WHAT IS MEDICARE?

Medicare is the nation’s largest health insurance program, currently converging about (44) million Americans. Enrollment is expected to rise to 79 million by 2030.

President Lyndon Johnson signed the Medicare program into law on July 30th, 1965 and Medicare became effective July 1, 1966
Medicare is a federal health insurance program administered by The Centers for Medicare and Medicaid (CMS) for three groups of people:
Medicare-eligible due to age
Medicare-eligible to certain disabilities
Medicare-eligible with end-stage renal disease (ESRD)

WHO IS ELIGIBLE FOR MEDICARE?

MEDICARE-ELIGIBLE DUE TO AGE:

An individual, age 65 or older will generally be entitled to Medicare if he or she has worked at least 10 years in Medicare-covered employment, i.e, paid the applicable FICA taxes.
A person age 65 or older may also be eligible for Medicare if his or her spouse worked at least 10 years in Medicare-covered employment.
Typically, Medicare coverage will begin on the first day of the month in which the individual attains age 65. The date of Medicare entitlement is, however, dependent on the month of enrollment into Medicare.

MEDICARE-ELIGIBLE DUE TO CERTAIN DISABILITIES:

In order for an individual to become eligible for Medicare due to disability, the individual must have a medical condition that meets Social Security’s definition of disability and the medical condition is expected to last at least 12 months.
The individual must also receive disability benefits from Social Security or the Railroad Retirement Board for at least 24 months.
The 24-month waiting period is waived for individuals that suffer from Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease. These individuals are eligible for Medicare’s first month of disability benefit entitlement.
Example: If a person became disabled on May 15th, 2020, Social Security disability benefits would first become payable in November 2020. Disability benefits commence the 6th full month after the disability begins. After a person has been entitled to disability benefits for 24 months, he or she is entitled to Medicare.

MEDICARE-ELIGIBLE DUE TO END-STAGE RENAL DISEASE (ESRD):

Eligibility for Medicare coverage because of End-stage Renal Disease is for patients for whom a regular course of End-Stage Renal Disease is for patients for whom a regular course of dialysis or a kidney transplant has been prescribed by a physician because they have reached that stage of renal impairment that kidney transplant or regular course of dialysis is necessary to maintain life.
Eligibility to Medicare is not automatic. To be eligible the patient must have:
Worked long enough under Social Security or Railroad Retirement Board
Been receiving or eligible for Social Security or Railroad Retirement Board benefits; or
Be the spouse or dependent child of a person who has worked the required amount of time, or who is receiving benefits from Social Security or the Railroad Retirement Board.

These individuals must have applied for Medicare benefits and been approved for Medicare coverage by Social Security or the Railroad Retirement Board.

If a Medicare beneficiary under the age of 65 has had a successful kidney transplant their Medicare coverage will end 36 months after the month of the transplant. The transplant is considered successful if it lasts 36 months without rejection.
Usually, Medicare coverage begins the first day of the third month after the month in which a regular course of dialysis begins.

PARTS OF MEDICARE

Medicare Part A, B, C and D

Original Medicare consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

MEDICARE PART A- HOSPITAL COVERAGE

COST:

Most people receive Medicare Part A premium-free if you paid FICA taxes for at least 10 years. If you paid FICA taxes for less than 10 years and meet Medicare eligibility requirements, beneficiaries can pay a premium to get Part A and they may have to pay a penalty if not bought when first eligible for Part A. The amount a beneficiary may have to pay for Part A can depend on how long they or their spouse worked in Medicare-covered employment. SSA determines if a beneficiary has to pay a Part A premium. In 2021, the Part A monthly premium is $259 (for a person who has worked 30-39 quarters) or $471 (for a person who has worked less than 30 quarters) of Medicare-covered employment. Once a beneficiary is enrolled into Medicare Part A, and if they want to disenroll at a later date after age 65, they will be required to pay back all of the money they received from Social Security as any Medicare benefits paid. Hospital Inpatient Care: all Medicare-approved services rendered in an inpatient setting, including medications, are covered under this benefit, with the exception of private duty during, telephone and televisions charges. Skilled Nursing Facility Care: the benefit period begins when a beneficiary is admitted into the hospital and ends when a beneficiary has been discharged for greater than 60 days. Home Health Care Services: Medicare covers medically necessary skilled nursing care, physical therapy, speech-language pathology services, occupational therapy, home health aide services, and medical supplies. Hospice Care: For beneficiaries with a terminal illness that are expected to live 6 months or less. Blood: In most cases, if a beneficiary needs blood in an inpatient setting there is no cost.

