Guide to Social Security Medicare Coverage & Benefits

Valencia Higuera Valencia Higuera is a writer from Chesapeake, Virginia. As a personal finance and health junkie, she enjoys all things related to budgeting, saving money, fitness, and healthy living.
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Run by the U.S. government’s Centers for Medicare and Medicaid Services division, the Medicare program is offered to individuals drawing upon Social Security benefits during retirement. American workers pay into the program throughout their professional careers, which entitles them to access the benefits earned through the Social Security contributions deducted from their paychecks.

The Medicare program is segmented into four parts:

  • Medicare Part A: Hospital Insurance
  • Medicare Part B: Medical Insurance
  • Medicare Part C: Medicare Advantage Benefits
  • Medicare Part C: Prescription Drug Benefits

Below, we’ll provide an overview of Medicare plans, coverage, benefits, eligibility, and enrollment. 

Medicare Part A: Hospital Coverage and Eligibility

Upon their 65th birthday, U.S. citizens and legal permanent residents are eligible to draw upon Medicare coverage provided that they’ve adequately paid into the program through their employment history. Fortunately, individuals who do not qualify for the free options from paying into Medicare and Social Security can pay a monthly premium to access healthcare benefits. 

The basic goal of Medicare Part A is to treat medical issues known as “spells of illness.” While the phrase may sound a bit dated, it involves visits to medical facilities including hospitals, home health costs, and assisted living facilities. 

Coverage lasts from the time the patient is admitted and ends until he or she has been released for at least 60 consecutive days. Patients who find themselves in and out of the hospital, and not out for over 60 consecutive days, will continue to receive benefit payouts within the same period.

Enrolling in Medicare Part A under a payment plan also requires that you enroll in Medicare Part B during the Special Enrollment Period. Together, Part A and Part B are referred to as Original Medicare.

Medicare Part B: Medical Insurance Coverage and Eligibility

If you qualify for the free Medicare Part A coverage, then you are also able to draw upon the benefits of Medicare Part B. However, if you do not qualify for free Medicare Part A, then you must meet the following criteria to receive Medicare Part B coverage:

  • Be a U.S. citizen and resident

OR

  • Be a permanent resident who has resided in the U.S. for five consecutive years before applying

While it’s designed to meet basic health care offered by doctors and clinics, Medicare Part B generally only pays for half of these bills on average. 

Medicare Part B provides coverage related to:

  • Physician’s visits
  • Health tests and lab work
  • Outpatient hospital services
  • Ambulance transportation
  • Administration of drugs in hospitals
  • Some oral surgery
  • Medical supplies and equipment
  • Some podiatry and optometry services
  • Psychological and emotional care
  • Preventative cancer screenings

Enrollment in Medicare Part A is automatic if you qualify at age 65. However, to avoid penalties, you must actively request Medicare Part B coverage during the proper enrollment periods. Premiums from Medicare Part B are deducted from your Social Security disability check.

Medicare Part C: Medicare Advantage Coverage and Eligibility

Medicare Part C or Medicare Advantage (MA) is a program managed through private insurers that work with Medicare. MA Part C includes the coverage provided in Medicare Part A and Part B, as described above. 

Many plans include prescription drug benefits as well. You’re also likely able to access hearing, dental, and vision benefits that Medicare Part A and Part B plans do not provide.

Since Medicare Part C is funded through private insurers, there’s an additional out-of-pocket expense that patients should anticipate. Other limitations may include the need for a referral before visiting a medical specialist. There’s also a higher likelihood that benefits and coverage may shift from year to year since they’re provided by a private election option.

Medicare Part D: Medicare Prescription Coverage and Eligibility

The good news is that if you’re eligible for Medicare Part A and Part B, then you also qualify for prescription drug coverage with the Medicare Part D program. Remember that if you don’t elect this type of coverage upfront, then you’ll likely face penalties at a later date when you decide to join the program.

You are not required to attend a health screening under this election and issued through private insurers. Prices and premiums are determined using a formulary, and drugs not covered under the plan are subject to out-of-pocket expenses if an approved generic option isn’t available.

What Medicare Does Not Cover

It’s no secret that Medicare does not extend coverage to all of your health care needs. Medicare currently does not cover the following services:

  • Acupuncture, massage, or chiropractic care
  • Medical services rendered outside of the U.S.
  • Cosmetic or “plastic” surgery
  • Dental treatments
  • Hearing aids
  • Home health care
  • Nursing home benefits
  • Non-essential medical services
  • Preventative maintenance
  • Vision screening and care

Billing Medicare for the above-listed services will most likely result in denial of coverage, meaning that you are responsible for out-of-pocket costs. If you have a Medicare Advantage Part C plan, your private insurer may cover some of these options. Contact them directly to find out if the procedure or treatment is covered beforehand.

Final Considerations for Medicare Coverage Options

There are several healthcare options available to qualifying individuals when they start collecting Social Security benefits upon turning 65 years old. Make sure you elect benefits that make the most sense for your medical needs and financial situation for the most comprehensive coverage available.

There are specific health care treatments that none of the programs cover, so you must work with your healthcare provider when making decisions related to your Medicare coverage needs, whether you live in the U.S., Puerto Rico or other U.S. territories. Notably, healthcare coverage options may be lacking in terms of hearing, dental, vision, and chiropractic care. 

To get the maximum benefits from your plan and avoid out-of-pocket costs,  you’re likely to fare better with your health insurance coverage needs by planning ahead. Request a free quote today.

 

 

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