Medicare Coverage

Introduction to Medicare Coverage

Medicare is a government-backed health insurance program that applies to almost all U.S. citizens aged sixty-five or older. Throughout your working life, a portion of your tax has been used to support Medicare operations and ensure that Medicare-based health insurance is available for you upon retirement.

Almost all citizens and legal permanent residents of the United States who have a history of employment are entitled to Medicare coverage as a matter of course. You will have a seven-month window of opportunity to enroll in the program when you reach the age of eligibility, sixty-five. Your window will begin about three months before your birthday and end about three months afterward -- with more opportunities to enroll each year.

Although many people are entitled to Medicare, that does not mean that you have no part in understanding your coverage or ensuring that you get every benefit you are entitled to. It is important to understand your insurance situation through a structured introduction to Medicare coverage.

This will allow you to make informed decisions about the areas of Medicare coverage where you, the patient, are empowered to make important healthcare decisions on your own behalf. Knowledge is power, and it will save you money.

What is Covered Under Medicare?

For the purposes of this introduction, we will discuss Original Medicare. Original Medicare is the government-backed health insurance plan almost all Americans are entitled to upon reaching age sixty-five. There is an alternative, known as the Medicare Advantage Plan, that will be discussed further down the page.

Medicare coverage includes two important parts:

Medicare "Part A" includes coverage that pertains to in-patient procedures, the kind that are performed on-site at a medical facility. In many situations, "Part A" insurance can also cover hospice visits and some kinds of in-home care deemed necessary for health.

Medicare "Part B" covers outpatient treatment. Outpatient treatment refers broadly to anything that isn't performed at a medical facility. That can also mean medical supplies such as oxygen, mobility aids, and some kinds of preventative care.

If you are a patient covered under Original Medicare, you will almost always have both "Part A" and "Part B" insurance. However, this does not mean that all possible medical treatments will be equally covered by your Medicare insurance.

What is a Medicare Claim?

One of the most important things to understand about all Medicare is the importance of the Medicare claim. The "claim" is paperwork filed by your treating physician or hospital that allows Medicare to accept your treatment and pay out benefits.

In virtually all cases, the claim will be filed by the facility that provided your medical care. You will only have to file a claim on your own behalf in case of an unusual dispute or emergency, where your medical provider has failed to file the claim on time.

Medicare reserves the right to evaluate each of your Medicare claims. In rare instances, it may deny coverage to some procedures. The most important litmus test of a procedure is that it be medically necessary. A broad spectrum of treatments can be understood as medically necessary depending on your needs.

In order to determine what is medically necessary, you may need to see a qualified specialist who can determine the seriousness of your condition. The word of a qualified specialist is a very important part of determining what coverage is possible in unusual medical situations. However, many forms of care will have an obvious, urgent medical basis that will not require further proof from healthcare professionals.

What Am I Expected to Pay?

Only in very rare cases will every penny of all of your treatment be covered by your Original Medicare coverage. You will almost always be expected to contribute a deductible; this is an amount you are expected to spend each year before your coverage "kicks in."

You will also be responsible for a small "co-pay" amount. However, the co-pay can be very affordable. For example, a chiropractic visit that might usually cost more than $300 can cost as little as a few dollars if you only use covered services. Generally, you will be covered for 80% of the costs of insured services. You remain responsible for 20%.

Medicare "Part B" coverage, which deals with doctors' services, requires you to pay a monthly premium. To understand a premium, you should think of the kind of money that is spent monthly on your car insurance. The premium will remain in effect for as long as you are covered by Medicare "Part B" -- usually the duration of your coverage by Original Medicare. However, there is an alternative to Original Medicare.

What Are My Other Options?

The major alternative to Original Medicare is called the Medicare Advantage Plan. Under this kind of plan, you are covered under a "Part C" arrangement, which includes Medicare "Part A" and Medicare "Part B." A Medicare Advantage Plan is operated by a private healthcare company, and you will generally only be able to receive treatment from doctors and facilities that are part of the Advantage Plan you select.