Insurance Law

Medicare Overview

Medicare is integral to medical care and health insurance for older adults. After retirement, many people are on a limited income and have trouble covering the increased cost of healthcare. Many retired people have too much money to qualify for Medicaid but not enough to pay for private insurance. The Medicare program helps make healthcare more affordable for retirees and people with disabilities.

Medicare is a federal program, but health care options for older adults vary in every state. If you have questions about your healthcare rights and legal options, an older adult law attorney in your state can help.

What Is Medicare?

Medicare is a federal government health insurance program for older adults and people with disabilities or permanent kidney failure. Medicare has different parts that cover different healthcare needs, including hospital care, nursing home care, home health care, and hospice.

Medicare insurance is also available for a monthly premium to cover doctor’s services and outpatient care. There is also prescription drug coverage to reduce the costs of medication. Individuals can get the original Medicare coverage or go through an approved company to get Medicare Advantage benefits.

Who Can Qualify for Medicare?

Medicare is available for most people who are 65 or older. To qualify, you must be a U.S. citizen or permanent legal resident in the country for at least five years. Most Medicare beneficiaries qualify after they or their spouse pay into Federal Insurance Contribution Act (FICA) payroll taxes for Social Security and Medicare. Government workers and railroad workers are also eligible.

If you do not qualify under your or your spouse’s work record, you may still be able to get Medicare by paying premiums for Part A coverage. Medicare eligibility can also include those who are disabled or have ALS or end-stage renal disease (ESRD).

When Can I Join a Medicare Plan?

Older adults who are not disabled can sign up during the initial 7-month enrollment period. The period begins three months before the month you turn 65. If you sign up before the month you turn 65, your coverage starts the day you turn 65. If you sign up during your birthday month or in the following three months, health coverage will begin the first day of the month after joining.

If you don’t sign up for Medicare by age 65, you may have to pay a continuing additional surcharge for each year you did not sign up for Part B coverage.

If you want to change or drop your plan, you can do so every year during the open enrollment period or the Medicare Advantage open enrollment period. You may also be able to enroll or change plans outside of open enrollment after a life change, like losing your insurance.

What Does Medicare Cover?

Medicare only covers certain parts of your healthcare needs. It can be challenging for people who have just enrolled in Medicare to know if the tests, medical items, or healthcare services are covered. To find out what is covered, you have to look at the different parts of Medicare and whether original Medicare or a Medicare Advantage Plan covers you.

What Are the Different Parts of Medicare?

Medicare is separated into different parts, with different parts covering various services:

  • Medicare Part A: Hospital insurance coverage, including inpatient hospital care, skilled nursing facility care, hospice care, lab tests, surgery, and home health care.
  • Medicare Part B: Medical insurance covers doctor visits, other health care provider services, and outpatient care. Part B covers some preventive services, home health care, and durable medical equipment.
  • Medicare Part C: Medicare Advantage Plans, also known as Part C, are offered by Medicare-approved private companies. These plans combine Part A hospital stay coverage with Part B medical insurance and often include Part D Medicare prescription drug plans.
  • Medicare Part D: Medicare prescription drug coverage (brand-name and generic). Some plans offer tiered coverage, with most generic drugs having a lower copayment than high-cost and non-preferred, brand-name drugs.

In general, eligible individuals can sign up for Medicare or Medicare Advantage. Original Medicare includes Part A and B, and individuals can join a Part D plan. Medicare Advantage is through a private company approved by Medicare that bundles Parts A and B, and often Part D. Medicare patients can see any doctor that accepts Medicare. Still, Medicare Advantage is more like an HMO or PPO, covering in-network services.

Types of Medicare Health Plans

Medicare health plans are provided by private companies that contract with Medicare to provide Part A and Part B benefits. Types of Medicare Health Plans include:

  • Medicare Advantage Plans
  • Medicare Cost Plans
  • Programs of All-Inclusive Care for the Elderly (PACE)
  • Medical Savings Accounts (MSAs)

Medigap Supplemental Insurance

Medigap is Medicare supplemental insurance intended to cover the gaps in care not covered by Medicare. Private insurance companies offer Medigap to cover health care costs like copayments, deductibles, coinsurance, and other out-of-pocket expenses. However, Medigap generally doesn’t cover things like long-term care, dental care, hearing aids, glasses, or some other services. Medigap policies may also offer emergency treatment for care outside the U.S.

State Programs for Health Care for Older Adults

Medicare does not cover everything. Many retirees and older adults find health care and prescriptions challenging to cover with the increased cost of living. Medicaid helps cover some costs beyond what is provided by Medicare, including extended nursing facility care, prescription drug coverage, eyeglasses, and hearing aids.

To qualify, you must meet state Medicaid requirements, which generally include income and asset limits. For example, for older adults in Missouri to qualify, they have to have an income limit of 85% of the federal poverty level.

Medicaid services are administered at the state level, and Medicaid coverage may differ in different states. For example, in South Carolina, Medicaid is through the South Carolina Health Connections Medicaid program. In Florida, Medicaid is administered by the Florida Agency for Health Care Administration.

Contact your state Medicaid office to find out if you qualify and how you can get coverage. If you have legal questions or need help with issues facing older adults, contact an older adult law attorney in your area.

Was this helpful?