Medicare Basics: Everything You Need to Understand About Medicare

Every year, according to research from the Kaiser Family Foundation, Medicare payments for people in the United States exceed $600 billion.

Have you been thinking about signing up for Medicare benefits? Are you unsure of whether or not you’re eligible or how you can choose the right plan for your needs?

If you’re feeling confused about or overwhelmed by the idea of Medicare, you’re in the right place. Read on to learn all of the Medicare basics you need to know.

What Is Medicare?

Medicare is a program that has been in place in the United States (on a federal level) since 1965. The goal of Medicare is to ensure that elderly individuals, as well as those who have long-term disabilities, have access to healthcare regardless of their income level, their medical history, or their health status.

Medicare is an essential program that helps millions of people throughout the United States access and pay for the care they need. It covers a wide range of services, including the following:

• Doctor visits
• Hospital stays
• Prescription drugs
• Preventive care
• Home health care
• Nursing facility care
• Hospice care

Could you use help paying for these kinds of healthcare services? If so, Medicare might be the solution you need.

Medicare vs. Medicaid

Before we dive into Medicare eligibility and start answering questions like “What’s the difference between Part A and Part B Medicare?”, let’s touch on the difference between Medicare and Medicaid.

Because the programs have similar names, it’s understandable that a lot of people confuse the two. Here are some of the key differences between Medicare and Medicaid:

• Medicare is exclusively a federal program
• Medicaid is both a state and a federal program
• Medicare is meant for the elderly and those with disabilities
• Medicaid is meant for anyone who has a very low income

It’s important to note that some people are eligible for both Medicare and Medicaid. This is known as dual eligibility.

Who Is Eligible for Medicare?

As we’ve mentioned, Medicare is meant for the elderly and individuals who have long-term disabilities. What, specifically, does this mean, though?

You become eligible for Medicare when you are 65 years of age or older.  If you or your spouse is at least 65 and is eligible for Social Security payments, you are likely entitled to Medicare benefits.

Keep in mind, though, that eligibility is also somewhat contingent upon your work history. If you’ve worked at least 40 quarters and earned at least $1,410 per quarter (and paid Medicare taxes), you are eligible for Medicare Part A, premium-free. If you have worked less than this, you can still qualify for Medicare Part A, but you’ll have to pay a premium for it.

As far as people who have long-term disabilities, you become eligible for Medicare if you receive SSDI (short for Social Security Disability Insurance) payments. However, you must also go through a two-year waiting period before you can start receiving Medicare benefits.

The only exceptions to this rule are those who have been diagnosed with the following conditions:

• ESRD (or End-Stage Renal Disease)
• ALS (or Amyotrophic Lateral Sclerosis

If you have been diagnosed with either of these conditions, you get to skip the two-year waiting period and can start receiving Medicare benefits sooner.

A Snapshot of Medicare Recipients

Of course, the majority of folks who receive Medicare benefits are elderly. What other characteristics do these recipients share, though?

The following are some interesting statistics, also from the Kaiser Family Foundation, that break down the people in the U.S. who are on Medicare:

• 32 percent of beneficiaries have a functional impairment (a disability that prevents them from carrying out activities of daily living)
• 25 percent consider themselves to be in fair or poor health
• 22 percent have five or more chronic health conditions
• 15 percent are under the age of 65 and have a long-term disability
• 12 percent of beneficiaries are over the age of 85
• 3 percent live in a long-term care facility (such as a nursing home)

The average Medicare recipient has a modest income, too. Approximately half of all beneficiaries have an annual income of less than $26,200. They also have savings below $74,000.

Types of Medicare Plans

You’ve likely heard terms like “Medicare Part A” or “Medicare Part D”, but how many different parts of Medicare are there? There are four different Medicare plans, and they are as follows:

Medicare Part A

Medicare Part A is also known as hospital insurance.

As this alternative name suggests, Medicare Part A primarily covers hospital-related healthcare costs. This includes hospital stays, of course, as well as care that one might receive while staying in a skilled nursing facility. It covers hospice care and some home health care expenses, too.

Medicare Part B

Medicare Part B is also known as medical insurance. This plan covers a variety of healthcare services, including visits to the doctor’s office, outpatient care, and preventative services. It covers the cost of some medical supplies, too.

Medicare Part C

Medicare Part C is more commonly known as a Medicare Advantage plan. If you have both Medicare Part A and Part B, you’re able to enroll in an Advantage plan.

This plan allows you to add extras to your healthcare coverage, such as dental care and vision care. If you’re enrolled in this type of plan, you’ll also likely pay an additional premium to a private insurance company.

If your Medicare Advantage plan includes prescription drug coverage, it’s known as an MAPD plan.

Medicare Part D

Speaking of prescription drug coverage, that’s what separates Medicare Part D from the other plans. Medicare Part D helps to reduce the cost of prescription drugs for Medicare recipients. It also covers many of the recipient’s recommended shots and vaccines.

How Much Does Medicare Cost?

Now that you know more about the Medicare Part A and B difference, as well as the differences between these and other plans, you might be wondering what your insurance premiums will look like as a Medicare beneficiary.

