By Debbie D.
Medicare was signed into law by President Lyndon Johnson in 1965 and covers health insurance for people age 65 or older. Certain younger people can qualify for Medicare too, including those with disabilities, like end-stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s Disease). You must be either a United States citizen or have been a legal, permanent resident for at least five continuous years.
What is Medicare Part A?
Medicare Part A primarily covers inpatient care, including care received while in a hospital, skilled nursing facility, inpatient rehabilitation facility, and, in limited circumstances, at home. As a patient using Medicare Part A, you will receive coverage for hospital expenses that are critical to your inpatient care, such as a semi-private room, meals, nursing services, medications, services, and supplies required for your inpatient treatment.
Medicare Part A is free if you or your spouse have worked and paid Medicare taxes for at least ten years (40 quarters.) If you do not have enough working quarters, you will have to pay a premium.
Medicare Part A: Home Health Care Benefits
Home health care services deemed medically necessary are completely covered and must be provided by a Medicare-certified home healthcare agency. These services may include:
- Part-time skilled nursing care
- Physical therapy
- Speech-language pathology services
- Occupational therapy
- Medical social services
- Limited home health aide services
To qualify for home health care services, a physician must certify that you are homebound. According to Medicare, you are homebound if you can’t leave home without the aid of another person, specialized transportation, or equipment.
Medicare Part A: Skilled Nursing Facility Coverage
Skilled nursing facility (SNF) stays are covered under Medicare Part A after qualifying hospital inpatient stays related to an illness or injury and must be for a minimum of three days. Follow-up visits as an outpatient do not count towards a qualifying stay. SNF care must be provided by a Medicare-certified facility and may include:
- Semi-private room
- Skilled nursing services
- Rehabilitation services
- Medical social services
- Medical supplies and equipment
- Ambulance transportation to a nearby provider for services not provided at the SNF
- Dietary counseling
Medicare Part A: Hospice Coverage
You may be eligible for hospice care if your doctor has certified that you have a terminal illness with an estimated six months or less to live. Hospice caregivers focus on providing pain control and comfort at the end of a patient’s life. To qualify for Medicare-covered hospice care, you must meet all of the following conditions:
- You must be enrolled in Medicare Part A.
- Your healthcare provider must certify that you are terminally ill.
- You must agree to give up curative treatments for your terminal illness
- Though hospice care is usually received at home, the care must be provided by a Medicare-approved hospice facility.
Medicare Part A hospice care may include:
- Physician services
- Nursing care
- Pain relief medications
- Social services
- Durable medical equipment
- Medical supplies
- Hospice aide services
- Homemaker services such as cleaning or preparing meals
- Physical and occupational therapy
- Dietary counseling
- Short-term inpatient care (to manage pain or ongoing symptoms)
- Short-term respite care
- Spiritual and grief counseling
You have the right to discontinue Medicare hospice care coverage at any time if you want to resume curative treatments. Of course, this is a decision you should discuss with your physician.
Medicare Part A: Eligibility
Most Medicare Part A beneficiaries do not pay a premium for coverage if they have worked at least 10 years and have paid Medicare taxes during that time. Individuals who aren’t eligible for premium-free coverage can still enroll in Medicare Part A and pay a premium. You are eligible for Medicare Part A if:
- You are age 65 or older.
- You are a U.S. citizen or permanent legal resident for at least five consecutive years.
- You are already receiving retirement benefits.
- You are disabled and receiving Social Security disability benefits.
- You have end-stage renal disease (ESRD).
- You have amyotrophic lateral sclerosis (ALS).
Most people don’t pay a Part A premium if they paid Medicare taxes for 10 years or more. If you don’t qualify for premium-free Part A, you may pay up to $471 each month.
Medicare Part A: Initial Enrollment Period (IEP)
The seven-month Initial Enrollment Period (IEP) for Medicare benefits begins three months before your 65th birthday includes your birthday month, and ends three months later. If you don’t enroll during your IEP, you will have to wait until the next general enrollment period, January 1 to March 31.
Part A benefits begin the first day of the month you turn 65. If your birthday is on the first day of the month, your benefits will begin the month before you turn 65. Your Medicare card will arrive about three months before your 65th birthday.
If you are disabled, enrollment in Medicare Part A will begin after you have been receiving Social Security disability benefits for 24 months. Your coverage will begin in the 25th month. You will receive your Medicare card about three months before your coverage begins.
If you have ALS, your Medicare Part A hospital insurance (and Medicare Part B medical insurance) will automatically begin the same month that your Social Security disability benefits begin. Your Medicare card will arrive about one month after you sign up for Social Security disability benefits.
If you have ESRD and require dialysis, your Medicare effective date is usually the first day of the fourth month of your dialysis treatments. However, you need to apply for Medicare benefits if you’re younger than 65.
Medicare Part A: General Enrollment Period
If you delayed enrolling for Medicare or need to make changes to your coverage, you may enroll during the next available General Enrollment Period (GEP), unless you are eligible for a Special Enrollment Period (SEP). The GEP occurs each year from January 1 to March 31. If you sign up during general enrollment, your coverage will begin July 1 of that year. Your Medicare card will arrive about three months before your coverage begins.
Medicare Part A: Special Enrollment Period
Everyone experiences unexpected events in their life so you can make changes to your Medicare Part A plan during what is referred to as a Special Enrollment Period (SEP.) For example, you have 8 months to sign up for Part A if you lose your employer-provided health insurance, or if you’re a volunteer, serving in another country.
What is a Medicare Advantage Plan?
Medicare Advantage Plans offer a bundled alternative to Original Medicare. They are offered by private companies approved by Medicare and most often include a combination of Medicare Part A, Medicare Part B and, Medicare Part D (prescription drug coverage.)
When Can You Make Changes to Your Medicare Advantage Plan?
You can make changes to your Medicare Advantage plan at any time during open enrollment, October 15 through December 7. The changes you make will take effect on January 1 of the following year.