Medicare

Community Legal Services provides assistance and representation to eligible clients with issues regarding Medicaid and Medicare. Each case is analyzed on an individual basis and persons are encouraged to speak with an experienced advocate in order to assess their case. Contact our helpline or apply online to see if you qualify.

What is Medicare?

Medicare is the federal health insurance program for people 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

What are the Benefits provided by Medicare?

Health care insurance that helps pay for hospital stays (part A), preventive care, doctor visits (part B), and prescription drugs (part D).

Eligibility

You must be 65 years of age or if you are married (or were married for at least 10 years) to someone who is qualified to receive Medicare; OR 24 months after receiving Social Security disability benefits. Persons with end stage renal disease also qualify. Medicare is mandatory at age 65 and not an option. 

When to Apply

If you are currently receiving Social Security (SS) retirement benefits, you will automatically be contacted by the Social Security Administration when you become eligible for Medicare benefits: 3 months prior to turning 65 or 24 months after receiving Social Security Disability Insurance (SSDI) benefits. If you are not receiving SS benefits, you can apply 3 months prior to age 65. If you chose to apply for SS within 3 months of turning 65, you will automatically be applying for Medicare at the same time.

Medicare Part A

The premium is free as long as the person has worked a minimum of 10 years. Otherwise the fee in 2013 is $441 (premium changes every year) and it covers hospitalization and some limited after-hospital care such as rehabilitation or hospice.  

Medicare Part B

The premium is $104.90 in 2013 (premium changes every year). It covers physician services, lab work, medical equipment and there is a deductible of  $147 yearly. There is NO maximum out-of-pocket ceiling which could be a problem if you have chronic medical issues. Must use doctors who accept Medicare (most doctors do). Fewer restrictions/exclusions than Part C Advantage plans.

Medicare Part C

These are private insurance plans regulated by Medicare. Often referred as “Medicare Advantage” plans, they can be selected instead of, but NOT in addition to, Part A and B. Advantage plans essentially cover the same expenses as Part A with B and sometimes prescription medications depending on the plan. Most plans have Health Maintenance Organizations (HMO) and Preferred Provider Organization (PPO) choices (PPO’s have less restrictions but usually cost more). Plans offer various choices of co-pays for hospitals, doctors and labs with maximum out-of-pocket limits. You must use a doctor in the network. You should read the fine print for exclusions. Private insurers employ staff who closely monitors those exclusions to coverage. These private insurance plans are significantly less expensive than a standard private insurance plan because Medicare still deducts the Part B premium from you and subsidizes the insurer since this option takes the place of A with B. If you select a Part C Advantage private plan, Medicare still deducts your Part B cost from your SS benefit and sends your premium directly to the insurer. The plan you select may have a higher premium cost than Part B cost.

Medicare Part D

Medicare prescription drug plans. Since Plan B has no prescription coverage or if you select a Part C plan that lacks prescription coverage you will have to select a Part D prescription plan. There are also Medigap plans sold by private insurers to help cover costs not covered by Plans A and B. They generally do not apply to Plan C. These Plans cover such things as the 20% co-pays, and other out of pocket expenses not covered by the A and B Plans. These plans are not tied to Medicare and are insurance supplements independent of the Medicare plans above. If you are denied Medicare benefits you have appeal rights. However, timelines for appeals processes will depend on whether you have regular Medicare or any other plan. Due to the voluminous amount of information about Medicare, coverage, appeals, etc. it is recommended that you visit the official Medicare website listed below and contact Community Legal Services of Mid-Florida, Inc. for legal advice.

Contact Information 

Learn more about Medicare by calling 1-800-MEDICARE or 1-800-633-4227. You can also click here to get help with your Medicare questions.

For additional assistance, click on the following link: SHINE, Serving Health Insurance Needs of Elders, also known as the Florida State Health Insurance Assistance Program (SHIP) or call their toll-free number at 1-800-963-5337.

Additional Resources

Florida Legal Services Prescription Drug Helpline – 1 (800) 436-6001 – is a statewide, toll-free helpline which provides assistance to Medicaid and low-income Medicare beneficiaries whose necessary medications have been denied.