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Medicare / Medicaid / SCHIP

At what age will I become medicare eligible?

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In most cases the eligibility age for Medicare is 65 years. Persons with certain medical conditions may however be registered at a younger age for coverage.

Medicare is the government-sponsored health insurance plan, which includes medical and hospital cover.

Most people who are covered by Medicare are 65 or older. According to the Kaiser Family Foundation, however, Medicare currently covers about 9.1 million people under the age of 65, many of whom have a chronic disability or medical condition. This is about 16 per cent of the population in Medicare.

This article explains how and when an individual is eligible for benefits from Medicare including factors related to age and health conditions.

When can a person enroll for Medicare?

A woman having medication
In most circumstances, a person becomes eligible for Medicare at 65 years of age.

A person usually meets medicare eligibility at age 65. Since 1965 Medicare has been available in the United States for people aged 65 and over. This is Medicare coverage which came into effect the same year.

Legislation has increased coverage over time for those with some medical conditions who have not yet reached age 65.

The Congressional Budget Office (CBO) has analyzed the feasibility of raising the limit of Medicare certification from 65 to 67 years and the potential cost savings. In 2013, the CBO released a report predicting that doing so would decrease the federal budget deficit by $19bn over seven years.

The current age for enrolment, however, remains 65 years.

Other qualifying factors for Medicare

Some people can qualify for Medicare coverage when they are younger than 65. This includes:

  • people with certain disabilities
  • people with end stage renal disease (ESRD)
  • people with amyotrophic lateral sclerosis (ALS)

The following sections will discuss what these conditions mean for Medicare coverage in more detail.

Disabilities

If a doctor believes a person has a disability and is unable to function, they may be eligible for Medicare until they reach age 65. The doctor will have to fill out forms confirming the person has an illness.

In people with the following medical conditions they will report a disability:

  • chronic heart failure
  • liver disease
  • multiple sclerosis
  • sickle cell disease

People with these conditions may have a waiting period before they can start receiving Medicare Part A benefits after their doctor confirms their disability. They should ask their office of Social Security about exactly when they can apply for Medicare.

Most people who are already eligible to collect Social Security for their disability are not required to pay a Medicare Part A fee.

ESRD

Typically, when a person requires dialysis or applies for a kidney transplant, it means they have ESRD.

Typically, a person with ESRD may obtain Medicare benefits around 3 months after dialysis at a health care facility, or nearly immediately if they qualify for dialysis at home.

When a person with an ESRD qualifies for Medicare, they do not have to pay Part A premiums. Medicare Part A includes services including a stay in a hospital (such as surgery), a stay in a skilled nursing facility or hospice, and home care.

ALS

If a individual has ALS, they’ll qualify for Part A of Medicare without raising the premiums. These will also usually qualify to obtain Medicare coverage without a waiting period.

What happens when a qualifying spouse is younger?

A individual is eligible for Medicare Part A if they have paid Medicare taxes for at least 40 quarters of the work, or their spouse.

This could become more complicated when 40 quarters didn’t work for an older adult with a younger partner but their spouse did.

If a younger spouse has been employed for 40 quarters, they will qualify their partner for Medicare coverage until they reach age 62 and the older non-working spouse reaches age 65.

If a person reaches 65 years of age, did not pay Medicare taxes for 40 quarters, and has a spouse under the age of 62 years, they may have to pay for their Medicare Part A benefits until their qualifying spouse reaches 62 years of age.

Preparing as the eligibility age nears

If a individual already receives benefits from the Social Security Administration, they are automatically enrolled by the Administration in sections A and B of Medicare.

A “Welcome to Medicare” packet will be given to the person 3 months before their 65th birthday, with instructions on how to sign up.

To receive Medicare a person doesn’t have to be retired. If a person does not currently receive benefits from the Social Security, they may apply for benefits from Medicare as early as 3 months before their 65th birthday.

For example, if a person turns 65 in April they can be in January of the same year for Medicare benefits.

