Medicare - Eligibility & Benefits

Medicare, which is funded by the federal government, is an insurance program for eligible individuals over the age of 65 and those who have disabilities, including End-Stage Renal Disease (ESRD). The two-part program assists with physician visits and hospital costs.

Medicare Eligibility Medicare enrollment for seniors begins at age 65. The Social Security Administration notifies the individual of his or her eligibility, at least three months prior to the birthday month. Those who are eligible, but have not yet retired, and are not receiving Social Security benefits, are responsible for making initial contact.

To guarantee the lowest rates, an individual approaching age 65 must sign up for Medicare within a seven-month period: three months prior to the birth date, the birth month, and the three months following. After that time, higher premiums, along with additional delays, may apply.

In addition to those who are 65 or older, anyone who has received disability benefits from Social Security or the Railroad for a minimum of two years may be automatically eligible for Medicare. Other beneficiaries include patients undergoing kidney dialysis, those who are in the final stages of renal disease, or anyone who has undergone a kidney transplant. Those who are eligible due to disability or ESRD will have an enrollment period based on initial diagnosis and treatment consultations.

Medicare Benefits Medicare is comprised of two parts: A (hospital insurance) and B (medical insurance). While benefits are automatic, Part B is optional. Part A pays in part for hospital stays and nursing facility care. There is no fee for Part A. Part B, which covers a portion of doctor visits and some outpatient services, requires a monthly premium, which is deducted from social security checks.

Medicare itself does not provide coverage for prescription drugs, vision or dental care, annual physicals, or most long-term care. Because of these limitations, private organizations offer approved Medigap plans as supplemental insurance. Controlled prescription drug plans are new to Medicare and will also be available through independent agencies.

Carriers determine the range of available Medigap plans and may not necessarily provide coverage for drug, vision, dental, or annual visits. By law, insurance companies offering Medigap plans cannot refuse an applicant.

In addition to Medigap insurance, individuals who are eligible for Parts A and B may elect to invest in a private HMO or fee-for-service plan. The rates and coverage will again depend on the carrier, but these policies can provide services beyond those available under Medicare.

Benefit periods along with a sliding scale of applicable fees apply to each Medicare coverage segment. For instance, if consecutive hospital stays occur within a certain timeframe, then only one deductible payment must be satisfied; if a second hospital visit is required, but the allowed benefit period has lapsed, then a second deductible applies.

Anyone who considers joining the Medicare program should become familiar with the coverage options. Detailed information regarding Medicare is available from the Social Security Administration and from the Department of Health and Human Services Medicare site.