Medicare Explained

What Is Medicare? While certain others may qualify, in general, Medicare is a federal health insurance program for people who are 65 or older. It’s necessary to understand that there are 2 fundamental components to “Original Medicare” – Part A and B. Beyond that, you may have heard of Prescription Drug Coverage (Part D), and Medicare Supplements (or “Gap” coverage). We address all this right here, and even talk about Medicare Advantage.

If you have questions: You may reach us by phone at 408-348-8930, or at your convenience, email us via our contact page.

Medicare Part A – Hospital Coverage

Medicare Part A is what covers Medicare member’s inpatient hospital care. Part A does NOT cover outpatient services such as doctor’s office visits or lab-work. Part A covers virtually all covered items at 80%, leaving a 20% co-insurance for the member. This means you must pay the remaining 20% of Medicare allowed charges for your hospital stay.

Medicare Part  B – Outpatient Medical Coverage

Medicare Part B is what covers a Medicare member’s outpatient care. Part B does NOT cover inpatient hospital services such as inpatient surgery. Part B covers virtually all allowed services at 80%, leaving a 20% co-insurance for the member. This means you must pay the remaining 20% of Medicare allowed charges for outpatient services and procedures.

The primary way you qualify for the Medicare program is by turning age 65- after having paid a minimum of 40 quarters worth of Medicare tax.
Also, for those who have not worked outside the home and paid the Medicare tax, any legal spouse who has been married to a qualifying worker for a minimum of 10 years is also qualified to enroll in Medicare.

Medicare Part D – Prescription Drug Coverage

Prior to 2006, Medicare did not cover prescription drugs at all. Since 2006, a program has existed known as “Medicare Part D”. Medicare Part D pays for a majority of prescription drug expenses for its enrollees. It should be noted Part D’s insurance carrier partners commonly refer to it as a PDP – Prescription Drug Plan. In fact, in their marketing materials and such, the term “PDP” may soon replace Medicare Part D altogether.

To avoid confusion, it is important to understand that “Part D”, unlike Parts A (Hospital) and Part B (Outpatient), is what is known as a public-private partnership. What this means in plain language is that while the Federal Government actually funds the entire program, private insurance companies (ex: Medco, Humana, etc.) administer the program. This means that they process and pay claims, handle premium billing, etc.. The program is rigorously regulated and supervised by Medicare to protect consumers and control fraud.

By contrast, Medicare Parts A (Hospital) and B (Outpatient) for all practical purposes are both funded AND administered by the Federal Government.

Disability and Medicare

You may know someone younger than 65, maybe significantly so, enrolled in the Medicare program. This is because Medicare, in certain cases, allows who the Social Security Administration considers is “permanently” disabled individuals to enroll, just like those who are 65 or older.

Medicare Enrollment

There are enough details about qualifying for Medicare, and the Step-by-step process of Medicare enrollment, that we have consolidated that information on its own page. – Step-by-step Medicare Enrollment – Click Here

Gap Coverage – Medicare Supplements

Because there is much to cover on “gap coverage,” and the advantages and disadvantages to both Traditional Medicare Supplements and Medicare Advantage, we thought it really deserved its own page. We keep it straight-forward and cover everything in easy detail. – Medicare Supplement Information – Simply Click Here