Health care has been a hot topic in the United States for several years now.  As health care costs climb, many people are faced with the dilemma of choosing between taking care of their health or putting food on the table.  Seniors are particularly vulnerable.  President Lyndon B. Johnson signed the Medicare bill into law in 1965, in an effort to provide the nation’s elderly with affordable, low cost health care and hospitalization.

Medicare is a very complex program with many different facets.  It is important to understand the various parts so that you can better choose which program works best for you.

Medicare is a federally funded health insurance program.  Administered by the Centers for Medicare and Medicaid Services (CMS) the nearly 40 million Americans who participate must meet at least one of the basic qualifying criteria:

• 65 years of age or older
• Under 65 years of age, but have certain disabilities
• Any age, but have end stage renal disease (kidney failure requiring dialysis or transplant)

Participants must also be a citizen of the United States in order to be eligible, although there some instances where this is not true.  Those who are not U.S. citizens can contact their local Social Security Administration office to see if they qualify for Medicare despite their non-citizen status.  It is the largest health insurance program in the U.S.

Original Medicare is usually the first Medicare program the people get on when they begin coverage.   This fee-for-service plan allows the insured to go to any doctor or provider that accepts Medicare and is accepting new Medicare patients.  They may also go to any hospital or other health facility.

Recipients pay a deductible before Medicare begins to pay its share.  When Medicare begins to pay, the recipients pay a copayment for services and supplies that are covered.  Some Medicare recipients have supplemental coverage or a Medigap policy.  This coverage will pay the deductibles, copayments and costs that Medicare does not cover.

Medigap policies are sold by private insurance companies.  They are insurance policies that are designed to handle gaps that may be left in the Medicare coverage.  They may pay some health care costs that are not covered by Medicare.  Monthly premiums are paid to the insurance company that manages the policy.

Medicare has four parts; each provides a particular type of coverage, or combination of services.

Medicare Part A Coverage

Medicare Part A covers various forms of hospital stays.  Its focus is inpatient care in hospitals, skilled nursing facilities, hospice and critical access hospitals.  Home health care is also covered under this plan.

Medicare Part B Coverage

Medical services and supplies are covered by Medicare Part B.  There is a premium that most Medicare recipients are required to pay in order to utilize the coverage.  Doctor’s visits and other services are covered by the plan, as are occupational and physical therapists, outpatient care and additional home health care.

Medicare Part C Coverage (Medicare Advantage)

The Medicare Advantage Plan, or Medicare Part C combines both Part A and Part B.  Part C differs from the other plans, though, because it is supplied through private insurance companies.  These companies have been approved by Medicare and the often offer additional benefits and lower costs.

Medicare Part D Coverage

Prescription drug coverage falls under Part D.  It is a stand alone insurance and covers all drugs that are medically necessary.  It does have different plans and each plan has its own differences and covers different medications.  Coverage for this plan does, for most people, require that a premium is paid, however, the insured can select the plan that best meets their needs.

When a person first becomes eligible for Medicare, he or she has the ability to assess their medical, prescription and health needs, then, in the fall, change their Medicare plan accordingly.  When assessing their needs, it is suggested that recipients use a 7 point system to adequately address all area of medical and personal requirements and needs.

1.        Provider, doctor and hospital.  Does the recipient have the ability to see the doctor of their choice?  Are they able to go to the hospital that they want to go to?  When seeing a specialist, do they need a referral?

2.       Cost.  Recipients should review the out of pocket costs associated with supplemental insurances, Medigaps and Medicare itself to determine what plans are best for them.

3.       Prescriptions.  The important thing here is to ensure that the recipient’s medication is covered under the plan that they have chosen.  From there they should examine the costs associated with premiums, copays and deductibles associated with the prescription plan.

4.       Benefits.  Some plans offer additional benefits like dental, vision and hearing aids.  Recipients should find plans that address their individual needs.  Additionally, they should thoroughly review the entire Medicare benefits package to see if it contains the parts (A, B and prescription drug coverage) that they need.

5.       Pharmacies.  The choice of pharmacies can have an impact on which plan a recipient uses.  Location, convenience and cost are all factors that play into where a person gets their prescriptions filled, so the plan that they select should be accepted at their chosen pharmacy.

6.       Quality of Care.  It is vital that recipients find a plan that offers a high quality of care.  This means that their individual needs are addressed.  The assessment should include whether the services provided are of good quality, timely and appropriate and that the results are the best that they can be.

7.       Convenience.  Providers for the plan, location of doctor’s offices and hours of operation as well as if they are accepting new patients are considerations that go into selecting a good plan.  Also, if the recipient spends any part of the year in another state, it is beneficial if the plan covers them in that state as well.