-approved amount and Part B deductible also applies.
  • Outpatient Medical and Surgical Services and Supplies: Medicare covers for approved procedures like X-rays, casts, or stitches. The patient has to pay the doctor 20% of the Medicare-approved amount, pay the hospital a co-payment for each service and Part B deductible also applies.
  • Durable Medical Equipment: Medicare covers costs for items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds for use in the home. Some items may be rented. The patient has to pay 20% of the Medicare-approved amount and Part B deductible also applies.
  • Home Health Services: Medicare covers medically necessary part time nursing care, physical therapy, speech-language pathology services and services for people with a continuing need for occupational therapy. The patient has to pay nothing for covered services.
  • Other (including, but not limited to): Medicare covers for clinical laboratory services, diabetes supplies, kidney dialysis services and supplies, mental health care, limited outpatient prescription drugs, diagnostic x-rays, MRIs, CT scans, and EKGs, transplants, and other services. The costs varies with each service.
  • Preventative Services: Medicare covers many preventative services to help the person stay healthy. Each person has to talk to his/her health care provider about the services which is right for him/her. Few services are listed below.
    • Alcohol misuse screening and counseling.
    • Bone mass measurement.
    • Diabetes screenings.
    • Lung cancer screenings and several other services.

Refer to our guide on Medicare Part B Covered Preventive Services for the complete list of preventive services.

Who are eligible for Medicare Part B?

People with the following criteria are eligible for Part B Medicare program.

  • People with the age 65 or above.
  • People who are disabled permanently.
  • People with the end stage renal disease.

Refer to our guide on Medicare Eligibility Requirement for in-depth eligibility requirments.

Premium and other costs associated with Part B

Part B Premiums

  • Each person pays a premium for Part B each month which depends on one’s income. The standard Part B premium amount in 2017 is $134.
  • If each person pays his/her Part B premium through his/her monthly Social Security benefit, he/she has to pay less ($109 on average).

Premium pricing chart for Part-B is based on the yearly income in 2015 (For what you pay in 2017)

File Individual Tax Return File Joint Tax Return File Married & Separate Tax Return In 2017 you pay
$85,000 or less $170,000 or less $85,000 or less $134
above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $187.50
above $107,000 up to $160,000 above $214,000 up to $320,000 Not applicable $267.90
above $160,000 up to $214,000 above $320,000 up to $428,000 above $85,000 and up to $129,000 $348.30
above $214,000 above $428,000 above $129,000 $428.60

Part B deductible and coinsurance.

A person has to pay $183 per year for his/her Part B deductible. After his/her deductible is met, he/she typically pays 20% of the approved amount of medicare for most doctor services, outpatient therapy and durable medical equipment.

When to enroll for Medicare Part B?

A person can enroll for Part B only during

  • his/her Initial Enrollment Period (IEP).
  • The annual General Enrollment Period (GEP) that is January 1 – March 31 each year.
  • The Special Enrollment Period (SEP) in limited situations.

If a person does not enroll in Part B during IEP, then he/she has to pay lifetime penalty.

Late Enrollment Penalty of Part B (Lifetime Penalty)

If the person does not sign up for Medicare Part B coverage when he/she is first eligible, then he/she has to pay a premium penalty of 10% for each full 12-month period where he/she could have had Part B but didn’t sign up for it, except in special cases. This penalty will always be included in Part B premiums (lifetime penalty).

For example, John’s IEP ended on september, 2009. He waited to sign up during GEP in march 2012. The total time delayed was 30 months. So his late enrollment penalty is 20% as 30 months includes 2 full 12-month periods and John needs to pay 20% more premium (20% more than indicated in the chart above) as long as he is enrolled in Medicare Part-B.

How to apply for Medicare Part B?

  • Visit the social security website for online application.
  • Visit the nearest social security office for offline application.
  • Call Social Security at 1-800-772-1213
  • Call the R.R.B at 1-877-772-5772,  if you are a rail road employer.

When a person must have Medicare Part B?

  • When the person wants to buy a Medigap policy.
  • When the person wants to join a Medicare Advantage Plan.
  • When the person is eligible for TRICARE for Life (TFL) or Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
  • When the person’s employer coverage requires his/her spouse or family member to have it when you become eligible for Medicare.