Applying for Medicare benefits as early as possible can help the Office of Social Security process the paperwork in time for the 65th birthday of the individual.

People applying too late that face a 10 percent higher premium than those applying on time. This premium will apply for doubling the amount of time a person is eligible but has not applied.

A individual may apply for Medicare during their month of birth or up to 3 months after their month of birth, without having to pay Medicare coverage penalties.

Though, their benefits won’t start until the Medicare and Medicaid Services Centers review their application.

Summary

A individual can apply for Medicare benefits when he or she reaches age 65. The cost of these services depends on whether they or their partner has served for at least 40 quarters and paid taxes on Medicare.

Before this age, those with disabilities, ESRD, or ALS will qualify for Medicare benefits.

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Health Insurance / Medical Insurance

What is health insurance?

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Health insurance is a form of insurance coverage that covers the cost of medical and surgical costs of an insured person.

To identify a clinic, hospital, doctor, laboratory, healthcare practitioner, or pharmacy that treats a person, insurers use the word “provider.” The “insured” is the health insurance policy owner or the individual protected by the health insurance coverage.

Either the patient pays out-of-pocket expenses and earns compensation, depending on the form of health insurance policy, or the insurer makes payments directly to the company.

Health insurance is generally provided in workplace compensation packages in countries without universal healthcare coverage, such as the United States.

According to the Kaiser Family Foundation, the number of people with insurance in the U.S. dropped from 44 million in 2013 to less than 28 million in 2016. The researchers put this down to recent legislative changes.

A 2011 Commonwealth Fund study found that a gap in health insurance coverage was faced by one-fourth of all working-age U.S. residents. When they either became unemployed or changed jobs, many individuals in the study lost their health care.

Depending on what form of health insurance a person has, the level of treatment in emergency departments varies greatly.

Types

Two main types of health insurance exist:

Private health insurance: The Centers for Disease Control and Prevention (CDC) states that private health insurance is heavily dependent on the U.S. health care system. In the National Health Interview Study, researchers found that 65.4 percent of people under the age of 65 years in the U.S. had a form of private health insurance coverage.

Public or government health insurance: In this form of insurance, in return for a fee, the state subsidizes healthcare. Examples of universal health insurance in the United States include Medicare, Medicaid, the Veteran’s Health Administration, and the Indian Health Service.

Other types

Through the use of the way they handle their policies and communicate with healthcare providers, people often describe an insurer.

Managed care plans: The insurer would have arrangements with a network of healthcare providers to provide their policyholders with lower-cost medical care under this form of arrangement. There will be penalties and additional costs added to out-of-network hospitals and clinics, but they will provide some treatment.

The more costly the policy is, the more flexible it is likely to be for the hospital network.

Indemnity, or fee-for-service plans: A fee-for-service contract covers all healthcare providers with fair treatment, empowering the insured to select their chosen place of care. The insurer will usually fund an indemnity plan covering at least 80 percent of the costs, while the patient will pay the remaining costs as co-insurance.

Health maintenance organizations (HMOs): These are organizations which directly provide the insured with medical care. Usually, the policy would include a committed primary care doctor who will manage all appropriate care.

HMOs will usually only finance the care referred by this GP and will have negotiated fees to reduce costs for each medical service. Normally, this is the cheapest form of plan.

Preferred provider organizations (PPOs): A PPO is similar to an indemnity plan in that it requires any doctor they prefer to see the insured.

The PPO also has a network of approved providers with which they have negotiated costs.

For out-of-network providers, the insurer will pay less for care. However, without having to see a primary care provider, people on a PPO plan will self-refer to specialists.

Point-of-service (POS) plans: As a combination of an HMO and PPO, a POS plan works. The insured can choose between arranging all services through a primary care doctor, providing treatment within the provider network of the insurer, or using non-providers of the network. The type of plan will dictate the progress of treatment.

Why is the type of insurance plan important?

The type of plan decides how a person will handle getting the care they need and how much cash they will need to spend on the day.

During 2003, the U.S. A new alternative was adopted by Congress, the Health Saving Account (HSA). It is a mix of tax advantages for an HMO, PPO, indemnity plan, and savings account. A policyholder must, however, combine this form with a current insurance plan that has a premium for individuals of over $1,100 and families of $2,200.

HSAs would expand coverage, expanding current plans to accommodate a broader variety of therapies. When an HSA is paid for by an employer on behalf of their workers, the payments are tax-free. In the HSA, a person can build up funds when they are safe and save later in life for instances of bad health.

People with chronic illnesses, such as diabetes, will not be able to save a significant amount in their HSA, however, because they have to pay high medical expenses annually for maintaining their health care.

These policies often have a very high deductible, which means that while premiums can be smaller, individuals often end up covering the full cost of any medical treatment required.

As plan types evolve, there is more overlap. The distinctions between policy types are becoming increasingly blurred.

Managed care strategies are used by the majority of indemnity plans to manage costs and ensure that adequate resources are available to pay for necessary care. Similarly, many managed care plans have embraced certain features of fee-for-service plans.

Legislation

Insurance logo
Make sure you research the insurance legislation in your state.

As part of the Affordable Care Act (ACA) 2010, providing a degree of insurance is actually legally required in the U.S. An person with no health insurance has to pay a fine.

The Individual Mandate in the ACA, however, has been withdrawn from the legislation, meaning that as of 2019, insurance will no longer be a legal obligation in the U.S.

If the policy also protects the children in the family, a person is permitted until the age of 26 years to be insured by their parents, even if they are:

  • married
  • living away from home
  • not financially dependent on their parents
  • eligible to be included on their employer’s cover

Insurance is controlled at the level of the state, which ensures that purchasing a policy in one state varies from doing so in another.

Although state laws may impact the price of a policy, the insurer is responsible for the important decisions regarding the coverage and reimbursements of an individual. People should be sure to address the effect of any evolving laws on their personal policies with their broker or customer services representative.

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Dentistry

Does Medicare cover dental treatment?

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Medicare usually does not cover dental procedures, unless it is a part of emergency or complicated facilities. Nevertheless, Medicare Advantage plans or other health benefits that help a person cover all or a portion of the cost of dental care.

According to the Kaiser Family Foundation, about 37 million Medicare enrollees have no amount of dental coverage.

But there are other ways to secure regular dental coverage, even if it’s not through Medicare itself.

Read in this article about when Medicare will cover dental expenses, and how to ensure coverage if not.

Does Medicare ever cover dental costs?

Dental medical treatment
A person’s Medicare plan may cover dental work if it is a part of emergency or complicated services.

Medicare can cover dental costs that are part of the treatment for a medical condition or injury that underlies it. Some of the dental services covered by Medicare include:

  • dental extractions for cancer treatment involving the jaw or nearby soft tissues
  • jaw reconstruction following an accident or injury
  • oral examinations before a heart valve replacement or kidney transplant

These services may be paid for by different facets of Medicare. For example, if the surgery is done by a non-dentist, Medicare Part B will be responsible for the costs. Part B is Medicare’s medical part, which usually includes doctor visits and health services.

However, funds may come from Medicare Part A if a dentist on the staff of a hospital performs the operation. It portion pays for in-hospital care, services, and treatment.

However, Medicare does not provide regular dental services in the majority of cases. This involves cleanings, extractions, and checks not related to an accident or illness requiring hospitalization.

Also, Medicare does not fund any replacements of lost or extracted teeth, such as dentures and fillings.

What about Medicare Advantage?

Medicare Benefit, or Medicare Part C, is a kind of Medicare provided by private insurance plans. Although policies vary depending on the healthcare provider network, geographic area, and private insurer, some offer regular dental care coverage.

Medicare Advantage incorporates sections A and B, as well as some components of Portion D. This part provides coverage of prescription drugs and other programs.

The types of scheme available can depend on the area a person lives in. Some Medicare Advantage plans require visiting a single physician or hospital group that have provisions with their Medicare Advantage plan.

