I started receiving Medicare in 2003, 25 months after qualifying for Social Security Disability Insurance (SSDI). It’s been really good, but it helps to know how to work the system.
To receive Medicare, one has to be over 65 years of age or have a permanent disability. (The U.S. still hasn’t joined the civilized world in providing health care for all.) For people with MS, qualifying for SSDI is the hard part, as I wrote about last time. Having qualified, how do we best use Medicare? What Medicare options should we choose?
What Medicare Covers
Original Medicare is a fee-for-service system, in which the government pays 80% of your health care providers’ fees. They set limits on what providers can charge, so some professionals will not accept Medicare coverage. But enough still do so that we can usually find a doctor we like who will take Medicare.
Like most people, I started with Medicare Parts A and B, which all SSDI beneficiaries get. Part A covers hospitalization, including inpatient hospital care, skilled nursing facilities, hospice, or home health visits. Part B covers medical services including ambulances, durable medical equipment such as oxygen, wheelchairs and walkers, mental health care, lab fees, and inpatient and outpatient doctor services. So, most people with MS need parts A and B.
In 2022, premiums for Medicare Part B start at $170/month and go up a bit for people with incomes above $90,000/year. The annual Part B deductible is $223 before Medicare starts paying.
For people who have paid into Social Security (FICA taxes) for 10 years or more, Part A charges no premiums. If you worked fewer years than that, premiums vary.
Parts A and B do not cover:
- Long-term care
- Dental care (with some exceptions)
- Vision exams needed to prescribe glasses
- Cosmetic surgery
- Hearing aids and related exams
- Routine foot care
Some people choose to get additional coverage along with Medicare, as I’ll cover later. I got much of this information from Medicareplans.com. Their site can teach you most of what you need to choose Medicare plans and work with them.
What You Have to Pay With Medicare
Medicare Part B pays 80% of an outpatient medical expense. Patients have to pay the remaining 20%. Because I see doctors as little as possible, I could handle those costs.
I was never hospitalized while on original Medicare, but having that coverage made me less fearful of needing it. Then Part A pays 100% of costs for 60 days in a hospital after a $1,550 deductible.
Medicare Part D is how the system pays for prescription drugs, which can be very important for people with MS. There are monthly premiums, copays for most drugs, and usually a deductible. If you don’t take prescription drugs, you might not need Part D, but the longer you wait to start it, the higher your premiums will be when you do start.
Part D covers most of the MS disease-modifying drugs, but it does not cover drugs considered experimental. Be sure to clarify your drug coverage with your doctor or pharmacist before a prescription is written.
Going Beyond Straight Medicare
When I first got Medicare, I had been a Kaiser nurse and a Kaiser patient for about 12 years. I decided to try something new, so I found a good doctor who took Medicare patients and went with straight original Medicare.
I was happy with Part A and Part B, but as time went on, I needed more medical care, especially after I lost bladder function and started having to catheterize myself. I needed to see urologists, buy supplies, treat frequent urinary infections (UTIs), and get physical, occupational, and mental health therapy. So I signed up for Kaiser’s Medicare Advantage plan under Medicare Part C.
Medicare Part C is usually called Medicare Advantage. Part C provides and pays for services that Parts A and B cover, but also for some services and deductibles Parts A and B don’t cover. They usually have their own premiums and copays, but less than the 20% Medicare Part B requires. Most Medicare Advantage Plans include Part D prescription drug coverage.
Some Advantage Plans offer additional coverage for dental and vision and even fitness memberships, but I’m not getting any of that. Advantage plans charge premiums, but in some cases, the premium may be the same as what straight Medicare A and B cost. I’m paying an additional $90/month, but I think it’s been well worth it.
Kinds of Medicare Advantage
My Part C is a health maintenance organization (HMO). I get all my care there and can’t go to outside providers except in emergencies. I like HMOs, because they profit from keeping patients healthy and don’t push extra services we don’t need. They are usually coordinated systems where any service or referral I need is right down the hall. But there are other kinds of Advantage Plans that might be better for you.
Patients whose needs go beyond what Medicare pays might want to consider supplemental or Medigap insurance to cover deductible costs, copayments, and coinsurance (the 20% Part B doesn’t pay) under original Medicare.
Very low-income people could apply for Medicaid. Medicaid + Medicare is really top-line coverage, including extended care, the kind of coverage everyone should have.
I am so glad to have Medicare. My HMO plan works for me, though I could have stayed with straight Medicare and left the insurance companies out of it. I still have to think and research for myself, because doctors don’t know everything, but with an HMO, I always have a place to go for help, and it won’t bankrupt me. I hope we all can have such coverage soon.
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