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Medicare Basics

December 2008
By Dr. Linda Mundorff, MPH,MSN,ND,RN,CNC,CTN

Medicare is a health insurance plan partially funded by the United States government, and supplemented by premiums paid thru individual members or their group health plans. Medicare eligibility is based on very specific criteria, it is important to note that financial income is not a criteria used in determining eligibility. Medicare is designed for those individuals who are 65 years of age and older, individuals who are on social security, disabled, and those diagnosed with End Stage Renal Disease (ESRD). Other covered categories include programs under the Federal mining or railroad Acts.

Medicare coverage is broken down into three basic categories: Hospital (inpatient), Outpatient and supply charges, and prescription medications. Reimbursement is based on diagnostic codes and pays up to 80% of most charges. Therefore, it is important to have supplemental health insurance to cover the remaining 20%, and to pay for Medicare non-covered charges.

Medicare coverage is divided into four sections:
Part A: This component covers hospital inpatient charges, skilled nursing care, and discharge to a rehabilitation facility. It also covers hospice care and some home health care services.
Part B: This component covers doctor visits, outpatient therapies, some equipment such as oxygen tanks, and supplies such as diabetic needles.
Part C: This component covers contractual services by other providers referred to as Advantage Plans and will provide Part A, B and sometimes D.
Part D: A fairly new component of Medicare, this covers prescription medications.

Currently there are three ways in which an individual can qualify for Medicare Part A benefits: Contributed to social security; qualify under their spouse’s credits, or contribute to Medicare directly. Medicare Part B is voluntary coverage that is available to United States citizens. It requires a monthly premium; which is currently about $97.00 per month and is deducted directly out of the individual’s social security benefit. Part D is also a voluntary add-on benefit with varying levels of prescription coverage.

The monthly premium for Medicare Part B coverage may initially seem expensive, but when you weigh in the potential cost of treating such disabling diseases such as renal (kidney) failure the $97.00 becomes quite the bargain! Individuals with chronic renal failure (CRF) must be on dialysis several times per week with an average cost of $375.00 per treatment. Medicare Part B coverage will reimburse 80% of that cost. The remaining 20% must be paid by either the patient, Medicaid or some other supplemental insurance.

Medicare is not the same as Medicaid; Medicare is a federally funded program while Medicaid is a state funded program. While Medicare coverage is based on specific criteria, Medicaid is designed to meet the health care needs of the indigent, the working adult whose income falls below state-legislated minimums.

If you or a loved one is ill and unable to return to work please look into Medicare coverage. The out-of-pocket costs of health care are reaching epidemic proportions, and for many Medicare can be the answer. If you are not sure if you or your loved ones qualify for Medicare, then call or go online. In either case, the cost is free, so you have nothing to lose and so much to gain.

For further information please contact Social Security at 1-800-772-1213 or on the web at www.socialsecurity.gov; Medicare at 1-800-MEDICARE or on the web at www.medicare.gov.

In health and wellness,

Dr. Linda Mundorff

Disclaimer: Dr. Mundorff is a Registered Nurse and Board Certified Traditional Naturopath, and not a medical doctor. The information in this column is for educational purposes only and should not be used to self-diagnose and treat diseases, nor be misinterpreted as a prescription. This information is provided with the understanding that the author is not engaging in a health-care practitioner/patient relationship with her readers. In the author’s best judgment, the information and opinions expressed here are accurate and sound at the time of publication. Readers who rely on the information in this book as a replacement of the advice of a medical doctor assume all risks of such conduct. The author is not responsible for errors or omissions. Please consult your doctor before starting any alternative modalities.