What is Medicare?

In order to account for the medical needs of its senior citizens, the United States government enacted the Social Security Act of 1965 that brought Medicare into law. Medicare is health insurance for anyone who has been a citizen of the United States for at least five years and is over the age of 65, or is any age and has Lou Gehrig’s disease or end-stage renal disease or is under 65-years-old and has certain disabilities. There are four categories of Medicare – Part A: hospital insurance, Part B: medical insurance, Part C: Medicare Advantage Plans, and Part D: Prescription Drug Plan (PDP).

Medicare provides medical insurance to millions of American seniors and disabled citizens. In 2008, 45 million Americans received Medicare coverage, and that number is expected to soar to 78 million by 2030.

Part A premiums are entirely waived if the Medicare recipient is:

• 65-years-old or older, a U.S. Citizen for at least five continual years and has paid Medicare taxes for at least 10 years.
• Under 65-years-old, disabled and has been receiving Social Security Disability Insurance (SSDI) or Railroad Retirement Board disability benefits for at least 24 months from the date of receiving the first payment.
• Receiving ongoing dialysis for a kidney transplant or end-stage renal disease.
• A sufferer of Lou Gehrig’s disease (amyotrophic lateral sclerosis) who is eligible for Social Security Disability Insurance.

Can You Still Get Medicare Benefits if You Haven’t Paid Medicare Taxes?

Yes. If you are over 65-years-old but neither you nor your spouse have paid Medicare taxes for 10 years, then you may still receive Medicare benefits. However, you must pay a monthly premium.

Can You Receive Medicare if You Stop Receiving SSDI Benefits?

No. People who are under 65 can receive Medicare benefits so long as they are receiving SSDI payments, but as soon as those payments stop so does the Medicare coverage.

Can You Receive Both Medicare and Medicaid?

Yes. Many people are dual-eligible and qualify to receive both Medicare and Medicaid simultaneously. For some beneficiaries who are below a certain income level, Medicaid will pay Part B premiums and for any prescriptions not covered by Part D.

What Does Medicare Part A Coverage Entail?

In-patient hospital stays are covered in Part A of Medicare but must at least include an overnight stay. Part A coverage includes:

• A semiprivate room
• Food
• Tests
• Doctor’s fees

Part A can also cover brief stays of up to 100 days in convalescent facilities, given certain conditions for the treatment:

• Not counting the discharge date, a hospital stay of at least three days and three nights must precede the nursing home stay.
• The stay in the nursing home must be for the main cause of the preceding hospital stay or for a condition diagnosed during the hospital stay.
• The patient doesn’t necessarily have to be receiving rehabilitation to be covered but must at last have a condition that requires nursing supervision.
• The nursing home stay must be for skilled nursing care. Medicare Par A coverage does not include care for long-term, custodial or non-skilled activities like daily care such as personal hygiene or cleaning.

The first 20 days spent receiving convalescent care are covered in full, with the final 80 days requiring a co-payment, which changes on a yearly basis. Once 60 days have passed after a beneficiary leaves the nursing home, he or she is again qualified for a 100-day stay in such a facility after again spending three days and three nights in the hospital.

What Does Medicare Part B Coverage Entail?

Part B provides optional medical insurance in addition to Part A and begins once a patient meets his or her deductible. In most cases Medicare pays for 80 percent of approved coverage, while the patient is responsible for the remaining 20 percent. Part B coverage includes:

• Physician and nursing services
• X-rays
• Vaccinations for flu or pneumonia
• Lab and diagnostic tests
• Blood transfusions
• Dialysis
• Ambulance transportation (on a limited basis)
• Blood transfusions
• Outpatient hospital services
• Chemotherapy
• Some prescriptions for organ transplant recipients
• Hormonal treatments
• Other outpatient medical treatments that are administered in a doctor’s office

Part B also provides coverage for durable medical equipment, such as:

• Walkers
• Mobile scooters
• Canes
• Wheelchairs
• Artificial limbs
• Prosthetic breasts following mastectomy
• Required eyeglasses after cataract surgery
• Oxygen for home use

What About Part C and Part D?

With the Balanced Budget Act of 1997 and the Medicare Prescription Drug Improvement and Modernization Act of 2003, the federal government gave Medicare beneficiaries the option of privatizing their coverage and extending it to cover prescription drugs. For more information on Part C and Part D, see our tab on Medicare plan types.