Before the Claim, Let’s Talk Medicare

Medicare is a national health insurance program in the United States, primarily for individuals aged 65 and older. However, some younger people with disabilities or specific conditions, such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), can also qualify for Medicare at any age. Additionally, younger adults who have been receiving Social Security Disability Insurance (SSDI) benefits for 24 months are also eligible for Medicare. 

So, when you first sign up for Medicare and during certain times of the year, you can choose how you get your Medicare coverage. There are 2 main ways to get Medicare:

1. Original Medicare(includes Part A and Part B): The Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). If you want Medicare drug coverage (Part D), you can join a separate Medicare drug plan.
2. Medicare Advantage(also known as the "Part C"): This is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health coverage. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t. The major players in this include UnitedHealthCare(with 29% market share as of 2024 reports), Humana(second largest with 18% market share), Blue Cross Blue Shield(BCBS)plan(holds 14% market share), Cigna, CVS HealthCare, Kaiser Permanente(known for high member satisfaction and comprehensive care according to medigap.com)

To better understand how Medicare supports healthcare coverage, it's essential to break it down into its four distinct components:

1. Part A(Hospital Coverage)
2. Part B(Medical Insurance)
3. Part C(Medicare Advantage)
4. Part D(Prescription Drug Coverage)

What do the above parts of Medicare cover?

Part A (hospital coverage) covers things like inpatient hospital stays, home health care, and some skilled nursing facility care. Typically, most people don’t pay for Part A if they have paid Medicare taxes for a certain amount of time while working. However, if you don't qualify for premium-free Part A, it can be purchased for a monthly premium. 

Part B (medical coverage) covers 2 types of services:

• Medically necessary services: Services or supplies that meet accepted standards of medical practice to diagnose or treat your medical condition. Also includes Ambulance services, clinical research studies, Durable medical equipment(DME)[Eg, Blood sugar meters, Hospital Beds, Nebulizers & nebulizer medications, Suction pumps, oxygen equipment & accessories].
• Preventive Services:  Health care to prevent illness (like the flu) or detect it at an early stage when treatment is likely to work best.

Medicare Advantage (also known as “Part C”) is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health coverage. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t.

Part D covers prescription drugs. Only private insurance plans offer it. It’s usually included in a Medicare Advantage plan, or you can get a separate Part D Plan. Though Medicare Part B does cover certain vaccines and medications (based on specific health conditions), Part D provides a much wider range of coverage of vaccines and outpatient prescription drugs.

Medicare General Enrollment Period

You can file for Original Medicare Parts A and B, or sign up for a private Medicare plan at any time during the three months before, the month of, and the three months after your 65th birthday. If you don’t sign up for Medicare Part A and/or Part B when you’re eligible, you can apply for Medicare for the first time during the General Enrollment Period from January 1 through March 31 every year. Coverage begins July 1. This enrollment period is only available to people who didn’t sign up during their Initial Enrollment Period and who aren’t eligible for a Special Enrollment Period.

Refer to this link to understand in depth the Plan Costs: Medicare Plan Cost

Final Thoughts

Medicare isn’t one-size-fits-all; it’s a set of choices that shape how you receive and pay for care. Whether you opt for Original Medicare or a Medicare Advantage plan, understanding each part A, B, C, and D helps you align coverage with your health needs and budget.

With enrollment timelines and plan options varying, staying informed is key. Make your decision with clarity and confidence, because the right Medicare plan means better care and fewer surprises down the line.