Medicare Coverage

Affordable Health Insurance: Understanding Medicare Coverage

When anyone reaches the age of 65, they can qualify for enrollment in the Medicare insurance program. This affordable health insurance program provides for several different types of insurance coverage and can give a senior the confidence they need to know that their medical treatments will be covered by insurance.

Coverage for Medicare [i] is determined partly by the national federal program, as well as by state Medicare laws.

What we will cover in this article

Here is some basic information about Medicare:

  • The Medicare program has been in effect since 1965.
  • Part of state and federal taxes go into the Medicare fund.
  • In 1962, about 48% of the senior population was left without health insurance.
  • Only 2% of the senior population is without health insurance today because of Medicare.
  • The senior population has more medical issues than younger populations due to aging.
  • Medicare also provides coverage for individuals with kidney failure.
  • Medicare provides coverage for treatment of Lou Gehrig’s disease.
  • Medicare pays for screenings for cancer, mammograms, and diabetes.

Let’s take a look at the Medicare coverage plans that are available today.

Medicare Coverage Infographic

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Types of Medicare Coverage

The Medicare plans [ii] were designed to provide affordable health insurance that could be tailored to each person’s healthcare needs. Medicare has several parts, which makes it confusing for some people.
Let’s break it down to make it understandable:

The types of Medicare coverages available today include:

  1. Part A – Hospital Coverage
  2. Part B – Medical coverage
  3. Part C – Medicare Advantage
  4. Part D – Prescription coverage
  5. Medigap – Supplemental coverage

What Is Medicare Part A?

Medicare Part A [iii] covers various types of hospitalization including:

  • Hospital care
  • Skilled nursing facility care
  • Nursing home care (as long as it’s more than custodial care)
  • Hospice
  • Home health services

The cost for Medicare Part A hospitalization coverage is significantly lower than paying for private insurance. Individuals that paid less than 30 quarters of taxes into Medicare while they worked will pay the highest premiums. Individuals that paid taxes into Medicare for more than 30 quarters can expect their premiums to be almost half as much for Medicare Part A.

With Medicare Part A, a senior will have their hospital stays covered by the insurance. This part of the Medicare plan also provides for rehabilitation stays and some home health care services.

It’s important to understand that Medicare Part A has strict limitations as to the types of hospital services it covers and the length of stay. Medicare Part A will also deny coverage for specific services that aren’t covered under the plan.

In most cases, Medicare Part A covers all or most of the costs of a hospitalization stay. For example, costs for using the Medicare Part A include $0 coinsurance for 60 days for each benefit period. Coinsurance will be paid on hospital stays longer than 60 days as well as over 91 days.

What is Medicare Part B?

Medicare Part B [iv] covers two types of medical services including:

  1. Medically necessary services- which includes things like services or supplies needed to diagnose or treat a medical condition that meets accepted standards of medical practice.
  2. Preventative services-which includes things like health care to prevent illnesses or detect them in the early stages when treatment may work best.

Part B Medicare insurance covers a senior’s outpatient care. This means that any type of medical coverage that occurs outside a hospital stay will be covered including ambulance rides, preventative screening, and medical equipment.

Medicare Part B insurance requires that individuals under the plan to pay a deductible. They are also required to pay 20% of the out-of-hospital medical costs for most doctor services using the Medicare-approved amount. This also includes costs for outpatient therapy and durable medical equipment.

Medicare Part B covers such things as:

  • Clinical research
  • Ambulance services
  • Durable medical equipment
  • Second opinions
  • Limited outpatient prescription medications

Part B also offers mental health coverage in the following types of programs:

  • Inpatient
  • Outpatient
  • Partial hospitalization

Medicare provides most preventative services at no charge as long as you receive them from a Medicare provider.

Additional parts have been added to Medicare since its enactment in 1965 that provide for more coverage for seniors. These additional coverage parts allow for added medical insurance, drug coverage, and help to pay for deductibles, coinsurance, and copayments.

What Is Medicare Advantage?

Seniors can also opt to select a Medicare Advantage plan [v] instead of the original Medicare coverage. Medicare Advantage was added to the affordable health care plan in 1997 and was alternatively known as Medicare + Choice. Private insurance companies offer this plan in partnership with the government.

The difference with a Medicare Advantage plan and the original Medicare insurance plan is that Medicare Advantage offers additional coverage that the original Medicare plan may not cover. Medicare Advantage provides all the same coverage as the original Medicare plan, along with more options.

