Medicare, a federally funded health insurance program that began in 1965, is designed for seniors and those with disabilities. This program covers nearly 20% of the American population or more than 60 million people. It is administered by the Centers for Medicare & Medicaid Services (CMS).
There are three main categories of Medicare services eligibility criteria: age, disability, and citizenship/residency. To qualify, you must meet one of the following criteria:
- Be age 65 or older, and you or your spouse should have worked in a job that has contributed to Social Security/Medicare taxes for at least 10 years.
- Be under age 65 and disabled and have received Social Security Disability Insurance(SSDI) benefits for at least 24 months. Certain conditions do not require 24 months of disability payments and apply to adults of any age, including those who have:
- End-stage renal disease (kidney failure requiring either dialysis or a kidney transplant)
- Amyotrophic lateral sclerosis (ALS, also called Lou Gehrig’s disease)
- Be a U.S. citizen or permanent resident who has lived in the U.S. for at least 5 years.
Medicare Eligibility by Plan
When people talk about “original Medicare,” they’re talking about Parts A and B. Most people get Medicare Part A for free and must pay for Parts B, C, and D in order to receive coverage.
Medical services under Medicare are paid for as received, and they typically involve a deductible that must be met each year. Enrollment is available beginning three months before the month in which you turn 65, and it ends after the third month following your birthday month.
If you miss that seven-month window, you can apply for Medicare during the annual January-March General Enrollment Period, and your Medicare coverage will begin on July 1st of that year. Once you have enrolled in Medicare, you can then opt to enroll in Part C (Medicare Advantage) and/or Part D (prescription drug coverage) from April through June of that same year.
Medicare Part A – Hospital Insurance
This part of Medicare coverage pays for inpatient hospital stays, care received at a skilled nursing facility, certain at-home healthcare services, and hospice care.
If you’re already receiving Social Security benefits, you will automatically be enrolled in Original Medicare (Parts A and B).
Medicare Part B – Medical Insurance
People who are receiving Social Security benefits will be automatically enrolled in Medicare A and B – although you can opt out of Part B because it will require that a premium be paid. If you decide to opt out of Part B even though you’re receiving regular Social Security payments, be sure to let Social Security know that you want to opt-out.
Medicare Part C – “Medicare Advantage”
These special plans are funded by private insurance companies that are Medicare-approved.
Medicare Advantage plans offer an alternative coverage method to original Medicare Parts A and B (inpatient and outpatient care). Most Medicare Advantage plans also wrap in Part D (prescription drug) coverage as well.
Depending on the plan you get, it may also include coverage for healthcare services that are not traditionally covered by Medicare, including:
- Mental health
- Wellness (i.e., gym memberships or discounts)
These plans are subject to annual changes, so your coverage and out-of-pocket expenses may change from year to year. In most cases, you will see doctors who operate within your plan’s network.
You can choose a Medicare Advantage plan that is either a health maintenance organization (HMO), preferred provider organization (PPO), private fee-for-service (PFFS), or medical savings account (MSA) plan. To qualify for Medicare Advantage, you need to already have Medicare Part A and Part B – plus, you will need to live within the service area of the Medicare Advantage plan you choose.
Medicare Part D – Prescription Drug Coverage
This coverage helps to pay for the cost of prescription drugs. It also includes the cost of necessary vaccines. It is available to everyone who has Medicare.
Medicare Supplemental Insurance –Medigap
This extra coverage is designed to help pay for the costs not covered by Original Medicare – such as co-payments, co-insurance, and deductibles. Only those who already have or are eligible for Medicare Part A and Part B can purchase Medigap coverage. Those who have Medicare Advantage cannot purchase this supplemental insurance, because Medicare Advantage is considered a more high-cost option.
Medicare-Eligible Primary Care in Miami, FL
Medicare eligibility and coverage can be confusing. At Palm Medical Centers in Miami and across South Florida and Central Florida, we are committed to providing top-quality, comprehensive healthcare to every single patient who walks through our doors. Our care coordinators can help you determine what services your Medicare plan entitles you to.