Medicare Solutions

Medicare is federal health insurance. It is primarily for America’s seniors, but also some people under age 65 with certain disabilities and those of any age with end-stage renal disease (ESRD).

The Centers for Medicare & Medicaid Services (CMS) administers the program, while the Social Security Administration (SSA) enrolls most individuals.* There are 4 parts of Medicare:

  • Part A – Hospital
  • Part B – Medical
  • Part C – Medicare Advantage
  • Part D – Prescription Drug Program

*The nation’s railroad workers pay Medicare taxes to the federal railroad administrative system rather than the SSA. These workers and their dependents are enrolled in Medicare through the U.S. Railroad Retirement Board.

What is Original Medicare

Medicare Part A, also called “original Medicare,” is the insurance plan that covers hospital stays and services. It also covers stays in skilled nursing facilities, walkers and wheelchairs, and hospice care. It even covers home healthcare services if you’re unable to get to a hospital or skilled nursing facility. If you need a blood transfusion, Part A covers the cost of the blood. Medicare Part A covers hospital inpatient costs. However, just because you visit a hospital doesn’t mean that you’re an inpatient. An overnight stay doesn’t mean you’re an inpatient either.

Difference between inpatient and outpatient

You’re an inpatient when you’re formally admitted to a hospital with a doctor’s order. You’re an outpatient if you receive any type of hospital services without being formally admitted to a hospital with a doctor’s order. This may include emergency services, outpatient surgery, lab tests, and X-rays. In these cases, you’re an outpatient even if you stay overnight at the hospital. Make sure you know if you’re an inpatient or outpatient, as this will affect your coverage.

Also, Medicare Part A will only cover a skilled nursing facility if you have a qualifying inpatient hospital stay — three consecutive days resulting from a formal inpatient admission order written by your doctor.

What is eligible for Medicare

Turning 65 is one way you become eligible for Medicare. You can also be under 65 and eligible for Medicare because you are receiving Social Security Disability Insurance or SSDI. In most cases, you qualify for Medicare due to disability if you have been receiving SSDI checks for more than 24 months. This 24-month period begins with the first month you receive an SSDI check and is also known as the two-year waiting period. You will be automatically enrolled in Medicare at the beginning of the 25th month that you receive an SSDI check.

If you receive SSDI because you have Amyotrophic Lateral Sclerosis, or ALS, Medicare automatically begins the first month that your SSDI benefits start. You do not have the 24-month waiting period.

Social Security, not Medicare, makes the determination of whether you qualify for SSDI checks and administers the program that provides the checks. For more information on the Social Security Disability Insurance program, it is best to contact your local Social Security Administration (SSA) office.

Note: Railroad workers should contact the Railroad Retirement Board for information about disability annuity and Medicare eligibility.

Another way that you can become eligible for Medicare is if you are under 65 with End-Stage Renal Disease, also known as ESRD or kidney failure. You may qualify for Medicare if you have been diagnosed with ESRD and you:

  • Are getting dialysis treatments or have had a kidney transplant apply for Medicare benefits (up to 12 months retroactively) and:
  • You are eligible to receive SSDI
  • You are eligible to receive Railroad Retirement benefits
  • Or, you, a spouse, or a parent have paid Medicare taxes for a sufficient amount of time as specified by the Social Security Administration.

If you are under 65 and have ESRD, when your Medicare benefits begin depends on your specific circumstances, including when you apply for Medicare, whether you receive dialysis at home or at a facility, and whether you get a kidney transplant.

Note: If you are a railroad worker with ESRD, you must contact Social Security, not the Railroad Retirement Board, to find out if you are eligible for Medicare. Because Social Security and Medicare eligibility rules are complex, you should call Social Security at 800-772-1213 to get the most accurate information regarding your particular situation.

What Does Medicare Cover

When it comes to healthcare, it’s important to know what is covered and what isn’t. Because there are so many different plans for Medicare, it can be hard to figure out which one is right for you.

Fortunately, there are tools to make this process easier.

Medicare is the insurance plan offered by the federal government for people 65 and over, as well as people with disabilities and those with permanent kidney failure.

There are four parts to Medicare: A, B, C, and D. Each covers a different aspect of healthcare.

You can enroll in one or more parts of Medicare. The most common are Parts A and B, which cover the majority of services. People usually have to pay a monthly premium, but this, too, depends on your income.

The Different Parts of Medicare

Here are four parts of Medicare: A, B, C and D, which cover specific services.

Part A provides inpatient/hospital coverage. Part B provides outpatient/medical coverage. Part C offers an alternate way to receive your Medicare benefits (see below for more information). Part D provides prescription drug coverage. Most beneficiaries choose to receive Part A and Part B benefits through Original Medicare, the traditional fee-for-service program offered directly through the federal government. It is sometimes called Traditional Medicare or Fee-for-Service (FFS) Medicare.

Original Medicare

Under Original Medicare, the government pays directly for health care services you receive. You can see any doctor and hospital that takes Medicare (and most do) anywhere in the country. You go directly to the doctor or hospital when in need of care and you don’t need to get prior permission or authorization from Medicare or your primary care doctor. You are responsible for a monthly premium for Part B. Some people also pay a premium for Part A. Beneficiaries typically pay coinsurance for each service they receive. There are limits on the amounts that doctors and hospitals can charge for your care.

If you want prescription drug program (PDP) coverage with Original Medicare, in most cases, you will need to join a stand-alone Medicare PDP.

Note: There are a number of government programs that help reduce health care and prescription drug costs, if you meet certain eligibility requirements.

Medicare Advantage

Instead of Original Medicare, you can decide to get your Medicare benefits from a Medicare Advantage Plan, also called Part C. Remember, you still have Medicare if you enroll in a Medicare Advantage Plan. This means that you must still pay your monthly Part B premium (and your Part A premium if you have one).

Each Medicare Advantage (MA) Plan must provide all Part A and Part B services covered by Original Medicare. However, they may have different rules, costs, and restrictions on how and when you receive care.

It is important to understand your Medicare coverage choices and to pick your coverage carefully. How you choose to get your benefits and who you get them from can affect your out-of-pocket costs and where you can get your care.

For instance, with Original Medicare, you are covered to go to nearly all doctors and hospitals in the country. On the other hand, MA plans typically have network restrictions. While this means you will likely be more limited in your choice of doctors and hospitals, some MA Plans do provide additional benefits Original Medicare does not cover, such as routine vision or dental care.