About the Medicare Program
Medicare is a federal government-run, national social insurance program, which provides medical insurance to adults over age 65, disabled persons of any age, and individuals with end stage renal disease. Established in 1965, Medicare gives people the ability to receive health care of various sorts, defined by the division in which they are enrolled. Medicare is managed by the Centers for Medicare and Medicaid Services (CMS), a subsidiary of the U.S. Department of Health and Human Services (HHS).
Medicare is divided into several benefit-specific areas, consisting of Part A and Part B for hospital care and medical coverage, and Part C and Part D for custom health management and prescription discounts.
Medicare Part A
Medicare Part A is also known as Hospital Insurance (HI), and offers assistance for plan members to be hospitalized, including coverage for supplies, testing, food, and a semi-private room. Home health care is also covered in Part A, which entails occasional visits from a health care professional for physical, occupational, or speech therapy. Such services are administered on a part-time basis, as is considered medically necessary for the recipient.
Part A also covers medical equipment for the disabled and elderly such as wheelchairs and walkers, as well as skilled nursing facility services in certain instances. Nursing home care is offered in the following instances:
- When an individual has been staying in a hospital for a minimum of three days.
- The skilled nursing facility stay pertains to a diagnosis from the hospitalization.
- If the patient is not being rehabilitated and has an illness in need of skilled nursing supervision.
- Care received is skilled, not qualifying as custodial, non-skilled, or long-term care.
Part A Limits: Skilled nursing stays are limited to 100 days per illness with Part A coverage. The first 20 days are fully paid for by Medicare, and the following 80 are offered for a copayment, which is currently $144.50 in 2012. Hospital stays are usually covered for a maximum of 90 days, with the first 60 covered by the plan, and day 61 onward for a copayment of $289 per day.
This division of Medicare is typically offered with no monthly premium responsibility, as Part A expenses are covered by payroll taxes.
Medicare Part B, or Supplementary Medical Insurance (SMI), covers physician office visits, outpatient hospital care, home health care, and more services deemed medically necessary. Part B beneficiaries must pay a monthly premium and meet a yearly deductible, and enrollment is optional. Some of the services covered by Part B include:
- Physician and nursing care
- Durable medical equipment
- Some immunizations
- Diagnostic and lab testing and X-rays
- Outpatient surgery and procedures
- Blood transfusions
- Renal dialysis
- Select ambulance transport
- Prosthetic devices
- Immunosuppressive drugs after organ transplants
- Some hormonal treatments
Part C/Medicare Advantage Plans
Medicare Advantage Plans, also called Part C or Medicare + Choice, gives members the ability to customized care specifically to their health needs. Such plans use private health insurance carriers to administer a portion of coverage, though specifics can range with the patient’s medical criteria and program rules. A selection of Medicare Advantage Plans partner with an HMO or PPO to give access to preventive care and/or specialists. Other plans have special concentration on the illness, such as diabetes.
Part D/Prescription Drugs
Several major national private insurance companies provide Medicare Part D coverage, a stand-alone prescription drug plan. Part D coverage varies based on the carrier you choose, whose formularies and prices are specific to each company. Those who use Medicare Part D pay a monthly premium as well as a deductible for the year.
Part D pricing is set up so that Medicare pays for 75 percent of prescription drug expenses, as long as you spend between $250 and $2,250 in one year. Medicare does not cover spending between $2,250 and $3,600, but after you exceed $3,600, they will pay for 95 percent.
For any additional questions about Medicare coverage and plans, please call us at 888 803 5917. East Coast Health Insurance also offers Medicare Supplemental insurance in addition to our array of individual plans. Fill out a quick form and get an accurate quote to compare Medicare Supplemental rates near you.