What is Medicare?
It is a federal health insurance program referred to as Original Medicare, which includes people 65 years of age, or older, certain people with disabilities who are under age 65 and those with end-stage renal disease (permanent kidney failure). It pays for a large portion of the health care expense but not all of it. The portion that Medicare does not pay is what the individual must pay for out of pocket such as coinsurance, co-payments, and deductibles. The gaps in Original Medicare coverage are commonly filled by a Medicare Supplement plan. Medicare in Texas and Texas Medicare plans are the same as Medicare in any state because it is a federal government that defines what the benefits are.
Medicare has four parts:
•Texas Medicare Part A: This covers area such as inpatient hospital, inpatient skilled nursing facility, home health, and hospice services. Most people do not have to pay for Part A due their contributions over 10 years.
•Texas Medicare Part B: provides covers outpatient and physician services. It also pays for other areas such as durable medical equipment, prosthetic devices, supplies incident to physician's services, and ambulance transportation. Most people pay monthly for Part B.
•Texas Medicare Part C: Are Medicare Advantage plans are offered by private insurance companies that serve as an alternative to Medicare. These plans can cover medical only or medical and dental. These plans are subsidized and regulated by the Federal government.
•Texas Medicare Part D: Prescription Drug Coverage plans are offered by private companies to provide coverage for prescription drug costs. These plans are subsidized and regulated by the Federal government.
Can you tell me more about Medicare Part A and Part B?
Part A referred to as hospital insurance, helps pay expenses for inpatient hospital care, some skilled nursing facility care, hospice care, and some home health care. The medical costs you incur with Medicare Part A include a large deductible per benefit period and copays if you are in the hospital for over 61 days. The benefit period for part A is your time in the hospital including 60 days after you are release.
Part B referred to as medical insurance, helps pay for outpatient hospital care, doctors' services, and some other medical services and supplies when they are medically necessary that Part A does not cover. The Part B deductible is based on a calendar year and is generally affordable. After the deductible is met you will be responsible for 20% of your Medicare Part B expenses. This can be quite expensive if you have any major medical treatments.
What is a benefit period?
A benefit period starts on day one of a Medicare approved inpatient stay and ends when you have been out of the hospital for 60 consecutive days. This also applies to a skilled nursing facility. After that a new benefit period begins and the beneficiary must pay a new inpatient hospital deductible.
What is the General Enrollment Period?
This period is during the time period between January 1 and March 31 when a Medicare beneficiary is eligible to sign up for Part B coverage. The beneficiary’s benefits will begin on July 1 of that year, and the beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare.
What is the Medicare Open Enrollment Period?
“Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65”
Open enrollment period is when the applicant is guaranteed a Medicare supplement insurance plan regardless of their current or past health history (generally, outside of this period the applicant must meet medical underwriting guidelines to qualify). Open enrollment is a six-month period from the date the beneficiary enrolled in Medicare Part B if age 65 or older (also includes a six-month period when you turn 65 if you were eligible for Part B benefits before age 65). No individual can be denied any Medicare supplement policy sold by any Medicare supplement issuer if the application is submitted during the six month period beginning with the first day of the first month in which an individual first enrolls for benefits under Medicare Part B at age 65 or older; or upon attaining age 65 for individuals that were previously enrolled in Medicare Part B prior to turning age 65. Additionally individuals under the age of 65 can purchase Plan A from any insurer during the six-month period beginning with the first month in which the individual first enrolled for benefits under Medicare Part B. Please note that, in, Texas, Medicare beneficiaries under age 65 have two open enrollment periods, one when they first enroll in Part B and a second one when they turn age 65.
What makes the open enrollment period so critical?
The open enrollment period starts the first day of the month you turn 65 and have Medicare Part B extending for 6 months from that date. This period is critical because no company can not offer you any Medicare Supplement Policy that they sell for any reason. After this your open enrollment period ends companies then are allowed to use medical underwriting and can accept or deny your application. This can make it very difficult and expensive, due to certain health conditions to obtain coverage after your open enrollment period expires.
There are several times when you can enroll in Medicare.
