What is Medicare and How Do You Qualify?

November 21, 2020

As we age, health becomes a primary focus for many of us. Fortunately, most Americans over the age of 65 will qualify for affordable Medicare coverage. Medicare has been providing quality health insurance to seniors and those with disabilities for the past 55 years, and while Medicare offers comprehensive coverage for those who qualify, it's important to point out that not everyone qualifies for the program automatically. 

Here’s everything you need to know about applying for and qualifying for Medicare coverage.

What is Medicare?

Medicare insurance has two parts, conveniently called:

  • Medicare Part A
  • Medicare Part B

Here's the difference between the two.

Medicare Part A (Hospital Insurance)

According to Medicare.gov, Part A typically covers:

  • Inpatient care in a hospital
  • Skilled nursing facility care
  • Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
  • Hospice care
  • Home health care

Medicare Part B (Medicare Insurance)

Part B on the other hand covers two types of services:

  • Medically necessary services: These are services or supplies required to diagnose or treat a medical condition and meet the defined and accepted medical practice standards.
  • Preventive services: These are health care services designed to prevent or detect illnesses at early stages. 

Part B also covers things like:

  • Clinical research  
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
  • Inpatient
  • Outpatient
  • Partial hospitalization
  • Limited outpatient prescription drugs

Under Medicare Part B, you will pay nothing for most preventative services, as long as you get them through a health care provider who accepts Medicare.

Who is Eligible for Medicare?

Medicare is available to people who are 65 years of age or older. It’s also available to younger people suffering from disabilities or those with End-Stage Renal Disease (classified as permanent kidney failure that requires transplant or dialysis). But you have to apply to meet certain eligibility requirements to get Part A Medicare coverage in the U.S.

Part A Medicare Eligibility Requirements

You are eligible for Medicare Part A with no premiums if…

  • You are 65 or older
  • You or your spouse worked and paid Medicare taxes for at least ten years
  • You are receiving Social Security Benefits or Railroad Retirement Board benefits or are eligible for either but have not yet claimed them
  • You or your spouse worked a Medicare-covered government job

Suppose you do not meet the above requirements. In that case, you may still be able to purchase Medicare Part A. If you are under age 65, you can get premium-free Medicare Part A if you have been entitled to Social Security or Railroad Retirement Board disability benefits for at least 24 months, or if you have Lou Gehrig’s disease and your disability benefits have begun.

Part B Medicare Eligibility Requirements

While most people pay no premiums for Medicare Part A, anyone who wants Medicare Part B coverage has to purchase it. The monthly premium will be deducted from your Civil Service, Social Security, or Railroad Retirement check. 

If you are not eligible to collect any of these payments, Medicare will bill you for Part B coverage every three months. According to Kiplinger, “The standard premium in 2020 is $144.60 per month and is projected to rise to $148.50 in 2021.”

To find out more about whether you qualify for Medicare Part A or B, visit Medicare.gov’s eligibility tool

What About Prescription Drug Coverage?

Since 2006, Medicare Part D plans (yes, this is a separate coverage plan from A and B) have covered prescription drug costs for everyone - regardless of health status, prescription drug usage, or income. Medicare D coverage can work together with your existing insurance plan or as an add-on to other Medicare plans.

To learn more about the specifics of this coverage and how much you can expect to pay for premiums in each tier, visit Medicare’s Prescription Drug Coverage site

5 Things to Know About Medicare Coverage

Applying for or using Medicare can be a confusing process. Here are five key things to know about Medicare coverage and what features will be available to you and your family:

1. You can fill coverage gaps with a personalized Medigap plan

If your traditional Medicare coverage doesn’t go far enough to meet your health needs, sign up for a Medigap supplemental insurance plan. These plans come in a range of options (Medigap plans in most states are listed from A-N). They're also issued by private insurance companies and can help cover things like deductibles, co-payments, and more. 

2. Medicare Advantage may be more streamlined in certain health care situations

You can sign up for the traditional Medicare coverage package of Part A, B, and D, or you can take a different approach and sign up for Medicare Advantage. Medicare Advantage plans (also known as Part C plans) provide prescription drug and medical coverage through private insurance companies. 

When you have Medicare Advantage, you won’t have to enroll in Part D coverage or purchase a Medigap policy. While these plans typically charge lower premiums, they tend to have higher cost-sharing structures. 

3. You’ll pay more if you had a high income

At the time of this writing, if your adjusted gross income is more than $87,000 (as a single person) or $174,000 if you’re married and filing jointly, you’ll pay more for Medicare Parts B and D. Since surcharges are based on the adjusted gross income for the past two years, high earners can expect steeper premiums.

4. You have to sign up 

Most people assume Medicare enrollment is automatic. It isn't. If you are already claiming Social Security benefits, you’ll be automatically enrolled in Parts A and B. But if you haven’t started Social Security, you’ll have to sign up for coverage. The initial enrollment period lasts seven months and begins three months before you turn 65. It ends three months after the month of your birthday, so make sure to set a calendar reminder for you or your family and friends to make sure they don't miss their enrollment window.

5. You may be able to access free preventative services

Medicare beneficiaries can access free preventive services, such as an annual wellness visit, free cardiovascular screenings every five years, yearly flu shots and mammograms, and regular screenings for prostate, cervical, and colorectal cancers. Talk to your healthcare provider to learn more about these preventative options. 

Preparation is Key for Medicare Coverage

While Medicare coverage can help you protect and maintain your health, getting enrolled can feel complicated. Fortunately, understanding Medicare’s basic ins and outs and knowing what to expect can go a long way. 

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