If you are 65 or older or you have a disability, you need to know about Medicare. Too many people do not understand what is covered and what is not — or even if they are eligible for care. Worse, many people think it’s free!
My goal — as a physician, as an advocate, and as a human being! — is to give you the info you need so that you can get the most out of your Medicare experience. That means dispelling any myths and making clear what Medicare does and does not do.
What Is Medicare?
Medicare is health care funded by the federal government and your tax dollars. Created in 1965, it provides a more affordable healthcare option for people approaching retirement and, starting in 1972, for disabled people unable to work. All those payroll taxes you paid into Medicare over the years will hopefully be put to good use when you need it most.
Medicare 101: Medicare is a worthy investment. Across the board, people get far more in Medicare benefits than they pay in taxes over their lifetime.
Medicare Eligibility
Not everyone is eligible for Medicare, though Medicare for All is always up for debate. You need to meet at least one criteria in each of two categories.
Residency:
- You are a U.S. citizen -OR-
- A permanent resident with a Green Card who lived in the U.S. the five years in a row before applying for Medicare -OR-
- A permanent resident married to a U.S. citizen or a permanent resident with a Green Card and that spouse has paid 40 quarters (10 years) in Medicare-taxed employment -OR-
- A legal immigrant who qualifies for Social Security retirement benefits, Social Security Disability Insurance, or Railroad Retirement Board benefits
Medical Need:
- You are 65 or older -OR-
- Have a qualifying disability
Medicare 101: As many as 64 million people are on Medicare in 2023.
Medicare Parts A, B, C & D
Medicare is unlike other types of health insurance. Rather than having a single health plan, Medicare is broken down into different parts that you can mix and match to suit your needs. To understand how Medicare works, you first have to learn what each part of Medicare covers.
- Part A: Hospital Insurance
- Part B: Medical Insurance
People refer to Part A and Part B as Original Medicare because they were the first ones signs into law in 1965. The federal government runs them. With Original Medicare, you can get care from any doctor in the country that takes Medicare.
- Part C: Medicare Advantage (everything Part A and Part B covers with the option for supplemental benefits)
- Part D: Prescription Drug Insurance
Part C and Part D took effect in 1999 and 2006 respectively and are run by private insurance companies that have signed a contract with the government. Unlike Original Medicare, these plans run on a local network and coverage will not be available nationwide.
Medicare 101: No one part of Medicare is going to cover everything you need. You need to decide which parts to sign up for.
Medicare Costs
Each part of Medicare has its own costs. That will include monthly premiums, annual deductibles, coinsurance, and copayments.
Everyone is responsible for paying Part A and Part B premiums but most people get Part A premiums for free if they or their spouse worked 40 quarters (10 years) in Medicare-taxed employment.
One common misconception is that Medicare is free. That is not true. Although some people may get their Part A premiums for free, they still have to pay for any care they receive under Part A.
Medicare 101: Medicare is not free, but you may be able to get federal assistance to keep your Medicare costs down.
How Medicare Works
Medicare has four parts but that does not mean you can sign up for all of them. You can choose Original Medicare or Medicare Advantage but not both. Don’t think that gets you out of paying Part A and Part B premiums though.
When it comes to prescription drug coverage, you can sign up for a Part D plan too, though that may not be necessary if your Medicare Advantage plan already includes coverage for medications. Part B does cover some medications but they are far and few between. They are usually limited to medications administered in a healthcare setting, not medications you take at home.
As long as you as you pay your monthly premiums, you can turn to Medicare for coverage. You will still be responsible to pay the deductibles, coinsurance, or copays for any services you get.
Why You Need It
To age is a beautiful thing, but it can be tricky sometimes. You are more likely to develop a medical issue the older you get. According to the Centers for Disease Control and Prevention, 87% of adult 65 and older have at least one chronic condition and 64% have at least two.
When you also consider how unpredictable life can be at times, from car accidents to natural disasters, even the healthiest person may need to see a doctor once in a while. Personally, I’d like everyone to see a doctor for basic preventive care!
Access to affordable health care is so important. Not only can it take care of you when you are sick, it can help prevent diseases from happening in the first place. It can even improve your quality of life. This is why you want to make the most of your Medicare experience.
Medicare 101: Medicare can offer more affordable coverage than you can get with other types of insurance but you need to know how to make it work for you.
References
Boersma, P., Black, L. I., & Ward, B. W. (2020). Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Preventing Chronic Disease, 17. https://doi.org/10.5888/pcd17.200130
CMS Releases Latest Enrollment Figures for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). (2021). CMS.gov. https://www.cms.gov/newsroom/news-alert/cms-releases-latest-enrollment-figures-medicare-medicaid-and-childrens-health-insurance-program-chip
Steuerle, C., & Smith, K. (2022). Social Security & Medicare Lifetime Benefits and Taxes: 2021. Urban Institute. https://www.urban.org/sites/default/files/2022-02/social-security-medicare-lifetime-benefits-and-taxes-2021.pdf
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