Senior Care Plan Guide to Medicare Coverage and Medicaid

senior care plan medicare health insurance older adults medicaid coverage medigap

It is not easy getting old and dealing with all of the many medical issues that inevitably arise, even if you lived a safe and healthy life. If you end up in the hospital due to illness or injury, you could be in for a hefty bill of over $3,500 per day even with some health insurance. So, it is easy to see how health insurance should be a priority for everyone, no matter their age.

None of us are immune to disease or injury, and age-related afflictions become an even bigger threat after the age of 65.

So, if you are of an age where you can benefit from the affordable senior care plan offered by Medicare, it is a good idea to do so.

Find out more about Medicare or Medicaid below and why it is a good option if you are looking for affordable health insurance as a senior citizen.

Medicare in a Nutshell

Medicare’s a federal health insurance program specifically for people aged 65 and older. It is designed to help cover the increasingly high costs associated with chronic conditions and emergencies.

In some instances, Medicare is a free service (although you have probably been paying into it for decades out of your paycheck and taxes), but most people pay premiums as well as various out-of-pocket costs for medical services.

How Do You Qualify for Medicare Benefits?

Most people qualify for Medicare subject to the following conditions:

  • You must be 65 years of age or older
  • You must be a permanent resident of the USA
  • You are under 65 and disabled or have end-stage renal disease

Medicare provides cover for people with renal disease as soon as they are diagnosed with this condition.

What Does Medicare Offer?

Medicare’s main function is to assist people who become injured or ill. Treatment options covered include:

  • Hospitalization
  • Lab work
  • X-rays
  • Hospice
  • Doctor’s services
  • A wide range of outpatient care

Medicare also covers some inpatient and outpatient mental health care as well as inpatient nursing facilities.

Preventive services and screening services are also covered by Medicare. These include:

  • Smoking cessation counseling
  • Screening for a wide range of cancers
  • Cardiovascular screening
  • Flu immunizations
  • Hepatitis B immunizations
  • Pneumococcal virus immunizations
  • Glaucoma tests
  • An introductory medical exam

In some instances, Medicare also pays for part-time health aides and nursing care, as well as occupational, speech, and physical therapy.

It may also cover wheelchairs, bandages, and other medical supplies. It also helps to have a medicare beneficiary identifier added to your plan to help your overall health and protection.

These services all depend on which parts of Medicare you have signed up for. That is where things can get a little complicated with your healthcare policy coverage. 

Understanding the Parts of Medicare

Medicare comprises four parts and each has a different payment system that affects your out-of-pocket payments concerning benefits.

These are the four different parts of Medicare healthcare insurance coverage:

Medicare Part A

Medicare Part A is a type of hospital insurance that contributes towards the following hospital services within the United States:

  • A semi-private or private room in a hospital as deemed medically necessary
  • Intensive care and coronary care if necessary
  • Charges for operating rooms
  • Non-private-duty nursing services
  • In-hospital supplies, appliances, and drugs
  • Drugs, supplies, and appliances provided in and by the hospital
  • Radiation and chemotherapy as required
  • X-rays and CT scans as well as other diagnostic tests
  • Physical therapy, speech therapy, and occupation therapy

The main requirement to receive this benefit is that the service takes place at an inpatient facility and a doctor deems it medically necessary.

Medicare Part A is free to American residents aged 65 and over as long as they:

  • Are eligible to receive Social Security
  • Are eligible to receive Railroad Retirement Board benefits 
  • Worked in a government job and paid Medicare taxes for a specified amount of time

If you don’t qualify for free Medicare Part A, you can buy into it for around $460 per month.

To sum up: Medicare part A pays towards the costs of medically necessary procedures performed in a hospital setting.

Medicare Part B

All American citizens and legal residents over the age of 65 are eligible for Part B Medicare for a fee. The minimum amount is $144 and this increases according to your earnings. 

Medicare Part B has an annual deductible of $198, which means you will pay for your medical care until you reach this limit. After that, Part B pays between 80 and 100% of the costs associated with the services covered by the plan.

This part of Medicare covers outpatient expenses, mostly doctor’s bills.

