What is Medicare?
What Is Medicare?
Medicare is a federally funded program coordinated through the Centers for Medical Services (CMS) and Social Security that offers health insurance to American citizens and legal residents typically over the age of 65 and also people with certain disabilities.
Currently being used by 57 million people, this program is often referred to as Original Medicare and has two parts – Part A and Part B.
You have two different ways to obtain your coverage. You can go through Original Medicare (Parts A and B), which is provided through the federal government, or you can purchase a Medicare Advantage plan (Part C), which is provided by private insurance companies contracted through Medicare.
Generally, when you first become eligible for Medicare, you’ll automatically be enrolled in Original Medicare. You can choose to stay in Original Medicare if you determine that Parts A and B provide you sufficient coverage. You can also join a prescription drug plan and and/or a Medicare Supplement plan to go along with your Original Medicare and increase your coverage.
If you feel that Plans A and B don’t provide you enough coverage, you can purchase a Medicare Advantage plan instead, which is an alternative to Original Medicare and operates like an HMO or a PPO. Part C plans typically come with built-in prescription drug coverage, but if not, you may be able to join a stand-alone Prescription Drug plan.
Want to learn even more about Medicare?
Check out 10 things that people typically don't realize about Medicare.
Medicare Versus Medicaid
What is the difference between the two? Medicare is a government-funded program that offers health insurance to individuals 65 and older, while Medicaid is a government-funded program that offers financial assistance to lower-income individuals with their healthcare costs.
Medicaid is operated through a joint effort of the federal and respective state governments that helps lower-income families pay the costs for medical care and custodial long-term care.
Medicaid has strict income restrictions that vary by state.
Additional eligibility requirements are in place to help others that may not be facing just poverty. These include families, women who are pregnant, children, caretakers of children, seniors and the disabled.
Your Medicare Card
Once you’re automatically enrolled in Original Medicare, or you enroll yourself, Social Security mails your Medicare card to the address on file with the Social Security Administration.
This card is for Medicare Parts A and B only. You’ll receive a different membership card if you’re enrolled in Medicaid.
You’ll receive an additional membership card if you enroll in a Medicare Advantage, a Medicare Supplement or a Prescription Drug plan.
How To Replace Your Medicare Card
If you lose your Medicare card, you can always get it replaced by contacting Social Security. You can easily do this by visiting the Social Security website, or by calling 1-800-772-1213, Monday through Friday, from 7AM to 7PM in all U.S. time zones.
Replacements take approximately 30 days to receive. If you need your card sooner, contact your social security office.
Safeguard Your Medicare Card
Remember to bring your card to all medical appointments and pharmacies to facilitate the claims process.
To protect yourself from Medicare fraud and identify theft, guard your card just as you do with credit and debit cards. Keep it in a safe place, and share your Medicare number with medical providers only.
Never share your Medicare number over the phone, via email or with someone whose identity cannot be verified.
Star Ratings
A Five-Star Quality Rating System was developed by the Centers for Medicare & Medicaid Services to measure the experience of Medicare beneficiaries when using their respective health care systems and health plans.
The purpose of the Five-Star Quality Rating System is to track and monitor the performance of each plan, including the general care provided by physicians, hospitals and other providers, as well as identify areas of success and those needing improvement. Star Ratings apply to Medicare Advantage and Part D plans only.
The CMS evaluates plan performances annually and releases new star ratings in October, which apply to the following calendar year.
Ratings range from one to five, with five being the highest and one being the lowest in quality performance.
CMS measures how well each plan performs by conducting an annual comprehensive review based on the results of the following categories:
RATING CATEGORIES
✓ Staying healthy: An analysis of the efforts members made to maintain good health, including routine check-ups, vaccines and screening tests.
✓ Managing Chronic (long-term) conditions: An analysis of the efforts members made to manage existing conditions, including treatments and tests recommended by their physicians.
✓ Member Experiences with the health plan: An analysis of the overall member satisfaction of the plan.
✓ Member complaints and changes in the health plan’s performance: An analysis of the frequency that CMS discovered problems with the plan, the frequency of member complaints and decisions to leave the plan, and any improvements of the plan.
✓ Health plan’s customer service: An analysis of how well the plan handled the appeals of members.
RATING SOURCES
The data that CMS utilizes to measure each of these categories is acquired through:
✓ member surveys performed by Medicare.
✓ information and input from clinicians.
✓ information submitted by the respective plans.
✓ results from routine Medicare monitoring activities.
RATING CATEGORIES
✓ Drug plan customer service: An analysis of how well the plan handled the appeals of members.
✓ Member complaints and changes in the drug plan’s performance: An analysis of the frequency that CMS discovered problems with the plan, the frequency of member complaints and decision to leave the plan, and any improvements of the plan.
✓ Member experience with the plan services: An analysis of the overall member ratings of the plan.
✓ Drug safety and accuracy of drug pricing: An analysis of the plan’s pricing information and the safety measures taken when prescribing medication to members with medical conditions.
RATING SOURCES
The data that CMS utilizes to measure each of these categories for Part D is acquired through:
✓ member surveys.
✓ billing information submitted to Medicare by each plan.
✓ results from routine Medicare monitoring activities.
Why Trust Star Ratings
Star ratings can be a beneficial resource to you as a consumer when comparing health plans in your service area.
After you review and consider all additional factors, such as coverage, costs and the network of physicians and pharmacies, we recommend you also use the plan’s star ratings from CMS to help you make your final decision when choosing a Medicare Advantage and/or Part D plan that’s right for you.
Where To Find Star Ratings
Star Ratings for your current Medicare Advantage or Prescription Drug Part D plan can be found by calling 1-800-MEDICARE or going online and using the Medicare’s Plan Finder tool.
