Medicare 101: Eligibility And Coverage

Medicare is one of the most important programs in the United States. It provides healthcare coverage for millions of people and is vital for those who rely on it. In…

July 25, 2022

Written by Nikki Grillo

Medicare is one of the most important programs in the United States. It provides healthcare coverage for millions of people and is vital for those who rely on it. In this blog post, we will explain everything you need to know about Medicare coverage and eligibility. 

We’ll discuss each term’s meaning, how they work, and why they’re important. If you’re nearing retirement age or are already retired, you must understand Medicare.

What’s Medicare? 

Medicare is a government health insurance program that’s available to people who are 65 years or older, as well as to some younger people with disabilities. 

It covers a range of medical services, including hospital stays, doctor visits, and prescription drugs. 

What Are the Different Parts of Medicare? 

Medicare consists of four parts: Part A, Part B, Part C, and Part D. 

Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care. 

Part B covers outpatient medical services like doctor visits and preventive screenings. 

Part C is also known as Medicare Advantage. It’s a private health insurance plan that includes all of the benefits of Parts A and B, plus extra benefits like dental, vision, and prescription drug coverage. 

Part D is the prescription drug benefit. It covers the cost of prescription drugs. 

How Do I Know If I’m Eligible for Medicare? 

You’re eligible for Medicare if you’re 65 years or older or have a disability. You may also be eligible if you’re under 65 but have a disability. 

There are other circumstances in which you may be eligible for Medicare, such as end-stage renal disease or amyotrophic lateral sclerosis. 

What Are The Requirements For Enrolling In Medicare? 

If you’re already receiving benefits from Social Security or the Railroad Retirement Board, you will automatically be enrolled in Part A and B when you turn 65. 

If you’re not receiving benefits, you can sign up for Medicare during your Initial Enrollment Period. This is a seven-month period that begins three months before you turn 65, includes the month you turn 65, and ends three months after that. 

You can also sign up for Part A and Part B during the General Enrollment Period, which runs from January through March. 

Medicare Eligibility For People Under 65

If you’re under 65, you may be eligible for Medicare if you have a qualifying disability or end-stage renal disease. If you have a qualifying disability, you’ll be automatically enrolled in Medicare Part A and Part B after 24 months of receiving Social Security Disability Insurance (SSDI) benefits. You’ll need to apply for Medicare if you have end-stage renal disease.

To learn more about whether you’re eligible for Medicare coverage, visit the official website or speak with a representative. You can also contact your state’s health insurance marketplace.

Medicare Parts Eligibility

Now that we’ve established the eligibility of Medicare let’s take a deep dive into eligibility for its different parts.

Part A Eligibility

Part A is hospital insurance covering inpatient care in hospitals, skilled nursing facilities, hospice, and home health care. You are eligible for premium-free Part A if you are 65 or older and have worked and paid Medicare taxes for at least 40 quarters. 

You can also get Part A at age 65 without having to pay premiums if:

  • You’re receiving disability benefits from Social Security or certain Railroad Retirement Board benefits.
  • You’re a government employee or retiree who didn’t pay into Medicare.
  • You or your spouse worked long enough under a federal job or job in the railroad industry.
  • Are under age 65, disabled, and you have been receiving disability benefits from Social Security or the Railroad Retirement Board for at least 24 months.
  • Are any age and have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

If you don’t meet any of the above criteria, you may still be able to buy Part A if you’re over 65. 

Part B Eligibility

Part B is medical insurance covering outpatient care, preventive services, some vaccines, and other services such as x-rays, lab tests, and durable medical equipment. You are eligible for Part B if:

  • You are enrolled in Part A 
  • You are 65 or older, and you are a US citizen or a permanent legal resident. 
  • Are under age 65, disabled, and you have been receiving disability benefits from Social Security or the Railroad Retirement Board for at least 24 months.
  • Are any age and have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

You’ll still be eligible for Part B even if you choose not to enroll when you first become eligible. However, you will be penalized with a higher premium, which rises 10% each year you don’t enroll since first becoming available. If your employer currently covers you or you’re part of your spouse’s plan, you won’t be penalized.

Part C Eligibility

Part C, also known as Medicare Advantage, is an alternative way to get your Original Medicare coverage (Parts A and B). It’s offered by private companies that contract with Medicare. To be eligible for Part C, you must enroll in parts A and B. 

If you decide to join a Medicare Advantage Plan, you’ll still have to pay your Part B premium. Medicare Advantage isn’t offered in every state, so you must ensure that it is available in your area before enrolling. 