INPATIENT HOSPITAL BENEFIT PERIOD AND COST:

Hospital Inpatient Care: the benefit period begins when a beneficiary is admitted into the hospital and ends when a beneficiary has been discharged for greater than 60 days. There is no limit to the number of benefit periods a beneficiary can have. For each benefit period in 2021, beneficiaries are responsible for the Medicare Part A deductible.

2021 Medicare Part A deductible- $1,484 for a hospital say of 1-60 days.

$371 copay per day for days 61-90 of a hospital stay.

$742 per day for days 91-150 (lifetime reserve days) of a hospital stay.

Medicare will pay for a total of 60 extra days when a beneficiary is in a hospital more than 90 days during a benefit period. Once the 60 reserve days are uses, beneficiaries don’t get any more extra days during their lifetime.

SKILLED NURSING FACILITY BENEFIT PERIOD AND COST:

Skilled Nursing Facility- care is covered in full for the first 20 days when a beneficiary meets their requirements for a Medicare-covered stay. In 2021, under Original Medicare, days 21-100 of SNF care is covered except for copays of up to $185.50 per day, of each benefit period. After 100 days, Medicare Part A no longer covers SNF care. A beneficiary can qualify for skilled nursing care again every time a beneficiary has a new benefit period.

HOME HEALTH CARE BENEFIT PERIOD AND COST:

Under Medicare Part A beneficiaries will pay the following for home health care:
$0 for covered home health care services provided by a Medicare-approved home health agency.
Medicare Part A covered up to 100 post-institutional home health visits.

To be eligible a beneficiary must meet the following conditions:
Must be homebound (means you are unable to leave your home or leaving your home is a major effort)
You must need skilled care on an intermittent basis, or physical therapy, or speech-language pathology, or have a continuing need for occupational therapy.
The home health agency caring for the beneficiary must be approved by Medicare.

HOSPICE BENEFIT PERIOD AND COST:

Under Medicare Part A, Medicare will cover hospice care for beneficiaries that are terminally ill and have less than 6-months to live. Beneficiaries must sign a statement choosing hospice care instead of routine Medicare-covered services to treat the terminal illness.
Medicare Covered Hospice services:
Durable Medical Equipment and Supplies
Medications for symptom control and pain relief.
Short-term hospital and skilled nursing facility stay.
Inpatient respite care. Beneficiaries can stay up to 5 days each time they receive respite care.
Hospice aid and homemaker services
Social worker services
Counseling for the beneficiary and family
Dietary counseling

BLOOD BENEFIT PERIOD AND COST

In most cases, the hospital gets blood from a blood bank at no charge, and a beneficiary won’t have to pay for it or replace it. If the hospital has to buy blood for the beneficiary, the beneficiary must either pay the hospital cost for the first 3 units of blood received in a calendar year, and then it will be covered at 100% by Medicare.

MEDICARE PART B- OUTPATIENT MEDICAL COVERAGE

Doctor’s Services: Services that are medically necessary (includes outpatient and some doctor services you get when you’re in a hospital inpatient) or covered preventative services. Outpatient Medical and Surgical Services and Supplies: Medical services and supplies that are medically necessary such as clinical laboratory, services, diabetic supplies, Kidney dialysis, mental health care, limited prescription drugs, x-rays, MRIs, Ct Scans, EKGs, transplants, and other services are covered. Home Health Care Services: Covered medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, a continuing need for occupational therapy, home health aide services, medical social services, and medical supplies. Durable Medical Equipment (DME): Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other healthcare provider are covered. Preventative Services: Medicare Part B covers preventative services like exams, lab tests, screening, and shots to help prevent, find, or manage a medical problem.


MEDICARE PART B COSTS:

If a beneficiary has Original Medicare, they will pay the Medicare Part B Deductible, which is the amount a person must pay for health care each calendar year before Medicare begins to pay. This amount can change every year in January. The 2021 Part B deductible is $203 per year. This means the beneficiary must pay the first $203 of their Medicare-approved medical bills in 2021 before Medicare Part B starts to pay for their care. Once a beneficiary has met their Medicare Part B deductible for the year, they will be responsible for 20% coinsurance for all Medicare Part B Medicare-approved services. In most cases, the 20% coinsurance is not capped throughout the year.

MEDICARE PART A AND B COMMON SERVICES NOT COVERED:

Medicare Part A and Part B do not cover everything.  If a beneficiary needs certain services that Medicare doesn’t cover, they will have to pay out-of-pocket unless they have other insurance that covers the cost. Items and services that Medicare doesn’t cover include, but aren’t limited to, prescriptions obtained at a retail or mail-order pharmacy, long-term care, routine and restorative dental care, cosmetic surgery, acupuncture, hearing aids, and routine vision services such as eyeglasses.