Holding Court is a series by retired Rye City Court Judge Joe Latwin. Latwin retired from the court in December 2022 after thirteen years of service to the City.
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By Joe Latwin
Medicare isn’t magic. Not only will mistakes cost you, but it will cost you. It ain’t free.
Medicare is a federal medical insurance program. It does not provide health care. It has no doctors for you to see. What it can do is pay for or reimburse some health care costs. To be eligible, you must be 65 or older, have a disability, end-stage renal disease, or ALS (“Lou Gehrig’s” disease). Unless you are already getting Social Security retirement or disability benefits, you must apply for Medicare at least 4 months before you turn 65. If you don’t sign up, you won’t get the benefits, but you will also be penalized for the rest of your life, even if you apply later.
Medicare part A covers inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. Part B covers services from doctors and other health care providers, outpatient care, home health care, durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment), preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits). Part D helps cover the cost of prescription drugs (including shots or vaccines).
Services covered by Medicare must be medically necessary. There’s no limit on what you pay out-of-pocket in a year unless you have other coverage (like Medigap, Medicaid, employer, retiree, or union coverage). If you go to a doctor or other health care provider that accepts the Medicare-approved amount, your share of costs may be less. If you get a service that Medicare doesn’t cover, you pay the full cost.
With original Medicare Parts A and B, you can go to any doctor or hospital that takes Medicare, anywhere in the U.S
Part A has no premium and a $1,676 deductible and a co-insurance of $419 per day after 60 days until the 90th day of inpatient care and $209.50 per day from the 21st through the 100th day in a skilled nursing facility. Part B has monthly premiums starting at $185 and is there are increases based upon your modified adjusted gross income ranging from $259 to $628.90. The calculation is based on your last years’ tax return, so if you apply now, SSA will use your 2023 income tax return to calculate your premiums. There are appeals available if your income drops due to death or divorce of a spouse, sale of income producing property, or loss of a pension. If you are receiving Social Security payments, the premiums are deducted from you monthly check.
Part (also known as Medicare Advantage) is a Medicare-approved plan from a private company that offers an alternative to original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. In many cases, you can only use doctors who are in the plan’s network. Plans often have different out-of-pocket costs than original Medicare or supplemental coverage like Medigap. You may also have an additional premium. Plans may offer some extra benefits that original Medicare doesn’t.
There are also Supplemental Insurance Plans (Medigap). Medigap is extra insurance you can buy from a private company that helps pay your share of costs in original Medicare. Policies are standardized, and in most states named by letters, like Plan G or Plan K. The benefits in each lettered plan are the same, no matter which insurance company sells it.
When you have Medicare and other health insurance (like from your job), one will pay first (called a “primary payer”) and the other second (called a “secondary payer”). Most private insurance works with Medicare by making Medicare the primary payer with the private insurer being secondary.
Once you are signed up and find a doctor that accepts Medicare, you can visit the doctor and the doctor will usually bill Medicare directly and any private insurance secondarily. You will be responsible for any unapproved charges.
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