Home > Elder Care Guide

Medicare and Senior Care – What You Need to Know

Here in America, people aged 65 and older qualify to get their healthcare from Medicare. This federal program was rolled out in 1965 and have provided coverage for well over 100 million people since then.

Navigating Medicare benefits can be tricky because the program has a number of moving parts. Let’s look at the parts of Medicare, what they cover and how they work.

Original Medicare

When you turn 65 in America, you can sign up for Medicare Parts A and B at one of the Social Security offices in your area or online at their website. Part A provides inpatient hospital coverage and Part B covers outpatient medical expenses.

Beyond just hospital benefits, Part A also provides for skilled nursing care, blood transfusions, and hospice care. Most other services fall under Part B, which covers everything from doctor visits and lab testing to skilled home health care, chemotherapy, radiation, and dialysis.

Most people don’t pay anything for Part A because the federal government collects FICA taxes during our working years that go toward this. However, Part B has a base monthly premium of $135.50/month in 2019 and some people in higher income brackets pay even more.

While these two separate parts of Medicare together make up the base of your coverage, you will pay some cost-sharing as you use medical services. These include deductibles for both inpatient and outpatient services as well as copays and 20% coinsurance on all outpatient Part B services. Many people enroll in supplemental coverage to help cover these items.

Covering the Gaps

There are two primary routes through which you can fill in these gaps: traditional Medicare supplements and the newer Medicare Advantage plans. Beneficiaries who choose a Medicare supplement will have the ability to treat with any Medicare providers nationwide.

There are no networks and you do not need to choose a primary care provider. When you see a Medicare doctor, his office staff will send an invoice to Medicare and Medicare will process that bill and apply any deductibles or copays due to the bill before paying its own share. Afterward, Medicare will send anything that’s leftover to your insurance company through which you purchased your supplement. This often leaves little to nothing for you to pay, depending on which supplement plan you purchased.

Medicare supplements, also called Medigap plans, do not include outpatient drug coverage, but you can enroll in a standalone Part D drug plan to go alongside your other coverage. This will help to reduce your costs for medications at the pharmacy.

The other route you can go when it comes to filling in the gaps in Medicare is the Part C Medicare Advantage plans. These are private insurance plans with local networks of providers. The two most frequently seen types of networks are HMO and PPO. HMO plans generally require members to select a primary care physician and see that doctor for a referral if they need to see a specialist. PPO plans offer you better flexibility with some out-of-network services available to you, although usually at a higher cost.

Advantage plans typically have lower premiums than Medicare supplement plans, but when you access healthcare services under these plans, you can expect to pay copays and coinsurance as you go along.

Beneficiaries can choose plans that include coverage for medications via built-in Part D coverage.

Things Not Covered

There are some things that Medicare does not cover, such as cosmetic procedures and long-term care services. These are expenses that you need to plan to pay on your own in your retirement.

Medicare also does not cover routine dental, vision and hearing services. While Medicare will cover injuries and illnesses affecting your eyes and ears, it doesn’t cover the routine testing, eyeglasses or hearing aids.

If you have Original Medicare, you can purchase a standalone dental, vision, and hearing plan on the private insurance market. Some Medicare Advantage plans also include ancillary benefits for dental, vision, and hearing expenses as well as gym memberships.

More to Read: