Medicare: what you need to know

Medicare is a federal insurance program that pays for medical care for people who qualify. People who have been determined to be disabled and have been receiving disability benefits for at least 24 months qualify for Medicare. People with lupus who need long term dialysis treatment for chronic kidney disease or require a kidney transplant will qualify for Medicare immediately after they are determined to be disabled. In general, Medicare pays 80 percent of reasonable charges. Remember, Medicare is not free.

What are the different plans under Medicare?

Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). The taxes you paid while you were working financed this coverage, so it is free.

Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. You will need to pay a monthly premium for this coverage if you want it.

Medicare Part C (Medicare Advantage) combines hospital and doctor coverage and is provided by private insurers. Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non emergency or non-urgent care). 

Medicare Part D provides prescription drug insurance. Private companies also provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

How to apply

If you are receiving Social Security Disability Insurance, you must wait 24 months from the time you are declared disabled before you can apply for Medicare, unless you have end stage renal disease which makes you eligible immediately.  For non-disabled people, you become eligible for Medicare when you reach the age of retirement.  Call 1-800-MEDICARE or visit www.medicare.gov for information. However, if you want to apply for Medicare coverage only (e.g., you are working and do not intend to file for monthly retirement or spouse's benefits at this time), you should call 1-800-772-1213 (TTY 1-800-325-0778) toll-free to arrange an appointment over the phone or in person at a Social Security office.