The United States has a variety of programs intended to aid those who are less fortunate or in need. Medicare is a program designed to supplement health/medical costs. It is important to understand how Medicare functions and operates because even if you are not a part of the program, it is likely that you are paying into the program. There is a possibility that you or a loved one may need to utilize Medicare in the future. To alleviate some of the stress in researching Medicare, here are some necessary facts about Medicare.
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- Medicare is the federal health insurance program for individuals 65+, young people with disabilities, under 65 and receiving Social Security Disability Insurance (SSDI), people with End-Stage Renal Disease (ESRD), and individuals with amyotrophic lateral sclerosis (ALS).
- Medicare began in 1966, to aid those who could not work but still needed health care.
- As of 2018, over 59.9 million individuals were provided health insurance through Medicare.
- Medicare is funded through payroll taxes, beneficiary premiums, and surtaxes from beneficiaries, co-pays and deductibles, and general U.S. Treasure revenue. The program is funded in part by Social Security and Medicare taxes you pay on your income, partly through premiums that people with Medicare pay, and partially from the federal budget.
- The Centers for Medicare & Medicaid Services (CMS) is the federal agency running Medicare.
Original Medicare Vs. Medicare Advantage Plans
- Individuals who are Medicare-eligible and enroll have two options to choose their Medicare benefits from including, Original Medicare (a traditional fee-for-service program offered directly through the federal government) or from Medicare Advantage Plan (private insurance offered by companies that contract with Medicare/federal government).
- Each plan varies in cost and drugs that are covered. Each plan must give a standard level of coverage set Medicare. Additional costs may accumulate throughout the year. Prescription drug costs depend on the plan you choose.
- There are 3 different parts of Medicare that cover certain services: Medicare Part A, Medicare Part B, and Medicare Part D.
- Medicare Part A (Hospital Insurances)- Covers inpatient hospital stays, care in a nursing facility, hospice care, and some home care.
- Medicare Part B (Medical Insurance) covers certain doctor services, outpatient care, medical supplies, and preventative services.
- Medicare Part D (Prescription drug coverage) helps cover the cost of prescription drugs and many recommended shots or vaccines.
- Original Medicare includes Part A and Part B coverage. To obtain Medicare prescription drug coverage with Original Medicare you’ll need to choose and join a stand-alone Medicare private drug plan (PDP).
- With a Medicare Advantage plan, one is still considered to have Medicare. One still owes a monthly Part B premium and Part A premium if there is one.
- Every Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but uses different rules, costs, and restrictions that may affect how and when you receive care.
- Medicare Advantage Plans can provide Part D coverage. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage.
- Medicare drug coverage includes generic and brand-name drugs. Plans vary in what drugs they cover (formulary) and how drugs are placed into different tiers on their formularies.
- If you have health coverage from a union, current employer, or former employer when you become eligible for Medicare, you may be automatically enrolled in a Medicare Advantage Plan that they sponsor. You can choose to stay with this plan, switch to Original Medicare, or enroll in a different Medicare Advantage Plan. Speak with your employer/union before making changes.
- How you get your benefits and who you get benefits from affects your out-of-pocket costs and where you can get care. With Original Medicare, you are covered to go to most doctors in the country. Medicare Advantage Plans usually have network restrictions, limiting access to doctors and hospitals. Medicare Advantage Plans can provide additional benefits that Original Medicare does not cover, like routine vision or dental care.
Medicare Vs. Medicaid
- Medicare and Medicaid are different government programs that provide health insurance.
- Medicaid is funded and run by the federal government which partners with states to cover people with limited incomes.
- Medicaid coverage depends on the state and can be available to people below certain income levels who meet alternative criteria including age, disability status, pregnancy. Medicare does not depend on income. Individuals may be eligible for Medicare and Medicaid (dual-eligible).
- Medicare recipients receive a red, white, and blue Original Medicare card. This card is shown to get services.
- If you get Medicare benefits through a Medicare Advantage Plan, you will still get an Original Medicare card, but you will need to show your Medicare advantage Plan card when you get services.
- Medicare Fraud occurs when someone uses your Medicare number without your knowledge or charges that occur for services that were not provided.
- Medicare fraud leads to higher health care costs and higher taxes.
- The Federal government estimates 60-90 billion is paid out of Medicare annually due to improper billing, errors, and abuse otherwise known as Medicare fraud.
- Do not accept offers for free medical care. Nothing is free and anyone offering free medical care has a hidden agenda.
- Be wary when items or services are not usually covered but someone says they have a method of billing Medicare. Often these individuals are only saying this to gain access to sensitive information and the services claimed to be covered still will not be covered.
- Don’t allow anyone to review your records. Only you or a trusted loved one should be able to review your records.
- Guard your social security and Medicare numbers. Until 2017, everyone’s Medicare card has their SSN, this has been removed for safety purposes. Hang up if anyone calls and asks for your SSN, Medicare, or credit card information. Only give your Medicare number to doctors and health care providers.
- Check your Medicare claims for errors. Mistakes can be made by anyone. Routinely checking your Medicare claims helps your and the health care provider avoid unintentional errors. Check your Medicare summary notice (MSN) as soon as your claim has been processed. Look for services not received or double billing.
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Government programs are implemented to serve the people. But how can you benefit without knowing as much about the program as possible? We do not learn about every government program while we come through the school. There are so many things we must learn on our own to be successful functioning citizens. Hopefully, these facts about Medicare shed some light on the program so that you can move forward making confident informed decisions and inquiries!
If you suspect Medicare fraud make sure to call 1-800-Medicare.