MEDICARE BASICS: Medicare Part A and Part B

Three groups of people are covered by the federal health insurance program:

  • People aged 65 and up
  • Under 65 with certain disabilities: receiving Social Security disability benefits for 24 months
  • Any age with End-Stage Renal Disease (ESRD)

Medicare is administered by the following agencies:

– Most people are enrolled in Medicare through the Social Security Administration (SSA).

– Railroad retirees are enrolled in Medicare by the Railroad Retirement Board (RRB).

– The premiums for federal retirees are handled by the Office of Personnel Management (OPM), and the Medicare program is administered by the Centers for Medicare and Medicaid Services (CMS). It is not in charge of actively enrolling people in Medicare.

What are four parts of Medicare?

How do people sign up for Original Medicare?

Enrollment is automatic for people who receive the following benefits:

– Benefits from Social Security

– Railroad Retirement Board (RRB) benefits

If you weren’t enrolled automatically:

– Call 1-800-772-1213 (TTY: 1-800-325-0778), call your local RRB office at 1-877-772-5772, or go to socialsecurity.gov (if railroad retiree)

– Schedule a visit to the SSA office in your area.

What are Medicare Enrollment Periods?

  • Initial Enrollment Period: First opportunity to enroll in Medicare
  • 7-month period
  • 3 months before turning 65, month of 65th birthday, 3 months after turning 65
  • If in Medicare due to a disability: 3 months before 25th month of disability, the 25th month of the disability, and 3 months after 25th month of disability

During this period the beneficiary can:

  • Enroll into Part A
  • Enroll into Part B
  • Join Part C (If have Part A and Part B)
  • Join Part D (if have Part A and/or Part B)

 

  • Open Enrollment Period (OEP)
  • Also known as the Annual Enrollment Period (AEP)
  • Runs from October 15th to December 7, each year
  • Coverage begins on January 1st

During this period the beneficiary can:

  • Join/Switch/Drop a Part C plan
  • Join/Switch/Drop a Part D plan
  • Return to Original Medicare

 

  • General Enrollment Period (GEP)
  • If did not sign up for Original Medicare during IEP, may enroll during General Enrollment Period (GEP)
  • Runs from January 1st to March 31st , each year
  • Coverage begins July 1st

During this period the beneficiary can:

  • Enroll into Part A
  • Enroll into Part B

 

  • Special Enrollment Period (SEP)
  • Changes made outside of open enrollment owing to a qualifying occurrence or unique circumstances
  • Beneficiaries may qualify for Special Enrollment Period if they meet the following criteria:
  • Permanently leaves the plan’s service region
  • Loses other
  • Enters, stays at, or departs from a long-term care facility (like a nursing home)
  • Is enrolled in a plan that leaves the Medicare program
  • Is dual-eligible (has Medicare and Medicaid) or qualifies for Extra Help

 

  • 5-Star Enrollment Period

–              Can be used to enroll in a 5-Star Medicare Advantage Plan

– Enrollment conditions for the plan must be met (eg: live in the service area)

–              Every year from December 8th to November 30th

–              New plan coverage starts the first day of the month after enrolled

  • Medicare Advantage Open Enrollment Period (MA OEP)

 

  • From January 1st to March 31st, every year
  • Coverage begins the first day of the month after enrolled
  • Must already be in a Medicare Advantage Plan on January 1st to use this enrollment period

During this period the beneficiary can:

  • Only make one change during this enrollment period
  • Switch Medicare advantage Plans
  • Leave Medicare Advantage to join Original Medicare
  • Add or drop Part D when switching plans (some exceptions)

Original Medicare

Part A helps cover Inpatient Hospital Care

  • Semi-private room, meals, general nursing, drugs as part of inpatient treatment, and other hospital services and supplies
  • Care in acute care hospitals, critical access hospitals, long-term care hospitals and inpatient rehabilitation facilities

Psychiatric hospital inpatient mental health care (lifetime 190-day limit).

In general, it covers all medications given as part of treatment during an inpatient stay.

Is there cost associated with Medicare Part A?

  • Most beneficiaries do not pay a premium for Part A if they or their spouse paid Federal Insurance Contributions Act (FICA) taxes while working. FICA – a United States federal payroll (or employment) tax imposed on both employees and employers to fund Social Security and Medicare.
  • Social Security determines if a person must pay a premium for Part A (buy into it)
  • Amount depends on how long the beneficiary/spouse worked in Medicare-covered employment

Part B covers doctor’s, home health and other services:

  • Medically essential doctor’s services (including outpatient and some doctor’s services the beneficiary receives while a hospital inpatient, as well as covered preventative services).
  • For permitted operations such as X-rays, casts, or sutures, outpatient medical and surgical services and supplies are available.
  • Medical Equipment That Is Long Lasting. DME – durable medical equipment that can be used at home, such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds. Some goods will have to be rented. Must be recommended by a doctor and purchased from Medicare-approved vendors.
  • Home health services – Medically necessary part-time or intermittent skilled nursing care, as well as physical therapy, speech-language pathology, and or services for people who need occupational therapy on a regular basis, as well as some home health aide services, medical social services, and medical supplies.
  • Other (including but not limited to) : Medically necessary medical services and supplies, such as clinical laboratory services, diabetes supplies, kidney dialysis services and supplies, mental health care, limited outpatient prescription drugs, diagnostic X-rays, MRIs, CT scans, and EKGs, transplants and other services are covered. Costs vary.

What do Part A and Part B not cover?

Most dental treatment, eye tests for glasses prescriptions, cosmetic surgery, routine physical exams, massage therapy, acupuncture, hearing aids and fitting exams, long-term care, and concierge care are all available.

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