Medicare

Medicare is the national health and social insurance program in the United States. The 47-year-old program guarantees access to health care as long as the applicant meets the requirements of the program. Currently, the official enrollment age is 65, unless an applicant meets specific requirements set for in regards to a disability.

What is Medicare?

One of the US government’s most debated defined benefit programs, Medicare serves as the conduit to medical care for millions of Americans that are either 65 years or older, or have disabilities. The program provides access to the US health system that is not tied to a recipient’s employment status, assets or income. It’s simply meant to provide health care to individuals during retirement or in the situation where an individual is limited in terms of their ability to work.

Yet Medicare is not the end-all in terms of providing health care, estimates indicate that it covers roughly half of all medical expenses incurred by enrollees. Often, people that receive services through Medicare carry supplemental insurance to cover expenses. Others are dually-eligible to receive both Medicare and Medicaid services.

It’s fair to assume that a person with Cerebral Palsy would apply for Medicare under disability provisions, but often, people with the condition are conventionally employed, which means they and their employers would have paid Medicare taxes. This means that if they are qualifying for Medicare in the typical fashion, they would enjoy the same coverages as other applicants.

About Medicare

Medicare is the national health and social insurance program in the United States. The 47-year-old program guarantees access to health care as long as the applicant meets the requirements of the program. Currently, the official enrollment age is 65, unless an applicant meets specific requirements set for in regards to a disability.

One of the ways that Medicare differs from typical insurance is it’s role is to provide a safety net to recipients, as opposed to calculating cost-versus-risk assessments based on an individual’s health and lifestyle.

Medicare is administered by the Centers for Medicare and Medicaid Services, or CMS; it’s a division of the Department of Health and Human Services.

Medicare’s part A program is funded by payroll taxes paid by American workers and employers; this care is called Federal Insurance and Contributions Act, or FICA taxes. The tax is equal to 2.9 percent of a worker’s income; this amount is shared by employers and employees. Self-employed individuals must pay the entire amount to secure their Medicare eligibility later on.

Why was Medicare created?

Medicare was created as part of sweeping social reform that took place in 1960s. The program was put into place by the Social Security Act of 1965 to provide health insurance to elderly and disabled Americans, many of whom were financially unable to tap into health services.

The program was also created to address the costs of health insurance for older Americans. Private insurance prices are based on risk assessments. That means that older individuals will likely pay more for insurance than their younger counterparts.

Medicare coverage was extended to people with disabilities in 1972; doing so allowed people with special needs that receive payments from the Social Security Disability Insurance, or SSDI, program, to receive health services without having to rely on private insurance.

What does Medicare cover?

Medicare covers a wide variety of services, either in-full or in-part, through four different categorical services. These are referred to as Medicare Parts A, B, C, and D.

Medicare Part A is hospitalization insurance. Most people have paid enough Medicare taxes through employment to qualify for premium-free coverage, but for those that have not, a monthly fee will be required to take part in this category. Enrollees may also elect to purchase additional coverages for a monthly fee that is deducted from his or her Social Security check.

Part A covers:

• Hospital stays/inpatient care (free for 60 days, then a premium is required. A copay is required.)
• Blood transfusions
• Medical tests
• Diagnostic services
• Skilled nursing care
• Hospice care
• Home health services

Medicare Part B is general medical insurance. Most Medicare providers require that an enrollee participate in both parts A and B. Those that enroll in a Medicare Part B will have to pay a monthly premium. Deductibles will also apply; thereafter Medicare will cover 80 percent of costs, and an enrollee will cover 20 percent.

Part B covers:

• Doctor’s visits
• Outpatient care
• Preventative care
• Mental health services
• Physical therapy
• X-rays
• Ambulance services
• Durable medical equipment (wheelchairs, canes, walking aids, mobility devices)
• Prosthetic devices

Medicare Part C is called Medicare Advantage, and it’s a different vehicle some people may choose to tap into medical services. Under this plan, all services provided by Parts A and B are provided by a private Health Maintenance Organization that an enrollee chooses. Not all states allow Medicare enrollees to choose this option, opting instead to enroll all recipients in traditional, fee-for-service Medicare.

