Medicare is a type of health insurance. The following five points are the most important things to understand.

You should know:

  1. Whether your loved one has or is eligible for Medicare;
  2. How they get health coverage;
  3. Whether they have drug coverage;
  4. Whether their health insurance covers their health care needs;
  5. How much they pay 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 they keep their Medicare card. This card identifies him as Medicare-eligible and lists their Medicare number.

How does your loved one get health coverage?

Be aware that your loved one may get health coverage from multiple sources. You should know about all of them.

If your loved one has Medicare, they will either get Medicare coverage directly through the government (Original Medicare) or through a private Medicare Advantage Plan, such as an HMO, PPO, PFFS or POS.

If your loved one has Original Medicare, find out if they have Medicare Part A (part of Medicare that covers inpatient hospital care) and/or Medicare Part B (part of Medicare that covers most outpatient medical care). If you are not sure, check their Medicare card or call 1-800-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 your loved one has Original Medicare, they may have a supplemental policy called a Medigap.

Do they 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 their circumstances. If your loved one gets their Medicare health coverage from an HMO or PPO, they may have Medicare drug coverage as part of that private plan’s benefits package. If they are in Original Medicare, they 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 their drugs covered through other insurance, or through a state pharmaceutical assistance program.

Does your loved one’s insurance cover their doctors’ visits and medical needs?

If your loved one is in Original Medicare, their insurance will help pay for visits to almost any doctor that participates in Medicare and for most medically necessary services. If they are in an HMO, their 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, their 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.

How much do they 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 their medical and drug costs, there are programs that can help. Depending on their 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.