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Medicare Part A (Hospital Insurance)

May 23rd, 2017     Medicare

Medicare is a health insurance program offered by the federal government for people who are 65 and above. Within Medicare, Part-A insurance covers the inpatient hospital care. Most people get Medicare Part A free of cost when they turn 65. Below are the services which come under Medicare Part A.

  • Hospital Care: This coverage includes benefits such as meals, semi-private room, general nursing, other hospital services and supplies, care in inpatient rehabilitation facilities and mental health care in a psychiatric hospital. To know the list of hospitals which are enrolled in Medicare, you can refer to our website //www.medicarelist.com/hospitals/
  • Skilled Nursing Facility Care: This coverage includes semi-private room, meals, skilled nursing care, medical social services, physical therapy, speech-language therapy, medical equipment, Ambulance transportation and Dietary counseling. To know the list of nursing-homes which are enrolled in Medicare, you can refer to our website //www.medicarelist.com/nursing-homes/
  • Hospice: This coverage provides services to people who are terminally ill and have less than 6 months to live. To get the services, doctor must certify that the patient is terminally ill. To know the list of hospice which are enrolled in Medicare, you can refer to our website //www.medicarelist.com/hospice-care/
  • Home Health Services: Face to face interaction with the doctor is necessary to avail home health services. Patient must be home-bound. To know the list of home health agencies which are enrolled in Medicare, you can refer to our website //www.medicarelist.com/home-healthcare/

Who are eligible for Medicare Part A?

People with the following criteria are eligible for Part A Medicare program.

  • People with the age 65 or above.
  • People who are disabled permanently.
  • People with the end stage renal disease.

Refer to our guide on Medicare Eligibility Requirement for in-depth eligibility requirments.

What is the cost of Medicare Part A?

Premium-Free

There is no monthly premium for Medicare Part A for individuals who paid their medicare taxes for atleast 40 quarters.

The eligibility for people at 65  is as follows:

  • People with retirement benefits from Social Security or Rail Road Retirement Board.
  • People who are eligible and yet to file for Social Security or Rail Road benefits.
  • People and their respective partners have medicare covered government employment.

The eligibility for people under 65 is as follows:

  • People who got disability benefits of Social Security or Rail Road Retirement Board  for 24 months.
  • People with end stage renal disease and meet certain requirements.

Premium

For the year 2017

  • People who paid taxes for less than 30 quarters have to pay $413 monthly.
  • People who paid taxes for 30-39 quarters have to pay $227 monthly.
  • People who paid taxes for 40 quarters or above avail free medicare coverage.

When to enroll for Medicare Part A?

  • Initial Enrollment Period (IEP): People can enroll 3 months before they turn 65 to get services from the day they turn 65. If they enroll during the month they turn 65, then they can avail services the next month. If they enroll in the last 3 months of this period, then they can avail services after 2 to 3  months they turn 65.
  • General Enrollment Period (GEP): People who did not sign up during Initial Enrollment Period can enroll during General Enrollment Period. It occurs every year from January 1 to March 31. If the person is not eligible for premium-free Part A and has not bought it in IEP, his/her monthly premium may go up 10%. He/She has to pay the higher premium for twice the number of years he/she did not signup for Part A.
  • Special Enrollment Period: Most of the people are not eligible for Special Enrollment Period. To be eligible, a person should have employer group health plan coverage based on his/her employment status. The SEP allows people to enroll for Medicare after IEP without needing to wait for GEP and there is no penalty as well.

How to apply for Medicare Part A?

  • Visit the social security website for online application.
  • Visit the nearest social security office for offline application.
  • Call Social Security at 1-800-772-1213
  • Call the R.R.B at 1-877-772-5772,  if you are a rail road employer.

How much does Medicare Part A pay?

Inpatient care:

Benefit Period in 2017 Pay
Days 1-60 $1316 deductible
Days 61-90 $329 per day
Days 91-150 $654 per day
(60 lifetime reserve days)
All days after 150 All Costs

Cost Working Examples

  1. Patient pays a $1,316 deductible and no coinsurance for days 1– 60 of each benefit period. For example, if the hospital bill for 7 days is $20,000, then the patient will pay $1,316 and the remaining amount will be paid by Medicare.
  2. Patient pays $329 per day for days 61– 90 of each benefit period. If the patient is hospitalized for 65 days, then he has to pay total of $2961 [$1,316 (deductible) + 5 x $329 ($1645 co-pay)]
  3. Patient pays $658 per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime).

