Overview on USA Healthcare Insurance - Medicare

Medicare

Medicare is the Federal health insurance program for Americans aged 65 years and older, some disabled individuals and individuals who have end-stage renal disease (ESRD). The Original Medicare Plan, which is available nationwide, is a fee-for-service plan that is managed by the Federal Government. It pays for numerous healthcare products and services and supplies, but it won't reimburse the entire healthcare costs incurred as part of the treatment. It is always advisable that an individual should enroll in Medicare when he/she becomes eligible for the health cover. Incase, the individual decides or chooses to enroll at a later time, he/she will be required to pay a late enrollment penalty. If an individual already possesses health insurance policy given by an employer or another

source, it is always recommended to discuss with the concerned benefits administrator as to whether the individual should avail Medicare facility or not while being still covered.

Medicare has four parts namely:

a) Hospital Insurance

• known as Part A

b) Medical insurance

• known as Part B which provides payment for medical professionals and related healthcare services

c) Prescription Drug Coverage

• known as Part D.

d) Choice of receiving the benefits of Medicare A, B, and D through a private health plan, like an HMO or PPO

• Part C

Such a coverage is called Medicare Most people don't pay a premium for Part A, since they already paid for it through payroll taxes while they were working or employed. There is a monthly premium for Medicare Part B. Usually the individual will pay the premium if he/she decides to enroll in Medicare's Prescription Drug Plan. If an individual does not enroll under Medicare plans as soon as he/she is eligible, then the premiums to be paid will be higher if he/she decides to enroll at a later time. In addition, once the individual is past the first eligibility, then he/she will have to wait for the annual enrollment period (generally November 15-December 31 of each year) in order to enroll in Medicare's Prescription Drug Coverage.

Medicare Prescription Drug Benefits

In January 2006, prescription drug coverage (Part D) became available to Medicare beneficiaries for the first time across USA. Through this new benefit, Medicare reimburses for a portion of an individual's prescription drug costs. Both brand-name and generic prescription drugs are covered at participating pharmacies across USA. All the individuals with Medicare are eligible to enroll under this coverage, regardless of income and resources, health status or current prescription expenses. If an individual chooses to avail this coverage, he/she will be able to get the medicaments in one of two ways. You can buy an individual drug plan or you can sign up with a Medicare Advantage Plan such as an HMO or PPO. Either ways the individual is required to pay a monthly premium, which differs or varies based on the insurance plan, coinsurance or co-pays for the drugs, and in certain cases, a yearly deductible. There are many plans that participate in the Medicare prescription drug program. Such a competition amongst the healthcare plans needs to have a positive effect on consumers' out-of-pocket costs. Nevertheless, the coverage for deductibles, out-of-pocket costs and medicines vary widely across the healthcare insurance plans. Some healthcare policy covers may provide more coverage and additional drugs for a higher monthly premium. If an individual has limited income and resources and he/she qualifies for extra help, he/she may not be required to pay a premium or deductible. If the individual is eligible, he/she will get the necessary assistance paying for his/her drug plan's monthly premium, yearly deductible and prescription co-payments. The amount of help derived by an individual depend on his/her income and resources.


If an individual already possesses prescription drug coverage from an employer, former employer or via other sources, he/she may be better off retaining the existing coverage. The individual should contact his/her benefits administrator to find out how his/her existing coverage works with Medicare drug coverage before taking a decision. The individual may decide to retain the drug coverage possessed by himself or may want to join a Medicare Drug Plan instead of or in addition to the current healthcare insurance plan. If the individual feels that he/she may be better off by getting rid of his/her employer-based drug plan, it is always advisable to consult with his/her employer as a first resort. If the individual decides to leave his/her employer coverage and later changes his/her mind, he/she will not be able to return to it for availing health or prescription drug coverage. It is always recommended that an individual's employer, is your best source of information pertaining to his/her current drug coverage. If an individual requires further assistance in taking an appropriate decision, he/she can call his/her State Health Insurance Assistance program to get personalized counseling regarding the subject.

Medicare Advantage Plans

Medicare Advantage Plans are available in many areas of USA. These Medicare plans include HMOs, PPO's, Private Fee-for-Services Plans and Special Needs Plans. In comparison to the Original Medicare Plan, Medicare Advantage Plans gives an individual more choices and extra healthcare benefits such as coverage for more number of days in the hospital. Many health insurance plans incorporate Part D drug coverage. To join a Medicare Advantage Plan, the individual must possess Medicare Part A and Part B coverage. He/She will be required to pay the monthly premium for Medicare Part B and also pay a premium for Medicare Advantage Plan for deriving the extra benefits it offers the policyholders under this plan.

References:

1. DEFINITIONS OF HEALTH INSURANCE TERMS - (http://www.bls.gov/ncs/ebs/sp/healthterms.pdf)
2. Glossary of Insurance Terms - (http://www.ambest.com/resource/glossary.html)
3. Patients & Consumers - (http://www.ahrq.gov/CONSUMER/insuranceqa/insuranceqa.pdf)

Cite this Article ⇣⇡

Please use one of the following formats to cite this article in your essay, paper or report:

• APA

  Dr. Sameer Sippy. (2013, April 19). Overview on USA Healthcare Insurance - Medicare. Medindia. Retrieved on Dec 22, 2024 from https://www.medindia.net/health/insurance/overview-usa-healthcare-medicare.htm.

• MLA

  Dr. Sameer Sippy. "Overview on USA Healthcare Insurance - Medicare". Medindia. Dec 22, 2024. <https://www.medindia.net/health/insurance/overview-usa-healthcare-medicare.htm>.

• Chicago

  Dr. Sameer Sippy. "Overview on USA Healthcare Insurance - Medicare". Medindia. https://www.medindia.net/health/insurance/overview-usa-healthcare-medicare.htm. (accessed Dec 22, 2024).

• Harvard

  Dr. Sameer Sippy. 2013. Overview on USA Healthcare Insurance - Medicare. Medindia, viewed Dec 22, 2024, https://www.medindia.net/health/insurance/overview-usa-healthcare-medicare.htm.