Medicare is health insurance. The following five points are the most important things to understand. These points are discussed in more detail below. You should know
- whether your loved one has or is eligible for Medicare;
- how he gets his health coverage;
- whether he has drug coverage;
- whether his insurance covers his doctors and medical needs;
- how much he pays for coverage—and where to go for help with those costs.
Is your loved one eligible for Medicare?
Medicare is the federal government program that gives you health care coverage if you are 65 or older or have a disability, no matter what your income. If your loved one has Medicare, you should know where he keeps his Medicare card
. This card identifies him as eligible and lists his Medicare number.
For more information on Medicare eligibility and coverage, click on “What is Medicare?” in the GO TO box.
How does he get his health coverage?
Be aware that he may get coverage from multiple sources. You should know about all of them.
If your loved one has Medicare, he will either get his coverage directly from the government (Original Medicare) or from a private Medicare Advantage plan, such as an HMO, PPO, PFFS or POS.
If he has Original Medicare, find out if he has Part A (which covers in-hospital services) and/or Part B (which covers out-patient services such as doctors visits). If you are not sure, check his Medicare card or call 800-MEDICARE and ask.
Medicare does not cover all health care costs. Your loved one may have other coverage in addition to or instead of Medicare coverage, such as employer or retiree insurance, Veterans Administration Benefits or Medicaid. If he has Original Medicare, he may have a supplemental policy called a Medigap.
To find out more about Original Medicare and private Medicare health plans, click on the links in the GO TO box.
Does he have drug coverage?
Medicare began to offer a drug benefit (Part D) for the first time in 2006. Whether your loved one should take the benefit depends on his circumstances. If your loved one gets his Medicare health coverage from an HMO or PPO, he may have Medicare drug coverage as part of that private plan’s benefits package. If he is in Original Medicare, he may have signed up for a separate private drug plan. All Medicare drug plans have a different list of drugs that they cover and different costs.
Your loved one may also get his drugs covered through other insurance, or through a state pharmaceutical assistance program.
For more information on where your loved one can get his prescription drugs covered, click on the links in the GO TO box.
Does your loved one’s insurance cover his doctors’ visits and medical needs?
If your loved one is in Original Medicare, his insurance will help pay for visits to almost any doctor that participates in Medicare and for most medically necessary services. If he is in an HMO, his plan will help pay for Medicare-covered services, additional services as defined by the plan, and visits to doctors that are in that plan’s network. If your loved one has drug coverage, his insurance will only help with the costs of prescriptions that are on the plan’s list of covered drugs (“formulary”).
You should carefully review any statements from Original Medicare (Medicare Summary Notices) and private plans to make sure your loved one’s insurance is covering what it should. If it is not, know that you can appeal.
For more information about the Medicare Summary Notice, click on the link in the GO TO box.
For more information on how to appeal with Original Medicare and private plans, click on the links in the GO TO box.
How much does he pay for insurance?
For most insurance (including Original Medicare) your loved one will pay a monthly premium and part of the cost of services (copayment or coinsurance), and the full cost of any services that are not covered. Make sure these costs are affordable.
If your loved one has trouble paying for his medical and drug costs, there are programs that can help! Depending on his income and assets, your loved one may be eligible for Medicaid (which covers medical care costs), Medicare Savings Programs (which help with the costs of Medicare health coverage), Extra Help (federal assistance that helps with the cost of Medicare drug coverage), or other assistance programs.
To see what programs can help people with limited incomes, click on the links in the GO TO box.