12/27/2022
In the United States there are several state health and medical assistance programs, most of which are geared towards covering those families and individuals who do not have sufficient resources to afford private health insurance.
Medicare is one of them and in this article we are going to analyze what it consists of, what coverage it offers and to know the different parts that compose it and how to apply to obtain its benefits.
What is Medicare?
The Medicare medical coverage program was born in 1965 together with the Social Security Act, which was approved by the then President of the United States Lyndon Johnson.
It is a system that mainly covers people over the age of 65 and those with certain degrees of disability or certain illnesses.
Medicare is administered through the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
Who is eligible for Medicare benefits?
Currently, this government program offers coverage for the following cases:
- Individuals 65 years of age or older, who are U.S. citizens or have permanently resided for at least 5 years in the United States. The individual or his/her spouse must have contributed to Medicare for a minimum of 10 years.
- Individuals of any age who have been receiving a Social Security disability benefit for a period of at least 24 months, who have kidney problems requiring dialysis or transplantation, or who suffer from Amyotrophic Lateral Sclerosis (ALS).
Medicare Parts
This government health program is divided into four parts or sections that offer different levels of coverage:
- Part A is hospital insurance that serves to help pay for hospital or clinic stays and home visits by medical personnel.
- Part B is the medical insurance that provides assistance for the costs of medical personnel and medical supplies when assistance is needed.
- Part C, or Medicare Advantage, is a special plan in collaboration with private insurers that offers all of the other parts plus some additional coverage.
- Part D is the one that offers subsidies for drugs prescribed by doctors.
Let's take a closer look at what each part of Medicare covers.
What does Medicare Part A cover?
The so-called hospital insurance offers a number of coverages for stays in medical facilities:
| Inpatient care in a hospital | Medicare-eligible inpatients will receive the following coverage during their stay:
- Breakfast, lunch and dinner.
- Shared room.
- Nursing care.
- Medications as part of treatment.
- Other expenses arising out of hospital confinement and treatment.
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| Specialized nursing clinic care | - Breakfast, lunch and dinner.
- Shared room.
- Skilled nursing care.
- Physical and occupational rehabilitation therapies.
- Other expenses derived from hospitalization and treatment, such as drugs, ambulance transfers, medical services or the use of the clinic's medical instruments.
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| Hospice care for terminally ill patients | - Medications, services and instruments used to alleviate the patient's pain.
- Medical and nursing care.
- Medical equipment.
- Home care and chores.
- Psychological and spiritual therapy for the patient and family members.
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| Home health care | In the event the patient is unable to travel to a hospital or medical clinic, Medicare also offers coverage for home care, providing the following supports:
- Physical and occupational rehabilitation therapies.
- Osteoporosis medications.
- Part-time medical and nursing care (does not cover 24-hour care).
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What does Medicare Part B cover?
This section is known as medical insurance and covers the costs of medical personnel and medical supplies required to both treat and diagnose the patient that are not covered under Part A.
| Assistance required for medical reasons | - Services, equipment and material to diagnose and treat the disease, such as wheelchairs, beds, crutches, infusion pumps or blood sugar meters.
- Ambulance transportation from the patient's home to a hospital or medical center for treatment.
- Some prescription drugs, such as antigens, blood clotting factors, immunoglobulin or vaccines.
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| Preventive assistance | Both care to prevent illness and tests to diagnose illness are part of this Medicare Part B section: - Checkups for diabetes, depression, cardiovascular disease, colorectal cancer or prostate cancer, among others.
- Medical exams for cervical cancer, HIV, STDs (sexually transmitted diseases), hepatitis B virus, abdominal aortic aneurysm and other pathologies.
- Annual check-ups.
- Mammograms.
- Smoking cessation counseling.
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What does Medicare Part C cover?
This plan, usually known as Medicare Advantage, is offered by private insurance companies, following Medicare guidelines. They usually offer all Part A, B and D coverage and some extra services.
It is possible to find different plans within Medicare Advantage, which offer different additional coverages, according to the preferences of the contracting client:
- Private fee-for-service plans. A co-payment is established on the services used.
- Preferred provider organization plans. There are a number of selected doctors and hospitals where less will be paid.
- Health Management Organization. The entire plan network is available to you for all types of medical services, except emergency care and out-of-area dialysis.
- Special Needs Plans. This is specific coverage for patients with specific pathologies that require specific care.
What does Medicare Part D cover?
In order to enjoy the drug coverage offered by Medicare Part D, you must have one of the other parts A, B or C. In addition, you must be a U.S. citizen or have a valid residence permit.
Within Part D there are different plans, each with its own drug catalog, known as a formulary. Each formulary offers an extensive list of drugs that you can access at different discount levels.
The drugs included in each plan should cover most of the medical spectrum, so that if a particular drug is not included, a similar drug may be substituted.
Thus, among the drugs covered by Medicare Part D we can find, for example:
- Analgesics
- Antiallergic drugs
- Antidiarrheals
- Anti-inflammatory drugs
- Antipyretics
- Mucolytics
- Vaccines
- Antidepressants
- Antivirals
English: Qué es Medicare, qué cubre y qué partes tiene