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Medicare Basics

Medicare is a federal health insurance program for those who are age 65 or older. Certain younger people with disabilities or End-Stage Renal Disease are also covered. Medicare provides hospital and medical coverage.


Eligibility

To receive Medicare, you must meet specific criteria and enroll. For specific information and how to enroll, see the Official U.S. Government Site for Medicare. In general, you are eligible for Medicare if:

  • You are 65 years of age or older*
  • You or your spouse have worked for at least 10 years in Medicare-covered employment (employment that pays into the Medicare system)
  • You are a citizen or permanent resident of the United States
  • Certain younger people with disabilities or End-Stage Renal Disease may also be eligible.

Medicare Benefits

There are several different parts to Medicare coverage, with different benefits and costs. You need to decide what you need.

  • Part A. Medicare Part A covers hospitalization. Basically, it pays for inpatient care, and some home healthcare, skilled nursing home care and nursing home care. It also pays for hospice care. Most people do not have to pay premiums for Part A.
  • Part B. Part B covers medical services such as doctor’s visits and outpatient treatments, as well as medical services and supplies not covered under Part A. Most people pay premiums for Part B.
  • Part C. Part C is more commonly called Medicare Advantage. It is provided by private insurance companies and combines Parts A and B. Part D may be included. Because Medicare Advantage is offered by private companies, the costs and benefits may vary from plan to plan. At a minimum, you must continue to pay your Part B premiums. There may be other costs. There also may be other benefits.
  • Part D. Part D covers prescription drug costs and is available to individuals who have Part A, B or C. Just like in a traditional insurance plan, the amount of coverage for each drug is determined by the type of drug and how it is classified on a Formulary. Most people pay premiums for Part D. If you don’t enroll in a Part D plan when you become eligible for Medicare Part A and B or if you drop your Part D coverage for more than 63 days, you may have to pay a late enrollment penalty if you decide to enroll in Part D at a later time.

Medicare is administered by the Centers for Medicare and Medicaid Services. Assistance may be available to low-income individuals to help with the costs of Medicare through Extra Help, also called Low-Income Subsidy (LIS).If you are eligible, this lowers your plan premium and drug copays, as well as eliminates the coverage gap (the donut hole). You must be on a plan that includes prescription drug coverage to qualify. Note: Levels are reviewed annually by the Social Security Administration and may change each year.

 

​Presbyterian Senior Care (HMO) is an HMO plan with a Medicare contract. Presbyterian MediCare PPO is a PPO plan with a Medicare contract. Enrollment in Presbyterian Senior Care (HMO) or Presbyterian MediCare PPO depends on contract renewal. || This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, co-payments and/or co-insurance may change on January 1 of each year. || The physicians and other medical professionals in our provider network participate through contractual arrangements. A provider may leave the network because of retirement, relocation, or other reasons before your next enrollment date. || The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. || You must continue to pay your Medicare Part B premium. || ​Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

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Last Updated: 09/30/2016