Medicare Advantage costs more than the original Medicare plan, but it gives seniors the assurance that they have the coverage they need for services that Medicare doesn’t cover. Medicare Advantage provides peace of mind that health care costs won’t get out of control, which makes it a popular choice for many seniors.

The cost for Medicare Advantage varies by plan selection. Some of the benefits and options for Medicare Advantage include:

  • Subsidies for gym memberships
  • Dental coverage
  • Hearing coverage

One of the disadvantages to Medicare Advantage is that Medicare providers can make changes to their plan each year. Seniors need to be aware that the services and medications that Medicare Advantage Providers cover at the onset of the plan may not be covered if the provider changes their coverage offerings during the course of the year.

What Is Medicare Part D?

A senior may also choose to add Medicare Part D [vi] to their affordable health insurance plan. With Medicare Part D, a senior will have additional prescription coverage. This plan is also offered through private insurance companies in a partnership through the U.S. government.

This part of the Medicare plan went into effect in 2006. It can help cover special prescriptions that are not covered under other parts of the Medicare plan coverage. The premium for Medicare Part D varies by plan selection.

What Is Medigap?

Seniors can also obtain additional coverage with the Medicare Supplement Plan, which is also called the Medigap plan. [vii] The Medigap plan can help pay the costs that a senior’s original Medicare plan doesn’t cover. This plan covers deductibles, coinsurance, and copayments that might be difficult for a senior to afford.

Medigap is a private insurance offering that is used with original Medicare plans. It is standardized across all states of the U.S. except Minnesota, Massachusetts, and Wisconsin and can’t be used in conjunction with Medicare Advantage.
So, when does a senior enroll in Medicare?

Medicare Verification

The federal government set up a portal [viii] that seniors can use to find out if they are eligible for Medicare. The portal also lists premiums for the various parts of Medicare. Those who qualify for Medicare can make changes to their plans only during the open enrollment period each year.

Seniors may enroll in Medicare between the three months before they become age 65 and three months after they turn 65. It’s wise to sign up during the enrollment window; however, seniors don’t have to enroll in all parts of the Medicare program. Since there is a cost to Medicare Part B, seniors may opt out of this part.

When enrolling, seniors should be aware that there are penalties for not enrolling in Medicare Part A even if they’ve chosen to enroll in Medicare Advantage. Those who opt not to take advantage of enrolling in Medicare Part A of the program may be accrued costly penalties.

Finding A Medicare Doctor

Finding a doctor through Medicare [ix] has never been easier. A senior will need to choose a primary care physician that accepts Medicare. The Medicare portal makes it easy to search for a doctor that’s geographically close and convenient.

There are two ways to find a physician who accepts Medicare:

  1. Call 1-800-MEDICARE any time of day or night
  2. Visit

Medicare allows you to go to physicians of your choosing but be aware that you’ll have less out-of-pocket cost when choosing a Medicare provider. The reason for this is because Medicare providers agree to pay certain amounts for their services. Patients will only be responsible for deductibles, copayments or coinsurance as they apply.

Individuals with Medicare Advantage need to select a primary care provider in the plan’s network. Medicare doesn’t require referrals from the primary care physician for specialists.
Next, let’s take a closer look at the prescription drug coverage for Medicare affordable health insurance plans.

Medicare Prescription Drug Coverage

One of the biggest concerns for seniors is coverage of prescription drugs. Unfortunately, there is no plan that covers all medications available. Prescription costs depend on the prescription plan they choose and the type of drug the physician prescribes.

The Medicare program places drugs into tiers. [x] Each tier has an associated cost. Drugs in the lower tiers cost less than higher tier drugs. Physicians may be able to get exceptions for certain medications that offer a lower copayment with Medicare approval.

Additional assistance can be provided for seniors through Medicare Part D with a program called Extra Help. [xi] The Extra Help program allows for assistance for low-income seniors in paying for prescriptions as well as covering deductibles, coinsurance, and copayments.

Other Benefits of Medicare

Medicare makes healthcare affordable for seniors and other qualified individuals as compared with standard health insurance plans. Enrollees for Medicare have some flexibility to select only the parts of Medicare that they need.

Caregivers that stay in the loop of changes in Medicare can be of great assistance to seniors, so they can maximize their Medicare benefits. Caregivers can be helpful by matching the senior’s health needs with the most appropriate Medicare plans and services at the least possible cost.

Choosing the best Medicare plan relieves much of the stress and burden for the seniors and their caregivers. If you want to learn more about Medicaid State Planning visit our blog about the topic.