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  • Writer's pictureValerie Smith, APRN

What You Need To Know About Medicare Health Insurance



Living with an autoimmune disease can be hard on the pocketbook.


From medications, prescriptions, and steroid creams to vitamin supplements, therapy visits, and specialty appointments, the cost of treating an autoimmune disease can really add up quickly. Not to mention, physical care items like wheelchairs, walkers, braces, splints, compression socks, custom shoes, and ergonomic assistive devices can get expensive.


Having health insurance is one way to mitigate the costs associated with an autoimmune disease diagnosis.


What is Medicare?


There are numerous ways to gain health insurance coverage, and the federal health insurance program known as Medicare is one of those ways.


Who is eligible for Medicare?


This national government health insurance option is available to any individual 65 years old and over, and in some cases, Medicare is available to individuals under 65 years old with specific conditions or certain disabilities.


Is Medicare different from Medicaid?


With such similar names, it’s no surprise that people tend to mix up Medicare and Medicaid health insurance coverage. Although Medicare and Medicaid are both government programs that help to cover the cost of healthcare, these two programs are not the same.


You do not have to be 65 years old to qualify for Medicaid coverage. Rather, Medicaid coverage is for individuals with limited resources and income.


Can you have both Medicare and Medicaid?


Yes, individuals can enroll in both programs if they have dual eligibility.


Can you have private health insurance coverage, such as coverage through an employer, in addition to Medicare?


Yes, you can have both types of insurance coverage. This means you will have one insurance plan listed as the primary payer and the other insurance plan acting as the secondary payer.


What is the difference between Medicare Part A, Part B, and Part D?


Medicare coverage is broken into parts. Part A is referred to as hospital insurance, Part B is known as medical insurance, and Part D is for drug coverage.


Part A extends coverage for inpatient care in hospitals and skilled nursing facilities as well as hospice care and home health care.


Part B is designed to cover outpatient care, visits with doctors, and services from health care providers as well as necessary medical equipment.


Part D is meant to help cover the cost of recommended shots, vaccines, and prescription drugs.


What is Medicare Part C?


Your Medicare options can be broken into two possibilities - “Original Medicare” and “Medicare Advantage” - and Medicare Advantage is known as Part C.


What is Original Medicare?


Original Medicare is a Medicare plan that includes both Part A and Part B. Medicare drug coverage (Part D) is separate.


What is Medicare Advantage?


If you choose Medicare Advantage, you get a Medicare-approved plan that is provided by a private company.


What is Medigap?


Medigap is Medicare supplemental insurance. In other words, Medigap is additional insurance from a private company that helps to pay the costs associated with Original Medicare. Most states refer to these policies as Plan G or Plan K.


When is Medicare enrollment?


Medicare enrollment is broken into different periods, and every period has particular restrictions. If you miss an enrollment period, you could incur late enrollment penalties and need to pay a penalty fee. Plus, you could miss out on coverage and end up with a gap in coverage.


Initial Enrollment Period

Initial Enrollment Periods are reserved for individuals turning 65 years old that will be new to Medicare coverage.


The dates of this period are dependent on your date of birth.


An Initial Enrollment Period lasts for seven months. It begins three months before you turn 65 years old, goes through your actual birthday month, and ends three months after the month of your 65th birthday.


Open Enrollment Period

The Open Enrollment Period is October 15 - December 7 of each year.


This period is for anyone who has Medicare coverage that wants to join, drop, select, or switch plans for the upcoming calendar year.


For example, if you have Original Medicare, you can switch to Medicare Advantage. Furthermore, if you have Original Medicare, you can join a Medicare drug plan or switch to another drug plan.


General Enrollment Period

The General Enrollment Period is January 1 - March 31 of each year.


The General Enrollment Period is for individuals that did not sign up for Medicare during the Initial Enrollment Period when they were first eligible.


Note: Check to see if you qualify to participate in a Special Enrollment Period to avoid paying potential penalties.


Special Enrollment Period

There is no specific time of year to participate in a Special Enrollment Period.


Special Enrollment Periods are for those that meet certain qualifications, such as life events that impact health insurance coverage.


Medicare Advantage Open Enrollment Period

The Medicare Advantage Open Enrollment Period goes from January 1 - March 31 of each year.


The Medicare Advantage Open Enrollment Period is reserved for those already enrolled in a Medicare Advantage plan.


If you are currently a Medicare Advantage plan member, the Medicare Advantage Open Enrollment Period is the time when you can switch to another Medicare Advantage plan or change coverage to Original Medicare.


Making the Most of Medicare


When you have complex medical needs, health insurance coverage is a must. In fact, having health insurance coverage is life saving. It provides opportunities to receive proper medical care as you strive to manage and better your health.


Health insurance coverage can be confusing to understand, though. It can be difficult to navigate the switch from private health insurance or commercial health insurance to health insurance coverage through Medicare.


Being informed and educated is the best way to ensure your Medicare health insurance coverage will be sufficient enough to cover your current treatment plan and future treatment options.


Be aware that Medicare coverage varies greatly, particularly the coverage between Original Medicare and Medicare Advantage.


Make note of the different enrollment periods and do not miss those time frames.


We don’t want you to not receive needed medical care due to lack of insurance coverage.


And as always, our team at Paducah Rheumatology is ready to help you manage your autoimmune disease. Give us a call today at 270-408-6100 to set up an appointment or ask questions about insurance coverage.


For more information about Medicare, visit the official government website of Medicare.

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