The enrollee will be responsible for a monthly premium in addition to his or her Medicare Part B premium if he or she chooses this option. An enrollee will also be beholden to ant in-network rules required by the private plan. However, this option often includes services not paid for by fee-for-service Medicare, such as dental or vision services.

Medicare Part D is a prescription drug coverage. This plan also requires that a premium be paid. Enrollees that take part in Medicare Parts A and B need to enroll in a separate plan; Part C recipients typically have drug coverage as part of their plan.

How does a person with disabilities qualify for Medicare coverage?

A person with disabilities that is approved for Supplemental Security Disability Insurance, or SSDI, will receive health insurance through Medicaid. Those who receive Supplemental Security Income, or SSI, will receive Medicaid.

However, people that receive SSI will receive Medicare once they have reached the age of 65; even if they have received Medicaid for several years. In the instance where a person collects concurrent benefits from SSDI and SSI, which is rare, a specific determination as to whether a person should receive Medicare of Medicaid will need to be made. This decision will be made by the Social Security Administration, which assesses Medicare eligibility for all Americans.

Once fact about Medicare and SSDI that people with disabilities must consider is that they cannot take part in Medicare until 24 months after they have been deemed disabled by the Social Security Administration. Because of this, he or she will need to make other provisions to cover the costs of medical services.

In terms of what Medicare covers, enrollees with disabilities will receive the same services, at the same costs, as other enrollees. Services do not have to be related to the disability, and services cannot be denied because of the disability.

Like other enrollees, Medicare recipients that have disabilities can be employed. Eligibility begins with a nine-month trial period after a person with disabilities retains a job. The second period lasts seven years, during which a person must continue to meet the federal disability guidelines. After eight and half years, if an individual is still disabled, he or she will be able to participate in Medicare indefinitely.

People with disabilities that are low-income may qualify for assistance with premiums, deductibles and copays if they are deemed dually-eligible for Medicare and Medicaid coverage.

When a person seeks medical treatment under Medicare, what happens?

Medicare is accepted by most – but not all – physicians and medical institutions. Although it might seem like a given that Medicare is accepted as payment, it’s always prudent to inquire about acceptance prior to seeking medical services.

Most providers that do accept Medicare have agreed to accept the program’s approved rate for specific services. However, other health services providers will treat Medicare recipients for rates that are slightly above those approved rates. There are other physicians that do not accept Medicare in any incarnation – they have entirely opted out of the system. These physicians are far and few between, however.

Medicare is not designed to pay for all of an individual’s health care needs – there are copays and, in some cases, coinsurances, that the enrollee is responsible for. There are also services that are not covered by Medicare, which means enrollees will be responsible for paying those fees out of pocket.

What are the eligibility requirements for Medicaid?

The chief qualification for Medicare coverage is one’s age – the current eligibility age for Medicare is 65 years old. However, there are some provisions that qualify a person with disabilities for Medicare coverage, even if they are not 65.

If a person wishes to seek Medicare coverage, and they have a disability, there is a 24-month waiting period from the date a person is deemed disabled under SSDI, unless a person suffers from end-stage renal failure or ALS.

The main qualifications for Medicare are:

• Enrollees must be 65 years old, unless they are disabled and receive SSDI benefits
• Applicants must be legal residents of the United States for five years

Enrollees can have Part A premiums waived if:

• They have been legal residents of the United States for five years
• They have paid Medicare taxes for at least 10 years
• They are less than 65 years old and are receiving SSDI payments

People may lose their Medicare eligibility if they lose eligibility for SSDI.

