What is Medicare – San Antonio’s guide to navigating Medicare

History of Medicare

President Lyndon B Johnson signed Medicare and Medicaid into law on July 30, 1965. Medicare was composed of two parts (Medicare Part A and Medicare Part B) which are called “Original Medicare.” Medicare Part A covers costs that are associated with inpatient care, such as hospital stays, while Medicare Part B covers costs that are associated with outpatient care, such as doctor’s appointments. Over the years Congress has made many changes to the program to try to make it more suitable for the aging population, such as the creation of Medicare Part D and Medicare Advantage.

Today Medicare is a program for individuals who are aged 65 and older, people who are under the age of 65 but have a certain disability, and people across the age spectrum with end-stage renal disease. Medicare is overseen by the Centers of Medicare and Medicaid Services (CMS).

Medicare Part A

The Medicare Part A premium is typically free for most people. This is because it was already paid for through taxes that were collected from the beneficiary or the beneficiary’s spouse. The beneficiary will most likely have to pay for services until the deductible is met. Covered costs under Medicare Part A include:

• Hospital Stays
• Skilled nursing facilities that follow hospital stays for any rehab that is needed. Full coverage of this care typically lasts 20 days. After the first benefit period has passed a copayment is required for the next 80 days.
• Hospice Care
• Home Health Care that is provided by a Medicare-certified agency. This must be ordered by a doctor for a beneficiary who is primarily homebound and needed for rehab purposes.

Medicare Part B

Medicare Part B is more commonly thought of as typical medical insurance. Beneficiaries receive outpatient coverage that Part A doesn’t cover. People do not have to enroll in Medicare Part B if they already have medical insurance. Premiums for Medicare Part B is based on income, but it isn’t uncommon to have a medical premium of about $100. Covered costs under Medicare Part B include:

• Doctor and other health care provider fees related to outpatient care. This includes services of physical and occupational therapists.
• Supplements costs for medical supplies such as wheelchairs and hospital beds
• Ambulance services and emergency care
• Annual wellness visits with the beneficiary’s personal care physician as well as any testing related to preventive care.

Medicare Part D

Medicare Part D is the drug portion of Medicare that is available to all beneficiaries who have Medicare. Coverage can be through CMS or through a private insurance company. Typical costs for Medicare Part D are based off the beneficiary’s income level and the coverage of different prescription plans. Because prescriptions can be a very expensive cost for the beneficiary, there are many public programs that may provide reduced or free prescription drug access:

• https://www.medicare.gov/pharmaceutical-assistance-program
• http://rxassist.org/
• https://www.benefitscheckup.org/
• Beneficiaries can also contact their State Health Insurance Assistance Program
  • hhs.texas.gov/Medicare or call 1-800-252-9240

Medicare Advantage

Medicare Advantage (also known as Medicare Part C) was created in 2003 but was originally knowns as Medicare+choice in 1997. This program allows beneficiaries to receive Original Medicare services through a private insurance company. In Medicare Advantage plans, often time beneficiaries are offered coverage that original Medicare does not offer such as vision and dental. There are typically two products covered under Medicare Advantage:

• HMO (Health Maintenance Organization): This is a closed medical network where coverage is only extended to in-network providers and hospitals. In the case of an emergency, coverage is extended to out-of-network hospitals. In order to see a specialist, the beneficiary’s primary care physician.
• PPO (Preferred Provider Organization): This is more of an open medical network where coverage is extended to providers outside of the medical network. Beneficiaries typically have to pay extra for providers who are out of network.

Medicare Supplement (Medigap)

Medicare Supplement (also known as Medigap) is a private insurance product that helps bridge the gap in Original Medicare coverage. To qualify for Medicare Supplement the beneficiary must be enrolled in Medicare Part A and Medicare Part B. There is also a separate premium that the beneficiary pays the private insurance company that is not allocated from the premium that the beneficiary pays for Medicare Part B. Medicare Supplement helps pay for health care costs such as copayments, coinsurance, and deductibles. However, Medicare Supplement does not help cover the costs for vision, dental, hearing, and long-term care. Medicare Supplement is a product that helps pay for the costs associated with Medicare Part B.

How to get started

People can start enrolling in Medicare programs three months before they turn 65.

It is important to enroll in Medicare as soon as you are eligible to avoid a late fee.

The enrollment process typically takes seven months (about three months after the individual turns 65). It’s never to early to look at the different Medicare products that are listed above and decide which coverage option best fits the individual’s needs.

Applying for Medicare in San Antonio

An Individual can apply for Medicare in several locations:

• Individuals can apply online through the Social Security website
• Individuals can apply by phone by calling 1-800-772-1213
• Or Individuals can apply in person by visiting the social security office. In San Antonio, Texas the offices are located
  • 402 Isom Rd, San Antonio, TX 78216
  • 411 Richland Hills Dr, San Antonio, TX 78245
  • 727 E Cesar Chavez, San Antonio, TX 78206
  • 3438 E Southcross, San Antonio, TX 78223

Thanks for reading!
Michelle