Common Medicare Questions: Answers From Medicare Expert Charles MacKay

What is Medicare?

Medicare is the U.S. federal government program that provides health insurance coverage to those over 65, certain younger people who are disabled, and those who have end-stage renal disease.

It has four parts:

  • Part A covers hospital services
  • Part B covers physician and other services
  • Part C (also called Medicare Advantage) is an alternative to Parts A and B (Original Medicare). Private insurance companies provide Medicare benefits to their enrollees, rather than the federal government.
  • Part D provides prescription drug coverage

Most people qualify for premium-free Part A if they paid enough taxes while working. Others may buy it for a monthly premium.

Parts B, C, and D require premiums, but the premium for some part C plans is zero.

Is Medicare eligibility different for disabled people and those with End-Stage Renal Disease (ESRD)?

Slightly. For those who are disabled and do not have ESRD, Medicare starts after they have received Social Security disability for two years.

For those with ESRD, it starts at the start of their fourth month on dialysis.

How much are 2019 Medicare premiums?

If one is eligible for Part A from having worked under Social Security for ten years (40 quarters), Part A is premium free.

The standard premium for Part B is $135.50 per month in 2019, with higher premiums for some higher earners.

Premiums for Part C vary by plan. All Medicare Advantage plans require you to pay your Part B premium in addition to the plan premium (if any).

Part D premiums vary by plan.

Do I Need Medicare Supplement Insurance Coverage?

If you are enrolled in a Medicare Advantage plan (Part C), no.

Medicare Advantage plans and Medicare Supplement Insurance (Medigap) are very different. You cannot be enrolled in a Medicare Advantage plan and a Medicare Supplement Insurance plan at the same time.

Otherwise, you might want to consider a Medigap plan, unless you are quite healthy and quite wealthy. A Medigap plan can help cover certain Medicare out-of-pocket costs, such as some deductibles and copayments and coinsurance.

One key thing to remember is that there is no out-of-pocket spending cap for Original Medicare. Your out-of-pocket Medicare costs could potentially keep adding up.

Medicare Advantage plans, in contrast, do have out-of-pocket limits, which are capped at $6,700 in 2019.

You may want to consider a Medicare Supplement Insurance plan if you are not enrolled in a Medicare Advantage plan.

What are the advantages of a Medicare Advantage plan?

While Medicare Advantage plans are required by the federal government to cover the same hospital and medical services as Medicare Part A and Part B, they have the flexibility to offer additional benefits that Original Medicare doesn’t offer. This is a great way to attract new members.

These services or items may include:

The extras vary by plan, and not all plans offer all of these benefits.

Medicare Advantage plans, unlike Original Medicare, have networks that may restrict the providers you can see and the hospitals you can use.

If you want the extra services that a certain Medicare Advantage plan may offer, and if you are confident in the providers a plan will make available to you, you may prefer Medicare Advantage.

If I am not eligible for Medicare based on work, can I buy into Medicare?

Yes.

If you have worked and paid taxes for at least 30 quarters, you can buy Medicare Part A for $240 per month in 2019. If you worked less than 30 quarters, the premium is $437 a month in 2019.

This still may be a lower premium cost than an available commercial plan (such as those available on Affordable Care Act exchanges) with comparable benefits.

Can I use any Medicare doctor or hospital?

With Original Medicare, you can visit any hospital or doctor who accepts Medicare.

Some Medicare Advantage plans restrict you to their network and do not pay anything for out-of-network care. Some Medicare Advantage plans, however, may allow you to use out-of-network providers, but your copayments for them may be larger.

Generally, the wider the range of providers that you can use, the higher your Medicare Advantage plan premiums may be.

What do I need to know about Part D?

Original Medicare did not typically cover most prescription drugs that aren’t administered in a hospital.

As more and more conditions could be effectively treated by drugs and care shifted out of the hospital and into physicians’ offices, pressure increased on Congress to cover prescription drugs.

In 2003, Congress created Medicare Part D.

Two questions you may want to ask when considering a Part D plan are:

  • Does it cover the drugs that you are taking or are likely to take?
  • Is the premium affordable?

Can I get help if I can’t afford my Medicare premiums?

Yes.

You may be eligible for Medicaid in your state. If you are, Medicaid may cover your Medicare premiums, deductibles, and co-payments. People who have both Medicare and Medicaid eligibility are called “dual eligible.”

You may also be a “Qualified Medicare Beneficiary” under the Medicare Savings Programs.

 If your income and resources are limited but you are not eligible for Medicaid, these programs can help pay for your Medicare premiums, co-payments, and deductibles.

What Medicare pitfalls should I be aware of?

If you do not sign up for Part B when you are first eligible, you will typically have to pay an increased premium for the rest of your life as long as you have Part B.

You also need to be very much aware that Original Medicare does not have an out-of-pocket limit. A serious illness can result in major financial exposure, even if you have Original Medicare.

You need to be a savvy consumer and remember that if it seems too good to be true, it probably is. You can check www.medicare.gov to see what is actually covered, and check with this Medicare Fraud Resource Guide if you suspect a scam.

Get answers to your Medicare questions

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Medicare expert Charles MacKay

Charles MacKay is the author of two health care books, including Medicare Made Easy. He has written over 300 academic papers, including many dealing with healthcare. He now lives in Pennsylvania.