Part D Eligibility

Part D is prescription drug coverage. You are eligible for Part D if you already have Parts A, B, or both. If you decide to join a Medicare Prescription Drug Plan, you’ll still have to pay your Part B premium. Like Part B, you can still enroll after the initial enrollment period but may be penalized with a higher premium. 

Medigap Eligibility

Medigap is a type of supplemental insurance that can help cover some of the costs that Medicare doesn’t. To be eligible for Medigap, you must enroll in Medicare Part A and Part B. 

You can enroll in Medigap during your six-month Medigap Open Enrollment Period, which begins the month you turn 65 and are enrolled in Medicare Part B. If you have a pre-existing health condition, you may be able to enroll outside of your open enrollment period.

There you have it! Now that we’ve established the basics of Medicare eligibility let’s move on to understanding the different types of coverage.

Plan Coverage

Medicare Plans offer different coverage options. Before deciding which plan is best for you, you need to know and understand what each plan offers. Let’s take a look at the different coverage 

options each plan has to offer: 

Plan A Coverage

Each plan covers specific services, so it’s important to know them. Medicare Plan A covers:

  • Inpatient Hospital Care
  • Skilled Nursing Facility Care
  • Hospice Care
  • Home Health Care

Talk to your healthcare provider to verify what Medicare will cover in your area. It’s important to know which plan is best suited for your needs. 

Plan B Coverage

Medicare Plan B covers:

  • Outpatient Hospital Services
  • Doctor’s Office Visits
  • Preventative Care Services
  • Diagnostic Testing and X-Rays

Medicare Advantage Coverage

Medicare Plan C covers:  

  • Coinsurance for Doctor’s Office Visits and Outpatient Hospital Services  
  • Part of the Coinsurance or Copayment for Skilled Nursing Facility Care
  • Hospice Care
  • Home Health Care  
  • Blood (First Three Pints)
  • Deductible for Part B

Plan D Coverage

Medicare Plan D helps you cover prescription drugs. Included in Plan D are: 

  • Brand name and generic prescription drugs 
  • Preventative drugs 
  • Part B deductible 
  • Coinsurance

Medicare Drug Plan Tiers:

Most Medicare drug plans have different “tiers” of drugs. Each tier has different coverage and cost. The drugs in each tier have different costs because of their clinical effectiveness or how they are made.

  • The first tier usually has the lowest copayment, most generic drugs. 
  • The second tier with medium copayment offers preferred brand-name prescription drugs.
  • The third tier usually has brand-name drugs that cost more than the first two tiers. 
  • Some plans also have a fourth tier, considered a specialty tier, for very high-cost drugs.

You will pay more for a drug in a higher tier even if you have a Medicare drug plan that covers the drug’s full cost. In some cases, you may be able to get help from your drug plan to pay for drugs in higher tiers. For example, your plan may offer discounts or rebates.

Medigap Coverage

In addition to the four plans above, there is Medigap coverage. Medigap is a type of supplemental insurance that helps cover certain out-of-pocket costs not included in Medicare Plans A through D. Private insurance companies offer these plans, and each company can offer different coverage options. 

Some of the common services that Medigap plans help pay for are: 

  • Coinsurance for hospital stays 
  • Copayments for doctor visits 
  • Part A and Part B deductibles 

Choosing the right plan can be difficult. There are many factors to consider when choosing a plan, such as your budget, your health needs, and whether you want comprehensive or basic coverage. It’s important to do your research and speak with a Medicare specialist to find the best plan for you.

Find The Medicare Plan That Best Fits Your Needs

At Nesso Senior Benefits, we want to provide you with all the information necessary to decide which plan to choose. Understanding what each plan offers is the best way to ensure you get the most out of your benefits while meeting your needs. 

Our Nesso Group team will guide you through every step of the process and keep an eye on your ever-changing needs to adjust the plans as needed. It’s important to know that you’re not alone in this process. Don’t hesitate to reach out now to learn more about how we can help you. 

LEARN MORE ABOUT US

Subscribe To Our Blog

Suscribe

Read More Entries

Let’s Talk About
What’s Important To You

Nesso
Solutions

Our approach to integrated solutions and comprehensive services alleviates stress and elevates success. We provide guidance across multi-dimensional areas of expertise for individuals and businesses. You can trust that we’re working together with your best interest in mind.

Image Item

Nesso
Tax

Image Item

Nesso
Accounting

Image Item

Nesso
Wealth

Image Item

Nesso
Insurance

Image Item

Nesso
Medicare

Image Item

Nesso
Benefits

Call Now Button