Skilled Nursing Facility:

Benefit Period in 2017 Pay
Days 1-20 $0
Days 21-100 $164.50 per day
All days after 100 All Costs

Home Health Care: Patient has to pay nothing for home health services in the original Medicare. For certain medical equipment like wheel chair or walker, he has to pay 20% of the amount and the rest 80% is covered by Medicare Part-B.

Hospice: Patient has to pay not more than $5 for each prescription drug and 5% for inpatient respite care. For example, if Medicare approved $150 per day for inpatient respite care, then he has to pay $7.50 per day.


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How Medicare Advantage Plans Differ from Original Medicare

May 19th, 2017     Medicare

Almost all people who want to enroll with medicare have to decide whether they want to keep original medicare or want to go with medicare advantage plans (Part C). Each of them have some tradeoffs against each other (in terms of cost, coverage and convenience) and it’s important to understand the difference between the two to select the best suitable plan for you.

Original Medicare (Part A and Part B)

Original Medicare is a coverage managed by the federal government. It includes Part-A (hospital insurance) and Part-B (medical insurance) coverage if you enroll in both. You pay a deductible and/or coinsurance when you receive healthcare services. Most people get Part A free of cost and pay a monthly premium for Part B. If you want prescription drug coverage, you must buy a separate prescription drug plan (part D) from a private insurance company. Also, separate medigap policies are available to cover the out-of-pocket expenses.

Medicare Advantage Plan (Part C)

Medicare Advantage Plan includes all benefits and services covered under Part A and Part B. Many times it also includes medicare prescription drug coverage (part D) as part of the plan and it is run by Medicare-approved private insurance companies that follow rules set by Medicare. You pay Part B premium and additional premium to private insurer. To understand how to choose the best MA plans, refer Choosing Best Medicare Advantage Plans.

Differences Between Original Medicare And Medicare Advantage Plan

Original Medicare Plan and Medicare Advantage Plan differ greatly and it is important to know these differences. Let us check out the comparison guide so you can decide which Medicare plan is better as per your needs.

Factors Original Medicare Medicare Advantage Plan
Costs? You pay medicare premiums, deductibles, and co-insurances. There’s no yearly limit for what you pay out-of-pocket. You usually pay a monthly premium for Part B, if you opted for medical insurance. You pay Medicare part B premiums and Part C premium (if any), deductibles, and co-insurances. However, most MA plans have max-limit on Out-of-pocket expenses.
Should I get a supplemental policy? You may already have employer or union coverage that may pay costs that Original Medicare doesn’t. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy if you’re eligible. You can’t buy a Medigap policy to pay your out-of-pocket costs in a Medicare Advantage plan. In most case, there is a max-limit on OOP expenses.
Do I have to get a referral to see a specialist? In most cases, no, but the specialist must be enrolled in Medicare. You often need to get a referral from your Primary Care Physician if you want to see a specialist.
Covers drugs? No, but if you want medicare prescription drug coverage, you can buy a separate Part D plan. Many MA plans include Part D drug coverage.
Out-of-pocket limit? There’s no max limit on the out-of-pocket expenses which you may need to incur. MA Plans have a max-limit on the out-of-pocket expenses which safeguard you in case of expensive medical care. The plan pays the full cost of your care after you reach the limit.
Covers extra services like vision and dental? Doesn’t cover certain services such as routine vision, hearing or dental care. MA plan cover services like routine vision, hearing and dental care.
Do the services are provided nation wide? Yes, you can go to any doctor or hospital in the U.S. that accepts Medicare. Usually not. Most people have HMOs or PPOs, which provide coverage through their network of healthcare providers. You may need to take additional coverage if you need to travel.

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Medicare Program: Medicare is a federal government program which provides health insurance to people who are 65 or older. This program also covers certain younger people with disabilities (who receive Social Security Disability Insurance - SSDI), and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD.

Medicare Assignment: Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

NPI Number: The National Provider Identifier (NPI) is a unique identification number for covered health care providers. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA (Health Insurance Portability and Accountability Act).

Our Data: Information on www.medicarelist.com is built using data sources published by Centers for Medicare & Medicaid Services (CMS) under Freedom of Information Act (FOIA). The information disclosed on the NPI Registry are FOIA-disclosable and are required to be disclosed under the FOIA and the eFOIA amendments to the FOIA. There is no way to 'opt out' or 'suppress' the NPPES record data for health care providers with active NPIs.