Texas Medicare 101
Medicare Made Easy
In general, individuals are eligible for Medicare if they (or their spouse) worked for at least 10 years in Medicare-covered employment and are at least 65 years old and are a citizen or permanent resident of the United States of America.
Individuals who are under 65 years old can also be eligible if they are disabled or have end stage renal disease. People under 65 and disabled must be receiving disability benefits from either Social Security or the Railroad Retirement Board for at least 24 months before Medicare automatic enrollment occurs.
Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those with certain income, Medicaid will pay the beneficiaries Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay any drugs that are not covered by Part D.
Part A- Hospital Insurance:
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. What Medicare covers is based upon, Federal and state laws, National coverage decisions made by Medicare about whether something is covered, local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
Part B- Medical Insurance:
Medicare Part B is available at a monthly rate set annually by Congress ($134 in 2017 for incomes $85000.00 or less for an individual). Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Some seniors are eligible to receive the medical insurance portion (Part B) free as well, depending on their income and asset levels. For more information, inquire about the Qualified Medicare Beneficiary (QMB), Special Low Income Medicare Beneficiary (SLMB), and Qualifying Individual programs through your county social services office.
Part C- Medicare Advantage:
Medicare Part C (Medicare Advantage Plans) is a type of Medicare health plan offered by a private insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), Private Fee-for-Service Plans (PFFS’s), Special Needs Plans (SNP’s), and Medicare Medical Savings Account Plans (MSA’s). If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and are not paid for under Original Medicare. Most Medicare Advantage Plans have prescription drug coverage included.
Part D- Prescription Drugs:
Medicare Part D (prescription drug coverage) adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare.
Most Medicare Advantage Plans also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. Keep in mind, you may owe a late enrollment penalty if you go without a Medicare Prescription Drug Plan (Part D), or without a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage, or without creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over.
Many people are automatically enrolled in Original Medicare, Part A and Part B, when they reach 65 years of age. But one may not realize that Original Medicare does not cover most of your medication’s (except those you may receive as a hospital inpatient, or in some cases, outpatient). Medicare Part B covers certain prescription drugs that you get in an outpatient setting, like a doctor’s office. However, these tend to be the kind of medications that you need a doctor to give you, like infusion drugs. If you want help with most other medication costs, you’ll need to sign up for Medicare Part D coverage.
Next, learn: How Medicare Works
Sarah began working in the healthcare industry in 2001, where she worked for many years with elderly Alzheimer and Dementia patients. From there she worked as a Group Benefits Administrator with a local healthcare company in the Human Resource Department for a period of 10 years. Since then, she has decided to work in the Medicare insurance industry full time and has joined the family business, Ashford Insurance, as a Medicare Insurance Agent.
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