The first time when you can sign up for Medicare, is called the Initial Enrollment Period (IEP). You may join Medicare Parts A, B, C and D during this time. Your coverage will start no sooner than your birthday month.
Here’s how it works - You have a 7-month Initial Enrollment Period:
3 months before your 65th birthday, the month of your birthday and 3 months after your birthday.
When am I eligible for Initial Enrollment Period?
Initial Enrollment Period is when the client can apply for Part B or Part D for the first time. For many it starts 3 months prior to when the person meets Medicare’s requirement for eligibility and goes on for the next 7 months. However, for SSDI, Social Security Disability Insurance applicants the period begins the 24th month of the SSDI’s payments. The person is not liable for medical history review during the enrollment period yet once the period is over any prior conditions that will create exclusionary problems can apply. “Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65.”
Am I automatically enrolled in Original Medicare?
You are automatically enrolled in Original Medicare Part A and/or Part B, if you are turning 65 and already getting Social Security or Railroad Retirement Benefits (RRB) benefits or will start collecting retirement at age 65.
• You will need to sign up for Medicare Part B at the time that you apply for retirement benefits, and Medicare Part A enrollment occurs automatically if you are eligible for Social Security retirement.
Do I need to sign up for Medicare?
If you aren't receiving Social Security or RRB benefits when you turn 65, you will have to sign up for Medicare A and/or Part B during your Initial Enrollment Period (IEP).
Do I have to pay for Medicare Part B and/or Part A?
Medicare Part B has a monthly premium. Most people don’t pay a premium for Part A, if they have paid Medicare taxes and worked at least 40 quarters (10 years) and. People that are still covered under an employer group plan or different plan may choose to delay enrollment in Part B.
I have Medicare Part A and Part B due to a disability and I would like to know which Medicare Supplement I can get since I am not 65 yet?
In Texas, insurance companies that offer Medigap policies are required to sell a Plan A to someone under 65 that qualifies for Medicare. Companies can offer additional plans as an option in addition to a Plan A to someone on disability.
What is a Copayment?
A set amount an individual must pay upon receiving medical services in combination with the amount paid by the insurer. For example, you may have to pay $10 each time you visit the doctor, with the understanding that the health insurance policy covers a large part or the remainder of the balance of the fee owed to the doctor. The copay amount is usually indicated on the prescription or insurance card. It is the portion the insured pays with the balance being paid by the insurer.
What does it mean to have Creditable Coverage?
Your current insurance company can guide you on weather their plans are creditable. When you are going from one health insurance plan to another the prior coverage will reduce pre-existing condition waiting period. However, if you didn’t have any health insurance coverage for more than 63 consecutive days, you cannot count them in the creditable coverage period.
What is a Deductible?
A deductible is the cost a person is required to pay for health services before the insurer or Medicare pays their portion. For instance, Medicare Part B requires one deductible that is paid on a calendar year basis and Medicare Part A has a deductible that must be met for each benefit period.
What is a Medicare Coinsurance?
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
What does a participating Texas Medicare provider mean?
A participating physician is enrolled in the Medicare program agreeing to accept assignment on all Medicare claims that are submitted. You may only be billed by these doctors for Medicare deductible and/or coinsurance amounts.
What does Centers for Medicare & Medicaid Services (CMS) do?
It's the federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace.
How do I apply for Medicare in Texas?
The Medicare laws and regulations are subject to change for Texas Medicare eligibility and enrollment at any time. Contact Social Security at
1-800-772-1213 to discuss the Texas Medicare application or look up your local Texas Social Security offices.
How do I know if I am eligible for Medicare?
Generally you are eligible for Medicare if you are a U.S. citizen or have been a permanent legal resident for 5 continuous years, are 65 years or older or if under 65 are disabled and have been receiving either Social Security or the Railroad Retirement Board disability benefits for at least 24 months, or they get continuing dialysis for permanent kidney failure or need a kidney transplant, or they have Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's disease). You can also be dual-eligible which means you are on Medicare and Medicaid. If you have limited income, in some states, Medicaid will actually pay for the Part B premium and for many individuals who have worked long enough won’t have a Part A premium, and also pay any drugs not covered by Part D.