What is Medicare

A federally funded health insurance program for the elderly in the United States of America. People who have end-stage kidney disease (on kidney dialysis or who have had kidney transplantation surgery) and certain other disabilities also are eligible for Medicare benefits. Administered by the federal Centers for Medicare and Medicaid Services (CMS), Medicare provides medical benefits for more than 40 million Americans.

There are two levels of benefits for Medicare, Part A Hospital Insurance and Part B Medical Insurance. Nearly all Americans are entitled to Medicare Part A when they become age 65, which provides benefits for hospitalization (inpa-tient care and services). Medicare Part B is available as a purchased option to provide benefits for outpatient care and services. There are no income or asset restrictions for Medicare. The Medicare website, www.medicare.gov, provides comprehensive information about Medicare benefits, premiums, policies, and contact phone numbers by state.

Medicare Part A: Eligibility and Benefits

Americans who are employed pay Social Security taxes that in part support the Medicare system. Those who do so for at least 10 years, and their spouses, are entitled to Medicare Part A at no cost at age 65. People who receive or are eligible to receive Social Security retirement or disability benefits also are eligible. Most people who do not qualify for Medicare Part A at no cost have the option of paying premiums to enroll for coverage. People who have medical insurance coverage through other pension systems and do not pay into Social Security may not be eligible for Medicare. The Social Security Administration fields general Medicare eligibility questions; the toll-free number is 1-800-772-1213.

Medicare Part A pays for defined levels of specified inpatient services within a benefit period, which begins on the first day of hospitalization and ends when 60 days pass without further inpatient services. In general, benefits include

• Up to 90 days in the hospital and medications while in the hospital

• Up to 100 days in a skilled nursing facility (shared payment, called coinsurance, for days 21-100) for rehabilitation and recovery after hospitalization

• Eighty percent of qualifying home health care expenses

• Hospice services

Medicare begins payment after the deductible for the benefit period has been met; deductible levels change each year. Medicare does not pay for custodial care and services in a long-term care facility. There are strict rules for covered services; most providers are diligent about following them, but the person with Medicare or a caregiver should monitor them.

Medicare Part B: Eligibility and Benefits

Only those who have Part A can purchase Part B, and they can do so only during specified enrollment periods. Medicare either deducts monthly premiums from Social Security payments or bills quarterly for them. Benefits include doctor visits, physical therapy, occupational therapy, and other specified outpatient services. Part B has an annual deductible and numerous copayments. As well, there are many exclusions and limitations. A person can receive such services but must pay for them in full.

Medicare Plans

People on Medicare receive medical care and services through community providers (doctors, hospitals, pharmacies, and others). As with private medical insurance, there are different kinds of plans through which a person can enroll for a year at a time to receive care. A person can change to a different Medicare plan during annual open enrollment.

• Original Medicare Plan (OMP): This is the payment for service plan in which everyone is automatically enrolled. Private insurance companies pay Medicare claims to providers, who agree to accept Medicare assignment (Medicare as payment in full for qualifying services). After Medicare pays its portions, providers bill patients for uncovered services and eligible balances.

• Medicare managed care: The person on Medicare receives medical care and services through a closed network of providers such as a health maintenance organization (HMO) or preferred provider organization (PPO). These networks agree to accept complete Medicare assignment and typically offer more extensive benefits such as routine health screenings and prescription drugs. A Medicare managed care plan has minimal out-of-pocket costs for a person with extensive medical needs, as long as the plan has good access to appropriate specialists. However, such plans are not always available in all areas.

• Private fee-for-service: Medicare pays a set fee for eligible services and the person pays all balances. Although this option offers the widest choice among providers, which may be important to a person with Parkinson’s who sees multiple specialists, it entails the highest out-of-pocket expenses.

Help with Medicare and Medical Expenses

Both Part A and Part B have deductibles, coinsurance, and benefit limitations that result in out-of-pocket costs. For the person with Parkinson’s who needs significant medical care, these expenses can become substantial. Some people have additional medical insurance that helps to cover some of these expenses. Social Security provides assistance with Medicare Part B premiums for people who meet income and resources guidelines (at or below the federal poverty level). As well, many drug companies offer prescription assistance programs for seniors who cannot afford to buy their medications.

See also financial planning; medical management; PLANNING FOR THE FUTURE.

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