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What is medicare and how does it work

what is medicare and how does it work

A gentleman who recently became Medicare eligible posed that question to me, and succinctly stated as it was, I thought it would be a good base for today’s column.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Most people become Medicare eligible upon reaching their 65th birthday. Furthermore you or your spouse need to have worked at least 40 quarters in this country to be fully entitled to Medicare. If you have not worked that many quarters, you may be able to buy into Medicare and pay a premium for Part A, and higher premium for Part B.

We will not discuss enrolling in Medicare as this column has discussed that many times, but if you need more information on enrolling in Medicare, please see or call Social Security who handles Medicare enrollment, at 1-800-772-1213.

Here is how Medicare works: Medicare Part A covers you at the hospital. Medicare Part B covers a portion of your medical expenses at the doctor or other providers’ offices. Medicare Part C is an option in lieu of traditional Parts A, B, and D, and is what is known as a Medicare Advantage plan. Medicare Part D is the prescription component which came into being in 2006.

Is there a deductible? Yes. The Medicare Part A deductible is $1,184 this year. That deductible is not per calendar year, which is what we are used to on group plans and individual plans, it is per benefit period. A new benefit period starts when you have been out of the hospital for 60 days.

The Medicare Part B deductible is $147 this year. This one is per calendar year. If you have enrolled in a good Medicare Supplement (as everyone should) depending on which plan you selected will determine if your Medicare Supplement plan covers that deductible. For those of you soon to enroll, give consideration to deductible coverage. Many people like to have the deductibles covered, and for some, there may be a premium savings by not taking deductible coverage that makes more sense to them. Explore it and determine what is best for you and your budget.

Do I have a co-pay

with Medicare? No. If your doctor’s office accepts assignment, they should not ask you for any money at the time of service. They will submit the claim to Medicare, and Medicare will pay 80% of the allowable amount. Again, depending on what Medicare Supplement plan you have will determine what gets picked up and paid after Medicare. If your doctor does not accept assignment, they may ask you for money up front, and then they will submit the claim to Medicare for you and Medicare will reimburse you.

Do I need referrals to see a specialist? No. Just make the appointment, check that the doctor is a Medicare Provider, and go.

What is the difference between being a Medicare Provider and accepting assignment? Being a Medicare provider means he or she is legally authorized to practice medicine and recognized by Medicare as such. If he or she accepts assignment, it means they agree to accept the allowable amount as payment in full and will not balance bill you the Part B excess charge. Part B excess charge is easier defined as the difference between the original charge, and what Medicare approved.

Do I need to make sure all my doctors accept assignment? Not necessarily. If you want Medicare to cover their bills, do be sure they are a Medicare Provider though. If you have elected coverage under a Medicare supplement plan F or G you will have full coverage for the Part B excess charges. If you have not selected a plan with part B excess coverage, and see a doctor who does not accept assignment, you may be responsible for the amount between what Medicare approved, and the original charge.

What about if I go visit a friend in Colorado and get sick? Will Medicare cover me there? Yes. Traditional Medicare will cover you anywhere you are inside the United States. So too will your Medicare Supplement. If you travel abroad, Medicare will not cover you. Some Medicare supplement plans offer Foreign Travel emergency benefits, or you may wish to consider travel insurance when traveling outside the United States.

Irene Card and Betsy Chandler are both licensed insurance professionals with MIC Insurance Services, a health insurance services company. If you have questions relative to this column or other related topics. we invite you to call us at (973)-492-2828.

Category: Insurance

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