The same may apply to the dentists in a person’s region as well. An patient may need to see an “in-network” provider to get coverage for their dental services.

Those considering switching to a Medicare Advantage program for expanded dental coverage will look at participating providers in their area as well as what the package would support dental services.

What about Medigap coverage?

Medicare replacement care, or Medigap, is a program that allows an individual to pay an extra fee per month. This premium will cut the out- of-pocket costs that often follow sections A and B of Medicare.

Medigap plans do not cover copayments or dental insurance. These are a way to make Medicare benefit replacements. Because Medicare does not provide dental benefits, Medigap is not helping a individual finance these.

What can people aged 65 and over do about dental coverage?

If a person wishes to have dental coverage associated with Medicare, they should choose a Medicare Advantage program that provides such benefits.

A person must first enroll in Medicare during their initial enrollment period, which begins 3 months before their 65th birthday, includes their month of birth, and continues to 3 months after their birthday to enroll in Medicare Advantage.

If a person fails this period of enrollment, they can enroll in Medicare during the General Enrollment Period, which starts in January and ends in late March.

A individual might subscribe to a Medicare Advantage plan from April through June after this date. To choose a Medicare Advantage package, they must be participating in the Medicare sections A and B. They would probably be required before pay a copayment or penalty to cover any dental expenses.

If a person does not want a Medicare Advantage plan, or if there are no suitable plans in their state, we may choose to buy a separate dental insurance policy.

Private health insurance companies sell dental covered policies. A person may want to study the different plans available to them before buying one, and choose one that best suits their needs.

Other options for dental care include:

  • contacting the local health department to find out if they offer free or low cost dental services at certain times
  • applying for Medicaid benefits, which may help provide dental benefits to some individuals and families (income qualifications may vary by state)
  • contacting local dental or dental hygiene schools to find out if they offer free or low cost services

Community organizations, such as United Way, can also help a person find dental services that are free or low-cost.

Summary

Good dental health is vitally important for general health. Reports have in turn linked poor dental health with a deterioration of other medical conditions, such as diabetes and heart disease.

Even if Medicare doesn’t cover dental health, a person can use Medicare Advantage or other community health services to receive dental benefits.

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Health Insurance / Medical Insurance

Medicare donut hole: What to know

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The Medicare donut hole is a colloquial term that defines a void in Medicare Part D coverage for prescription drugs. For 2020, Medicare is making any improvements that are helping to fill the donut hole more than ever.

Medicare Part D is the Medicare portion which helps an individual pay for prescription medicines. A person enrolled in Medicare does not have to choose Medicare Part D. However, they do need to have some other prescription drug coverage, usually via private insurance or health insurance.

We explain the donut hole in this article, and how it applies to the cost of Medicare prescription drug.

What is the Medicare donut hole?

Medicare donut hole

Medicare Part D plans will vary depending on the insurance selected by one person.- coverage lists the medications it covers, as well as other medicines for which a portion of costs may be covered.

The word donut hole refers to the manner in which a individual must pay for coverage.

A person pays for their prescription drugs a set amount, and if they reach the deductible, their program takes over the funding.

However, the individual has entered the donut hole when the plan has payed up to a defined limit.

When they reach this point, a person must start paying back for their medications before they reach another specified amount. After this, their program once again takes over payment.

The problem with the donut hole is that when they reach the donut hole, many people in the U.S. stop taking their drugs because they can’t afford to pay the high drug prices. Often they have to pay thousands of dollars for prescription drugs until they close the gap in coverage.

They achieve “catastrophic coverage,” nonetheless, once a individual crosses the donut hole. If they reach this stage, they only have to pay about 5 percent of the prescription drug costs. Nonetheless, getting to the point of catastrophic coverage is alarming or unlikely for many consumers in the U.S.

Legislators have passed legislation that has, like the Affordable Care Act, gradually helped to close the donut hole. Consumers also experience changes in their coverage, however, as they spend on prescription drugs. Reporting stops once a person reaches their drug spending financial cap and re-starts during a catastrophic coverage.