Coverage includes medical services provided by Medicare doctors in any setting i.e. in hospital, at a clinic, or a doctor’s office.

It also includes any drugs administered in this setting as well as services performed by the doctor’s staff.

Apart from this, Medicare part B also covers:

  • Ambulance services
  • Some chiropractic care
  • Lab work and X-rays
  • Emergency care at an urgent care or outpatient clinic
  • Medical accessories like walkers, diabetic supplies, wheelchairs, and pacemakers
  • Mental health services and substance abuse counseling
  • Cardiac rehabilitation
  • Kidney dialysis
  • Vaccines
  • Prosthetics and orthotics
  • Preventive screenings
  • Telehealth services
  • Tobacco use cessation therapy

These services are only covered if they’re deemed medically necessary and ordered by a physician.  

Together, Medicare parts A and B comprise ‘Original Medicare’.

Medicare Part C and D

Medicare Part C, also called Medicare Advantage, refers to private health insurance that is available in place of Original Medicare.

When you enroll in a Part C, plan, you don’t receive any of the benefits of Part A and B.

Although Part C plans are private, they are subject to regulation by the federal government. These regulations require that Part C plans offer at least the same coverage as the federal Medicare plans.

Every insurance provider adds its own benefits in addition to these basic ones and may eliminate some Medicare co-payments and deductibles.

Likewise, Part D refers to private plans covering prescription medications. The government also has some basic rules for these plans. Part D’s sometimes included in your Part C plan. 

Medigap Insurance

Although Medigap doesn’t fall into the realm of Medicare, it is a popular option for most seniors. Anyone over the age of 65 can sign up for Medigap, provided they have Medicare Part B or an equivalent Part C plan.

This type of insurance is a supplemental product, offered by private insurers. It helps pay some of the additional costs not covered by Medicare. Medigap coverage varies from state to state and offers a huge variety of options.

Other Considerations for Your Senior Care Plan 

Apart from hospitalization and doctor-provided care, some seniors might need a little extra help as they age. Although it is impossible to predict what may happen in the future, it is important to bear these things in mind.

Here is what to expect if you need additional care during your later years.  

Assisted Living

Medicare and Medicare Advantage plans don’t cover the costs of assisted living facilities.

If you need this kind of care, you can apply for Medicaid, administered by the individual states. Medicaid offers free or low-cost assisted living care for disabled and low-income individuals. You usually can’t have many or any assets to receive Medicaid coverage though, so most people will not qualify for this policy or benefits.

Residential Care

Medicare only covers limited short-term residential care, so Medicaid is your go-to in these situations too.

It does cover limited short-term in-home senior care and some in-home care services. For example, if your doctor prescribes skilled nursing care or physical therapy, you are covered by your Medicare policy. 

These benefits are always of short duration though. 

The Ins and Outs of Signing Up for Medicare

If you are receiving Social Security payments, the government will automatically enroll you in Medicare Part A on your 65th birthday. You don’t need to do a thing luckily.

Otherwise, you can sign up three months before you turn 65 and for three months after your birthday. If you miss this deadline, you can’t enroll until January of the next year, and your coverage won’t start until July 1 after that.

If you want to join a Part C or D plan instead of Original Medicare, you can do so during the annual enrollment period. This falls between October 15 and December 7 every year. Some plans may allow you to enroll at any time of year.

The same rules apply if you want to switch from Medicare Part A and B to a private plan.

You must enroll in Medigap policies within 6 months of your 65th birthday. If you miss this window or decide to enroll later, Medigap policy providers have the right to refuse your application based on your medical history.

Planning Your Best Life

Nobody is immune to the ravages of time, illness, and injury. So, even if you still feel like a spring chicken, it is important to start planning for your future wellbeing as soon as you turn 65.

Finding a senior care plan that suits your needs and budget is an important part of getting older. So, be sure to sign up within the required time frame for Medicare, so you can save on the medical care you need when you need it.

For more advice on the best and most sensible decisions for your life, keep reading my blog. We have a wide variety of articles on health insurance, senior care, Medicare, and Medicaid.