Everyone’s expenses will look a bit different depending on their specific needs and the particular plan they choose. However, here’s a breakdown of what Medicare premiums, co-pays, and deductibles look like in 2020:

• Part A Monthly Premium
  • For those who have 0-29 qualifying quarters of employment: $458
  • For those who have 30-39 qualifying quarters of employment: $252
• Inpatient Hospital Costs
  • Deductible, per each spell of illness: $1,408
  • Co-Pay for days 1-60: $0
  • Co-Pay for days 61-90: $352 per day
  • Co-Pay for Lifetime Reserve Days: $704 per day 
• Skilled Nursing Facility
  • Co-Pay for days 1 – 20: $0
  • Co-Pay for days 21 – 100: $176
• Standard Monthly Part B Premium
  • $144.60
• Part B Deductible
  • $198

Premiums for Medicare Advantage Plans and Part D coverage will vary depending on the insurance provider you choose to work with.

How to Choose the Right Medicare Plan

How do you know which Medicare plan you should choose? What if you want coverage beyond Part A and B?

It can be hard to decide which plan to sign up for, especially if you want to sign up for supplemental coverage with a Medicare Advantage or an MAPD plan. If you’re in this position right now and aren’t sure what to do, here are some tips that will help you make the right decision for your needs:

Consider the Cost

Of course, one of the first things to think about is your budget. How much can you afford to spend each month on healthcare premiums? The answer to this question will, of course, influence whether you stick with Medicare Part A and B only or if you expand and add additional coverage to your plan.

Evaluate the Coverage

Before you decide which plan you’re going to choose, you’ll need to think, too, about how much coverage you need. Do you want coverage beyond hospital care and regular doctor visits?

Do you want to make sure you can still go to the dentist and the optometrist without spending a fortune? If the answer to these questions is “yes”, you’ll likely want to look into a more comprehensive plan, such as a Medicare Advantage plan.

Look into Additional Coverage

Do you have other coverage through your job? If you plan to continue working past the age of 65, for example, and your employer offers insurance benefits, you might be better off joining a Medicare Advantage plan.

This will reduce your cost-sharing (premiums, deductibles, etc.). It’ll also ensure that you get access to additional types of coverage, such as hearing care, vision care, and dental care.

Consider Prescription Drug Needs

Do you take a lot of prescription drugs? If so, then it’s in your best interest to look into the best rated Medicare Part D plans. That way, you won’t have to worry about paying for all of your medications out of pocket.

Even if you don’t take any prescription drugs now, keep in mind that this could change in the future. If you want to be prepared and ensure you have coverage, consider enrolling in Medicare Part D so that you can be safe instead of sorry.

Think About Hospital and Doctor Choice

Do you have a specific doctor that you want to consider seeing or a particular hospital that you want to go to if needed? Make sure your current preferred doctor or hospital will accept your coverage before signing up for a specific plan. Consider whether, under a particular plan, you need referrals or have to choose from a specific network, too.

Consider Travel Requirements

For those who often have to (or choose to) travel outside of the United States, it’s important to note that Medicare plans typically do not cover healthcare services that are required in other countries. If you want to make sure you’re covered while traveling abroad, you’ll need to purchase supplemental insurance before you leave on your trip.

How Do You Enroll in Medicare?

Okay, you know what kind of plan you want to purchase. How do you enroll, though? What’s the process for signing up and making sure you receive benefits?

The following are the steps you’ll need to go through to enroll in Medicare:

Monitor Dates

Most people don’t need to go through any special steps to enroll in Medicare (at least Part A and Part B). If you receive Social security or Railroad Retirement Board benefits, you’re automatically enrolled in Part A and Part B, and you’ll start receiving benefits starting on the first day of your birthday month the year you turn 65.

You should receive a Medicare card about three months prior to your 65th birthday. If you don’t receive a card, you can reach out to the Medicare office and let them know.

Enroll Online if Needed

For those who are not receiving Social Security benefits, you can apply online for retirement benefits. You can also file for Medicare only by applying over the phone (call 1-800-772-1213).

Consider Joining a Medicare Advantage Plan

If you want to join a Medicare Advantage Plan, you can enroll online during your initial enrollment period (three months before or after your 65th birthday) or during the annual open enrollment period. This period lasts from October 15 to December 7.

Keep in mind, if you enroll in a Medicare Advantage Plan, you can switch to a different plan or go back to Original Medicare (Parts A and B) within the first three months of receiving Medicare Benefits.

For Those with Disabilities

If you are disabled and younger than 65, you’ll automatically be entitled to Medicare Part A and Part B 24 months after you start receiving Social Security or Railroad Retirement Board disability benefits. At the beginning of the 25th month, you’ll become eligible, and you should receive a card about three months prior to this date.

You may need to reach out to the Social Security Administration if you don’t receive a card or if you have questions about benefits. This might also be the case if you have ALS or ESRD and get to skip the 24-month waiting period.

You’ve Mastered Medicare Basics: Now What?

There you have it: the most important Medicare basics that everyone ought to know. Do you feel more confident now that you know more about Medicare and can answer questions like “What is the difference between Medicare Part A and B?” and “What is the difference between Medicare Part B and D?”

Do you want to learn more about Medicare or other types of healthcare coverage before you select a specific plan? If so, check out some of the other insurance-related articles on our site today for additional information.