The improvements Medicare is making are aimed at reducing the costs people bear while they’re in the donut hole.

What is the donut hole gap in 2020?

The government took numerous steps in 2011, which started to close the hole in the donut. Those encompassed:

  • 2011: The Affordable Care Act required pharmaceutical manufacturers to introduce discounts of up to 50% for brand name drugs and up to 14% for generic drugs, making it easier for people to buy medications once in the donut hole.
  • 2012‑2018: The discounts continued to increase.
  • 2018: The Bipartisan Budget Act sped up changes to prescription drug discounts when a person was in the donut hole. Examples included manufacturer discounts and decreasing a person’s costs on brand name drugs once they enter the donut gap.

Such reforms were aimed at making medications more accessible once a person hit the donut hole, which would allow people to continue taking their drugs and reduce the risk of a treatment break.

As of 2020, prescription drug coverage takes the following shape:

  • A person pays their co-payment for their prescription drugs, depending upon their drug plan. Their plan funds the remaining portion.
  • When a person and their insurance company have jointly paid out a total of $4,020, the individual reaches the next stage — the donut hole.
  • In the donut hole, a person pays for 25% of their medication costs out-of-pocket and receives discounts from drug manufacturers to cover the remaining costs.
  • The insurance company will add up what a person has paid out-of-pocket for medications in the donut hole. Once this total reaches $6,350, a person has crossed the donut hole.
  • A person is now in the catastrophic coverage stage of their medication coverage. Their insurance company now requires that they pay either 5% of a drug’s cost or a minimum copay, whichever is higher.

Ideally, such changes would allow a person to have long-term access to the medications prescribed by their doctor.

How does it work?

Here is an example of how a Medicare patient passes through the donut hole and achieves catastrophic coverage by 2020.

  1. An individual and their insurance company have spent $4,020 on medications since the start of their plan. That person is now in the donut hole.
  2. The person pays 25% of their medication costs. For example, if they have a medicine that costs $100, they will pay $25. The pharmaceutical company then discounts the medication by $70, and the insurance company pays the remaining $5.
  3. The person continues paying 25% out of their own money until they have spent $6,350. When this occurs, they are out of the donut hole.
  4. A person is now in the catastrophic coverage portion of their coverage. They will pay either a minimum copay or 5% of the drug’s cost.

An estimated 4.9 million Medicare Part D enrollees exceeded the catastrophic coverage portion of Medicare Part D in 2017, according to the most recent Kaiser Family Foundation statistics.

How to get out of the donut hole

Individual can get out of the Medicare donut hole by meeting their requirement for out- of-pocket expenses of $6,350 by 2020.

There are, however, ways to receive assistance to finance prescription drugs, especially if a person meets certain low-income requirements. Including:

  • Extra Help: Extra Help is a Medicare program that helps people pay for medications and other aspects of medical care. A person can qualify for Extra Help if their income is $18,735 or less when single or $25,365 or less as a couple. They must also have less than $14,390 as a single person or $28,720 as a married couple in resources. Resources include savings, stocks, or bonds.
  • Medicaid: Medicaid is a federal program that helps low income individuals pay for healthcare. People who qualify for Medicaid are automatically enrolled in the program.
  • State Health Insurance Assistance Program (SHIP): These state-specific programs can provide additional assistance for people in funding healthcare costs, including medications.

Most pharmacy firms now provide drug aid services that can cut costs. Sometimes, a doctor or pharmacist might make suggestions to contact the drug company.

Summary

According to an article in < em > The New England Journal of Medicine, some 42.5 million people in the US obtain prescription drug coverage through Medicare Part D.

Closing the hole in the donut will help a person reduce the cost of prescription drugs. However, once they hit the donut hole, they will still be liable for 25 per cent of costs.

If an person has trouble paying for pharmaceutical drugs, state, federal and private organizations can help.

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