There is often confusion as to whether a person can work and receive Medicare benefits, and the answer is yes, a person can be employed full- or part-time and take advantage of Medicare coverage. This is to the benefit of people who work until the reach the full retirement age of 67, which is the age that people can retire from work and collect Social Security.

Spouses can also enroll in Medicare at age 65 if they turn 65 prior to their spouse have not worked for 10 years, as long as his or her husband or wife is at least 62 years old.

What is Medicare/Medicaid dual eligibility?

In some cases, a Medicare enrollee’s income is so low that he or she can qualify for both Medicare and Medicaid.

This occurs if an individual has worked and paid Medicare taxes, but has an income that qualifies him or her for Medicaid. This dual-eligibility means that Medicaid will pay and enrollee’s Part B premiums, along with some out-of-pocket expenses. To qualify for Medicaid, an applicant will need to meet federal low income guidelines; an enrollee will need to apply separately for both programs.
What is the Medicare application process?

The Social Security Administration oversees the Medicare application process. A future enrollee can apply in-person at his or her local Social Security office, or can request that forms be mailed to them by calling 800-772-1213.

Additionally, an enrollee can apply for Medicare coverage at www.medicare.gov.
When a person applies for Medicare, they may be asked to show documents. Those documents include:

• Birth certificate
• Driver’s license
• Proof of employer-provided insurance or private insurance
• Social Security Card

Additionally, an applicant might be asked for further information if he or she is applying under rules for individuals with disabilities. That information includes:

• Physician’s address and phone number
• Information about hospitals or clinics where an applicant has been treated

Because there are a tremendous number of US citizens applying for Medicare coverage each day, it takes time for the Social Security Administration to process applications. Therefore, it’s important to file all the necessary paperwork with the Administration at least three months prior to an applicant’s 65th birthday. If a person is applying for Medicare under disability rules, he or she should do so at the two-year mark after they were first determined to be SSDI-eligible.

What happens if I’m denied coverage?

The first step to take if a person has received a claim denial is to make sure they meet all of the guidelines for Medicare coverage, and that the procedure that is being disputed is a covered Medicare service. If an applicant believes a denial was made in error, and the exclusion of coverage for a specific service is not spelled out in a Medicare policy, he or she may file for a reversal by filling out forms and explaining why a service should be covered.

To file for redetermination after then appeal has been denied, fill out a form at a local Medicare office, or download it from Medicare.gov and mail it to your representative. A Qualified Independent Contractor, or QIC, will make a decision regarding the claim sometime during the next several weeks. If this request is denied, an enrollee may file for a third, and final administrative appeal. To qualify for the administrative process, a claim must be at least $120 dollars. You must file for an appeal within 60 days of a denial of a second reconsideration.

Be sure to have copies of the following documents during a final appeal:

• Proof the medical service took place
• The original denial letter
• Copies of previous requests
• Written copy of insurance policy
• Medical records

Is Medicare portable from state to state?

Generally, yes. All Medicare recipient that are enrolled in the traditional program enjoy transferability from state to state if they move.

However, enrollees of the Part C Medicare Advantage program will have to check to see if there plan will continue if they move – many plans place no restrictions regarding residency on their plans, but others have strict guidelines. If an enrollee learns that his or her plan is not portable under Medicare Advantage, he or she will be able permitted to contract with a new insurer.

Also, Medigap plans can be adversely affected by a move. Because an enrollee may be moving outside of a plan’s geographic coverage area, it may be necessary to find a new policy. Additionally, premiums on Medigap plans can increase, or decrease, based on where an enrollee lives.

Enrollees in Medigap plans should be certain to pay all premiums as they transition policies to make sure that coverages are continuous. Also, if a person feels that may be making several moves, and they are enrolled in Medicare Advantage, it may be advisable that they enroll in conventional Medicare.

If an enrollee is dually-eligible for Medicare and Medicaid, he or she will have to enroll in Medicaid in his or her new state of residence, and will need to meet all of that state’s requirements.