Here’s an Overview of Medicare Health Insurance

HNWElder Care Law

  • medicareMedicare is a federal program of health insurance.
  • Medicare pays for acute illness but it is not a program designed to provide benefits for long-term or custodial care.
  • To be eligible, one must be 65 years of age and have paid into the Social Security system. If the person you care for is 65 or older and is already receiving Social Security benefits, he or she will be enrolled automatically in Medicare. Individuals receiving Social Disability benefits will get Medicare coverage automatically after they have received disability benefits for two years.

Note: If an individual does not sign up for Medicare when first eligible, he or she may have to pay a penalty or a higher premium to sign up later. Open Enrollment occurs each year, from mid-October until mid-December. During that time, each Medicare enrollee is encouraged to review all their options for coverage for the coming year.

Medicare Part A

Medicare Part A is primarily hospital insurance. Following payment of an annual deductible, Medicare Part A will pay patient expenses for 60 days of hospitalization. After 60 days, the patient is required to pay a greater amount of the hospitalization cost. Part A will help pay, in certain circumstances, for limited stays in skilled nursing facilities, home health care, and hospice care. Most people do not have to pay a monthly premium for Part A.

Medicare Part B

Part B pays for doctors’ services, outpatient care, outpatient physical and speech therapy, some home health care, ambulance services, and some medical equipment and supplies. Medicare Part B also covers preventative services. Part B is optional and requires a monthly premium. There is also an annual deductible that must be met before Medicare starts to pay its share of health costs.

Medicare Advantage Plans (also known as MA Plans or Medicare Part C)

Generally speaking, do not get a Medicare Advantage Plan unless you truly can’t afford traditional Medicare Part B.  Medicare Part C offers Medicare Advantage Plans that combine your Medicare Part A (Hospital) and Part B (Medical). Private insurance companies approved by Medicare provide this coverage. In most cases, the premiums and/or copays can be lower than in the original Medicare plans. Medicare Advantage Plans offer a number of types of plans including Preferred Provider Organization (PPO) Plans or Health Maintenance Organization (HMO) Plans. There is also the Private-Fee-for-Service (PFFS) and the Special Needs Plan (SNP). These plans coordinate your loved one’s medical care with some plans having stricter network and referral requirements than others. Many of the plans include Medicare Part D (Prescription Drug coverage). It is important that you read the plan information carefully to ensure you are selecting the right plan for you or your loved one.

Medicare Prescription Drug Plan Part D

Medicare offers prescription drug coverage for everyone with Medicare. This is called Part D. This coverage may help lower prescription drug costs and help protect against higher costs in the future. It can give you greater access to drugs that you can use to prevent complications of diseases and stay well. These plans are run by insurance companies and other private companies approved by Medicare. Part D is optional.

If your loved one joins a Medicare drug plan, they usually pay a monthly premium. If they decide not to enroll in a Medicare drug plan when first eligible, there will be a penalty if they choose to join later. If your loved one has limited income and resources, they might qualify for extra help paying for Part D costs.

This is only a general overview of the system.  Individual circumstances and situations will vary.  For more information, or a comprehensive look at the details of this program:

Centers for Medicare & Medicaid Services (CMS)

Medigap Insurance Plans Also Referred to a Medicare Supplemental Benefit Plan

Medigap is also called “supplemental insurance.” Generally, a person must have Medicare Part A and Part B to buy a Medigap policy. There is a monthly premium for Medicare Part B. In addition, a premium must be paid to the Medigap insurance company. A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in original Medicare Plan coverage.  Medigap policies help pay some of the health care costs that the original Medicare Plan doesn’t cover.  If your loved one is in the original Medicare Plan and has a Medigap policy, then Medicare and your Medigap policy will both pay their share of covered health care costs.

To discuss your NJ Medicare or Medicaid matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at  Please ask us about our video conferencing or telephone consultations if you are unable to come to our office.

By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold Township, Monmouth County, NJ Elder Care Attorney

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